NEW   ELEMENTS
OPERATIVE    SURGERY:
           ALF, A, L. M. VELPEAU,
                         ? * •
Professor of Surgical Clinique of the Faculty of Medicine of Paris, Surgeon of the Hospital of La
      Cliarite, Member of the Royal Academy of Medicine, of the Institute, etc.,

       CAREFULLY REVISED,  ENTIRELY REMODELLED, AND  AUGMENTED WITH

   A  TREATISE ON  MINOR  SURGERY.

                    ILLUSTRATED BY

       OVER 200 ENGRAVINGS, INCORPORATED WITH THE TEXT:
                   ACCOMPANIED WITH

  AN ATLAS IN QUARTO OF TWENTY-TWO PLATES,

    REPRESENTING THE PRINCIPAL OPERATIVE PROCESSES, SURGICAL INSTRUMENTS, ETC.

                TRANSLATED WITH ADDITIONS BY
           P. S. TOWNSEND, M.D.,
        Late Physician to the Seamen's Retreat, Staten Island, New York.

       UNDER THE SUPERVISION OF, AND WITH NOTES AND  OBSERVATIONS BY
            VALENTINE  MOTT, M.D.,
Professor of the Operations of Surgery with Surgical and Pathological Anatomy, in the University of
      New York; Foreign Associate of the Acadomie Uoyale de Mudecine of Paris.
               of that of Berlin, Brussels, Athens, etc.
             FOURTH EDITION, WITH ADDITION8 BY,
      GEORGE C.  BLACK MAX, M.D.,
Professor of Surgery in the Medical College of Ohio, Surgeon to the Commercial Hospital, etc.

            IN THREE ^VOLUMES.
                  VOL. I.
                      ■XAIAAL
            ----------------------s,-«.«j---------"

              NEW  YORK:
      SAMUEL  S.  & W.   WOOD,
            No.  389 BROADWAY.
                 ~T~8 5 6. 
WJ
v./
r ■*pC'r * >
         Entered, according to Act of Congress, in  the year 1847, by
                   SAMUEL  S.  &  WILLIAM  WOOD,
In the Clerk's Office of the District Court for the Southern District of New York.
   STEREOTYPED BY                             PRINTED BY
 THOMAS B  SMITH.                      E.  N.  GROSSMAN.
82 A 84 Beekman Street, N. Y.                        84 Beekman <t. 
PREFACE.
  In preparing a new  American edition of Velpeau's  great work
on Operative Surgery, it has been  the object of the  subscriber to
arrange it more methodically,  and  to  incorporate  the more  im-
portant contributions made in this department  during the  past
ten years.   His statistics of operations  on the arteries, of ampu-
tations, and exsections  of the bones, will be  found in  the text
of the work.   The Appendix, alphabetically arranged  at  the  end
of the third volume, it is hoped, will  not prove unacceptable to
the surgeon.
  The account of Dr. Mott's  recent and successful ligature of the
internal iliac was received too late  to  be inserted in  the  body
of the work.    A brief notice may be found at the end of  the
third volume.   The details of a very successful case  of  amputa-
tion  at the hip-joint, in  the  practice  of the writer,  (performed
some  eighteen  weeks  since,) must,  for  the same   reason,   be
omitted.
                                     GEO. C.  BLACKMAK
    Cincinnati, April 10th, 1856. 
 
                       PREFACE

                               TO THia

FIRST TRANSLATION AND FIRST AMERICAN  EDITION

                                  OP

      VELPEAU'S  OPERATIVE  SURGERY,

                                  BY

                   P. S.  TOWNSEND, M.D.
  If I were addressing myself to those who have read and studied the great work
of Professor Velpeau on Operative Surgery, it would be  quite superfluous to dilate
upon its merits.  For its general reception as a classical production, written with a
faultless purity of style, and the unqualified approbation which has  been bestowed
upon it by those of the profession in Europe, and in this and other countries, who
can peruse it in the language in which it is  written, are a sufficient evidence and
guarantee of the estimation which is attached to it.
  I believe it may be safely asserted that there was no work more wanted, than one
precisely of this description ; for none written upon the plan that the Professor of
Paris has adopted, has,  as far as I am acquainted,  ever before been offered to the
public.  For  the most  part, general works on surgery,  whether  issued from the
English, French, or German press, have the fault of being either  too voluminous
and unsystematized for  common use, as elementary treatises either for students or
practitioners, or they are too circumscribed and exclusive in their objects, being in
most cases confined to specialities, as, for example, to  certain branches or depart-
ments only of surgery, to general views on the anatomy  of relations, surgical an-
atomy, surgical pathology, monographs on this or that disease, &c, all of which,
however, are extremely useful in  their place, and requisite to be  completely mas-
tered in detail by all those who wish to arrive at any distinction in their profession.
  There was wanted a work which should embrace all the general axioms, precepts,
and facts of Operative Surgery and of Surgical Anatomy, absolutely essential to an
elementary treatise, and systematized and arranged  upon some natural  and well-
defined principles, which should be in perfect concordance with the known laws and
structure of the human organization.
  Such a work is that of M. Velpeau, as contrasted with all others.
  In this work the author has shown how requisite it is  that in every book on a
vast scientific subject like that of  Operative Surgery, the whole  fabric  should be
constructed and sustained upon some approved philosophical  plan, conformable to
the  received axioms of anatomy, physiology, and pathology, and the  different parts or
subdivisions of which should grow out of, or be  developed, one from the other, so
that the entire edifice  should form a perfect whole in itself; while all the details
should be in such necessary connection,  harmony, and proportion with each other,
that as  in the study of the living human organization itself,  each  one  should in
some sort be an exponent or co-relative of all the rest.
  We conceive that M. Velpeau has happily and fully attained this desideratum—
and that but very little is wanting  to make his work one of such standard value that
no public school or university in medicine, and no individual practitioner or student,
can hereafter possibly dispense with it.
  The peculiar fitness which the author possesses for such an undertaking, is seen
in the sound and well-disciplined mind with which he is gifted by nature—his ample 
iv                        translator's preface.
 education—his great professional ability and distinction as a practical  operator and
 teacher of surgery—his practised pen  as a man of extensive literary acquirements,
 together with his habits of untiring industry, patient research,  and lastly, what is
 perhaps fully as important as all the rest, the  clear  judgment, the dignified impar-
 tiality, amenity of temper, and spirit of thorough philosophical investigation which
 he brings to  every disputed or difficult question, or point, which  is presented to his
 notice.
   The fruits of these rare intellectual and moral endowments, which are perhaps in-
 finitely more desirable, certainly in general far more  serviceable  in soeiety, than the
 irregular sallies and random efforts and effusions of mere isolated genius, are en-
 countered upon every page of his work.  As for example, whatever others may say
 to the contrary, the exact and full descriptions which he gives in all the first portion
 of this volume in relation to Minor Surgery, or those common and indispensable
 operations, manipulations, dressings, &c, of a  general though not difficult nature,
 which it is nevertheless  important to be thoroughly  conversant with  as  the  rudi-
 ments of our art, and the only secure basis of all  correct  knowledge to be attained
 afterwards.   The student cannot place too high a price upon this part of the volume.
 And we particularize these matters because,  though to the  practitioner wno has
 passed through this ordeal these minutiae may at first sight seem prolix or tedious,
 he will, on closely inspecting them, find that they are in fact a perfect and admira-
 bly systematized condensation (instead  of a  diffuse or verbose  amplification) of
 every thing of any utility whatever upon this  subject that has been known  in past
 times, or been proposed or invented by the moderns, and that the whole is not only
 absolutely essential to be known by the student, and  re-perused  and re-studied by
the practitioner himself, but has also the rare merit  of being  imparted in the clear
and agreeable style peculiar to  the author;  and which of itself gives a charm even
to a subject naturally, and we may say necessarily, dry and destitute of attraction.
   The professional  reader also, whoever he may  be, if imbued with the proper zeal
and enthusiasm which should belong to him, will have  reason to thank  Professor
Velpeau for the mass of valuable erudition which he has brought to bear, by his un-
conquerable application and assiduity, upon  the true history of every operative sur-
gical process, principle, or discovery, which adorn or can  illustrate the  annals of
the science, fortified as the whole also is by direct and specific references to every
name, authority, or  work, ancient or modern, upon which the proofs of his asser-
tions and citations rest.
   We consider that this vein of rich, and much of it new historical contributions  in
surgery, and  which so steadily  courses or threads its way through the pages of the
work, constitutes as it were the natural woof upon which the  whole superstructure
is woven, and thus forms to it a substratum of inappreciable value.  Because it not
only shows what has been done, and what has stood and still stands the test of time,
and will doubtless continue to be approved of and recognised as  of established utility;
but it points out also as dangerous, if not forbidden  paths to future explorers, those
fruitless speculations and experiments that are to  be avoided as not only a destruct-
ive waste of time to the student, but as exposing his mind to be seduced by visionary
pursuits, and  thereby into researches which will be liable to end in the repetition  of
similar abortive results.
   Another advantage that we acquire, by having always thus at hand in the course
of our endeavors, to add some new improvement  to surgical science, an exact tran-
script of what others have done before  us, and of what has failed and what succeed-
 ed, and why and wherefore such have been the results, is this, that we are so much
the better enabled,  as before  observed, to economize our time, to husband our
 resources, and to concentrate the full force of our investigations upon the point  or
 points which  it is desirable to elucidate.
   Professor Velpeau has thus  also rendered a grateful service to the whole profes-
 ion, vindicated the silent and unprotected dead, as he has rebuked the ambitious and
 reckless  living, by according to each his appropriate  claims  and property, and by
 stripping of their spurious honors all that class of persons who, actuated  by moral
 principles that sit loosely upon  their  consciences, have always, in every age and  in
 every clime,  been constantly addicted to the pernicious habit (which to them seems
 to be a source of morbid pleasure) of decorating themselves with the plumes which
 righteously belong to the reputation of others. 
translator's  preface
T
  We repeat, that we  thirii M. Velpeau, by assigning  to every distinguished man,
who has ever adorned  the annals of surgery, the exact measure of gratitude which
the world owes to him for  his services and discoveries, has done a real and great
good to the profession, and especially to the rising youth who intend to embrace
this pursuit.   For who of them  would be inspired with an  ardent zeal and elevated
desire to strike out new routes, and to associate their names with brilliant discoveries
and improvements in operative surgery, whether for personal fame, or for the cause
of humanity and philanthropy ; who,  I  repeat, would be ambitious to make new tri-
umphs  and farther conquests upon the domain of our art, if he felt assured that, in
a few years, the evil spirit of a  grasping cupidity  and  rapacity would, by misrepre-
sentation,  suppression  of the truth, false  and fabricated statements, and personal
detraction, defamation, and persecution, combine to rob him of these cherished pos-
sessions, which he had fondly hoped would reward his  years of laborious study and
of painful toil*
  What will  also strike the reader, and particularly the student, in  this great ele-
mentary work on operative surgery, as  a portion that possesses intrinsic excellence,
are the perspicuous and condensed anatomical and pathological details which are
judiciously made to precede  all  the different operative  processes practised upon the
various regions of  the body.
  What renders this  present volume  one which will generally be considered  of
higher interest in many respects than any other part  of the work, is the fact that
it contains nearly all the latest discoveries and processes in that most important
branch  of the art which has not inaptly been called New Surgery ; since it has
sprung  up, or rather, made such astounding advances within the last ten years only,
that  it may almost be said  to date its very birth and existence within that short
period of time.   The  reader will readily anticipate that we allude to the entire de-
partments of, 1. Anaplasty, or, as some call it, Autoplasty, or" the restoration of
destroyed  parts and reparation of deformities, as of the  nose, lips, neck,  &c. ; 2.
Subcutaneous Surgery, or Tenotomy and Myotomy, meaning the subcutaneous sec-
tion or  division of tendons, muscles, bridles,  aponeuroses, fasciae, synovial capsules,
articular  ligaments, cartilages, bones, &c.; also, directed  for the most part against
deformities proceeding from abnormal muscular contractions, alterations, and distor-
tions of the limbs, feet, hands, neck, spine, &c, and now already promising to cover,
on  its great fundamental principle of  occlusion of  the external air from the divided
parts, a far greater extent of ground than had ever been anticipated, by being adopted
with even more  consideration than the illustrious Hunter attached to it, for the basis
upon which almost every surgical process  should hereafter be conducted.
   We have, in various parts of  the work,  it will be seen, expressed our own views
and those of others freely, in relation to the earnestness with  which the division of
parts under the skin, so as to effect as perfect occlusion  of the external air as  possible,
has been advocated by some  distinguished  surgeons, whose reputation is much iden-
tified with subcutaneous surgery.   Some qualifications to  such sweeping utilitarian
doctrines are undoubtedly desirable as guards and precautions against  allowing
ourselves to be too much carried away by the absorbing  impulse, which naturally
presses every one  into the service  of a cause whose march has been attended with
such uninterrupted and dazzling, but, nevertheless, for the  most part, we are free to
add, solid, triumphs, as has been that of those two great modern and most important
of  all acquisitions to the treasures of our art.  And in this opinion we are sustained
by the judgment of  Dr. Mott.  All this surgery in itself,  however, is of im-
mense value, and especially of  inconceivable utility by the facility with which the
operations which it comprises  can  in  general be performed, and by its special
adaptation to the relief of the  great masses of the poorer classes, who are  most
frequently the subjects of these, to them, more particularly distressing infirmities.
But we repeat that we should guard ourselves against being too much seduced by these
utilitarian popular views, and the  eclat which  is elicited from  the world without,
when they see a cripple, by a sudden plunge of a bloodless tenotome, instantly raised,
as from the dead, upon his feet, the distorted eye, or twisted  neck,  righted to their
just position, and a becoming and natural nose  in the place of one that is lost, made
to adhere and to perform all the necessary offices, upon a face that shortly before
presented a hideous and disgusting aspect.
   But while we express ourselves  thus candidly  we would not  be thought to take 
vi
translator's preface.
away in any one iota from the immense benefits which this branch of our new sur~
gery, under proper limitations and in skilful hands, and with persons of sound ana-
tomical knowledge, has conferred, and is, as we firmly believe, destined  to confer
upon mankind in every part of the earth.
  We have not found it possible or  practicable, step  by  step, in the course of the
translation, to incorporate in its proper place all the new matter which it has been
thought necessary to add, and some  of which would perhaps have found a more ap-
propriate location under each particular head to which it belongs.   The student as
well as the practitioner, however, will find himself compensated in some measure for
the detention which has attended the progress of this volume through the press, by
the valuable communications which, through this  accidental delay, it has thus been
in our power to embody in the work. Among these acquisitions, will be recognised
those which have been transmitted to us from Paris, for this American edition, from
the  distinguished author,  M. Velpeau himself; of which none  will be read with
greater pleasure and instruction than his  interesting letter to Dr.. Mott;  also some
excellent treatises from his  industrious pen, published recently, and since his last
edition of this work, viz., that  on the new treatment of erysipelas; his  complete
history of strabismus up to the year 1843, and the account of the late discussion on
tenotomy in the  Royal  Academy of Medicine at Paris, 1842, in  which  last our es-
timable author, it will  be seen, took, as was to  be  expected from him, a leading
part; all of which publications have been carefully translated and abridged, in such
manner as to adapt them more conveniently to the limits of this volume, to which
they belong, without, however, omitting any thing whatever of value or interest to
surgery contained in those treatises.  The principal  reason, however, why a large
portion of the new matter added has not been found in the body of the text, is that
most of these materials were not made public in Europe or America until after the
work had nearly passed through the press.
  We have,  therefore, in addition to what is scattered throughout the pages of the
text, on anaplasty, on tenotomy, myotomy, &c,  preferred  to  consign the principal
part of what we had to say on these subjects to the  form of a brief historic summary in
the Concluding American Appendix, which contains every thing, as will be seen,
belonging to the branches treated of in this volume, booked up to the last moment.
In that also we have endeavored to do full justice to our own countrymen, for all they
have contributed in this great  department of surgery ; and it is with pride we say,
that they have not been behind-hand in following the  example of our trans-Atlantic
brethren of France, Germany, and England.  Two  communications of this nature,
of a very instructive character, have  been inserted in that  Appendix, from Drs.
Watson and A. C. Post, both surgeons of the New York Hospital.   We have also
in that Appendix drawn copiously from the  recent valuable works of MM. Serre,
Malgaigne, Pancoast, Mutter, &c.
  A very useful  table in the  beginning of the volume,  and showing the names  of the
muscles of the human body, as adopted, on the one hand, by the French, and, on the
other, by the English and American surgeons, the differences of which terms  (some
French, and mostly Latin) lead to much embarrassing confusion, at this time particu-
larly, when the whole subject of myology  is rapidly acquiring enhanced importance,
has been kindly communicated to me by Dr. William Darling, prosector in surgery
to Dr. Mott.
  To Dr. Darling I am also much indebted, in the course of the translation, for the
assistance he has rendered me, in giving a just interpretation to many of the epithets,
exclusively technical, in those parts of the work which touch upon the anatomy of the
various regions.   His accuracy as an  anatomist, and his attainments as a scholar,
area guarantee of the correctness of his judgment in those particulars.
   I have to say  but a  few words in respect  to the motives which led to this under-
taking, and of the manner in which it has been executed.
   I confess, that the intrinsic value of the  work, as one especially adapted for the
classes at our medical colleges and universities, had often struck both my friend Dr.
Mott and myself, in various conversations ; but  there  was a feeling beyond this,
which attached  us both to all that concerned the  great school  of medicine at Paris,
and its noble band of professors.  He had been for years resident there, and  knew
intimately most of those contemporaneous surgeons who now occupy the more promi- 
translator's preface.
vii
nent positions in the profession, and  who have added, or are now adding, so much
lustre to surgery.
  I had also, in two different sojourns at Paris and Montpellier, in 1821-22, and at
Paris again in 1827-28, had the happiness to become acquainted with, or to follow
upon the clinical lessons of, some of the most illustrious of these men, as well as of
their predecessors.   It was natural  that I  should recur back with satisfaction of
hours  agreeably, if not profitably, spent under the instructions of  such men as the
Barons Larrey, Dubois the elder, Percy, and Dupuytren, Cuvier, Lacepede, Delpech,
Richerand, Thenard, Gay-Lussac, Boyer, Roux, Lallemand, Civiale, Lisfranc, Clo-
quet, Velpeau, &c. &c* And if, in the preparation of this volume, with the constant
advice  and  supervision of my long respected and much honored friend and former
preceptor, Dr. Mott, our united efforts shall have succeeded in conveying a just in-
terpretation of the spirit and language of our mutual and estimable friend, M.  Vel-
peau, and in thereby helping, by means of this English dress in which he now for
the first time appears, to give wider circulation on this  as on the  other continent,
to the important truths in surgery  his elaborate  work  embraces, it will be but a
slight return for the gratification  and benefits  which we (speaking  for myself, at
least) have  personally derived  from his instructive lessons, and those  of the illustri-
ous  men with whom he is and has for so many years been honorably associated, in
the most eminent walks of our  profession.
   Of the translation itself, and its general merits, I will briefly say, that it has been
revised and re-revised, both by Dr. Mott and myself, and constantly collated  with
the  original text of M. Velpeau, as the only sure guide to direct  us.  If labor,
therefore, and devotion the most unremitting, can have imparted  any value or
accuracy to this the purely mechanical and most fatiguing part of our duty, the work
is entitled to a full share of both.
   As to the absolute correctness and fidelity, therefore, of this English version of
M.  Velpeau's work, we venture, from the pains that have  been bestowed  upon it,
and from some knowledge which we think we possess of both languages, to assert
that we pride  ourselves upon  this production, as adhering as closely and rigidly as
possible to the original text of the author, verbum verbo, at the risk of appearing, at
times, to be speaking in an idiom  somewhat  Gallican.
   We preferred to err on this safer side, rather than to run the hazard, in a work
devoted to one of the exact sciences, as we consider operative surgery to be, of
making ourselves obscure, or perverting the true meaning of our author by any
attempted circumlocution  or improvement upon his pure and elegant diction.
   Like all other works of human labor, it doubtless possesses imperfections ; none,
however, we feel  assured, of a  grave character, and not one blunder, we almost
venture to assert, in the  matter  of strict and legitimate grammatical translation.
 To  which we should add,  that the publishers have, in every thing  that relates to the
typography and to the engravings, both in  the body  of the work and in the atlas,
 quite surpassed our most sanguine anticipations.
   I have been the more particular in a work of this extreme value, destined, as we
hope, from its own merits, to be adopted  generally in our schools, because the
American press and the standard of American education  and character have, of late
years, all been not a little  discredited and depreciated, by the book-making attempts
of certain adventurers in the profession, who, having one object solely in view, that
 of pecuniary gain, have given  to  the world  pretended translations of French, Ger-
man, and other works, on anatomy,  surgery, &c, the  inexcusable and gross  blun-
 ders contained in which, while they spread error and  confusion to an interminable
 extent, indicate the utter incapacity of the individuals  in  question to undertake a
 task of this description.
   We profess to have been actuated by a higher feeling and purer motives in this
labor, and we therefore consign it to the public without asking any other favor than
that of a just and unbiased searching criticism upon its merits as well as demerits.
                                                            P.  S.  Townsend.
  JVew York, December, 1844.
  * At the same sitting of the Institute, in my first visit to Paris, could be seen assembled in familiar dis-
course, not only some of the older of the above illustrious savant, but also such as the  venerable La
Place, Counts Berthollet and Chaptal, Barons Portal and Desgenettes, Legendre, &c, &c. 
 
             PREFACE

                     TO

THIS  AMERICAN  EDITION.
BY VALENTINE MOTT, M.D.
  The reasons which have induced me,  in connection with my friend, Dr.
Townsend, to undertake the laborious yet agreeable task of placing for the
first time before the profession, a complete and faithful English translation
(with all  the required additions) of the last Paris edition (1839) of M.
Velpeau's celebrated work on Operative Surgery, are so fully set forth in
my letter to that eminent surgeon, and so kindly and satisfactorily responded
to and approved of by the author's  valuable reply, that I must, at the risk
of incurring the charge of personal vanity, be permitted  the  privilege of
inserting them both in this place, as embracing nearly all that I would wish
to say in a distinct preface to this edition.
  I would remark, that the whole of this volume (constituting over 900
octavo pages, and  being  the  first of the three which the translation will
make) has been several times carefully and thoroughly  revised under my
immediate supervision.  The  notes  and additions on the subjects embraced
in it, designed to bring the whole work up to the improvements and discov-
eries in Operative Surgery at  the present moment, (1845,) have been also
carefully  prepared by Dr. Townsend, and  meet with my entire  sanction
and approval.   They have  been incorporated with the text, or more  fully
given in detail in the concluding appendix.
                                       New York, May 24th, 1843.
My Dear Sir,—
  It is with  muoh pleasure that I announce  to you  the  intention of the
Messrs. Langleys, publishers of this city, to bring out at  my suggestion,
as speedily  as  possible, a complete and faithful English translation  of
the last Paris edition (1839) of your  invaluable standard work in four
volumes, octavo,  on Operative  Surgery,  together with the folio atlas  of
plates  belonging thereto, and the nearly 300  engraved illustrations that
are incorporated with the body of the work.   I have for several years past
sensibly felt the want of a standard work  on Surgery in the English Ian.
guage, and  which  should  be  properly systematized  and classified,  upon
                                  B 
X
DOCTOR MOTT'S PREFACE.
the philosophical principles upon which the  basis pf this greatest  depart-
ment of the healing art now, thanks to the brilliant march of surgical dis-
covery within the past thirty years,  firmly and triumphantly reposes.
  It is  true  that we have the  elaborate dictionary of my friend, Mr. S.
Cooper, of London, as a most inestimable archive of surgical  knowledge,
and  an indispensable historical record for reference.   It is also true that,
both in England and in America,  there have been  from time to time pub-
lished, for some few years past, excellent compendiums of a limited charac-
ter.  But there was still wanting a great philosophical system and practical
treatise upon every  branch, more  especially of Operative  Surgery, and I
have unhesitatingly recommended  your  work  as  the one which comes
nearest, in my  view, to the objects desired, and which, on that account, I
have constantly referred to as the one most suitable to be adopted as a text-
book in the University in which I am a  professor.   To effect this object
more thoroughly, I have, in association with my friend, Dr. P. S. Townsend,
of this  city, made the necessary arrangements to  prepare with  him  a
faithful and exact version of the same,  and to have incorporated  with this
first American  edition, all  such new surgical matter of interest or value
as may have been  contributed to the general fund in Europe as well as in
America, since  the publication of your last edition in  1839.  I shall  also
herein  present a more minute and authentic detail than has ever yet been
anywhere published, of all that relates to what I myself may be justly and
conscientiously  entitled to claim as  my own property, in the entirely new
operations and new classes of operations,  as well as new improvements and
views, such as they have been projected and carried out into successful practice
and execution by myself, as the fruits of more than  forty years almost in-
cessant occupation and labors in all the different departments of Operative
and Pathological Surgery.
  I have taken  thus the liberty to enter my name as a compagnon de voyage
with you, upon the great high-road of the science, where it has been so long
our cherished pride, fortune,  and pleasure to travel.  Because I felt that
in associating my labors with  those which have received the approbation
of your  judgment, and  whicji  your genius and  untiring  industry  have
wrought  out in  your estimable work, as  an  enduring monument to  your
fame, I might  find an appropriate  place  and guarantee for indulging the
ambition that I,  like others, must naturally have of seeing legitimately trans-
mitted, through  an orthodox and approved organ,  for the judgment of an
impartial  posterity, an authentic account at least (if only at best  but an
abrege one) of my stewardship also  in the great field of surgical science.
This, so far as  concerns myself, (and  independent  of perhaps paramount
considerations, to give wider diffusion upon this continent to your great and
useful  work,) I  felt admonished by the time of life at which I have arrived,
to be due as well to myself and my own  reputation,  as to my country and
profession. 
DOCTOR MOTT's PREFACE.
XI
  As such, then, my dear sir, I have ventured thus, while life is so short
and  art so long, to ask for  myself a niche in the great edifice of surgical
facts and truths of which you are  the constructor and owner.   I have to
ask of you the privilege that I may be allowed within this storehouse, con-
taining so much of the  treasures of our science, to make safe deposite and
registration  of the detached fragments of the scaffolding at least, of that
extended work of  my own on Operative Surgery, which, as you are aware,
[ have  for so long a time meditated, and of which these offerings must for
the present be received  as the pledge.
  For the fidelity of the translation of Dr. Townsend I feel satisfied, from
carefully collating with him the part of the work he has  already finished,
that I may safely stand as his sponsor; as but few, also, from his travel and
residence several  years abroad, have had better opportunities than he has
profited of,  to  become familiarly and critically conversant with the French
and other foreign tongues.   To these,  permit  me  to  add the additional
pledge that you will have of not receiving any disparagement at his hands,
by  having him for your interpreter, from the fact of his own personal and
extensive experience in the  practice of physic and of surgery, and the dis-
tinguished and  well-deserved reputation he has for many years enjoyed,
both in Europe, in the West  Indies, and in this his native country,  by his
medical works on  various subjects.
  I write you thus opportunely upon the subject, with the hope that it may
be agreeable to you to  signify your commendation to this proposed under-
taking, and under the  possible contingency that  it might be your wish  to
suggest some alterations or additions to this American edition  of your work.
Whatever may be agreeable to you  in these particulars, will be rigidly
conformed to,  and your intentions in that respect, or whatever contributions
you may be pleased to  favor us with, will arrive in time for the first volume,
(the first one-third of your work,) if they reach here when that volume com-
plete is placed in the hands of the publishers, which it will be on September
1st ensuing.   My correspondents, Messrs. Green &  Co., bankers, Place St.
George, Paris, will, with pleasure, give safe and quick conveyance to whoever
you may place in  their hands for me.  The second volume (or secMd third
of your work) will, it  is hoped, be ready for the press Jan. h 1845, and
the  last or third  volume (the last third of your work) no^unul Mav or
June, or perhaps August, 1845, as  you perceive, and ca* readily imagine,
it must and ought to require time, to put into a pe*®0* English, or  rather
Anglo-American dress, with the addition of two/undred pages or more of
new matter, and in the beautiful style  of typography, paper, and plates,
that it is contemplated  and  intended it shafl be executed with, a work of
such magnitude as your last edition (Paris, 1839) of over 3000 octavo
pages.
   It affords me great satisfaction to have an occasion like this, (that I can-
not but believe, from the substantial good that it offers for both of us to do, 
xii
DOCTOR MOTT's PREFACE.
should be mutually acceptable to both,) of recalling to mind the  years of
unalloyed gratification which I enjoyed  in the society of yourself and my
other friends, during my residence in your justly renowned capital.
        With every consideration of professional respect and personal
             esteem, I am, my dear sir, your devoted friend,
                                                   V. MOTT.
  P. S. As anxious inquiries are made here, be pleased to inform me when
you contemplate a new edition of your Analomie Chirurgicale.
   To M. VELPEA U,
       Professor, &rc, Paris.
                         (translation.)

         TO DR. VALENTINE MOTT, NEW YORK.

My very distinguished Friend,
  I have learned, with  very  great  pleasure,  that  a complete
translation of  my  work  on operative surgery  is  to appear at
New York,  under your able supervision ; in associating your nu-
merous labors with mine, in selecting this translation as a repository
for all  the discoveries and  improvements which you have  intro-
duced into surgical practice, you will obviously make  my work an
important treatise, of unquestionable  utility, for our old  Europe
especially, where your labors, in spite of my efforts, are still but
imperfectly known.
  If your characteristic modesty induces you to suppose that my
work may serve as & passport to your name, you will permit  me to
add, with greater exactness, that my feeble  authority will be more
than doubly enhanced by being sustained  upon your high  repu-
tation.
   Thus  a^ured of being put in possession of all your labors, of
being enabled to consult them  every day and on every occasion, I
myself shall enjoy the pleasure of having it  in  my power to  repro-
duce them in our own tongue,  and in a shape  perfectly authentic,
both for students and for practitioners.
   Persuaded that I have  -^sembled in my work  almost the  entire
 amount of scientific  and practical details, indispensable for those
 who have occasion to consult  a didactic treatise on operative sur-
 gery, I feel no  hesitation in saying, that  your proposed publication
 will assist in rendering this branch of human knowledge popular 
DOCTOR MOTt's PREFACE.
xiii
on both sides of the Atlantic. It would have been unfortunate, too,
that an experience so extensive as yours, during a practice of forty
years,  and that the reflections of the most celebrated and distin-
guished surgeon of America, should have been nowhere found em-
bodied together in the same work.
  I was already in part acquainted with what you say of Dr. Town-
send : he has a reputation which was not unknown to me.  I have
read many articles from his pen, and I had already formed to my-
self a high opinion of  his talent.  I am therefore much gratified
that he has undertaken the task, as you so well express it, of in-
vesting me in an  Anglo-American  dress.
  As to the changes, corrections, and additions, which you  speak
of,  and which it  might be advisable to introduce into the  work
while it is in the  press, I have been seriously occupied with them,
and it is on this account that I have not sooner replied to your kind
letter of the 24th of May last.
  The corrections in relation to certain names of authors, and cer-
tain dates, must  necessarily be numerous in a work of this  de-
scription, so numerous, in fact, that I have not the  courage to point
them out.  I flatter myself, moreover, with the hope that Dr. Town-
send will rectify the greater portion of them.
  Thus, in the paragraph at page 31, of the Appendix of the first
volume, M.Fearn should be substituted in the place of M.Morrisson,
while the numbers at the quotations at the foot of the page are for the
most part misplaced as to their figures or in the titles of the journals.
At page 33 of the same Appendix, No. 4, and not No. 5, must be pla-
ced after the  name of M. Gagnebe.  Especially is it desirable not to
omit to correct in volume IV.* pp. 228 and  229, [French text,] the
phrase relative to M. Parcel y Venuales, which must be inserted
in place of Pur eel; moreover, that it was in 1807 and not in 1788
that the work of this physician was published.
  I have thought, moreover, that in order to enable you to  select
from my labors what may appear  to you to  be of value, I could
not do  better than to send you some  copies of the notice recently
published for my  candidateship to  the Institute.  You will see in
this notice what  I have  published since J<S38, and consequently
such as I could not avail myself of for the last edition of my work.
  The  Dictionnaire de  Medecine, or Btyertoire  des  Sciences Medi-
cates,  commonly  known  under the name of the  Dictionnaire de
Bechet, comprises the greater part of the articles enumerated near

           * Vol. III. of this translation, not yet published.—V. M. 
xiv
DOCTOR MOTT's PREFACE.
       the conclusion of my notice, and this Dictionary may be found, as
       I presume, in the bookstores of New York.
         The  Journal entitled, Les  Annates de la Chirurgie, embraces
       many of my articles: for example, my treatise  on Amputation at
       the lower third of the Leg, on  Sulphate of Iron in Erysipelas, on a
       New Species of Hernia, on Glossotomy in stammering, on Strabismus*
       &c.   Having preserved some copies of this last essay, and of my
       memoir on Shut Cavities, I hasten to transmit them to you, and I
       regret that I have not kept also those of my other articles.
         In the possibility that you do not receive the Bulletin of the Royal
$      Academy of Medicine, I send  you also an extract from a long dis-
       cussion on Tenotomy, inserted by M. Vidal  (de Cassis)  in  the An-
       nates de Chirurgie.\  You will also find in the  pacquet a short
       explanation in relation to certain of my labors, the authenticity of
       which had been called in question by certain charitable and inter-
       ested persons, while I was a candidate for admission into the
       Institute.   I take the liberty of pointing  out to your notice, in this
       sheet, the question relative to the Ligature upon Veins, either for
       varices or varicocele, and to that also upon  the Torsion of Arteries,
       the article on Erectile  Tumors, Immoveable Bandages,X &c.
         A point which I deem important is that which relates to my new
       processes for Extirpation of  Tumors, the Amputation of the Jaws, and
       Exsections.   Persuaded that you must perceive at a glance all the
       advantages to be derived from the  curved incision, substituted for
       the  straight, in the extirpation of tumors which  may be removed
       without trenching also  upon the integuments, I will make no further
       remarks on this subject in addition to those which you  will find in
       my notice.
         Have the goodness to recollect only that  I have now made use
       of this  incision in a great number of instances, in the  extirpation
       of tumors of every description, situated  under the jaw, or in the
       parotid region, above the clavicle, upon the  shoulder, and different
       points of the trunk and limbs ; also in exsections of all the articula-
       tions, of the bones of the metacarpus and metatarsus, of the carpus
       and tarsus, the astragalus, olecranon, acromion, and great trochan-
       ter,  and in the long seqv,estra from necrosis in the body of the limbs,
       &c.  And add to this, if you  are so disposed, that amputation of
  * See Abr6g6 of the author's treatises on Erysipelas and Strabismus, ia the text of
this volume.—V. M.
  t See Abre"ge* of this brochure in the text of this volume.—V. M.
  t Not received.—V. M. 
DR.  MOTT's PREFACE.
XT
the fingers and toes, with the corresponding bones of the metacar<
pus or metatarsus, without making any incision into the palmar or
plantar region of the part, have, by the aid  of  Liston's  scissor^,
afforded me results of the most satisfactory nature.
  My process  for amputation of the lower jaw now consists in
a curvilinear incision, which enables us to lay bare the whole dis-
ease without dividing the lips, and leaves  a  cicatrix only in the
supra-hyoidean region.  Suppose it should be required to remove
one of the halves of the jaw ?   Having commenced near the chin,
under the lower lip. the incision is continued under the jaw, back-
wards, in form of an arc, which is prolonged as far as the volume
of the tumor may require, towards the angle of the jaw and to near
the temple in front of the ear, or only merely  to  the  anterior bor-
der of the mastoid process;  dissected from below upwards, the flap,
circumscribed in this manner, may be raised up on the face as high
as we wish, and enables us to lay open fully the entire correspond-
ing half  of  the jaw.   The bone  is then sawed  by means of the
chain saw of Jeffrey, first  in front, then behind, after which the
soft parts that have been preserved fall again by their own weight
to close up the wound, leaving altogether intact the circumference
of the lips.
  You are too much familiarized with the great operations of sur-
gery, to make it  necessary for me to enter into more full details
upon a subject of this nature ; and I have no  need of adding what
should be done when we apply this method to the amputation of
the chin, or of any other part of the maxillary bone.
  In the upper jaw I require also  but one incision, whose curvature
scarcely  exacts as  much  depth  as  for  the  lower jaw;  carried
from  the commissure  of the lips to above the  attachment of the
ear and to the temporal region, this incision,  which avoids the
canal of Stenon, enables us to raise upon the forehead the entire
teguments  of the face, and the whole corresponding half of the
nose;  we then proceed to the section of the bones  in front from
above backwards and then outwards; that is to say, in passing
the chain saw, 1. Through the nasal passage to bring it out of the
mouth, in cutting through the soft parts of the palate, and sawing
the entire palatine  and maxillary vault from  behind forwards;
2. In cutting the root of the nose with Liston's  scissors, or, what
is as well, with the chain saw passed from  the inner side  of the
orbit into the  nasal  passage to  divide from  behind  forwards the
base of the ascending process of the maxillary bone ;   3. In passing
also from the  orbit into the temporal fossa in  order to cut the su 
xvi                    dr.  mott's preface.
perior angle cf the cheek bone, either with the chain saw, or with
Liston's scissors;  4.  Finally, in acting in the same manner on the
zygomatic arch, and  with the same scissors, or, what is as well, in
sawing this arch with Jeffrey's saw.
   All these  sections, which are effected without embarrassment,
and with sufficient rapidity, being finished, it requires only a slight
effort made with the  aid of a lever, applied in some of the cuts  of
the saw,  to detach the bone, the separation of which is completed
by dividing with the  bistoury the soft parts which still hold to  it.
A single wound only remains, which a few stitches of suture soon
convert into  a linear  cicatrix.
   When  the  whole breadth  of the lower or upper  jaw  is not
involved  in the disease, the operation, which consists only in re-
moving the affected portion of  bone,  affords me  results which are
more and more gratifying.  If it  is the dental border, the curved
scissors, carried beyond the insertions of the gums, removes the tu-
mor with one cut, without making any wound in the face, and
places the patient in  the same position  required for a person who
is to undergo the operation of having some of his teeth extracted.
If we are operating upon the  lower border of the bone, the curved
incision enables us to lay it bare, and to remove it by a cut of the
saw applied  horizontally above it.
   You  are at liberty to make  such use of these details as  shall
seem agreeable to you, and you will change or criticise them with
the greatest  degree of freedom, and conformably to  the  estimate
which your excellent judgment may put upon them.
      A thousand thanks  and a thousand kind wishes.
  Paris, the 16<A of August, 1843.                         VELPEAU.

  For the reasons doubtless alluded to by M. Velpeau, that the work which
I  had long since contemplated  on those capital operations and new processes
in surgery, of which I consider myself the legitimate author, has never yet
appeared, he is unacquainted with the fact, that in all my operations for the
removal of the lower jaw, and  which go back to the year 1821, (see this case,
with the  plate  accompanying it, American Journal of the Medical Sciences,
Aug., 1830, p. 553,) I have invariably, from the first, always made use  of
the curvilinear incision, to which he justly attaches so much importance.  His
description of its advantages and superiority over every other mode of reach-
ing the osseous structures to be exsected by the saw or nippers, is so clear
and graphic, that I have nothing to add to it whereby I could  impress upon
the mind of the surgeon its decided preference over every other mode.
  A very recent case of osteo-sarcoma, for which I  have operated within a
few days past, and while these last sheets of the work were going through
the press, opportunely presents itself in illustration of my practice  in the
employment of the curvilinear  incision.  W. E. B----, a young gentleman 
DR. MOTT's PREFACE.
xvii
 of New York,  aged twenty-five, of sanguine temperament, robust  form,
 and strictly regular in his habits, was attacked, last April, with a swelling
 in the middle part of the lower jaw of the right side, and, as usual  in these
 affections,  without any  pain, except occasionally,  and then slight  only.
 About four months since he applied to me, when I found the.tumor possessing
 a degree of hardness, accompanied, however, with a certain elasticity on
 pressure  peculiar to those  osteo-sarcomatous growths.   The  face was
 generally  enlarged  on  that side, the  hardness extending down to the os
 hyoides, and so around  beyond the posterior angle  of the jaw.  Upon in-
 specting it carefully, the tumor was found to reach to the cuspidatus tooth
 in front, and as  far up on the ascending ramus of  the jaw under the parotid
 gland as could be felt from without and within the mouth.   From circum-
 stances, I was led also to believe  that it reached, in fact, near or  quite up to
 the temporo-maxillary articulation.
   I apprized him  at  my first interview of its nature,  and of the necessity
 which I believed there would  be of a  surgical operation  to  remove it.
 I,  however, stated to him that it would be  satisfactory to try what benefit
 might possibly be derived  from  local and general treatment.  He accord-
 ingly, by  my  directions, applied  several  leeches once a week to the tumor,
 within the  mouth, and used internally the  alterative treatment of the hydrio-
 date  of potash,  and  compound sirup of sarsaparilla with decoction of our
 indigenous yellow dock root.   I enjoined upon him, at the same time, a mild
 light diet.  This course was carefully and  faithfully persevered  in  for at
 least about four months; but, finding that the disease sensibly augmented
 rather than diminished, I stated  to him that  the operation of exsecting the
 entire mass was his only alternative.  This he soon became sensible of him-
 self, and fully made up  his mind  to submit to.
   On Saturday, at half-past one,  P. M., November 23d, 1844, I  performed
 the operation.   Being satisfied that, it would be necessary  to remove the
jaw at the  temporo-maxillary articulation, I tied the  primitive carotid in the
middle third of the neck, as the first step, and as I had done in other similar
cases, and as long ago as in the year 1821.   I then commenced an  incision
a  little  in  front  of  the  meatus  auditorius, over  the tumor,  and carried it
downward  behind  the posterior angle of the jaw, traversing the lower front
of the tumor, and  thence proceeding upward upon the chin to within near
three quarters  of an inch of the vermilion border of the lower lip, terminating
at  a point opposite the second incisor tooth.   An opening was thus  readily
made into the mouth. The soft parts were detached a short distance upon
the chin, to determine that the bone there was perfectly sound.  The second
incisor tooth was now extracted, and through an opening made close to the
bone within by a sharp-pointed curved bistoury, a chain-saw was conveyed,
by means of an  eyed probe, from within downward, and thus brought out
below the chin, and the bone immediately sawed through from below upward.
  The flap of integument was now dissected  off the  tumor from below up-
ward, until the upper part was exposed and  the cheek extensively opened.
The bone was now laid  hold of where it  was sawed through, and the dis-
eased mass carefully dissected from the subjacent parts on the side of the
tongue and pharynx, sometimes detaching it from below and sometimes from
above, with a view constantly to keep such vessels as should be cut acces-
sible to  the ligature,  instead  of cutting in  one direction only, which, though
it might make  the operation appear to. be  more rapidly executed, would, in
our judgment,  be less surgical, because it would  be, frequently, cutting in
the dark, and at the risk of dangerous loss  of blood.
                                   c 
xviii
DR. MOTT's PREFACE.
   The  masseter was  now  entirely detached; and as it was very much
 thickened and degenerated where attached to the diseased mass, it was neces-
 sary to divide it very high up.  The last external incision was  now made,
 extending from  a little  above the glenoid cavity, over the  condyle  and
 through the  parotid gland,  directly downward,  to  unite with the first in-
 cision.   The  parotid gland  was now detached in front from over the  con-
 dyle,  carrying with it the upper portion of the masseter, so  as to expose
 the root of the coronoid process, which latter was now followed up, and the
 temporal muscle completely detached from  it.  This gave much mobility to
 the diseased mass, which was  .urned over towards the ear.  A few strokes
 of the scalpel now enabled  me to open the articulation, and to separate the
 condyloid extremity by cutting as closely as possible to this process anteriorly,
 so as to avoid the internal maxillary artery.  The diseased mass was found
 to have extended  as far up as to the neck of the condyle.
   In this extensive dissection there were a number of vessels tied.  All the
 arteries cut bled with a continuous stream.   The vessels being all secured,
 the flap was turned down, and a cloth wet  with warm water applied in the
 wound,  so as to invite any bleeding from  arteries that had not been tied.
   After waiting half an hour,  and refreshing the patient, and  doing every
 thing to contribute to his comfort,  and promote the warmth of his lower ex-
tremities by warm  blankets and  a bottle  of warm water, the wound was
dressed  by a number of interrupted sutures,  adhesive plasters, lint, a com-
press, and a double-headed roller.
   The dressing being completed, the patient was conveyed into a warm bed
 and placed on the sound  side.   He bore  the  operation with  extraordinary
 fortitude, though it was severe and necessarily somewhat tedious.  He was
 much less exhausted than many persons  are after operations comparatively
trivial.   In a short time he fell into a very tranquil sleep, and  passed a very
 comfortable  night,  without  the necessity of  any  anodyne, except twenty
 drops  of Magendie's solution of morphine,  which had been given an hour
 before the operation was commenced.   A gentle reaction soon  came on, and
 at the time of writing this, (Dec. 11th, eighteen days after the operation,) not
 the slightest untoward symptom has appeared, and all the ligatures have
 come away.
   The wounds, up to this time, have been regularly dressed, and the agglu-
 tination of the borders of the incision appears to have been wholly comple-
 ted by the first intention.   Not the least hemorrhage has shown itself since
 the wound was first dressed.
   This  subject, however, will  be again recurred to by me, when we reach
 that part of the work which treats of exsections of bones.  In the  mean time,
 without arrogating  any particular  merit  for the very large  additions of new
 matter which have been  made, by Dr. Townsend and myself conjointly, to
 this edition  of the  author,  we will confine  ourselves to  recommending,
 especially to all  who  wish  to obtain an exact  and perfect knowledge of
 operative surgery, the subject matter of the text  of M. Velpeau  himself, as
 well as the contents of those important and  recent treatises embraced in this
 first volume, which he has had the  kindness  to transmit to us from  Paris.
 In the hope that this American edition of this admirable work may receive
 the full share of approbation by the profession, which I candidly believe it
 entitled to over all others, I have but to add, that I cordially recommend it to
 be adopted as a text-book  for surgical  classes, not only in our American
 colleges and universities, but in  all other institutions where the English
 language is spoken.
    .Yew York, December, 1844.                                      V. MOTTi 
          PREFACE
                  TO

THE  FIRST  EDITION.
  In publishing the first edition of this treatise, in 1832, my object was to satisfy a
want generally felt.   That which M. Roux promised in 1813, has not been effected.
The work of M. Sabatier had already become old.  A crowd of neglected opera-
tions, scarcely known in the time of this author, and which to-day engage the atten-
tion of the learned world, had not yet found a place  in classical  works.  Rhino-
plasty, cheiloplasty, blepharoplasty, otoplasty, bronchoplasty, staphyloraphy, torsion,
puncture of the arteries, lithontrity, cauterization of the urethra, amputation of the
uterus, extirpation of the ovary,  and of the anus, and many exsections, were of this
number; and we may say that a review of operative surgery entire, had really be-
come indispensable.
  The course of instruction which I have undertaken since 1823, made me recognise,
at the  very outset, the species of void of  which I speak, and would have induced
me at an early occasion  to have attempted to remedy it, had I not been fearful of
undertaking a task beyond the measure of my strength.   I limited  myself at first
to the idea of a simple manual; but the researches into which I naturally found my-
self drawn^on this occasion, soon convinced  me  that, to be truly useful, not only a
manual, but a complete treatise was necessary.   Many chapters were already com-
pleted  with this view, when the journals  announced,  in 1825, a work of  the same
kind which would immediately appear, but which has not yet been published.  1
thought it  proper to arrest my course and wait.  Other motives encouraged me to
this delay.   Sustained only upon the demonstrations  of the amphitheatre, my as-
sertions would  have  been  but of feeble value.   The  processes essayed upon the
dead body cannot be definitively adopted but after having been submitted to the tes*
of the  Hospitals.   My position at this epoch, would not then have  given me the
right to appeal, with a sufficient  degree of confidence, to my personal experience.
  Four years of practice at the Hospital of Perfectionnement, the  service of th*
Hospital of St. Antoine, with which I have been intrusted for nearly two years-
and the wards of which I have had the direction  at La Pitie, procured me at length
the opportunity of applying frequently to the living body, the processes which I had
so often repeated  on  the dead subject.   To set out from that point, I thought  iJ
might be permitted me to express an opinion on the propriety, absolute or relative,
of the different methods which should be examined in a treatise like the present.
  Writing  in the sole interest of truth, I accepted thus the labors of all, without
distinction of country, school, or persons,  reserving to myself the right to discuss 
XX
PREFACE  TO THE FIRST EDITION.
their merits with independence, and of stating, without prejudice,  what, in  my
opinion, they might offer of useful or defective.  Our  epoch presents, under this
point of view, difficulties which can only be appreciated fully by him who should un-
dertake to make an impartial history of it.  While men are living, they are rarely
just towards one another.
  The improvements for which we are indebted to the greater number of practitioners
who share the domain of science, being unpublished by their authors  and unknown
but by  tradition, it was indispensable to make a conscientious examination of them,
and to  seek out with care their true sources.  No work having been composed in
this spirit, and  the history of surgery of the  nineteenth century being a  task  yet
unattempted, I have been, under the necessity of consulting an infinity of periodical
collections, particular memoirs, and monographs of every description.
  A work of great application, where every thing is to be in some sort mathemati-
cal, treating of  dates,  of inventions, and of processes which  have given birth to so
many discussions, and to controversies so multiplied, the subject and each one of the
objects of which have been presented in so many different forms, and so differently
interpreted, exacted in this respect an  attention, a care, and a  labor, which few
persons would suspect, and an amount of researches of  which it is, in reality, diffi-
cult to  form an idea, except by one who has himself undertaken it.
  In short, in order to be sure of omitting nothing essential, I frequently addressed
myself to the persons themselves, to those especially whose researches  were un-
published, or have been written  by a third  party.  It was thus, in order  to know
what Dupuytren had done on certain operations, I believed it my duty to  make  in-
quiry of M. Marx, his special pupil.   I  have in this manner learned, through  M.
Moulinie, that the success attributed  to the refrigerant method in the treatment of
aneurisms, was  far from being  well established; that all, or almost  all of it, waa
due to other means concurrently employed, for which no allowance  was made in
the detail of the observations.
  As to what relates to the epochs that are past, I have done all in my power to go
back to those sources.  When I have not been enabled to do so, either  from  the
scarcity of works or owing to the language in which they are written, I have relied
for my authority upon Sprengel, confirmed by that of Le Clerc, Freind, Dujardin,
and Peyrilhe.
  Having scarcely anywhere given the title or passages of the works that I have
drawn  from, I might have dispensed also with giving the name of the authors.  One
may thus neglect all historical research, and have no need of contradicting, person-
ally, any one, whoever he may be ; but nothing  appears to me more contrary to the
true interests of science.   Seeing thus no name in the text they read, students, un-
just without knowing  it, constantly impute to the author whom they have in their
hands, ideas which often date many ages back, or that  twenty others have already
originated.   Hence comes that credulity so adroitly experimented upon in all times,
and now more .so than ever, by the inventors of new methods ; hence so many of
those academic mystifications, and that currency which the fabricators  of discoveries
obtain among numerous practitioners, who, in this respect, are scarcely less difficult
to be imposed upon than pupils.  In collecting upon each subject upon  which I
treat, the principal names that belong to it, I in the first place acquitted myself of
a strict sense of justice ; and have also thought that my assertions gained by this
means a support and an authority which it would have been wrong to  have deprived
them of.  In a word, I find also here the advantage of  showing to the reader, that 
PREFACE  TO  THE  FIRST EDITION.
xxi
 the object with which he is occupied is or is not new, or that such and such persona
 have already spoken of it.  To persons who would reproach me that I have thereby
 rendered  it impossible for them to verify the  exactitude of my citations, I would
 reply, that in reproducing the opinion of others, I have in general given it as I un-
 derstand  it, without pretending in any manner to render them responsible for my
 interpretations.  Addressing myself, as I do, to pupils, I have desired, in pointing
 out things, to lead them to suppose that there is a history of them, and thus to give
 them, in advance, some taste for scientific literature.
   No one has ever called in question the  importance of anatomy in the practice of
 operations.  Nevertheless, as it was not possible to introduce but a small number
 of its details in a treatise on operative surgery, I have thought it advisable to look
 to those only that are indispensable, and to nhonsfi the form which is best adapted
 to their abridged exposition.
   Sabatier, who was capable of giving the state of the science with so much clear-
 ness, has, nevertheless, from his want of descriptive details, the  defect of not satis
 fying  any hut those who are already acquainted  with it, or who are content  with
 studying it in their closet, and of being, therefore, insufficient for those who operate
 in amphitheatres.  Seeing this rock, I have endeavored to shun it, without losing
 sight  of the opposite  inconvenience, knowing how fatiguing by their  aridity, and
 how irksome by their multiplicity, are those long and interminable manual directions
 that are found in some publications of our time.
   As for  the rest, in order to satisfy all on this point, I have, under the title of oper-
 ative process, given, as often as the extent of the  subject has permitted me to  do so,
 the details purely mechanical and practical that are absolutely required for the per-
 formance of the operation, whether on the living body or on the dead subject.   The
 history, the examination, the discussion, the appreciation of the methods, the acci-
 dents, the consequences, the indications, forming the subject of so many distinct
 titles, will always be easy to consult separately by those who would not desire to
 read the article entire.  I have not applied these divisions, however, except to the
 operations somewhat complicated, and have not thought  it necessary to adopt them
 in those which may be conveniently described  in a few pages.  Not having  made
 up my mind to treat exclusively of operative processes, nor wishing, on the other
 hand, to make a book on surgical pathology, I have confined myself on this point to
 the discussion of the indications, setting aside, except in cases of special necessity,
 whatever  relates to  the nature, to the development, symptoms,  and  general treat-
 ment of the diseases.  The comparison of the methods, and the results that  they
 have furnished, formed another point too much neglected  up to the present time,
 and one too unquestionable in its utility, not to require from me every attention pos*
 sible.
   If I have often adverted to processes long since forgotten, or justly proscribed ;
 if I have, also, not omitted a crowd of recent inventions, which may not have any
 value in themselves, and that science can derive no advantage from ; it is because,
 on the one hand, there is no method, however extravagant we may suppose it to be,
 which does not run some risk of being reproduced at some future time by some new
 inventor, and that, on the  other hand, it  is indispensable to enlighten  students, not
 only on what they ought to adopt, but also on what they ought to reject, when the
 subject is  the cotemporary history of assertions and of opinions that they are every
day accustomed  to hear unjustly praised or censured.  Although I may have done
all this, in order to follow out, under this double relation, the march of mind, and to 
xxii
PREFACE  TO THE FIRST EDITION.
represent with exactitude and impartiality the actual state of the science ; and that
I have neglected nothing which might enable me to procure correct information on
its most modern improvements, I nevertheless apprehend that I may have forgotten
some things that are useful, and I make  no pretension of having described every
thing.   As to the rest, I shall  receive with gratitude the advice which the judg-
ment of learned men may be pleased to furnish me with.
  The engravings annexed to the descriptions are  not  as numerous as the nature
of the subject would seem to render necessary ; but the  price of the book is already
so much enhanced by them, that I have not thought it  proper to extend them fur-
ther.   All have been taken from nature with the greatest care.   Though for  the
most part considerably reduced, the objects will be found represented with neatness
and precision.  I have chosen, as much as possible, new points of view, and those
which permit us to seize at a glance the ensemble of the operation.
  Their only object being to replace tedious  written details, I  have looked less to
their finish than to the accuracy and clearness of the design.   The execution of
them was, moreover, confided to one of our most distinguished  artists, M. A. Cha-
zal, Professor of Iconography at the Museum of  Natural History, who, as is well
known, possesses great skill in this particular  branch.   Such instruments as I have
not been able to find in the collections of the faculty, have almost all been procured
for me  by M. Charriere, the most extensive and skilful manufacturer in this branch
at Paris.
    Paris, 1833. 
            PREFACE
                    TO

THE  SECOND  EDITION.
  A more extended practice, the service of a large hospital, and the requirements of
teaching, have made it a more and more imperious duty for me to submit to the cru-
cible of experience, almost the whole round of surgical operations.   Led by these
means to compare the various resources of surgery with each other, I have thought
it proper to consign to the present edition of this work the conclusions to which I
have arrived from the researches which I have  made, and never to shrink from
giving a positive appreciation and judgment, when the questions have appeared to
me susceptible of it.
  In this respect I have had to divest myself more than ever of opinions deduced
from the dissections of the amphitheatre. Habituated, like my cotemporaries,to judge
of the importance of  operations  by the processes on the dead body, I had at first
attached too much value to a great number of methods and precepts of which I now
recognise the insignificance or puerility.  In  imitation of surgeons  who, taking
for serious the approbation of some young students, have believed that they could
remodel operative surgery by directing the incision of  tissues at so many lines or
inches from such or such a groove, under an angle of such or such a degree, follow-
ing out, as they say, the rules of geometry, I had abandoned myself also to the
innocent pleasure of extolling the superiority of methods that  were altogether inap-
plicable, or utterly useless.   I now know, that on living man  it is less important to
act  quickly than to act properly; less important to establish regular wounds, and
geometrical incisions, than to follow the line indicated by the diseased tissues; less
important to give to  the  divisions a ready approximation, than to place them in
conditions which offer the greatest possible security.
  Believing that  I  have the right, at the present time, to modify and to  change
what has been erroneously said or done by others, I have not hesitated, as formerly,
to declare what I have found best, or least objectionable, in the  processes which I
have tested or projected.  After having pointed out and described the different pro-
cesses, I have taken upon myself to propose a choice among them to students and
to surgeons, and to designate those which appeared to me to merit the preference, by
whatever title it may be.   Considering that the dressings, bandages, and the small
operations which are  generally known under the  title of minor surgery, exercise
the greatest influence on the subsequent success of operations, and are not, in fact,
sufficiently studied, neither by students nor  by the mass of  practitioners, I have
believed it my duty to treat of them at length in this edition. 
Xxiv                 PREFACE TO THE SECOND  EDITION.
   The books that science possessed already on this subject, it is true, are numer
 ous and sufficiently complete; but as they form treatises apart, few persons attach
 any value to them, and they thus attain but imperfectly the object in view.
   Having perceived that long descriptions were not equal in value to a few figures,
 I  have thought that designs on wood would here be of true service.  In place of
 forming an atlas of them, or separate tables, I have believed that this was  a suita-
 ble occasion to intercalate them with the text, in the manner of the ancients, and
 as has been the practice for some years past in England and America.
   Wishing  thus to embrace all operative surgery, I have thought it necessary to
 add numerous chapters to my first work.  An entire new class of operations has
 been created in our days, that of operations relative to deformities.  I have conse-
 crated a long article  to it.  The section of cicatrices, bridles, tendons, and retract-
 ed muscles,  thus  demanded  a  place in  a systematic  treatise.  Neither could  I
 neglect the operations relative to the maladies of the nail, and those of the  epider-
 mis and  teeth.  The operations which concern kinepock, the application of cup-
 ning-glasses, moxas, leeches, the  cautery, bleeding, etc., could  not, for the same
 reasons, be  passed over  in silence.  The restorations of organs have led me to
 ustablish the great class of anaplasties; so that, in adding also what relates to ab-
 ncesses, fractures, and the generalities of operative surgery, I have out of the whole
 ijomposed the first volume and the  half of the second, of all of which there is no
 trace in the first edition.
   As special operations, which I likewise had  to treat anew, or on a more  enlarg-
 (id plan, I mention those which comprise the numerous  series of  tumors, and thoso
 jf exsections.  Other diseases, the openings in the perinaeum, vesico-vaginal fistu-
las, and polypi  in the urethra, are likewise made the subject of articles almost en-
tirely new;  so  that the entire book is in reality completely recast, and increased to
double its size.
   The reasons that I had given for not indicating the sources from which I havo
derived materials, have not appeared satisfactory to most of those who have occu-
pied themselves with my work.   Yielding to a wish that has often been expressed
 \)y them,  I have on this occasion followed the opposite course.  Nevertheless, thu
new plan has encroached so much on the space destined to the  text, that  I have
found it necessary to modify it a little in  the two last volumes;  I have abstained,
for example, from subjects which I have treated of elsewhere, whether in the Dic-
tionary of Medicine, in my Tocology, or my Anatomy, or in the particular memoirs
 whose titles  are seen at the head of this work.   Under this point of view I ought
to  recall, as  in 1832,  the fact that my intention never has been to give a history of
surgery;  and that, if I often cite the labors of others, it is solely out of a spirit of
 equity, to enable those who read me to be capable of understanding what  has been
done by the ancients as well  as by  the moderns, and also by myself, in order that,
"tfter having read  me, both the student and the practitioner may know what  are
 ihe true merits  of the question under consideration.
   Not always having it in my power to verify the facts announced by certain au-
 thors, I have, therefore, not made  myself the  guarantee of their declarations, but
 have made them incur all the responsibility.  My quotations,  then, have no other
 end than to  awaken  the attention of the reader, and to apprize him, that whether
 right or wrong, such a fact has been mentioned or such an  opinion advanced.  I
 had perceived, indeed, that writers from whom I borrowed in this manner  materials
 of a certain  description, were often  inexact.  I may on  this subject refer to the 
PREFACE  TO THE SECOND  EDITION.
XXV
researches of Jaeger on Exsections.  The suspicions of inaccuracy which I had in
regard to this writer have been since fully confirmed in the Thesis of M. Vulfrand
Gerdy.
  Convinced that in order to be useful to students and to other readers, in a classi-
cal work,  it  is necessary to  make an examination and review as complete as possi-
ble of the  riches that science possesses; and persuaded that the name of a man, or
the locality of a place, does  not change the nature of facts faithfully narrated, I have
addressed myself to every one, in order to obtain precise information.  Not being
able  to bring myself to believe that whatever is interesting in surgery is  exclusively
confined to Paris, I have received with satisfaction what  many practitioners of the
departments have had the kindness to communicate to me.   It is thus that I have
obtained materials from Messieurs Castara, surgeon of the Hospital of Luneville ;
Chaumet and Moulinie, surgeons of the Hospital of Bordeaux ; Caffort of Narbonne,
Buret of Caen, Haime and  Tonnele  of Tours, Philippe of Reims, Stoltz  of Stras-
bourg, Lallemand and Serre of Montpellier, Pichausel of Cleirac, Fristo of Sierck,
Jacquier of Evry, Robert of Chaumont, Lefevre of Joinville, Loreau of Valenciennes,
de Mazieres of Bergues, Jozzet of Vannes, L'Herminier et Rufz of Guadaloupe,
and from many others.  At Paris even, to be more exact, I have thought it right
to apply to M. Roux for the exsections that he has practised; to M. Le Roy d'Eti-
olles, M. Laugier, M. Robert, M. Sedillot, etc., for certain processes of their inven-
tion, and to  M. Toirac for what concerns the teeth.
   I have obtained like communications from many foreign practitioners.   In Italy,
M. Fabrizi  has communicated to me the operations that he practises  on the  ear.
I have received from Germany, from MM. Sprengler and Adelmann,  suggestions
and observations of great value in relation to the exsections practised at Wursbourg.
M. Rorhbye has given me all that there is important in  Denmark.  I am indebted
for some information of the same kind to M. Baroni, and M. Peyrogoff for Russia,
and to MM. Hysern and S. de Toca for Spain.   M. Kerst of Utrecht has furnish-
ed me valuable facts relative  to Holland.   An extended note has been communi-
cated to me from  M. Warren, on what  this surgeon  has  done at Boston.  MM.
Rodgers, Gibson, Paul Eve, and Norris, have  also communicated to me some facts.
But  the most  detailed illustrations  that I have  obtained relating to America, are
due to Mons. V. Mott.
   Communications and notes  without number have, moreover, been furnished to me
by M.  Champion of Bar-le-duc.   This  surgeon,  as remarkable for the qualities of
his heart as for his prodigious learning, has, by his own efforts, procured  for me an
infinity of facts relative  to anaplasty, tumors, exsections, and deformities.   The
reader will  then  recollect,  in reading this  work, that many facts and  opinions of
which I cite the author, without pointing out any work from which I have taken
them, have  come to me by direct communication.  I have been enabled in this way
to embody a crowd of materials unpublished or  little known, that they may speak
for their country, and for surgeons of high ability, or worthy of being  placed  in a
high rank in the dominion of science.  It has also resulted from this, that in place
of laws and precepts dogmatically prescribed, I have  willingly confined myself  to
an accumulation of facts on a given point, when those facts themselves have ap-
peared to  speak with clearness.
  Works  on operative surgery have, moreover, been published in different places,
and  by different authors, since the publication of mine.  Without speaking of nu-
merous articles inserted by M. Berard in his dictionary of twenty-five  volumes, of
                                     D 
xxvi
PREFACE TO THE SECOND  EDITION.
the treatises of M Liston, of M. Syme, of M. Gibson, and of some German works
I will make mention of the excellent Manual of Operative  Surgery, by M. Mal-
gaigne, the Essays of M. Dieffenbach, of M. Korneziewski, of M. Mayor, and of
M. PI. Portal.  An extended work, which treats however more of surgical patholo-
gy than of operative surgery, has been published by M. Begin.   At Paris, also, we
have seen the commencement of a treatise of the same kind, a treatise which, con-
ceived upon a larger plan, seems to promise better to place us in possession of the
actual treasures of surgery, than that of the professor of Strasbourg.  It is a work
whose completion we look forward to  with impatience ; I speak of the work of M.
A. Vidal, (Traite de Pathologie Externe et de  Medecine Operatoire, Paris, 1839,
t. i. et ii., in 8\)  If the conclusion corresponds with what  I have already seen,
the new manual of which M. Sedillot has just given us the first part, will constitute
in that respect a work of real utility.  The operative processes borrowed by the
author from military surgery, will make an excellent practical surgical compendium.
I sincerely regret that the seventh edition of the Dictionary of Surgery of M. S
Cooper did  not reach me till the month of February,  1839.   This  work, which
posts up the actual state of surgery in  Europe, and which the author has considera-
bly augmented, would have furnished me some important materials.
  Nevertheless, having analyzed with care whatever of note has been said among
ourselves, and having interrogated on all sides for correct information, I believe I
have made  a recapitulation sufficiently exact of what exists  to-day in the science
of the operative surgeon.  Perhaps, in consideration of so much effort, and of my
own  proper experience, I shall be pardoned for having indulged the hope of im-
parting an aspect less mechanical, and an impulse more medical, to operative sur-
gery than my predecessors had  done, while I have endeavored to enlarge and  to
systematize the field, and the basis of the processes which have from time imme-
morial formed its legitimate domain. 
           WORKS  OF M.  VELPEAU,

                          [IN FRENCH,]

REFERRED TO BY HIM IN THIS WORK ON OPERATIVE SURGERY
Complete Treatise on the Art of Midwifery, or Theoretic and Prac-
    tical Tocology, etc.
Embryology, or Human Ovology.
Convulsions in Women during Pregnancy and Labor, and after Par.
    turition.
A Small Treatise on the Diseases of the Breast.
On the Operation of Trephining in Wounds of the Head.
A Complete Treatise on the Surgical, General, and Topographic An-
    atomy of the Human Body.
Manual of General and Topographic Surgical Anatomy.
Description of a Remarkable Case of Cancerous Disease.
Researches on the Spontaneous Cessation of Traumatic Hemorrhages
Contusion in all the Organs.
Laryngeal Fistulas and Bronchoplasty.
Amputation of the Leg at the Articulation of the Knee.
Mercurial Frictions in Peritonitis.
Memoir on the Membrana Decidua, (Caduque.)
On Artificial Anus, (Contre Nature.)
On the Treatment of Burns.
On Diseases of the Lymphatic System.
On Luxations of the Shoulder.
Letters on the Introduction of Air into the Veins. 
 
MUSCLES  OF  THE  HUMAN BODY,
arranged according to their regions,
WITH THEIR  CORRESPONDING  NAMES IN FRENCH AND ENGLISH AUTHORS,
BY WILLIAM DARLING,  M. D.
MUSCLES OF THE CRANIUM.
 Name in French Authors.
Occipito-frontal,
Auriculaire supeYieur,
Auriculaire anterieur,
Auriculaire posterieur,
     Name in English Authors.
Occipito-Frontalis.
Superior Auris.
Anterior Auris.
Posterior Auris.
MUSCLES OF THE FACE.
Orbiculaire des Paupieres,
Sourcilier,
Pyramidal du nez,
Orbiculaire des levres,
Transversal, ou triangulaire du nez,
Elevateur commun de l'aile du nez, et
  de la levre superieure,
Elevateur propre de la levre supdrieure,
Canin, ou e"le"vateur de I'angle des levres,
Grand Zygomatique,
Petit Zygomatique,
Abaisseur de l'aile du nez, ou myrti-
  forme,
Triangulaire, ou abaisseur de I'angle des
  levres,
Carre* du menton, ou abaisseur de la
  levre inferieure,
Muscle de la houppe du menton,
Buccinateur,
Masseter,
Crotaphyte, ou temporal,
Pterygoldien interne, ou grand ptery-
  goldien,
Pterygoldien externe, ou  pet:t ptery-
  goldien,
Orbicularis Palpebrarum.
Corrugator Supercilii.
Pyramidalis Nasi.
Orbicularis Oris.
Triangularis Nasi.

Levator Labii Superioris Alaeque Nasi.

Levator Labii Superioris.
Levator Anguli Oris.
Zygomaticus Major.
Zygomaticus Minor.

Depressor Labii Superioris Alaeque Nasi,

Depressor Anguli Oris.

Quadratus Genee,  vel Depressor  Labii
  Inferioris.
Levator Menti, vel Levator Labii Infe-
  rioris.
Buccinator.
Masseter.
Temporalis.

Pterygoideus Internus.

Pterygoideus Externus. 
XXX
MUSCLES OF THE  HUMAN  BODY.
MUSCLES OF THE ORBIT.
      Name in French Authors.
L'e'le'vateur de la paupiere superieure,

Droit supeneur, ou e"le"vateur de l'oeil,

Droit infe'rieur, ou abaisseur de l'oeil,
Droit interne,  ou adducteur de l'oeil,
Droit externe,  ou abducteur de l'oeil,
Oblique supeneur de l'oeil, ou grand ob-
  lique,
Oblique infe'rieur, ou petit oblique,
      Name in English Authors.
Levator Palpebral Superioris.
Rectus Oculi  Superior,  vel  Attollem
  Oculum.
Rectus Inferior, vel Depressor Oculi.
Rectus Internus, vel Adductor Oculi.
Rectus Externus, vel Abductor Oculi.

Obliquus Oculi Superior.

Obliquus Oculi Inferior.
MUSCLES OF THE EAR.
Interne du marteau, ou tenseur du     Internal muscle of the Malleus, or Ten-
  tympan,                             sor Tympani.

Externe du marteau,                \ Ext(fmS Muscle of the Malleus'or La*
                                   I   ator  lympani.
Muscle de l'e'trier,                    Stapedius.
MUSCLES OF  THE NECK.
Peaucier,
Sterno-cleido-mastoidien,
Omoplat, ou scapulo-hyoidien,
Sterno-hyoldien,
Sterno-thyroidien,
Thyro-hyoi'dien,
Digastrique,
Stylo-hyoi'dien,
Mylo-hyoi'dien,
Genio-hyoi'dien,
Hyo-glosse,
Genio-glosse,
Stylo-glosse,
Lingual,
Platysma Myoides.
Sterno-cleido-mastoideus.
Omo-hyoideus.
Sterno-hyoideus.
Sterno-thyroideus.
Thyro-hyoideus.
Digastricus.
Stylo-hyoideus.
Mylo-hyoideus.
Genio-hyoideus.
Hyo-glossus.
Genio-glossus.
Stylo-glossus.
Lingualis.
MUSCLES OF THE PHARYNX  AND PALATE.
Constricteur inferieur,
Comstricteur moyen,
Constricteur superieur,
Stylo-pharyngien,
Peristaphylin externe,
Peristaphylin interne,
Palato-staphylin,
Pharyngo-staphylin, ou palato-pha-
  ryngien,
Glosso-staphylin,
 Constrictor Pharyngis Inferior.
 Constrictor Pharyngis Medius.
 Constrictor Pharyngis Superior
 Stylo-pharyngeus.
 Circumflexus Palati.
 Levator Palati Mollis
 Levator Uvulae.

> Palato-pharyngeus.

! Constrictor Isthmi Faucium, -vel Palato.
    Glossus.
DEEP MUSCLES OF THE NECK.
Long du cou,
Grand droit ant6rieur de la tete,
Petit droit anterieur de la tete,
Droit lateral de la tete,
Scalene anterieur,
Scalene posterieur,
Longus Colli.
Rectus Capitis Anticus Major.
Rectus Capitis Anticus Minor.
Rectus Capitis Lateralis.
Scalenus Anticus.
Scalenus Posticus. 
MUSCLES OF THE  HUMAN  BODY.
xxxi
MUSCLES OF THE  BACK.
  Name in French Authors.
Trapeze,
Grand dorsal,
Rhomboide,
Angulaire de l'omoplate,
Petit dentele" posteneur superieur,
Petit dentele" posteYieur inferieur,
Sple"nius,
Long du dos,
Sacro-lombaire,
Long epineux,
Transversaire du cou,
Petit complexus,
Grand complexus,
Transversaires epineuses,

Interepineux du cou,
Inter-transversaires du cou,
Inter-transversaires des lombes,
Grand droit poste*rieur de la tete,
Petit droit posteVieur de la tete,
Oblique inferieur de la tete,
Oblique supeneur de la tete,
     Name in English Authors.
Trapezius.
Latissimus Dorsi.
Rhomboideus.
Levator Anguli Scapulae.
Serratus Posticus Superior.
Serratus Posticus Inferior.
Splenius.
Longissimus Dorsi.
Sacro-lumbalis.
Spinalis Dorsi.
Transversalis Colli.
Trachelo-mastoideus.
Complexus.
Semi-spinalis Colli, Semi-spinalis Dorsi,
  and  Multifidus Spina?
Interspinals Cervicis.
Intertransversales Colli.
Intertransversales Lumborum.
Rectus Capitis Posticus Major.
Rectus Capitis Posticus Minor.
Obliquus Capitis Inferior.
Obliquus Capitis Superior.
MUSCLES OF THE  THORAX.
Grand pectoral,
Petit pectoral,
Sous-clavier,
Grand dentele,
Intercostaux externes,
Intercostaux internes,
Surcostaux et souscostaux,
Petit  dentele" anterieur, ou trian-
  gulaire du sternum,
Pectoralis Major.
Pectoralis Minor.
Subclavius.
Serratus Magnus.
Intercostales Externi.
Intercostales Interni.
Levatores Costarum.

Triangularis Sterni.
MUSCLES OF THE SHOULDER.
Deltoide,
Sus-e"pineux,
Sous-epineux,
Petit rond,
Grand rond,
Sous-scapulaire,
Deltoideus.
Supra-spinatus.
Infra-spinatus.
Teres Minor.
Teres Major.
Subscapularis.
MUSCLES OF THE  ARM.
Coraco-brachial,
Biceps humeral,
Brachial anteYieur,
Triceps brachial,
Coraco-brachialis.
Biceps Flexor Cubiti.
Brachialis Internus.
Triceps Extensor Cubiti.
MUSCLES OF  THE FORE-ARM.
Rond Pronateur,
Radial anterieur ou grand palmaire,
Petit palmaire,
Pronator Radii Teres.
Flexor Carpi Radialis.
Palmaris Longus. 
xxxii
MUSCLES OF THE HUMAN BODY.
  JVame in French Authors.
Cubital anterieur,
Fiechisseur superficiel ou sublime,
Fiechisseur profond,
Long fiechisseur du pouce,
Carre" pronateur,
Long supinateur,
Premier, ou long radial externe,
Second, ou court radial externe,
Extenseur commun des doigts,
Extenseur propre du petit doigt,
Cubital posteneur,
Ancone",
Court supinateur,
Long abducteur du pouce,
Court extenseur du pouce,
Long extenseur du  pouce,
Extenseur propre de l'index,
      Name in English Authors.
Flexor Carpi Ulnaris.
Flexor Digitorum Sublimis.
Flexor Digitorum Profundus.
Flexor Longus Pollicis Manus.
Pronator Radii Quadratus.
Supinator Radii Longus.
Extensor Carpi Radialis Longior.
Extensor Carpi Radialis Brevior.
Extensor Digitorum Communis.
Extensor Proprius Minimi Digiti.
Extensor Carpi Ulnaris.
Anconeus.
Supinator Radii Brevis.
Extensor ossis Metacarpi Pollicis.
Extensor Primi Internodii Pollicis.
Extensor Secundi Internodii Pollicis.
Extensor Proprius Indicis, vel Indicator
MUSCLES OF THE HAND.
Court abducteur du pouce, ou scaphoido-
  phalangien,
Opposant du pouce, ou trape"zo-m6ta-
  carpien,
Court fle"chisseur du pouce, ou trape"zo-
  phalangien,
Adducteur du pouce, ou me"tacarpo-pha-
  langien,
Palmaire Cutane, ou peaucier de la main,
Opposant du petit  doigt, ou unci-me"ta-
  carpien,
Court flechisseur du petit doigt, ou pisi-
  phalangien,
Adducteur du petit doigt, ou pisi-pha-
  langien,
Lombricaux,
Interosseux dorsaux,
Interosseux palmaires,
Abductor Pollicis Manus.

Opponens Pollicis.

Flexor Brevis Pollicis.

Adductor Pollicis.
Palmaris Brevis.
Abductor Minimi Digiti, vel Opponena
  Minimi Digiti.
Flexor Brevis Minimi Digiti.

Adductor Minimi Digiti
Lumbricales.
Dorsal Interossei.
Palmar Interossei.
MUSCLES OF THE ABDOMEN.
Grand oblique, ou oblique externe
  l'abdomen,
Petit oblique, ou oblique interne de I
  domen,
Cremastre,
Transverse de  l'abdomen,
Grand droit de l'abdomen,
Pyramidal,
Diaphragme,
Carre des lombes,
Grand Psoas,
Petit Psoas,
Iliaque,
> Obliquus Abdominis Externus.
'ab-
i Obliquus Abdominis Internus.
 Cremaster.
 Transversalis Abdominis.
 Rectus Abdominis.
 Pyramidalis.
 Diaphragma.
 Quadratus Lumborum.
 Psoas Magnus.
 Psoas Parvus.
 Iliacus Internus.
MUSCLES OF THE PERINEUM.
Sphincter,
Transverse du perinee,
Ischio-coccygien,
Releveur de l'anus,
Sphincter Ani.
Transversus Perinei
Coccygeus.
Levator Ani. 
MUSCLES OF THE HUMAN  BODY.
xxxiii
Name in French Authors.           Name in English Authors,

               PECULIAR TO MAN.
Ischio-caverneux,
Bulbo-caverneux,
Pubio-urethral,
Ischio-bulbaire,
Erector Penis.
Accelerator Urinae.
Sling Muscle of Wilson.
Transversus Perinei.
              PECULIAR TO WOMAN.
Ischio-caverneux,           Erector Clitoridis.
Constricteur du vagin,       Constrictor Vaginae.


      MUSCLES OF THE  HAUNCH.
Grand fessier,
Moyen fessier,
Petit fessier,
Pyramidal,
Jumeau superieur,
Obturateur interne,
Jumeau inferieur,
Obturateur externe,
Carre de la cuisse,
Glutseus Maximus.
Glutaeus Medius.
Glutseus Minimus.
Pyriformis.
Gemellus Superior.
Obturator Internus.
Gemellus Inferior.
Obturator Externus.
Quadratus Femoris.
MUSCLES OF THE FORE AND LATERAL PARTS  OF THE THIGH.
Muscle du fascia lata,
Couturier,
Droit anterieur,
Vaste externe,
Vaste interne,
Crurale,
Droit interne,
Pectine,
Deuxieme adducteur superficiel,
Petit adducteur profond,
Grand adducteur profond,
Tensor Vaginas Femoris.
Sartorius.
Rectus Femoris.
Vastus Externus.
Vastus Internus.
Cruralis.
Gracilis.
Pectineus.
Adductor Longus.
Adductor Brevis.
Adductor Magnus.
MUSCLES OF THE POSTERIOR PART OF THE THIGH.
Biceps femoral,
Demi-tendineux,
Demi-membraneux,
Biceps Flexor Cruris.
Semitendinosus.
Semimembranosus.
MUSCLES OF THE LEG AND DORSUM  OF THE FOOT.
Jambier, ou tibial anterieur,
Long extenseur commun des orteils,
Extenseur propre du gros orteil,
Peronier anterieur,
Pedieux,
Long peronier lateral,
Court peronier lateral,
Jumeau externe,
Jumeau interne,
Sole aire,
Plantaire Grele,
Poplite,
Jambier ou tibial posterieur,
Long fiechisseur commun des orteils,
Long fiechisseur du gros orteil,
                                 E
Tibialis Anticus.
Extensor Longus Digitorum Pedis.
Extensor Proprius Pollicis Pedis.
Peroneus Tertius.
Extensor Brevis Digitorum Pedis.
Peroneus Longus.
Peroneus Brevis.
Gastrocnemius Externus.
Gastrocnemius Internus.
Soleus.
Plantaris.
Popliteus.
Tibialis Posticus.
Flexor Longus Digitorum Pedi3.
Flexor Longus P< ilicis Pedis. 
xxxiv
MUSCLES OF THE  HUMAN  BODY.
MUSCLES OF THE  SOLE OF THE  FOOT.
       Name in French Authors.
Abducteur oblique du gros orteil,
Court fiechisseur commun des orteils,
Abducteur du petit orteil,
Accessoire du long fiechisseur commun
  des orteils,
Lombricaux,
Abducteur transverse  du gros orteil,
Court fiechisseur du gros orteil,
Court adducteur du gros orteil,
Court fiechisseur du petit orteil,
Interosseux plantaires,
Interosseux dorsales,
      Name in English Authors.
Abductor Pollicis Pedis.
Flexor Brevis Digitorum Pedis.
Abductor Minimi Digiti Pedis.
Musculus Accessorius, vel  Massa Car
  nea Jacobi Sylvii.
Lumbricales.
Transversus Pedis.
Flexor Brevis Pollicis Pedis.
Adductor Pollicis Pedis.
Flexor Brevis Minimi Digiti.
Plantar Interosset
Dorsal Interossei. 
             NEW  ELEMENTS

                         or


OPERATIVE    SURGERY.
              DEFINITION  AND DIVISION.

   In medical science the word operation may be defined a mechani-
 cal action, directed by the hand, and designed as a remedy upon
 one who is infirm or sick.  It embraces thus the same idea as that
 of surgery; but usage has resulted in giving to it a value, if not
 different,  at least very much  restricted.  To-day, surgery means in
 fact surgical pathology, and all diseases are included in  its domain
 in which  a topical application  forms the leading feature of the
 treatment, whilst operative surgery (la medecine operatoire) is  con-
 fined to the study of the  therapeutic  means  which require the in-
 tervention of the hand, whether by itself or armed with instruments.
 One is a true science, which is scarcely distinguished from medical
 pathology, properly so called ; the other approximates more to the
 arts.  The first cannot be cultivated with advantage but by those
 who are endowed with a great aptitude  for labors  of  the mind;
 the hand, on the contrary, is the instrument, and the indispensable
 and characteristic agent of the second. As for the  rest, it is im-
 possible to establish between them an exactly defined limit.  Thus
 also do we see them constantly   trenching upon one  another  in
 the works that have been devoted to each.
  If it is permitted to operative surgery to include within its  pro-
 vince the  rules relative to the employment of cataplasms, plasters,
 ointments, leeches, cupping, acupuncture, blisters, moxas, cauteriza-
tion, the seton, and  bleeding, we  cannot see by what title the re-
duction of fractures and of luxations, and  the  study of bandages
 and dressing, should be excluded from it.
  Catheterism in general, the extraction of a foreign body, whether
in the ear or between the eyelids, and the section of the fraenum
 of the tongue, require neither more address nor knowledge than ve-
 nesection or the opening of an abscess.  The manner then of cir-
 cumscribing the field of operative  surgery is an affair purely  con-
 ventional, which every one has a right to interpret according to his
 own mind or particular views.  For myself, I shall treat of opera-
 tive surgery under four principal heads: the first section will be
   vol.  i.                       1 
2             NEW ELEMENTS OF OPERATIVE SURGERY.

devoted to operations in general; the second  will include  every
thing relating to minor surgery;  in the third I shall occupy myself
with the ordinary operations;  and special operations  will be de-
tailed in the fourth.
                     ORDER FIRST.

                OPERATIONS  IN GENERAL.

  There are an infinity of rules which are not peculiar to any opera-
tion in particular, from  the fact that  they are applicable to all.
The examination of the classifications, methods, indications, and
counter-indications, and of what it is necessary to do before, during,
and after an operation, all justify this assertion.
                         CHAPTER I.

                     CLASSIFICATION.

  There has always been felt an urgent necessity of distributing
operations into a certain number of divisions.  The ancient division,
mentioned by Celsus, which would refer them all to dieresis or synthe-
sis, to exeresis or prothesis, and which reigned for so many ages in all
the schools of Europe, cannot now be retained.  In the eight classes
substituted for them by Ferrein, he is still more unfortunate.   The
union, the separation of tissues  accidentally united, the dilatations
and the re-establishment of natural passages, the closure or oblitera-
tion of channels that have become useless, the extraction of certain
liquids, the removal and the extraction of foreign bodies, the reduc-
tions, of which he makes so many different kinds, form, in fact, the
most unnatural distribution that could be imagined.  Diarthrosis,
or the process of remedying deformities, added, at the time of Dionis,
to the four  primitive  orders ; dilatation and compression, to which
M. Roux accords  a separate place ; while prothesis, rejected also by
Ferrein, does not appear to be worthy of any, would answer but
very imperfectly to complete the arrangement.  The exploration of
the bladder, of 'the  Eustachian tube, and the lachrymal passages,
the injection of those different parts, and the pure and simple torsion,
for example, of the vessels, would have no rank, though  in  them-
selves they  may frequently constitute important operations.
   The  efforts of Lassus and of Rossi, to avoid  the difficulties
pointed out by the preceding authors, have had  no success; and the
plan at last adopted by Sabatier has so many disadvantages,  and is 
CLASSIFICATION.                        3
so inconvenient, that hereafter no one will ever think of reviving it.
In fact, with what incongruity it strikes us, when, for the eye, for
example, we see fistula of the cornea, hypopeon, hydrophthalmy, sta-
phyloma,  scinhus, procidentia iridis, foreign bodies, cataract,  and
artificial pupil, scattered about  in  the midst of three volumes, and
into so many distinct classes.    It results from this, that it is next
to impossible to know in what part of the  work to search for the
article we wish, unless we run over beforehand an interminable
index.  For example, to open the anterior chamber of the eye, we
should be obliged  to consult in turn the second, third, and fourth vol-
umes, according as it may relate to the extraction of pus, a foreign
body, or the crystalline lens.   In this point of view the essay of Del-
pech is  still more unfortunate.  Nor, in fine, is the method  devel-
oped by M. Richerand, though  one of the most advantageous for
study, and conceived in an intellectual spirit, totally free from the
objections  which  may so justly be made against  that of Sabatier.
From whence it results, that the topographic arrangement that had
already been  proposed by J.  Fabricius, and  from which Boyer did
not think proper to deviate, notwithstanding  the criticisms, more or
less just, that were made upon it at different  epochs, is still the best,
and the  only one,  perhaps, which can, up to the present time, be of
any help to the reader in a treatise on operative surgery.
   It is the only system which embraces the general ideas in use by
all the world.   By its aid there is no one who  may not know immedi-
ately where to  find trephining, cataract, empyema, lithotomy, &c.;
whilst in imitating Sabatier  or Delpech, we should have to  ask
whether such operations belong rather to  wounds  and foreign bo-
dies, or to  fractures and effusions, &c, and  afterwards to find in
what order of those different  chapters they are to be classed in re-
gard to one another.  The nature and the causes of disease are too
little known, or too changeable, to serve as the foundation for the
classification of operations.  In  proceeding exclusively by the ar-
rangements of functions, or by the  organic system, we take our de-
parture,  it  is true, from fixed points, but we are. obliged to associate
together subjects the most dissimilar, (salivary fistulas,  abdominal
hernias, polypi of  the rectum, &c.,)  or to separate others, (foreign
bodies in the trachea and the oesophagus, tracheotomy, oesophagoto-
my, &c.,) which have the greatest analogy to each other.
  We may here glance at the operations under two general points
of view: first, as independent subjects, and class them according to
their greater or less analogy or difference ;  secondly, as therapeutic
resources, and submit them to the same divisions as the affections
they belong to.  In practice, the first of these methods is not  appli-
cable but to the very smallest number of operations ; for example,
to trephining, amputation, ligature of arteries, and suture.   The
incisions, extractions, and special operations cannot in truth be ad-
justed with it.   The second would be yet more difficult to general-
ize ;  for if  cataract, fistula lachrymalis, hare-lip, &c., may serve a&
heads of chapters  in a work of operative surgery, it is not so with
complicated fractures, caries of. the joints, gangrene, and wounds 
4             NEW ELEMENTS OF OPERATIVE SURGERY.

from fire-arms.  Perceiving, by the difficulties  against  which all
others have vainly struggled up to the present time, that it would
be impossible for me to create a  classification  well systematized
and regulated, I have believed it to be my duty  to decide in favor
of the plan the least fatiguing for the pupil.  This plan approaches
more an anatomical arrangement than any  other.  It  is the only
one, with some few modifications, that is allowed to be followed in
the amphitheatres, and is the one of which  M. Dubois (Traite des
Etudes Med., Paris, 1837, p. 600) has endeavored to point  out the
advantages.  Founded upon the same principle as that of my treat-
ise on surgical anatomy, it permits me to place in the first class all
the general operations, and to reserve for the second all the special
operations.  It has afterwards appeared to me, that for the special
operations, the best plan was to run over the whole trunk, from the
head to  the pelvis, taking sometimes the operation itself, sometimes
the diseases, and sometimes the organ, or the parts which belong to
it, for my guide and chapter.   Having had  no  other  intention in
adopting this method than to render  a knowledge  of the  subjects
more easy, and to aid as much as possible the memory of the reader,
I attach no further importance to it, and consign it without a mur-
mur to the criticism of those who are capable of judging of it.
                       CHAPTER II.

                   NATURE OF OPERATIONS.

Article 1.—Systematized Operations, and such as are without  any
           rules—(Operations Reglees et non Reglees.)

  Among operations, there are those  of which all the  steps are
known in advance, and others in which no rule can enable us to
foresee the difficulties.
  The first, generally  designated under the title  of Operations
Reglees, are fortunately numerous and important.   It is to these
that we  assign amputations, the operation of aneurism by the
method of Anel, cataract, hare-lip, lithotomy, &c. The second com-
prehend tumors, whether cancerous or of other descriptions, which
develop themselves upon the cranium, face, neck, axilla, and in the
abdomen, and which we are obliged to extirpate. There exists
a third class of operations which hold in some sort the middle place
between the two preceding ; such are those which have reference
to cancers of the breast, sarcocele, fistula in ano, hernias, and even
exsections and the operation for aneurism by the ancient method.
We know effectively what are the coverings to divide in  an opera-
tion of strangulated bubonocele, but we are more frequently igno-
rant of what is the  true pathological condition of the parts to be 
NATURE OF OPERATIONS.                    5
reduced. Thus operations are arranged naturally into three series:
1. In the one, the instrument acts on parts altogether sound, or
scarcely disturbed by the disease ;  2. In the second it bears upon
points whose principal anatomical relations have been changed, or
its object is the eradication of a tumor, whose limits, if not its very
nature and seat also, it is at first  almost  impossible to determine;
3. In the third, in fine, we apply it  to  diseases  whose limits it is
easy to establish, and which are surrounded by organs well known,
but  which are too numerous in variety to  permit the rules for ope-
rating in one case to be exactly proper for the others.

            Article II.—Operations on the Dead Body.

  The convenience of the division, essentially practical, of which I
have just spoken, is especially confirmed by the processes  that are
performed on the dead body.   There it is possible, in fact, to imi-
tate the removal of limbs, the ligatures of arteries, in a word,  all
.the operations  which  apply to the organs in their normal state, that
is, all the systematized operations.  Nothing like this can be had
for sarcomas of the face, and of the maxillary sinus, for amputation
of the upper jaw, of the parotid, of the thyroid, for a cyst of the
ovary or the interior of the  abdomen, and, in fact, for all the ex-
temporaneous operations.
  There is no pupil who does not know that the ideas that we get
in the amphitheatre  of  ligatures upon polypi, of excision of the
neck of  the uterus, and of the operation for fistulas in perineo  or
in ano, and especially for hernias, are extremely imperfect, and but
feeble aids when we come to operate upon the living patient. We
should therefore be grossly deceived if we believed ourselves per-
fectly instructed in all operations, because we had repeated them
a great number of times on subjects for dissection.   No one, how-
ever, can be a skilful surgeon without having been for a long time
thoroughly versed in those exercises.   They give precision, confi-
dence, address, and a manual adroitness that the most minute ana-
tomical knowledge can never supply.   But this is not all, even  for
the  operations of the first kind.   While the eye is more flabby,
more soft, and less transparent on the dead body, nothing there
gives us that idea of mobility, that tendency of the vitreous humor
to escape, and  of the eyelids to contract, and of the tears incessant-
ly to flow, which are seen in life.   When we  amputate a limb, the
tissues, being more firm  and better extended, are, it is true, more
easy to cut than after death ; but in this last case we have no mus-
cular retraction, no blood which incommodes or disquiets us, and no
explorations to make, to know  if certain hemorrhages  proceed
rather from veins than arteries.  However superficial an artery
may be, we cannot  lay it bare  without dividing  some vascular
branches, whose contents sufficiently mask the parts to render the
power of distinguishing them more  or less embarrassing ; while in
the  dead body  nothing analogous  to this is met with.  The pulsa-
tion of the vessels, which, at the first glance, would seem to be a com- 
6
new elements of operative surgery.
pensation, is. however, so  little manifest, and so indistinct  at the
bottom of wounds, that we cannot in reality derive but a very fee-
ble advantage  from it.  In tracheotomy and oesophagotomy, is it
possible to represent even the smallest number  of the embarrass-
ments which arise from the venous plexuses, anastomoses, and the
numerous arteries of the neck ?  In passing to the other two classes,
we must note also the difficulties that are  inherent in them from
these general differences.   We do not operate for fistula lachry-
malis, unless the angle of  the eye is glued together, ulcerated, or
more or less altered.   It is the same, most usually, with the nasal
fossae when we wish to extract polypi from them. The movements of
the throat, the desire to vomit, the mucus or the blood, and the state
of agony into which the patient falls at every  moment while we
are operating for a hypertrophy of the tonsils, or a bifurcation of
the velum of the palate, are not found on the dead body.   The
states of caries and necrosis which render the exsection of a joint
indispensable, constantly and profoundly alter the surrounding soft
parts.  From whence  it follows, that there is no possible compari-.
son between what we are then forced to do, and the trials that we
make on the dead body. In those different cases we know,  never-
theless, what is the number and the situation of the coverings and
of the organs that we  are to divide, or where the part is that we
wish to take away or perforate ;  but let me suppose that a morbid
mass, of a certain volume, develops itself  in  the perineum, of
what use to the surgeon will be his exercises on  the cadaver ?  But
what I say of the perineum, is applicable to the groin, to the  axilla,
the neck, the abdomen, and  all other points of the body.  Though
this kind of exercise, therefore, is  not to be neglected, we must
guard ourselves from according to it too much importance.
   The  experiments on living animals, which, under this point of
view, are of infinitely  greater value, have not, nevertheless,  all its
advantages.  First, the "forms being rarely similar, we obtain, in
general, but fallacious results, if we  would make rigorous deduc-
tions from one to the other.  Moreover, it is necessary to study an
operation with the mind at  rest, and with all necessary care, and
to practise it on the dead  body, and not  on a being  endued with
life ; so that there are two kinds of means that come to the  aid of
each other, without our having it in our power to substitute the one
for the other. .
   Operative Surgery, then, is definitively founded—1. On anatomy ;
2. On operations on the dead body ; 3. On living dissections ; 4. On
pathological anatomy; 5.  On the constant practice of operating on
the living subject.


                     Article III.—Methods.

   As there are but few operations that cannot be performed in dif-
 ferent ways, we must seek out in season for a proper word to ex
 press the ensemble of the steps of which each one of them is com
 posed.   The terms methods,processes, and modes, have been applied 
                the care required in operations.              7

to this use.  These three words, which are nearly synonymous,
have for a long time been employed  almost indiscriminately, and
they are so still on a great many occasions.  It has, however, been
attempted, following the example of  M. RouX, to give to each of
them a' distinct value, and a special signification. The term method,
for example, has a much more extensive signification than the two
others.  It is thus that we say method, and not process, or mode,
when we  speak of extraction or depression of cataract;  whilst in
the operation for stone, with the concealed lithotome, (lithotome
cache,) we make use of the word process, and not that of method,
to point out the modification of the operation by Boyer.  The liga-
ture upon polypi is a method.  The ligature, after the ideas of such
or such an author, is only a process.   In short, we generally under-
stand by method something fundamental, sufficiently  broad  to be
divided and modified in many ways;  while  the word process is
more restricted, and is scarcely used  but in designating  a diminu-
tive of some method.  The operations of aneurism,  amputation,
hydrocele, and  lithotomy, are all excellent examples  to  point out
the justness of these  distinctions.   To place a ligature on the
artery without touching the tumor, is called a method  ; to place it
higher or lower, takes the name  of a process.  To open the sac  is
a method; the manner of opening or that of placing the ligature is
a process.  To sum  up the  whole,  method  embraces the entire
thing, while process is applied to each one of its modes of applica-
tion.   It is far from happening, however, that, in ordinary language,
we do not constantly deviate from these conventions purely arbitrary,
or that we do not often use, even in works that are the most carefully
written, the words process and mode of operation, in place of the
word method, and vice versa.  Fistula lachrymalis, among other
things, proves  this sufficiently.  In  fact,  we almost  indifferently
say the method and process of Dupuytren, Desault, and  Boyer.  Hy-
drocele, hernia, and lithotomy, are  subject to  the  same remark.
The process and the method of cauterization and of injection ; the
method and the process of dilatation, and  dividing strictures ; and
the process and the method of Frere  Come, are in daily use.  This,
at  best, is a question entirely of a secondary  character, and  of no
moment.  It is permitted to every one, in such a discussion, to ad-
here to such usages if he pleases, or to reject them, and  place no
value upon them.
                       CHAPTER III.

             THE CARE REQUIRED IN OPERATIONS.

                    Article I.—Indications.

  The first object which  should  engage the solicitude of the sur-
geon, before jjerforming an operation, is to ascertain the indications. 
9
NEW ELEMENTS OF OPERATIVE SURGERY.
It is on such occasions that the most extended and precise medical
knowledge becomes a matter of indispensable necessity.  After hay-
ing established that the cure is more difficult or even impossible in
any other manner, it is then necessary that he should recognise the
utility of it; that he should acquire the conviction that the patient
incurs less of danger  in submitting to it than in remaining under
the action of the disease that has rendered the operation necessary.
It is not that we are permitted to perform  operations only, as Du-
puytren (Sabatier, Med. Opir., Paris, 1824, t. i., p.  13-16) lays it
d0Wn—1.  When these are the only means indicated; 2. When we
have vainly essayed all other  means ; 3. When they form the last
resource;  4.  When we are sure of  being enabled to complete
them; and, 5. When there is to result from it an entire and perma-
nent cure ; but, likewise, when compared  with other therapeutic
resources, and with the inconveniences of the disease, they present
both more advantages and  fewer dangers.   1. We operate, and
with propriety, upon a  great number of tumors which it would not be
possible for us to cure, but with difficulty, by the aid of caustics or
certain ointments; 2.  It is useless to try all the  other remedies be-
fore operating for fistula lachrymalis, hydrocele, cancers, &c.; 3. In
phymosis,  cataract, hare-lip, and  abscesses, the  operation ought to
be the first rather than the last resort; 4.  We proceed to the ex-
amination of a strangulated hernia, of a foreign body, and of a
wounded artery, without being sure of succeeding or of completing
the operation ;  5. The puncture of the abdomen, of the bladder, and,
the thorax, and  the extraction of polypi from the nose, are practised
every day, without being followed in  general by any other result
than a temporary relief.                         •
  A diagnosis, therefore, elucidated  by a thorough knowledge of
pathological anatomy, a prognosis founded upon what the most
sound judgment can ascertain  of the progress or probable issue of
the derangements of the organism, and as exact an appreciation as
possible of the  power or of the value of the ordinary therapeutic
agents, will alone enable the surgeon to resolve this first problem,
which, in  one of its aspects, does not seem to me to have hitherto
been considered in a proper point of view.
  I shall now speak in relation to the choice that is to be made
between  the  operation properly so called, and the other medica-
ments that might be substituted for it.  Thus, because the lachry-
mal tumor, hitherto  considered of a nature which  confined  it
within the limits of operative surgery, yields sometimes to regimen
and the antiphlogistic method, and because certain  tumors  of the
breast are discussed by means of compression, we should be alto-
gether wrong, in  my opinion, to conclude from this,  as some have
lately done, that the application of this treatment ought always to
precede and be made  trial of, with the view of dispensing with the
aid of the cutting instrument.  In fact, the question is not to know
if cancer  or any tumor whatever may be made to disappear under
the action of such or such a medicament, or by the intervention of
a serious operation; but to know which of the two offers in **"*ldrit 
THE CARE REQUIRED IN  OPERATIONS.
9
resort the most advantages to the animal  economy.  I agree  that
the application of leeches, frequently repeated, and that emollient
cataplasms and abstinence cure a certain number of tumors, and
even lachrymal fistulas;  but should we therefore infer that this
treatment, the  success of wjiich is far from being constant, and
which may be prolonged many months, deserves to be substituted
in the place of a metallic tube in the nasal canal, if it is true  that
this application, which is made in a second of time, would cure in
two days a disease of ten years' standing, and succeed  in  a great
majority of  cases ?   Allow that leeches and diet may sometimes
prevail over masses that have the appearance of sunhus or cancer,
I do not deny it; but if these  tumors were moveable and favora-
bly placed, who would venture to maintain that the bistoury would
not remove them still more effectually,  certainly with more rapidi-
ty, at the same time  producing a less severe shock  upon  the sys-
tem, and causing in reality a much less amount of suffering ?  But
what I say of  lachrymal fistula and of cancer is applicable to a
crowd of other maladies, and  is the  basis of an  observation that
the surgeon should never lose sight of.   If it is cruel to subject to
the operation of the  actual cautery those whom we might  treat  by
more gentle means, it would be still  less conformable to the inter-
ests of humanity to compromise the future health of the patient,
under the vain pretext of exempting him from a little suffering.
The slightest puncture, it is  true, opens a gate to death;  but this
axiom, which  is applicable to the bite  of leeches, to bleeding, cup-
ping, blisters, cauteries, setons, moxas,  and the capital operations,
does not  and ought not to prevent us from resorting to abstraction
of blood, to revulsives, or to drains ;  and there is no internal medi-
cation, if it possess some activity, to which we may not apply the
same remark.

                Article II.—Various Precautions.

                  § I.—Hygienic Precautions.

   The choice of the  season is certainly not a matter of indifference
for the performance of operations.  Other things being equal, if the
spring and autumn suit better than the winter or  midsummer, it is
not only  because their temperature is more mild,  but  also because
the system is then in a better condition to  resist general morbid  re-
actions.   So also we should not perform, except in temperate sea-
sons, lithotomy, the removal of large tumors, or  any  other opera-
tions which produce a severe shock upon the system.
   But we must not accord too much importance to this precaution,
since we know that  there is no season  capable of rendering impos-
sible the success of an operation, whatever it may be, and that the
question of time cannot be any other than a mere matter of greater
or less convenience.   At the hospital where I operate for cataract,
stone in  the bladder, fistula lachrymalis, tumors of the breast, both
in winter and summer, I have not  observed that  success or failure
depended upon one season more than another.  No doubt the ap-
   vol. i.                        2 
10
NEW ELEMENTS OF OPERATIVE SURGERY.
 pearance of an epidemic is a substantial reason for greater caution,
 and that we must at the same time look to the morbific constitu-
 tions that exist at the moment.  We cannot, however, apply  this
 rule but to operations  where  urgency may be questionable.  A
 strangulated hernia, a  wound of an artery  or  of the  intestines,
 croup, or foreign bodies in the oesophagus,  would not admit of
 delay.
  Pelletan and Dupuytren were in  the habit of keeping  patients
 in the hospital some time before operating upon them, in order, they
 said, to acclimate them.  MM. Viricel and Champion do not con-
 form to this rule, unless it has been impossible for them to operate
 immediately.  On this subject I find it  difficult to lay down rules.
 We  cannot deny that  the  atmosphere, regimen, exercise,  and the
 concomitant circumstances, constitute an entirely new life to most
 persons who, for the first time, enter a hospital, and  that to most
 people from the country especially, this sudden transition  may be
 a formidable cause of disease.
  A man having an artificial anus comes from a remote province,
 and wishes to be operated upon immediately.   I object.  The third
 day he is seized with a gangrenous erysipelas, and on the fifth day
 dies.  The operation for a fistula lachrymalis, which I was asked tc
 perform on a mason from the country, was  deferred for some days
 A peritonitis  supervened,  and  proved fatal  in  forty-eight  hours
 Another countryman wished me immediately to extirpate  a can-
 cerous eye, in order that he might quickly return to his labors.  He
was seized with an erysipelas, which proved fatal to him in a  few
 days.  The  day was fixed for taking away a polypus from the
uterus in a peasant girl, who was in other respects in good health.
 All  the symptoms of a violent  peritonitis showed  themselves the
 same morning, and death took  place on the third day.  An opera-
tion  would  not  have prevented these patients  from dying:  and
who does not see that if, yielding to their entreaties, I had per-
formed it, it would have been made to assume the responsibility of
all these fatal results !
  What I have said of hospitals I might also wply to private houses,
 when speaking of patients who are strangers to  the city, and who
 visit it for the sole purpose of being operated upon.
  It is certain, on the other hand, that in operating immediately, we
 relieve the patient of one cause of ennui, of anguish, and of moral
 suffering, which also are sources of  danger.  On this subject there
 is nothing absolute.   For trifling operations, or for those of a mode-
 rate degree of severity, for cataract, fistula lachrymalis, hare-lip, sta-
 phyloraphy, and excision of the tonsils, for example, and for those ope-
 rations intended to relieve acute pains in some severe maladies, de-
 lay, as it appears to me, would be improper. For the great operations,
 the extirpation of tumors of considerable size, lithotomy, and opera-
 tions for aneurism, if life is not actually compromised, it is on the con-
 trary prudent, as I conceive, to wait some days, and not to be in a
 hurry.
  The  age also is  a condition which must be taken into account. 
THE CARE REQUIRED IN OPERATIONS.
II
With infants we need not be in haste to operate for lachrymal tu-
mors, small erectile tumors, hydrocele, the removal  of enlarged
tonsils, &c, because the growth of the individual often  causes these
diseases to disappear.  We desist often from the operation for hy-
drocele, cataract, artificial pupil, and a great number of other ope-
rations in old people, because at that period they offer less chances
of success, and that in the decline of life, even under the most fa-
vorable circumstances, they lose a great many of their advantages.
I shall, however, be obliged to recur to many of these  questions
when speaking of particular operations.
  In selecting the morning rather than the  afternoon, the operator
has the advantage of finding his patient less fatigued, and himself
better enabled to watch with care the wants of the patient imme-
diately after the operation.' In other respects, there is nothing im-
perative in this matter; and the  most plausible argument for this
preference is, that in general the forenoon  is most convenient for
every body.   As to urgent operations, we perform them as soon as
we can, without taking  into consideration  the season or hour of
the day ;  on which account authors have been induced to establish
two periods, a time of election and a time of necessity.

                   §  II.—Moral Precautions.

  Moral precautions, so far as operations are concerned, vary, and
must vary, according to the individuals.  The first rule is to inspire
an unlimited confidence in the patient;  and we all know that con-
fidence is acquired in a thousand different ways.  The second is, to
convince the patient that the operation is the  best possible means
of arresting the progress  of his sufferings, and we should take care
to undeceive him if he exaggerates the dangers of it.  In short, we
must do every thing, without exceeding the limits of truth, to induce
the person to be operated upon, not  only to desire, but to demand
the operation, and to look forward to the moment of its performance,
if not with pleasure, at least with resignation.   In this respect we
have two sorts of people to deal with.  Some, of  extreme pusilla-
nimity, are so alarmed at the idea of the slightest cut of the bistoury,
that we are compelled to deceive them upon the duration and the
acuteness of the pains they must undergo, as well as the dangers
they are about to be exposed to. Others, and who are  rarely met
with except in public establishments,  imagining that they must be
operated upon whether or  no, and even without any  notice being
given to them, nevqf speak to  the surgeon but with an air of in-
quietude, and remain in a continual state of apprehension until we
disabuse them of their error.   Upon this subject it has been asked.
if it was well to announce to the patient the day and hour of the
operation.   To this we may reply yes and no.  As a general rule,
operations with the day and hour fixed, as was formerly the practice
in public establishments, and which Pouteau compares to a species
of auto-da-fe, are  bad.  I have also taken care completely to eradi-
cate this practice from La Charite, where there were still some 
12            NEW ELEMENTS OF OPERATIVE SURGERY.

traces of it when I first entered upon my duties in this hospital.
But we are not to infer from this that we ought to conceal from
every patient what we are going to do to him up to the last mo-
ment.  If there are some that we ought to prepare without their
knowledge, and take them, so to speak, unawares, there are a great
number of others who should  be gradually familiarized with the
idea of the operation, and  be  not  only made to understand and
reason  upon the details of it, but informed beforehand of the time
fixed upon.
  Practice shows us, moreover, two other kinds of persons whom it
is necessary to look to in a moral point of view.   Among these we
may arrange such as, having no fear of the dangers  that they run,
and making a boast of their courage, submit themselves with per-
fect indifference to the knife of the  operator, and  take pride in re-
ceiving the cuts of the knife without making any complaint.
  The  second class of whom I would speak, comprises persons that
are naturally timid  or very  susceptible, but who, after  having
hesitated a long time, become convinced that an operation  is abso-
lutely necessary, and then concentrate all their courage with such
force that they refrain from uttering a single cry, suppress even a
reasonable manifestation of suffering, and stifle the  slightest mur-
mur of complaint.
  The  fear of Pope  Innocent  was so  great,  says  St. Augustine,
(Cite de Dieu,) when they announced to him that it was necessary
for him to be operated upon a  second time for fistula in ano, that
the physicians, the day after, found only a firm and solid  cicatrix
in the  place  of the sinuses and of  the small openings which were
seen the evening before.  A hemorrhage which yielded to nothing,
was suddenly arrested when F. Collot had told the patient that he
was in danger, and that it was necessary for him to put his affairs
in order.  (Operat. de la  Taille, p. 141.)   M. A. Petit, on the con-
trary, has often  caused hemorrhages to be arrested by dispelling
fears with which the patients were overwhelmed.  (Med. du Cceur.)
An artificial stoicism  is no more favorable to the success  of oper-
ations  than an extreme pusillanimity, as is familiarly known to all
well-informed surgeons.
   It is  consequently sometimes as useful  to calm and repress the
extravagant courage of some patients, as it is to quiet the fear and
timidity of others. To the  former  it  is necessary to point  out the
grave  nature of what they are disposed to treat  so lightly, and to
show them the necessity of not making up their minds with so little
reflection.  To the others we must explain th^t  assumed  bravery
can never take the place of true courage ; that it is as dangerous
to suppress their sufferings as it is improper to  exaggerate them,
or to utter them when there is no reason for doing so;  that in acting
thus they do violence to nature, whose intention is, that the distress
of each  suffering organ should be expressed freely and  without
constraint.  Nothing, moreover, is a more unfavorable augury than
these forced exhibitions of courage, and these affected displays of
calmness or of resignation. It seems that the vital power is ex- 
THE CARE REQUIRED IN OPERATIONS.
13
hausted in thus retracting upon itself, and that it is afterwards in-
capable of resisting the onset which has been made upon it.  The
fact is, that operations performed under such circumstances have
generally a less  favorable issue  than others, and are of a  nature
not to be relied upon.
  Ought we to operate upon a patient against his will ? is a ques-
tion that I have often heard asked.  For myself, I answer, no, if the
person is an adult and of sound mind; but, yes, on the contrary, if
we have to deal with a child or  an idiot.   Though all the family
should desire  it, the surgeon would, in my opinion, be culpable in
operating by  force upon a  patient who enjoyed his civil  rights.
Our duty is to explain to patients what  is most  suitable  for their
complaints, and to enlighten them upon the dangers to which they
are exposed in not submitting to the proper remedies;  but they, and
they alone, have the right  to do or not  to do what we  advise.
Children and   idiots  are exceptions, because, not  having their
will free, and  dreading only the pain, they do not know how to pro-
tect themselves from the dangers of the future; but  we must not
in such cases attempt any thing without the consent of relatives.
  We are, however, sometimes permitted  to operate  upon  certain
patients, not absolutely in spite  of themselves,  but without their
knowledge, and by surprise.  Prompt and easy operations of little
importance are of this kind, especially with pusillanimous and very
timid persons; such are simple incisions, the opening of abscesses,
the excision of small pedunculated warts, the removal of a nail
which is partly detached, some operations  for hydrocele, &c.
  If an operation  can be performed in  many  different ways, I
would advise the surgeon to apprize the patient or his family of it.
We operate thus for cataract by extraction or depression;  we re-
move a stone from the  bladder by lithotomy or lithontrity; we
amputate the  leg near the ankle or near the knee.   It is possible
that the patient may have a preference for one of these methods to
the exclusion of the rest.  If his  choice is not the best, his physi-
cian will endeavor to convince him of his error; but if, after  having
used every means of persuasion, he finds him  resolute, he may, if
there is no serious objection, accede to his  wishes.

                 § III.—The State of the System.

  Not  to operate unless we are  sure of removing all the disease,
and that there does not exist in the system an affection more serious
than that for which the operation is performed, is a law which has
a great number of exceptions.
  I have proved by a great number of examples, that  even in cases
where it is  impossible to take them  entirely away, the extirpation
of  lymphatic tumors should nevertheless be  attempted.  The
amputation  of a limb is sometimes indicated, though  there may be
other parts of the osseous system or other articulations affected, as,
for example,  in  scrofulous patients.  A  consumptive patient, a
paralytic, a  patient affected with aneurism of the heart, or a can 
14
NEW ELEMENTS OF OPERATIVE SURGERY.
cerous lesion, ought, notwithstanding, to undergo amputation imme-
diately in the event of a serious injury to the limb.  These diseases
also should not prevent us from performing the operation for stran-
gulated hernia, aneurism, or tracheotomy.  It is nevertheless true,
that we ought then to apprize the family or the friends of the pa-
tient of the object we have in view in undertaking the operation,
and that in such patients we ought not to take the bistoury in  hand
except in cases of urgent necessity.  In fine, it  is better to  wait for
death than to run before him.
  The operation often is the only remedy we have ; but the patient
is in so serious a state, and the malady so far advanced, that there
is scarcely any thing to be hoped for from it.  Then what  must be
done ?   If we do not operate, death is certain; but after how long
a time ?  If we  operate, one patient in ten, twenty, or thirty, will
be saved ; but the rest will  sink under it a month or a year later.
If it is just to say with Celsus, Melius anceps remedium quam nullum,
it is also just to say, better to let  the patient die than to kill him.  In
supposing then that the operation may be very dangerous in itself,
and that, in the circumstances  in which we are placed, it offers
only one chance of success in ten, it would  in my opinion be  com-
promising surgery to subject the patient to it.   The extirpation of
the womb, when  not out of  its  place, of the thyroid body, degen-
erated throughout its substance, and of the entire lower jaw, &c,
are cases of this kind.  If the chances for success, on the contrary,
are more numerous, and if,  in  spite of the dangers, the operation
is one of easy execution, we  ought  not  to hesitate, and it becomes
a case of conscientious duty from which the surgeon ought not to
shrink.  Such are certain  cases of strangulated hernia, where,
whether from extensive peritonitis or from  the probabilities  of
gangrene, the success of the operation, so to  speak,  is rendered
impossible.
  One circumstance, important to be considered, though the classic
authors who have preceded me  have scarcely paid any attention to
it, is that which concerns the serious consequences which are actu-
ally complicated with the disease which we wish to remove. I will
suppose, for example, that a tumor, or a bone to be excised, or a finger
to be amputated, may be surrounded by an acute diffused inflamma-
tion, whether erysipelatous or phlegmonous, the limits of which are not
yet in any manner definable,  and which  has not ceased to keep up an
evident general reaction.  Following that old axiom, sublata causa,
tollitur effectus, it would%eem that in such a case we ought to operate
as soon as possible.   This, however, would be an error; observation
proves that in such cases operations succeed badly, that they aggra-
vate the inflammation, and do  not save the patients  from death.
With the exception of some particulars,  the inflammation is here like
that of gangrene, and before  operating we must wait until it is  posi-
tively located and definitively circumscribed. I would not, however,
wish that, from excess of timidity, we should be deterred from per-
forming any operation upon persons who are troubled with certain gen-
eral complaints: diarrhoea, for example, a febrile movement, whether 
THE CARE REQUIRED IN OPERATIONS.
15
permanent or intermittent, loss of appetite, loss of  sleep, night
sweats, &c, are not a sufficient reason to postpone lithotomy or the
amputation of limbs.
  In short, I postpone the operation, if the general  disturbance is
connected with an acute inflammation, developed in the neighbor-
hood of the part to be removed, rather than in the primitive disease
itself;  I hasten, on the  contrary, if the general symptoms are under
the influence of the evil we wish to remove.  If, in  destroying the
diseased part, we may  hope to eradicate the germ,  we must  then
operate ; but if, when the operation is terminated, the germ should
remain in the system, it is better to temporize.  Such is the law
which I would venture to lay down.
  The examination of the precautions relative to the lesions which
may be complicated with the principal malady, would be superflu-
ous.  We do not undertake the performance of a serious operation
which may be postponed in a pregnant woman, or a nurse, or while
the patient is under the influence of a formidable disease, unless it
may be the best means of putting an end to the functional disturb-
ances of the  whole economy.  Moreover, these disturbances should
have been resisted by the surgeon in proportion as they presented
themselves, before, as well as after having made up his mind to op-
erate.  The manner of recognising and of treating them being ne-
cessarily detailed in works  of pathology, it would be  abusing the
patience of the reader to repeat them in a work on operative surgery.
  The preparations, then, of which we are permitted to speak, are
those which the state of  a patient, otherwise in  good  health, may
require.  On this point authors are  far from being agreed.  vThere
are some who scarcely prescribe  a single day of tliet, while a
greater number  only  operate  after using tisans, purgatives, re-
vulsives,  bleedings, or a regimen of great severity, and precautions
the most  minute, in fact, during one or more weeks.  So that it is
difficult to lay down a  general rule  as to which  is right or which
wrong.
  Almost all  the preparations,  whether hygienic or medicinal, to
which  patients were  formerly subjected before being operated upon,
have been abandoned by the moderns.  These preparatory steps are
nothing, in fact, says Pouteau, but a protracted meditation upon the
malady.  (CEuvr.  Posth.,  t. iii., p.  113.)   And M. Champion, (Cor-
respond. Privee, 1837,) on the strength of the success which attends
operations of immediate urgency in the army, submits none of his
patients to these  preparatives.  Nevertheless, there are* some of
them that deserve to be retained, when the nature  of the  lesions
allows of delay.
  It is  in treating upon each operation in particular, that it will be
proper to touch upon this question.  I will confine myself for the
moment to remarking, that every operation, sufficiently important
to exact, immediately after it, a rigid diet during a certain number
of days, in order to diminish the general reaction, and to effect a
temporary change in the habits of the patient,  requires  that we
should precede it by a gradual diminution of the aliments, and that 
16
NEW ELEMENTS OF OPERATIVE SURGERY.
nothing more should be given the day before  than some  soup or
light broth.  The use of some light and refreshing diluent, one or
more bleedings, whether by phlebotomy or by leeches, if the patient
is robust, or but little enfeebled, a purgative, or at least enemata,
or laxative drinks, in order that the transition may not be too sud-
den, and that there may not remain any germ  of morbid derange-
ments in the system other  than those which may be produced  by
the consequences of the operation itself, are also necessary to  be
attended to.
  All the preceding considerations ought equally to be  understood
of local preparations. The only one which it is necessary to recall
here, is  that the part which is about to sustain the action of the  in-
struments, or of bandages  or other portions of  the dressings, must
be carefully shaved and washed.
                       CHAPTER IV.

    THE CONDITIONS THAT ARE ACCESSORY TO OPERATIONS.

  Operations, once decided upon, exact three  orders of auxiliary
means, according as these become necessary before, during, or after
the operation.

               Article I.—Before the Operation.

  Before taking the instrument in hand, we must look well to  the
locale, the assistants, and the dressings.

                       §  I.—The Locale.

  In hospitals it is generally to the amphitheatre that the patient
is taken, in order that his companions in misfortune  may not hear
his cries, or see the mutilation he is about to undergo.   This locality,
expressly intended for  this purpose, has no other inconvenience,
though it be otherwise commodiously arranged, than that it is more
difficult to warm than an ordinary chamber.  It  is the only place
which can give those present an opportunity  of appreciating all
that the operator is doing.   Strictly speaking, it is fitted only for  a
small number  of  operations.   That of hydrocele, lithontrity, her-
nia, cataract, fistula  lachrymalis, and trephining, may and should
be frequently performed in the ward  where the patient  is.  It .is
scarcely for any other than lithotomy,  amputations, and the dissec-
tion of certain tumors, that the amphitheatre is really indispensable.
In private practice, we choose the room which is the largest  and
the best ventilated, and gives the most light, in place of  the sick-
room itself, when that does not appear suitable.  Here the number
of persons present ought to be as small as possible';  seeing that
those who are of no service almost always do harm, either by their 
THE CONDITIONS THAT ARE ACCESSORY TO OPERATIONS.      17
indiscreet or inconsiderate remarks, or by the impressions that are
depicted in their countenances;  the vitiation which they cause in
the air of the apartment, or the inconvenience they give to the pa-
tient or the operator.  The interests of  the pupils, and of science,
are in hospitals paramount to these considerations; but here every
thing being public, the patients know beforehand what they are to
expect, and resign themselves to it without complaint.

                        § II.—Assistants.

   The  subject of Assistants merits  also the  greatest attention.
Their number cannot be fixed, some being absolutely necessary,
others merely useful.   Private  practice admits  only of the  first;
while in public  establishments we employ all whose services can
afford the least advantage. In the country we are often from neces-
sity for the most part deprived of them.  Some of them may not
have yet passed through any medical studies;  to such we  confide
duties that exact  only physical strength, coolness, and a little ad-
dress or intelligence.  It is important, also, that all have their du-
ties well defined, and that each one know beforehand  what he has
to do.  The  surgeon takes care to arrange the parts according  to
the skill, sagacity, stature, or strength of the persons  who are  to
be employed, and  to select his aids, as far as possible, among pupils
who  have been in the habit of assisting him in practice, who can
 divine his thoughts by the slightest  sign,  and who have at heart
the success of all  his operations and labors.

      § III.—The Instruments and Dressing—(i. e. VAppareil.)

   The instruments and dressing form another department whose
 importance is not to be forgotten.  The objects  which compose it
 are naturally divided into three orders.  Some  of them,  like the
 garrot,  tourniquet,  pelote, compressing bandages,  &c, have for
 their object the prevention of certain accidents during the opera-
 tion ; the second comprise everything necessary to the manipulations
 of the operator himself; the last belong to the dressings. Thus we
 must be provided :  1. With one or more flexible tapers, commonly
 called rats-de-cave, rather than lighted candles, in case the natural
 light  is  not sufficient; 2. A  chafing-dish  full  of live coals and
 cauteries;  3. A  little wine, vinegar, Cologne water, and brandy,
 in so many separate  glasses; 4. Hot and cold water, basins and
 sponges; 5. The  means of temporarily  arresting the current of
 blood in the part which is about  to be operated upon;  6. Com-
 presses, lint, bandages, and  folds of linen (alezes) to dress  the pa-
 tient or protect certain organs.
    The second series comprehends the different instruments that we
 may require, such as bistouries, knives, needles, scissors, saws, liga-
 tures, tenaculums, forceps, &c, which are arranged on a platform
 or on a table, in  the order  in  which they are  to be successively
 employed.   The strips of adhesive plaster, the pledgets of lint,
    vol. i.                       3 
 18           NEW ELEMENTS OF OPERATIVE SURGERY.

 iplumasseau.v,) compresses, bandages, and other portions of the dress-
 ings, are then arranged on another table, so as to be presented in
 their turn without confusion.  As these  details will be again re-
 ferred to in a great number of operations, amputations and aneu-
 risms among others, where their utility will be best  appreciated, I
 do not think it necessary to dilate upon the subject here.
   The position of the patient, of the surgeon, and the assistants,
 being necessarily governed by the nature of the operation, the part
 affected, and the preferences of the operator, cannot be advanta-
 geously pointed out except under each particular head.  The same
 may be said of the means of arresting  the flow of blood, whether
 provisional or definitive, and also of those which are proposed for
 moderating the pain.
   These remarks apply also to the attention that we must give to
 syncope, convulsions,  spasms, and all other matters that relate to
 the immediate consequences of the operation.  As we shall  be
 obliged to pass in review these last chapters, as well as dressing,
 the question of union by the first intention or not, and the prin-
 cipal  accidents  to which the great operations are exposed, when
 we come to treat of  minor surgery and elementary operations,
 of amputation  of  limbs and of aneurism, it would, in truth,  be
 a  useless repetition to  occupy the  reader with those matters at
 present.
   Neither will  I stop t© discuss the sense or propriety of the old
 adage, Citb, tutb, et jucunde, which was formerly proclaimed in the
 schools.  This saying is of Asclepiades and not of Celsus, as some
 are pleased  to repeat it.  Hippocrates and Galen said : Ccleriter,
 jucunde, prompte, et eleganter, which no longer has any value.   To
 say t«hat  an operation ought to be performed  with promptitude,
 steadiness, and some  address, is a triviality which has no need ot
 being repeated in our days.  The important part of it is, not to
 sacrifice  one of these advantages to the  others ;  to keep constantly
 in view, for example, that  promptitude is not  precipitation, nor
always quickness ; and that in surgery  it  is safety which ought to
be paramount to all.   I shall not therefore treat of these different
 subjects but in a very general way.


                Art. II.—During the Operation.

      §  I.—Position of the Patient, Assistants, and Surgeon.

  As  a general rule, it is better to operate upon patients lying
down than sitting up; the former of these  positions is the only one
which suits for  almost all  operations  that are performed on the
neck,  chest,  abdomen, genito-urinary organs, and the inferior ex-
tremities ; the second, perhaps, is more  convenient for the opera-
 tor, in operations to  be performed  on  the face, the  cranium, and
 certain parts of the neck, the chest, and superior extremities ; but
 it is not really more advantageous to the patient, except the oper-
 ation  is of short duration and of little severity.  In truth, there are 
        THE CONDITIONS THAT  ARE ACCESSORY TO OPERATIONS.     19

scarcely any other than the operations in the interior of the mouth
or of the nose, which render the sitting posture absolutely prefera-
ble, and that because of the blood, which  otherwise would have a
tendency to be carried towards the pharynx rather than to the ex-
terior.  In a sitting posture, the patient grows feeble much sooner,
is more difficult to hold, and is more exposed to swooning, (lypothy-
mies,)  and to syncope; while".lying down  he has no need of any
muscular effort, and seems better able to support the pain; nothing
then prevents us from allowing  him to repose from time to time ;
no embarrassment is experienced in giving him such a degree of
inclination rather than another, and of being  prepared on the spot
for whatever accidents may happen.
   As for the rest, when we desire to operate upon a patient in the
sitting posture, it is sometimes a matter of indifference whether he
be placed on the  edge of a bed, table,  or any other object; for ex-
ample, for puncturing a hydrocele, the introduction of the bougie,
or of a porte-caustique into the urethra, &c. ;  in some cases a stool
is better, from the liberty it permits to move the patient round ; it
is, however, a chair or an  easy chair that is most commonly  used ;
an arm chair for persons very  feeble or intractable, and an  ordi-
nary chair for those whose position we may wish to vary.
   I need not add, that the  assistants must  incline  the  head of the
patient sometimes to one  side, sometimes to another;  that  they
must retain it in  the most perfect immobility, by supporting it with
napkins and with pillows; that it will be  proper  for them to turn
the back, face, or side of the patient towards the back of the chair,
according as the  disease has its seat in the right or left, in front or
behind.
   If the patient is to  be placed in a recumbent posture, we  may
often dispense with changing him from his bed.  The operation for
cataract, tracheotomy, catheterism, hydrocele, fistula in ano,  and
lithontrity, are of this description.   Patients that are very weak,
operations in which the  least  shock might aggravate the conse-
'quences, such as  strangulated hernia, the  trephine, and aneurisms,
often demand the same precaution.  On the contrary, for all opera-
tions  accompanied with a considerable discharge  of blood,  and
whose success cannot be endangered by slight starts or movements
of the  patient, it  is better to operate on  a  separate bed.  There is
in hospitals, for this purpose, a table, whose two ends may be raised
or depressed at pleasure, and which is supported on a pivot, which
permits the whole to be turned in any direction.   This table, which
is about thirty inches high, and which  would be still more perfect
if it were possible to vary its entire elevation or depression, accord-
ing to  circumstances, is to  be furnished with a mattress, also with
a sheet and with folds of linen.   Out of the public establishments,
they use a  solid cot, furnished  with  mattress, cushions, pillows,
sheets, and napkins;  in the absence of a solid cot, the mattress is
placed on a table, or drawers, or on some planks fixed firmly on chairs
or  arm-chairs;  the important part of it  is,  that the bed shall be
firm, solid, straight, without bed-posts,  or raised edges; that it shall 
20
NEW  ELEMENTS OF OPERATIVE SURCERY.
be of a convenient height, and so arranged as  to  allow of passing
all around it.
  Upon the bed we give to the patient a variable position, neces-
sarily in relation with the exigencies of the operation about to be
performed upon him.  Lying on  his back,  belly,  or on one of his
sides, sometimes lengthened out almost horizontally, now bent up
almost double, sometimes  seated with either the head or lower
limbs elevated, he ought to be held and supported by a sufficient
number of assistants.
  In former times, surgeons made use of cords, straps, and machines
to control the  movements of the  patient during operations ; now
we" have  recourse to nothing analogous, except in some cases of
operations for stone.  Such contrivances  have been renounced:
first, because they are useless, and that intelligent assistants may
almost always be substituted for them ; secondly, because they had
become an object of terror for many  patients.  It does  not, how-
ever, result from this, as Dupuytren seems to wish us  to infer, that
assistants are  never obliged to use force or violence during  opera-
tions.  In saying, " It is almost unheard of that  any  patient ever
manifested a desire to have an operation suspended, or made seri-
ous attempts to interfere with its completion," this practitioner evi-
dently deceives himself.  For we every day see  individuals  pray-
ing in mercy that we would stop, that we would finish, thus  im-
ploring and menacing us, and who would not fail to escape if they
were not firmly secured.  The  assistants ought  not, however, to
forget that their strength is uncalled for, while the patient makes
only slight movements ; and that they ought not to restrict, stop, or
prevent any but those which might interfere with the manipulations
of the surgeon.
  The position of the operator, and of the assistants about the bed,
during the operation, can have no general rule : provided it is the
most commodious for all concerned, and the least  fatiguing to the
surgeon, we have all that can be said ; it is in treating of opera-
tions in particular,  that we  may  be  allowed to speak definitively
on this point.

    § II.—To arrest the course of the Blood in the Diseased Part.

   It is scarcely ever required at the present day  to recur to a  pre-
cautionary ligature upon the arteries to suspend  the  circulation in
the part upon which we are to operate ; direct pressure is almost
always sufficient, but this is not equally practicable on all the  ves-
sels.  While  it  is  difficult on the subclavian arteries, fatiguing on
the  abdominal aorta and  the iliac arteries, it is  impossible on all
the  arteries of the splanchnic cavities: it is only upon the limbs.
neck, and head, that it is generally easy and certain; it is effected
by means of the fingers of an assistant, by a pelote, the  garrot, the
 tourniquet,  or some other compressor.
   A.  Circular  Compression.—To obtain compression, the circular
 mode was for a long time in use.   It was the  means adopted by 
        THE CONDITIONS THAT ARE ACCESSORY TO OPERATIONS.     21

Avicenna, and by the Greeks, and which Pare also  continued to
practise.  Some, however, among the ancients, employed tempora-
ry hemostatic expedients of a more efficacious kind; it  appears,
in fact, that Archigenes encircled the whole thickness of  the limb
with a ligature, which he thus applied directly upon the artery.
  B. Garrot.—The  circular bandage was gradually perfected in
the hands of the French surgeons.   They commenced by separating
it from the course of the vessels, by the aid of a square compress
of linen of greater  or less  thickness. In  1674 Morel changed it
into a true  garrot.   This garrot, successively modified by Nuck,
Verduc, and La Vauguyon, is still in use at present.  To prevent
the skin from being pinched, to diminish as much as possible com-
pression on  the points of the limb that do not correspond to the
artery, there is previously placed on  this last a compress  of many
thicknesses.   A piece of pasteboard, horn, or  leather, slightly con-
cave, is moreover applied on the point opposite, in order to support
the small stick (batonnet) of the garrot.
  C. The Tourniquet, invented by  J. L. Petit, towards the begin-
ning of the last century, and of which different modifications have
been proposed in England and Germany, has rendered the employ-
ment of the garrot  much more rare than formerly.   The  instru-
ment of Petit, in  fact, is so arranged, that it  acts with a certain
force only on the course of the vessels  that we wish to compress.
Once applied, it may afterwards be left to itself; while the garrot
has need of being watched or supported by an assistant to the end
of the  operation.  When we have  at our disposal  only a small
number of assistants, or when these are not sufficiently instructed,
as in the country and in the army, for example, or when unlooked-
for circumstances render indispensable some great operation, the
garrot, being an instrument that we can make on the spot and any-
where, forms a valuable resource.  The tourniquet of Petit would
be still more advantageous if we  could procure it;  but  in every
other case, it is on the hand of the assistant that we must  rely.
  D. Bridle, (bride.)—An easy and sufficiently safe mode of com-
pressing an artery, when we have at  our disposal intelligent assist-
ants, consists in placing on a rolled band (globe de bandes) or any
other solid pelote previously adjusted upon the track of the vessels,
the middle portion of a bandage, whose two extremities are brought
together on the opposite side, in the same way as with the  garrot.
The two middle fingers, passed under the knot of the bandage thus
arranged, while the thumb and other fingers rest on the two halves of
the banagbe, as on the sides of a bridle, give the assistant the power
of augmenting, diminishing, or varying the compression of the arte-
ry, without the least fatigue, and without incommoding the neigh-
boring parts.
  E. The naked hand, however, is most frequently quite sufficient;
m this case we apply the  pulp of the  four fingers on the  artery,
while the thumb takes a point of support on the other side.  We
may also effect the compression with the thumb  itself.  In that
case it is well to place the  last phalanx of the thumb crosswise on 
22
NEW  ELEMENTS OF OPERATIVE SURGERV.
 the  course of the vessel; fixing then the thumb or fingers of the
 other hand perpendicularly upon this, we may, in acting sometimes
 with the first thumb, sometimes with the second, compress for a
 very long time without being fatigued.   The same rule is applica-
 ble to the fingers.
   F. When the  artery lies very deep, we make use of a sort of
 bureau seal, padded, in form of a pelote.   With this instrument we
 cause less pain, and do not interfere with the retraction of the mus-
 cles, or the movements of the.operator.
   G. In certain cases a still more secure method may become in-
 dispensable.   We lay bare the artery at a certain distance from
 the place where the operation is to be performed, and apply a liga-
 ture to it.
   Whatever may be the  method that we prefer, it is nevertheless
 indispensable to  confide this part of the operation to an assistant
 that can be relied upon, and one of  acknowledged coolness.  It is
 evident, also, that this assistant must be possessed of certain phy-
 sical strength, be of tall stature, and have great composure ; that
 he ought to be thoroughly acquainted with the anatomical relations
 of the artery to be compressed, and should understand all the steps
 of the operation.
  The  great operations thus require the compression of the artery
 between the  heart and the seat of the  disease.   Also, it is  laid
 down as a rule, that they are not to be undertaken until we are as-
 sured beforehand of the course of the blood above the part.  This
ifule, however, has many exceptions.  Every time, for example, that
the operation does not of itself require  the opening of  large arte-
ries,  as in the operation of aneurism by the modern methods, and
Ihe extirpation of most tumors,  we may dispense with this precau-
tion. We disregard it, also, when the section of the principal vessel
is not to take place until towards the end of the operation, as may
be the case, we will suppose, in amputation at the shoulder-joint;
(30 that the law of which I  have just spoken has full application
 only to amputations in the body of the limb, and in the operation
 of aneurism by opening the sac.

                   § III. To Prevent  Pain.

  It has long been a subject of research to discover a  method of
 performing operations without  causing suffering to the  patient.
Theodore, and many  after  him, recommended  placing under the
 nose a sponge impregnated with opium, with water of night-shade,
 henbane, and lettuce,  in order to induce the patient to sleep, to be
 awakened afterwards by  applying in the same manner a  sponge
 wet with vinegar, or introducing into his nostrils or ears the juice
 of the fennel or of rue.
   [If any efficacy could be derived from  such applications, or if
 the  plan  still sometimes advocated of blunting the sensibilities
 of the  nervous system by morphine were not of doubtful utility,
 from its impeding afterwards a full and  healthy reaction, then the 
        THE  CONDITIONS  THAT ARE ACCESSORY TO  OPERATIONS.      23

 anodyne effects of opium might be introduced  into the system in
 the  manner  which  is now believed  to  be  the most  gentle  and
 innocuous,—we mean that practised by the Chinese  of inhaling
 the fumes of opium into the lungs, which, according to the recent
 experience  of some British surgeons at Hong-kong, during the
 expedition just closed, appeared  to them to  be eminently the
 best mode of administering this medicament.   Some  more recent
 marvellous accounts of putting  the patient  in a profound  state of
 sleep, or trance, by what  is called Mesmerization  or .animal mag-
 netism, and then amputating or performing other severe operations
 without the subject  indicating the slightest twinge of a muscular
 fibre, or the faintest expression of complaint, need confirmation.
 And were there truth in Mesmerism, it could  even, by the confession
 of those who produce it, be but of very  partial  application.  And
 we have still to recur to  the objection of narcotics of every kind
 that diminish nervous excitability, and thus throw  the system, as it
 were, off  its  guard, and therefore render  it less capable of rallying
 after the operation, when all its energies are demanded.   Thus it
 is that small-pox, before vaccination was  introduced, was observed
 to be always more fatal when taken in the natural way, where, as
 Sir Gilbert  Blane has  remarked, the virus was unconsciously im-
 bibed into the system, than where communicated artificially by in-
 oculation, when the will and consciousness, being prepared for the
 shock, resist, as it  were, its full effect on the  constitution.  The re-
 mark of jM. Velpeau (supra) on the bad  effect of  foolhardiness in
 patients on the operating table, is in unison with these views.—T.]
  Others limited themselves, from the time of Guy de Chauliac, as
 Sassard (Journal de Physique, 1781) and others have done since, to
 the prescription of opium.  For a long  time  it was thought we
 could succeed better by applying a strap  tied tight above the place
 where the parts were  to be divided.   M.  Liegard  has  shown
 (Melanges de Med. et de Chir., p. 350, Caen,  1837, in 8vo) that this
 practice, so much  extolled by Juvet, is not to be despised in some
 cases.  It is preferable, in my opinion, to the compression of the ner-
 vous trunks towards the root of the limb, as advised by J.  Moore,
 (Ancien Journal de Med., t. lxv., p. 306) and  B.  Bell, (Cours de
 Chir., t. vi., p. 61.)   Recurring back to the usage of the ancients,
 M. Hirckman has recently maintained that  we may perform  the
most  extensive operations without causing  pain, if we make the
patient respire a certain quantity of stupifying gas. [See our pre-
ceding note.—T.]
  Nor has magnetism been forgotten.   All the journals have rung
with  the account of an extirpation of the breast without  the  pa-
tient  being conscious of it.   It is also known that a woman who
was in a magnetic sleep underwent, without awaking, the extrac-
 tion of a molar tooth.   But every thing leads to the belief  that in
 such cases the operators must have been  deceived by the insensi-
 bility or the chicanery of the patients, or  by some confederate.
  The Earl of  Mansfield caused an arm to be  amputated under a
 blast of trumpets.  La  Peyronie, whose  leg was to be amputated,
# 
 24            NEW ELEMENTS OF OPERATIVE SURGERY.

 himself arranged  on  his bed the apparatus and instruments that
 were necessary.  A peasant even amputated his own limb with a
 coarse saw, according to Scharschmidt.   M. Champion speaks of
 two women and of some men, who exhibited the same  calm and
 the same resignation.   1 have amputated the thigh of three  pa-
 tients, who did not utter the slightest cry during the operation.
 A robust man, otherwise very susceptible, chatted tranquilly with
 the assistants while I was removing from him a large-sized sarco-
 cele, without his manifesting the least sign of pain.
   To avoid pain in operations, is a chimera that we can no longer
 pursue in our time.  A cutting instrument and pain in operative
 surgery,'are  two words  which are never presented separately to
 the mind  of the patient, but in an association which he must of
 necessity admit. ' The efforts of the surgeon ought then to be con-
 fined  to the  point of rendering  the pain of operations as  little
 acute as possible, without diminishing the certainty of the  prin-
 cipal  result.   The pretension of some writers,  who  believe they
 attain this  end in  not using the bistoury until they have dipped it
 in oil, does not appear to me to have any foundation.  The oil, in
 attaching itself to the porosities of the wound, would, in fact, have
 the inconvenience of  obstructing  the circulation of the fluids,  the
 exudation of the  plastic matters,  and the  agglutination of  the
 bleeding surfaces.   Cerate, succeeding to washing, would be much
 better if any fatty substance whatever could be of utility.   We
 cannot deny, that the instrument dipped into hot water, as M. Rich-
 erand advises, or brought in some  other  way to the temperature
 of the body, or even above it, as M. Guillot wishes, gives less pain
 to the patient.  But in the result the  difference is not sufficiently
 important; the precaution would be too troublesome  to  introduce
 into general practice.  It is not to such accessories, but to the  hand
 of the operator and the qualities of the bistoury, that we must look
to obtain the desired result.  Let the hand be light and steady, and
 the bistoury smooth and well sharpened, and give with  the first
 stroke the whole length and depth that the incision should have, if
you can do so without danger ; then act with promptitude and with-
out hesitation, and give to the wound rather a little more than less
 extent, without uselessly prolonging it, and you will have no  other
pains  to encounter than  those which are inherent in the operation,
and which nothing can separate from  it.  Longer details on this
subject would be entirely superfluous.


                       § IV.—Accidents.

  The principal accidents which may take place during an opera-
tion are hemorrhage, convulsions, syncopes, and the entrance of air
into the veins.
• 
         THE CONDITIONS THAT ARE ACCESSORY TO OPERATIONS.       25


                        A.  Hemorrhage.

   The issue of blood from  the  divided  vessels during operations
 becomes an accident only when  it  has not been foreseen, or when
 it is more abundant and more difficult to check than we expected.
 In feeble subjects it is of a nature  to give immediate cause for real
 danger.  Sometimes it  is owing to  the  tourniquet, the garrot, or
 the  fingers of the  assistant having  been displaced.  Sometimes,
 also, it arises from our wounding vessels that we had hoped to
 avoid, from its having been impossible to retain the patient in the
 position that we had given  him.   The blood in such cases comes
 either from the veins or the arteries, and oozes out. or forms a jet.
   I. Venous hemorrhage in these cases presents two aspects, accord-
 ing as the vessel  is cut  through,  or only upon the side.  In this last,
 we stop the blood by the application of the finger, a ball of lint, or
 small masses of sponge or agaric  upon the wound, or by surround-
 ing with a thread the circumference of the wound, whose lips have
 been previously seized by the forceps.
   If the blood runs from  the gaping  extremity of a vein, it  is al-
 most always owing to the  central circulation being more or less
 impeded.    The accident  is owing then  sometimes to  the circular
 strangulation of the part, sometimes solely to the mere compression
 of the large vascular trunks above the wound, which last compres-
 sion, acting on the  veins,  hinders the blood from proceeding on its
 course to the heart, and forces it to flow  backwards and out of the
 vein.  At other times the obstruction is owing to the patient vio-
 lently contracting the muscles of the  chest, and to his impeding as
 much as is in his power his natural respiration.  The remedy for this
 kind of hemorrhage, which is more frequent after than during an
 operation, is to remove  all pressure on the course of the veins, and
 to induce the patient to respire freely, and not to restrict, but e\en
 to multiply his inspirations.
   II. Though the hemorrhage may in reality be arterial, even when
 the blood oozes out, it is unnecessary to  occupy ourselves with it,
.unless the patient is very  much weakened.  In this case we arrest
 the bloody exudation by means of pieces of agaric or sponge, and
 then hasten on to finish the operation.  If the  blood escapes in
 jets, we effect compression  by the  fingers, by torsion, or by the lig-
 ature.
   Before considering direct compression  or the ligature, it is neces-
 sary to see that  the haemostatic means  have not been disturbed.
 If the tourniquet, the garrot, the pelote, or the hand of the assistant
 have been previously applied on the principal trunk of the artery,
 the hemorrhage is evidently caused by these having been displaced,
 and the first thing to do is to replace them in a proper manner.  In
 the event that this precaution is not  sufficient, or cannot be adopt-
 ed, from the operation being of a nature that does not admit of these
 means, we  must  then recur to  one of the modes already pointed
 out.
   a. Application of the fingers.—In having recourse immediately to
  vol. i.                          4 
26
NEW  ELEMENTS  OF OPERATIVE SURGERY.
the ligature or to torsion, the surgeon is obliged  to  suspend the
operation at every cut he makes with the bistoury.  If, on the con-
trary, he can avail himself of intelligent assistants, he may continue
on without hinderance to the end, in directing them to place the pulp
of the finger on each artery he opens.  Unfortunately, the fingers
employed in this way sometimes interfere considerably with the ma-
nipulations of the operator ; and there are so many of these required
in certain operations, that we  cannot have recourse to this expe-
dient   In proceeding thus, we arrest, it is true, the hemorrhage on
the spot;  but we  crowd the  blood more  or less  into the vascular
branches  in the tissues, and render  their  separation  afterwards
very difficult. ' Nevertheless, it is a kind of resource which  I prefer,
when there is but  a  small number of arteries to close, and when
the whole operation is not to be of long continuance.  In the other
cases, I prefer torsion or the  ligature.
  b. Torsion.—To twist the  arteries  in proportion  as we cut  them
in operations, is neither  difficult nor  an  affair that requires much
time ; but in treating of torsion, we must take into consideration all
the good  or evil that has been attributed to it, and of that we shall
speak further on.
  c. The Ligature, at last, is that which offers the most  security
and advantages, unless  it be in respect  to wounds, of which it is
our intention  to  undertake  the complete  and immediate union.
Those  surgeons who, like J. L. Petit and some moderns, wish that
the small arteries should be  closed by the fingers of an assistant in
proportion as  they are opened, have principally in view the com-
pletion of the  operation as  quickly as possible, and of thus effec-
tually putting  an  end to the  hemorrhage.  Those who prefer tying
the arteries in proportion as they present themselves, know well
that they render  the operation longer, because at each moment it
is necessary to stop for each new ligature, and that sometimes we are
obliged to use a great number of them ;  but they add, that we are
thus sure of letting no important artery escape ; that we are better
protected from consecutive  hemorrhages;  and that we have  no
difficulty in finding  the wounded vessel: in fact, that  the amount
of the pain is not thereby increased,  and that the whole operation
is thus made  more regular  and complete.  It is, in fact, what in
reality exists; and if we apprehend that we shall not afterwards find
the vessels whose hemorrhage we dread, or that we shall be obliged
to open a great number of them, or if we have no particular motive
for proceeding with great rapidity in  our  manipulating movements,
this method is without contradiction the  most advantageous to
the patient, and that which offers the greatest security to the sur-
geon.

                     B. Nervous Accidents.

   I. Certain patients, during  operations, experience swoonings or
syncopes, which alarm all the  assistants, and may also disquiet the
surgeon.   These  accidents happen  sometimes from  exaggerated
s—- 
        THE CONDITIONS THAT ARE ACCESSORY TO OPERATIONS.      27

fears.  We prevent them in  this case by the aid of reasoning and
of moral means, in order to  inspire the patient with courage, by
demonstrating to him, as well as we can, that he is deceived, and
that he is exposed to no danger.   If the pain is the cause of it, as
happens with persons who are  nervous or very susceptible, espe-
cially with inhabitants of the south, we have no other means of
remedying  it, but by operating as rapidly as possible, and with in-
struments that are perfectly keen.   It is on such patients that the
employment of narcotics, the benumbing the parts by means of com-
pression, the immersion of the bistoury in hot water, and even mag-
netic influences, may offer some  benefit.  (Vide a note above on
magnetism, &c.—T.)
  Faintings and swoonings, from hemorrhage, are to be apprehended
in patients already enfeebled, and in those in whom every  loss of
blood, however inconsiderable, produces this result.  In these cases
the preventive means are found in the previous and perfect com-
pression of the arteries, and in the employment of the fingers or of
the ligature, as has already just been said.
  Though the accidents of which we speak are such as rarely dis-
turb us seriously, they nevertheless require to be remedied as soon
as possible.   The first thing  to  do  in  such a case is to give free
and easy access to the air about  the patient, to open the windows,
and remove from about the bed  all the assistants that are  not in-
dispensable.  If  the operation is far advanced, we terminate it
rapidly; and then  give to the patient a position perfectly horizon-
tal, and even more or less lowering the head.  This  position of
itself alone  is capable of preventing the syncopes, and causing them
quickly to disappear, by returning the blood upon the brain.  More-
over, we shake him, and push him about the chest, and slap  him on
the face, the temples, or the neck, but, better still, throw cold water
upon his face. Cologne water, brandy, ammonia, and vinegar, placed
under the nose, or applied by  friction on the temples, forehead, and
region of the heart, ought to be combined with the foregoing  means,
whether as preventive or curative remedies.  As to the rest, every
person is too familiar  with the remedies for fainting and swooning
to make it necessary for me to say any thing more on the subject.
If, nevertheless, the syncope should resist and continue for too long
a time, and that the operation should also be necessarily protracted,
it would be advisable to lay the bistoury aside and return to it
afterwards, rather than to persist, especially if the operation should
of itself be  one of a dangerous nature.
  II.  Convulsions.—The convulsions which happen in the  course
of some operations, are generally ascribable to the same causes as
the syncope; so also do we  employ the same means to prevent
and overcome them.  Convulsions, however, being, more than syn-
cope under the influence of pain and of fear, demand also more fre-
quently the suspension  of the operation.  If, then, it concerns an
operation that must be long, and which is at the same time of a
grave character, and that the convulsions have interfered with our
progress from the very beginning, it is  far  better  not to continue, 
28            NEW ELEMENTS OF OPERATIVE SURGERY.

but to  replace the patient on the bed, and wait until his feelings
and his courage are in a better condition.
  III. Operations  at two times, (Operations en deux temps.)—Those
operations that we desist from to resume at another time, have re-
ceived the name of Operations en deux  temps;  and should be di-
vided, in this point of view, into those of necessity and those of
choice.
  The first are not performed at two different times by the surgeon
but from necessity, and in  consequence of particular  accidents;
others are completed on two different occasions, because particular
reasons, known beforehand  to the operator, give the preference to
this method.  It  is thus that some surgeons still act with respect
to the double hare-lip; as  others formerly did in  lithotomy by
the perineum, and as a certain number  of moderns now propose
for  the  hypogastric incision for that operation.  As for myself,  I
never determine  upon operating at two different times, unless it is
impossible for me to do otherwise without real danger  to the pa-
tient.  As a method of choice, this kind of operation appears to me
to be essentially  pernicious.
  [Dr. Mott remarks, that he totally disapproves of, and does not
recognise, any rule in surgery, by which an operation, which is a
unit, or an entire, and a whole in itself, should be directed to be
performed at two different times ; or  in other words by halves.  He
himself, in his very extensive and varied practice, has never done
it, in any one instance.  If reference be  had in the above expres-
sion, en deux temps, to certain complex operations, or complications
in which parts are involved that require distinct operations in them-
selves, then  there  are certainly cases, and  even these are rare, in
which an intermission of a day or more may intervene between
the execution of one portion of the duty of the surgeon, or one of
the preliminary steps he is obliged to take, and the final processes
which are to complete the work before him.  Thus, in the case of
a child of three months old,  with  complicated  hare-lip, where
there is a bony  hook, or proboscis, of an inch  or more in length,
that grows from, or rather is a prolongation of, the septum narium,
(as it often happens, also, from  one side of the fissure of the jaw,)
such may be the extent of the hemorrhage after the preliminary
removal of  that  excrescence, which may,  in most cases, be most
effectually and conveniently accomplished by a blunt-pointed scis-
sors, of strong and short thick  branches, that the hot iron or other
means become  necessary to arrest it,  and a delay of a day or
two is demanded, to give the infant time to recover itself for the
completion of the operation upon the hare-lip itself, whether that be
single or double.  Though it is to be remarked, enpassant, that there
is no operation in  surgery,  apparently, so formidable, (and which
may so frequently be made  so, in reality, by want of delicate and
adroit manipulation in the operator, as this of hare-lip in infants,
in all its forms,) that cures with such rapidity, and so perfectly, by
first intention, or that evinces  such irresistible recuperative ener-
gies, in  the system.  In two cases only of the numerous hare-li"? 
        THE CONDITIONS  THAT ARE ACCESSORY  TO  OPERATIONS.      29

 operated  upon by Dr. Mott, and one of them was of the nature of
 the one just described, was it found necessary to wait the interval
 of several days after the removal of the proboscis, before the opera-
 tion for the hare-lip proper, which was of a most complicated char-
 acter and of the double variety, was undertaken.   Another case in
 which such double duty was required, was one in which, for the
 first time, Dr. Mott tied the carotid artery, many years  since, for
 the removal of a large osteo-sarcoma of the lower jaw.  As it was
 the  first occasion upon which he  was to  operate in that class of
 important jaw operations, as projected and established by him, and
 the first time,  also, in which he had ever had  occasion to tie the
 carotid in an  operation of that kind, he naturally felt disposed to
 adopt  every possible precaution.   He,  therefore, reflected  with
 himself whether in such cases  it would not be sometimes advisa-
 ble, both for the purpose of cutting  off hemorrhage and consecutive
 inflammation,  to tie the primitive carotid before proceeding to  the
 removal of the tumor.   And we believe the  credit of first making
 this  suggestion is due to Dr. M.  Accordingly,  the patient being a
 young lady, who, but  for  this most  unpleasant  deformity, was
 extremely comely, (as the restoration of the natural  form and con-
 tour of her face after  the  cure fully testified,)  the carotid was on
 the first day tied with facility without the slightest  untoward symp-
 tom following.  On  the succeeding day, finding her in a state so
 exceedingly comfortable and favorable, and in such good spirits and
 strength, he determined at once upon the  removal of the osteo-
 sarcoma, and was astonished to find, that throughout the extensive
 incision and the section of the side of the jaw containing the tumor,
 and  which was made in two  places, to wit, near the symphisis of
 the chin, and then at the bifurcation of the processes of the lower
jaw  near  the angle, there was, so to speak, scarcely a table-spoon-
 ful of blood from  the vessels, and the cure afterwards was directly
 and speedily effected by the first intention.   The advantage of re-
 moving the jaw so soon after tying the carotid lay in this: that hem-
 orrhage was, in a measure, totally cut off, and the consecutive con-
stitutional inflammatory reaction, both for the operation on the caro-
tid and that for the  osteo-sarcoma, were  both anticipated, as it were,
by the direct  adhesive  inflammation in the parts themselves, all
those important results  being imputable to the fact that there had
not been  time in  the interval of the twenty-four  hours  for anas-
tomosing arterial connections to be established.  Dr. Mott was only
induced to defer the operation for the osteo-sarcoma, because of the
 anxious state  of the mind of the   patient, after he had tied the
 carotid, she knowing, as Dr. M. told her, that the  removal of the
 jaw was  a new and untried operation.  These are  the  only two
 instances  in which Dr. Mott has  ever performed upon a patient
 operations which, by any latitude of construction, could be deemed
 to accord  with the phrase en deux temps, or two stages; and as a
 general rule, except in the event of double operations being required,
 as in the cases above mentioned, he totally disapproves of and pro-
 scribes the practice in all cases to which it may be supposed to be 
30
NEW ELEMENTS OF OPERATIVE SURGERY.
applicable, that is. the  practice of  commencing with an operation,
and then, from apprehensions (generally not well grounded) of dan-
gerous consequences, leaving off in  the very inception or middle of
them, and afterwards, recommencing and completing them at the
expiration of an interval of some days.  Yet there may be, as he
thinks, some rare exceptions, as in great exhaustion from hemor-
rhage, to these remarks; as, for example, in some large and ex-
tremely vascular tumors of the scalp.—T.]

              C. Entrance of  Air into  the Veins.

  The introduction or development of air in the vessels of man or
tnimals during life, recognised during the last two centuries by a
certain  number of pathologists, whose observations are referred to
by Morgagni, had, almost for the last twenty years, been entirely
forgotten.  It was even necessary for an unfortunate event to occur
in the practice of a celebrated surgeon, to draw attention to this
grave subject, and to persuade persons to believe that air  entering
into the veins could cause death during an operation.
  We knew by the experience of Bichat, as well as by the physi-
ologists of the seventeenth and the eighteenth centuries, that animals
could be  killed by  introducing atmospheric  air  into the heart.
After having multiplied and varied his experiments almost to in-
finity, Nysten, in 1809, concluded that air injected into the veins, in
a certain quantity, caused  death, but he maintained, also, as  Lan-
grish  had already done, in  1746, that this is caused by its arresting
the movements of the heart, and not by destroying  the functions of
the brain, as Bichat had believed.
  More recently, the experiments of Barry,  which I myself wit-
nessed, and especially those of M. Poiseuille, which I also attended,
showed, as did those of M. Magendie, not only that the air, when
forced artificially into the heart, speedily caused  death, but also
that  this gas may spontaneously introduce itself  into  veins  that
have  been previously  opened.   We must, however, add, that the
observations of M. Poiseuille  scarcely admit  the possibility of this
phenomenon but in veins subject to the venous pulsation, or in which
is observed  an actual  reflux of blood during life, that is, in those
large veins  which extend for some inches beyond the apex of the
chest.  Beyond that, in fact, the expansion either of the heart or
the thorax appears  to have no influence on  the column  of blood
Atmospheric pressure,  by immediately flattening the calibre of the
vessel between the opening of  the vein and the apex of the  chest.
seems to present an insurmountable obstacle to the admission of
air in the direction of the heart.
   It remained to ascertain why the blood may thus flow back to a
 certain distance, and not to some inches beyond.   M. Berard the
 elder undertook  this inquiry.   Anatomical  examination and an
 attentive dissection of the parts  demonstrated to him, as I also
 have often been enabled myself to confirm, that the internal jugu-
 lar, subclavian, and axillary veins  are naturally united to the  bones 
        THE CONDITIONS THAT ARE ACCESSORY TO OPERATIONS.      3}

or to the muscles of the neighborhood, by fibrous plates or bridles, so
solid, that when those veins are opened they remain gaping after the
manner of inert canals :  from whence it follows, that up to two or
three inches above the sternum, that is to say, to near the larynx.
the internal jugular vein is not flattened under atmospheric pres-
sure when the blood ceases to fill it, and that it is the  same with the
subclavian  vein throughout its whole length, and  also  with the
upper half of the axillary.
  By recent experiments, we have seen that dogs of different sizes,
horses, and mules, that have received air into the veins, either  by
injection or inflation, almost always die at the end  of from five
to forty or fifty minutes, when there'.,had been introduced  a con-
siderable quantity of this gas into the heart.  To effect this, how-
ever, it was necessary for the opening in the vessel to be from
two to six lines in diameter, to be kept gaping open, and also to be
made in the regions indicated by MM. Poiseuille and Berard.   We
have also seen that the introduction of air was announced by a dull
sound, generally perceptible, sometimes nearly inappreciable, being
in the horse a sort of gurgle, (glougou,) and not a hissing (sifflement)
or whizzing, (reniflement,) as some persons have said.  Agitation.
convulsive movements, and epileptic-like attacks, soon announced
the danger and formed the common preludes of death.   The autop-
sy of the dead body disclosed the distension of the right auricle and
ventricle of the heart, the presence in the cavities of this organ of a
red blood mingled with a great quantity of air, and perfectly frothy,
that is, "a sanguineous froth," (mousse sanguine,) as already observed
by Magendie.   In some cases the same state of things was seen in
the left cavities of the heart, and also air was detected even in the
vessels of  the brain.  As to the rest, the opening of the jugular
veins on the side of  the face, or of the  axillary vein in its lower
portion, and, a fortiori, the brachial veins, were not followed by any
accident.
  In fine, these experiments, demanded by the Academy of Medi-
cine, in 1837, and made in presence  of  a commission, of which I
formed one, by M. Amussat on one side, and M. Barthelemy on the
other, show, as the  ancients did, that air  can, by the opening of
a vein, be introduced  spontaneously into the heart, and destroy the
animal ;  provided  this aperture shall have at least two lines of
diameter, that it shall exist near the  apex of the chest, and that it
shall  allow to enter from ten to forty cubic centimetres of air into
the circulatory system of the wounded individual.  Let us now see
to what point the observations made upon the human species are
analogous to the facts derived from animals.
  Surgical practice had long since afforded instances of almost im-
mediate death in the course of certain operations ; Dut these acci-
dents had been attributed sometimes to hemorrhage, sometimes to
the exhaustion of the patient by excess of pain, sometimes to fright,
and sometimes to syncope.  For my own part, I know that many
patients  have succumbed in a few minutes, while removing from
them a degenerate thyroid gland, a tumor at the bottom of the ax- 
32
NEW ELEMENTS OF OPERATIVE BURGERT.
ilia, or in the simple operation of tracheotomy ; and that no other
explanation has been  sought after than those I  have just  given.
Not  satisfied with these reasons, and availing themselves of the
experiments of physiologists on  animals, modern  surgeons have
called to their aid the entrance of air into the veins to account for
cases of unexpected death happening in the course of an operation.
The facts of this kind that have come to my knowledge are  about
forty in number.   I have given  the  analysis of them in a special
paper.   (Lettre sur VIntroduction de VAir, etc., Paris, 1838 ; et Gaz.
Med. de Paris, Mars, 1838.)
  We may divide them into  four groups; one  for  facts of trivial
importance, the second  for those where death  has not ensued, a
third for cases followed by .death but without an autopsy, and  the
fourth for those with autopsy.
  1.  Rejected Cases.  I arrange among trivial facts such as rest
only on hearsay evidence.  They are five in number.  Such  are
those of MM. Graefe,  Cooper, Lodge, Stevens, (Cornack, Inaug.
Dissert, etc., Edinb., 1837,) and Duportail.  Everything indicates,
in truth, that these cases had no existence, or that they have arisen
only from  some erroneous statement.
  2.  Cases not followed by death.   Sixteen of the observations that
have come to my knowledge, showing that the patients have been
at first restored, seem at least to prove that they  did not die from
the effects of the first  accidents.  These cases are those of Sim-
monds, 1;  MM. Mott, 1; Clemot, 2;  Barlow, 1; Warren, 1; Roux,
1 ; Mirault, 1 ; Rigaud, 1 ; Delaporte,  1 ; Dubourg,  1 ; Malgaigne,
1 ; Begin,  1 ; Toulmouche, 1 ; Amussat, 1 ; and one of my own;
total, 16.
  These observations differ much in importance.   Those of M. Ri
gaud, of M. Malgaigne, and of  M. Mott, show only a wound of
the external jugular vein.  Those  of MM. Amussat and  Toul-
mouche relate only to the  mammary veins.  In the case of M.
Barlow, and  in some  of those of M. Clemot, it  seems that  the
wound had nothing to do with the veins, neither with the  axillary
nor the internal jugular.
  There remain, then, only those of  Simmonds, (Med. Facts and
Obs., vol. viii., p. 23,) MM. Roux, Warren, Begin,  Delaporte,  Du-
bourg, Mirault,  and my own, with one of those  of M. Clemot,
which  permit us to allow the fact to be possible, according to the
region and the part of the veins wounded.
  3.  Cases followed by death, without autopsy.  The cases followed
by death, but which have not been accompanied by a post-mortem
examination, are six  in number, and are authenticated  by the
names of MM. Warren, 1 ;  Clemot, 1;  Barlow,  1 ;  Goulard, 1 ;
Klein, 1 ;  and Maugeis, 1 ; total, 6.
  In these six cases, we perceive  that the  wound was on a vein
not well ascertained in the case of M. Clemot, probably on the in-
ternal  jugular in that of M. Barlow, the thyroid plexus in that of
Klein, and a sub-scapulary branch in that of M. Warren.  M. Du
plat says positively that it was  the  axillary in the case which he 

         THE CONDITIONS THAT ARE ACCESSORY TO OPERATIONS.      33

attributes to M. Goulard.  The median vein in the fold of the arm
was the only one opened in the case of M. Maugeis.  This simple
enumeration shows the uncertainty which must remain in the mind
with such facts before us.
  4. Cases followed by death, and in which there was an autopsy.   In
this last group I find seven observations.   They are those of M. Pie-
dagnel, 1 ; of Dupuytren, 1 ;  of Delpech,  1;  of MM. Castara,  1 ;
Ulrich, 1 ;  Roux, 1; and Putegnat,  1; total, 7.  That of M. Pute-
gnat, being given without any detail and on the authority of a,
third person, ought, I think, to be  laid aside.   M. Piedagnel says
that it was the  external jugular vein which was wounded in a pa-
tient of Beauchene.  This practitioner has also told me  that in the
case of Dupuytren, the  tumor  occupied  the  posterior  and right
lateral region of the neck.  It is not possible, therefore, that it was
either the internal jugular or subclavian which was wounded.   In
the case of  M.  Roux and that of Delpech, the operation was  the
amputation at the shoulder-joint, and veins other than the axillary
vein, had  alone  been wounded when the accidents took place.
M.  Saucerotte  says, that in the patient of M. Castara it was, like
that of M. Warren, a  subscapulary vein which had  been opened,
and that to the  extent of at least a line.   The case of M. Ulrich is
then the only one which  accords with the region where, after our
experiments upon animals, the introduction of air into the veins
may occur and  prove dangerous.
  If now we take a survey of the whole question, we are in some
measure forced to admit the following conclusion:  Either the  ex-
periments which have hitherto been made on living animals are in-
complete and delusive, or the  cases of  introduction of air into
the veins of man are not conclusive. In viewing it with the great-
est  impartiality, I see,  in fact, 1. That from direct experiments, a
large quantity of air is necessary to destroy a dog : that this gas is
not introduced spontaneously  into the heart, but by means of suffi-
ciently large openings into the jugular,  subclavian, or axillary
vein; that the right cavities of the heart are then always distend-
ed,  by a matter of a red color, and  frothy, and evidently made up
of the intimate  mixture of the air with the blood.   2.  On the other
hand, the facts collected in reference to man,  show that many of
them relate to the veins of the breast or shoulder, the external jug-
ular, or the veins of the face.  In  the others, the opening of the
vein was small, and there could  not enter  but a small quantity of
air.  In fine, autopsy does not disclose in any of them, what direct
experiment has  permitted us to establish.
  It is not my province to refute, in this place, the language of those
who, without doubt,  through inadvertence,  have always either
in the  course of our  experiments,  or during the  debate in the
academy, which resulted from them, travelled out of the limits of
the subject under discussion, and who have always reasoned, as if
myself and many others had ever denied the  possibility and the
dangers of the  entrance  of air into the  veins.  Without seeking
for  the motives which could  have  induced some  of our brethren
  vol.  i.                        5 
84            NEW ELEMENTS OF OPERATIVE  SURGERY.
 constantly to fall into this pernicious habit, it is sufficient for me to
 refer to the account of the discussions in the academy, to show the
 falsity of such reasoning.   (Bulletin de TAcademic Roijalc de Mede-
 cine, Paris, 1837 et 1838, torn. i. et ii.)
   May it not be said, then, that all the observations collected upon
 the human species, have in them something strange and altogether
 unusual I   If it is true that patients may die of syncope, of hemor-
 rhage, of fright, and of exhaustion during the performance of cer-
 tain severe operations, then  is it  also  true, that  life  may be
'extinguished with another order of  symptoms  than those that
 have been related.  If we take away from the  catalogue  which
 I have  given, the cases  of  Klein,  of MM. Duportail,  Lodge,
 Cooper, Dubourg, and Maugeis, which are utterly of no importance,
 or which are satisfactorily explained without the intervention of
 air into the veins, it will prove difficult to withhold the  same  ex-
 planation for the others.  In supposing, that in the cases related
 by MM. Rigaud, Clemot, Begin, Malgaigne,  and in that of  mine,
 the jet of a small artery against some of the organic  tissues, or
 the introduction of air into  some of the sinuous culs de sac, may
 have assumed a resemblance to the hissing, gurgling, or bubbling
 (bouillonnement)  mentioned  by the narrators,  it is almost impos-
 sible not to concede something more  in the facts of MM. Piedag-
 nel, Dupuytren, Castara,  Delpech, Ulrich, Barlow, Warren, and
 Goulard.
   In this  state of uncertainty, may it not be asked, if, at the mo-
 ment of operating upon a man, the veins, being kept pervious (cana-
 lisees) by the nature even of the tumor, or by the tractions exerted
 upon it, might not have been  temporarily put in the state in which
 we find that those of the apex of the chest naturally are in  living
 animals ?   By means of this interpretation, however, we could not
 include in the group of facts that are very probable, any but those of
 MM. Goulard, Piedagnel, Dupuytren, Castara, Delpech, Warren, and
 Mirault.   It appears evident to me that nothing  had effected this
 change in the cases of MM. Rigaud, Amussat, Toulmouche, Mott,
 and Malgaigne.
   Could we not also call to our aid the previous  debility of the pa-
 tients ?  Every thing shows, although  our  direct experiments still
 present some doubts on this point, that the loss of a great quantity
 of blood must render the admission of air into the veins more dan-
 gerous.   But in  analyzing  the facts, we see that, apart from those
 of M. de  Piedagnel, of M. Roux and of  Klein, all the patients
 were still strong; that most of them, moreover,  enjoyed perfect
 health, and that they had scarcely lost over a few ounces of blood
 at the moment when the accidents happened.
    If we do not wish  to  abandon  this comparison, there  remains
 only one other resource :  it is to admit, that whether under a physi-
 cal, or a physiological, or pathological point  of view, the conditions
 upon which air enters the veins present marked differences in tho
 human  species and in animals.  We may look upon these differ-
  ences as possible, when we consider  that air in the veins destroys 
        THE CONDITIONS THAT ARE ACCESSORY TO OPERATIONS.     35

the horse more quickly than the dog ;  that under the influence of
this gas, death is more rapid when we hold the animal  in one
position rather than in another ; that by means of the air blown in
by  the  mouth  we kill  sometimes with the velocity of lightning,
whilst, with a syringe, a long interval of time is required to produce
the same result.
  I will, nevertheless, admit, that none of these reasonings are con-
clusive, and that there is nothing in them which places  the accu-
racy of what has been said  in favor of the introduction of air
into the veins of man, beyond  dispute.
  To express frankly my opinion,  I consider the introduction of air
into the veins of men to have  been probable in the patients of Sim-
monds, MM. Begin, Malgaigne, Mirault, Warren. Barlow, Delaporte,
one of those of M. Clemot, the first  case that M. Roux speaks of, and
my own.  Nothing proves that the accident took place in the cases
of MM. Toulmouche, Mott, the second and third of M. Clemot, and
those of MM. Rigaud, Dubourg, Maugeis, and Amussat.   It  was, in
my opinion, extremely probable in the case of Delpech, and in  that of
M.  Ulrich,  and I think it almost certain in the cases of Dupuytren,
and of MM. Castara and Goulard.
  Thus, without denying the possibility of this phenomenon, when
the veins form canals that open in the chest, I am of opinion that
new experiments are indispensable to resolve this  question defini-
tively.   If  the fact is true of man, we must seek another physical
explanation than that which has been given by MM. Poiseuille and
Berard; for there have certainly been seen elsewhere than in the
neck and axilla, phenomena similar to those which seem to denote
the introduction of air into the veins.
  Treatment.—In all scientific discussions, there is a rock that we
should  do all in our power to avoid, viz.:  that of adopting an opin-
ion too hastily, and of coming to a conclusion too positively,  in spite
of the absence of proofs, either for or against;  without  protecting
ourselves always, at any sacrifice, in doubtful questions, with the
saving clause, I know nothing of it, which is so often the substance
of our knowledge or of our answers.  Because the facts hitherto ad-
duced in favor of the introduction of air into the veins are  incom-
plete, we should be wrong, for example, to conclude from thence
that the accident itself has never  existed.  As for myself, I repeat,
that this kind of accident appears to me to have been many times
met with;  only I feel that until there  are proofs more conclusive,
this opinion cannot be any thing but a personal belief, and that sci-
ence possesses nothing at the  present day which  can change this
belief into  a fixed and general conviction.
  With this idea, I have thought it due to consider, as so many others
have done,  the means that we  may use to meet the dangers attribu-
ted to the introduction of air into the veins.  Our intentions should be
confined here to two kinds of remedies, viz., preventive and curative.
  Preventive means.—An important difficulty will  for a long time
render doubtful the efficacy of the attempts that it might be possi-
ble to make to prevent the admission of air into the veins of a person 
36
NEW  ELEMENTS  OF OPERATIVE SURGERY.
during operatiqns.  This difficulty is,  that no  one can tell before-
hand, whether, on the  supposition of opening such or such a vein,
the phenomena will or will not take place.  I have, myself, more
than fifty times extirpated submaxillary, parotid,  axillary, supra-
clavicular, or supra-sternal tumors, which have  placed me  under
the necessity of approaching very near the large veins of those
regions, and often even of opening them.  It is  nevertheless true,
when I say, that the case of which I  have given  an  extract, and
that of the young boy, are the only ones which have for a moment
alarmed me under the impression that air was introduced into the
veins.  I will add, that, while serving as assistant to M. Roux, I
have seen this surgeon open freely the  upper part of the subclavian
vein in one case, the superior portion of" the axillary in another,
and the inferior portion of the internal jugular in a third, without
any thing resulting therefrom that could be referred  to the  intro-
duction of air.  When we reflect upon the number of  amputations
that have been made at the shoulder-joint, the frequency of opera-
tions that have been performed in the axilla for cancerous or lym-
phatic tumors, and the numerous cases of ligatures upon the arte-
ries in the  supra-clavicular  and  carotid regions, without  being
followed  by any result similar to that which  air  produces  when
carried into the heart, we are forced to admit that the accident in
question cannot, at least, take place but  seldom.  .How then can
we become certain, if it  has  not taken place  in any given  oper-
ation, that we  are to impute  this  exemption  to the  precautions
employed, rather than to  the natural resistance of the organs.
   We thus see clearly, that in order to solve this question of pre-
ventive means, as for all the others, it will be necessary to have fur-
ther and repeated experiments.   Let us, however, examine those
which appear to have hitherto claimed attention.
  The compression of the thorax, during the entire continuance  of
the operation, does not appear to me  proper, neither theoretically
nor from the experiments already made.  If the compression were
sufficiently powerful in the human species wholly to  prevent the
elevation of the ribs, the  patient would obviously experience from
it great inconvenience, if it did not in fact become insupportable.
Besides, the chest would  not the less  enlarge itself in its vertical
diameter by the depression of the diaphragm.  Moreover, it  is not
yet demonstrated thjat  the dilatation of the heart has any part in
the inhalation of the air.
  Reasoning  upon the supposition that  inspiration  alone  could
draw the air into the heart, M. Poiseuille thought it would suffice,
to prevent this accident, if we charged the  patient carefully to
avoid any thing like a full inspiration.  But experience has long
shown surgeons,  that during serious  operations, the  chest of the
patient is generally kept contracted in a spasmodic manner; that
respiration is retarded and made by small movements, and that  we
are   ^.^ obliged ^ urge the patient to make full inspirations than
to prohibit him from  doing  so,  provided we guard against  the
venous circulation being thereby too much obstructed. 
        THE CONDITIONS THAT ARE ACCESSORY TO OPERATIONS.     37

   Compression of the veins between the heart and the wound.—When
the idea of the introduction of air into the heart of man presented
itself to practitioners, the first remedy which naturally offered was
evidently the compression which I have  named above, so natural
and certain does  this means  seem to be.   Thus  M. Larrey had
already remarked, in speaking of taking blood at the neck, that we
must compress the vein below the puncture, and until the dressing
is finished, if we would prevent the entrance of air into the heart
Dupuytren is careful to point out the same precaution while relat-
ing his case.   We find a similar recommendation in the memoir of
M. Barlow.  M. Putegnat also gives it in his thesis.  I perceive at
p. 266 of the Treatise upon  Tumors,  by M. Warren, that the sur-
geon who operates in the neighborhood of the jugular, subclavian,
axillary, or iliac veins, or even of the  saphena when it is dilated,
should reserve to the last the separation of the peduncle of the
tumor upon that side, in order to be better enabled  to compress the
veins before opening them.   This author  adds, that, if the thing is
possible, we should compress the veins between the incisions and
the heart.  I  have believed it myself right to adopt this advice
and to practise it in some cases of extirpation of parotid and submax-
illary tumors.   But it must be admitted that this remedy is but of
little value.  If, with the first observers, we could admit the possi-
bility of the inhalation of the  air at a very considerable distance
from the heart, it would deserve to be taken into serious considera-
tion.  Nothing would  be more easy than to put it  into practice
with the internal saphena, or the femoral, or iliac  veins, the veins
of the arm and face, and the external jugular; but  if it  is true that
the introduction of air into any of these regions is impossible, com-
pression, as a preventive means, becomes for that reason altogether
useless.  On the other hand, who does not see that for the supra-
clavicular region, the upper part of the axilla, and the  supra-hyoi-
dean region, where its aid might be invoked, it is quite impractica-
ble ?  Concealed by the clavicle or sternum, and  separated from
the ribs by the lower attachment of the  scaleni muscles, the sub-
clavian vein is so placed that  nothing can obliterate the cavity of
it by pressing  through the skin.  It is the same with the  internal
jugular vein below the larynx.  We  must also add, that the com-
pression of this vein, in operations near the parotid region, favors
the engorgement of the face, and increases  the volume of all  the
veins that we are in danger of wounding.
  After these various reasons, then, we are compelled to admit that
the compression of the venous trunks  between the  .wound and the
heart is, in fact, a resource of but little importance,  and rarely
practicable.
  It results from this  examination  that, in  practice,  we cannot
count on the efficacy of any of the preventive means of which we
have hitherto spoken; that  we must make still further researches ;
a§d that, under this point  of view, the only resources within  the
reach of the surgeon resolve themselves into these :  First, To do
every thing during an operation to avoid wounding the  interna] 
88            NEW  ELEMENTS OF OPERATIVE SURGERY.
Jugular and  subclavian  veins:  and, secondly, In the event of his
being forced to penetrate to the neighborhood of these  vessels, he
must not separate the peduncle of the tumor without halving first
seized it. on the side of the heart, with two fingers, or included it in
a strong ligature : third,  To avoid, as much as possible,  extending,
pulling, or moving the parts, raising the arm, or throwing back the
shoulder, or the neck, when the bistoury approaches the large ves-
sels at the apex of the thorax.
   Curative Means.—If therapeutics possesses no means which can
absolutely prevent the air from entering into an open vein, it is no
less  humiliating  to confess that it is still more  powerless in the
means of expelling this gas from the heart.   I very much doubt if
placing the patient on  the right side, as M. Forget recommends, can
be of any great efficacy.
  The alternate raising and depressing of the thorax, (compression
saccadee,) by the aid of which, Nysten thought to expel the air from
the auricle through the wound of the vein,  is evidently useless, at
least  in the human subject.  Even in dogs, we cannot thus make
the air contained in  the right ventricle ascend; and the auricle
will  yield only a small portion of it.  Who  does not perceive that,
in the human species, the thorax, infinitely less compressible than
in dogs, will not admit of being sufficiently flattened to react effica-
ciously on  the heart.
  The means  which  first suggests itself, that is to say, the closing
of the venous wound, a  means practised in  a great number of
instances, presents, perhaps,  as  many dangers on one side, as ad-
vantages on the other.  If it  puts a stop to the introduction of air
into  the wounded vessel, it has the evil, also, of preventing the
egress of that which the contractions of the heart tend to force out;
so that it cannot  succeed, unless, at the moment of its application,
the gas is not in sufficient quantity to cause death.   Inhalation by
the mouth, through the opening of the vein, will scarcely ever be
practicable;  the  plainest reflection, also, suffices to show that  it
could not succeed.  Artificial respiration,  whether effected by tra-
cheotomy,  or by  introducing a tube through the natural air-pas-
sages, as attempted by M. Warren, could not, as it appears to me,
have any object.   The introduction of a  saline liquid by some other
vein, as is also recommended by that physician, could not but add
to the  danger that  the patient is already exposed to.
   There remains, then, suction with a tube or a syringe, conveyed
even into  the heart;  but this resource, originating in experiments
upon animals, ought to be, in my opinion, severely proscribed on the
human subject.  It is obviously clear, that the  wounds of the in-
ternal jugular only would admit of its application.  Who does not
also see that, in order to introduce the tube, it would be necessary
to put the vessel precisely in the conditions which would most  favor
the introduction of the air ?  In short, who has not felt that, during
a serious operation, it is necessary first to ask if the accidents whiil
take place, in reality depend  upon this phenomenon; to seek, after-
wards, for the opening of the vein; to demand of the assistants the 
THE CONDITIONS THAT ARE  ACCESSORY TO OPERATIONS.
39
tube arranged for this purpose ;  to introduce this tube, and to ap-
ply to it the syringe or the mouth ; and that all this would neces-
sarily exact more time than is required for the patient to expire, if
what has been said of the entrance of air into the heart during the
course of certain operations on man is realy true 1
  We  are  then  reduced,  in this matter, to the means generally
resorted to for syncope, unless bleeding, as formerly recommended,
and still eulogized by MM. Boulay, Le Blanc, &c, may, in reality,
have some  efficacy; to place the finger upon the wound, and imme-
diately suspend  the   operation, when the  alleged characteristic
sound has been heard  ; to keep the patient in a horizontal position;
to stimulate him with the  vapor of ammonia, alcohol, and vinegar;
to use frictions on the body, and to throw water in the face;  such
are, at present,  the only measures that reason and experience per-
mit us to  make use of, with  safety.   A pupil  of the  hospitals  of
Paris,  M.  Mercier, has made experiments  which would tend  to
prove, that the  compression of the abdominal aorta is a means of
great efficacy ; that in forcing the blood to mount towards the brain,
it brings back to life animals that appear to be on the point of ex-
piring ; and that it is, in short, an infallible remedy; but I have not
yet had an opportunity of testing the value of this method.
   [Entrance of Air into the Veins.—In the case of  Dr. Mott, above
alluded to, he was then convinced, and ever has been since more
and more confirmed in the belief, that the symptoms in that case
were entirely ascribable  to the admission or  suction of air  from
without into the incised facial vein.   And he also would embrace
this occasion to add, that  reflection upon the subject, and upon the
facts that have, been so clearly given by M.  Amussat in his Report
to the Paris Academy of Medicine,  1839, and by other  practi-
tioners who- have witnessed this phenomenon, and also that the de-
tails of another  remarkable case to which he has himself been an
eye-witness, satisfies him fully in his own mind of  the entire possi-
bility of this alarming event during operations.   The case of which
Dr.  Mott would now speak, was that of a French lady at  New
York, from the southern states, of middle age and tolerable health,
in whom an  enlargement of the thyroid  body assumed, strange to
say, the complete character of a malignant bleeding fungus hczma-
todes of the worst description.  Dr. M., not being  able to bring
himself to the propriety of attempting to remove  so  formidable a
mass of disease of that nature in so unfavorable a subject, declined
the operation, which,  however, was undertaken by another surgeon.
   The operator had proceeded but very little distance in his incis-
ions, when it was discovered that the calibres of the venous and
arterial plexuses, particularly those of the former,  were, as so gen-
erally happens, enlarged to a prodigious  extent, and that therefore
the hemorrhage would, as it  began to evince, be most profuse.  At
this critical moment of suspense, a wheezing or whizzing noise was
suddenly heard  by all present, (some  twelve  to twenty persons,)
resembling in sound that of air quickly rushing into a tube by suction,
and so unusual and unaccountable as to cause the late deceased 
40            NEW  ELEMENTS  OF OPERATIVE SURGERY.
eminent professor Dr. David Hosack, who was present, to involun-
tarily  exclaim,  "What's  the  matter?   Have  you  cut  into the
trachea ?"   This of course had not been reached or disturbed, and
the remark had scarcely been uttered when the patient  instantly
expired.  Take this one pathognomonic symptom alone of the ac-
cident, we mean the peculiar and readily recognisable and charac-
teristic  sound as of suction of bubbling air (as if, for example, from
frothy blood) suddenly rushing into the aperture of a  tube, or, as
Dr. M. expresses it in the case he has published, into an aperture
in the exhausted receiver of an air-pump ;  and it is quite sufficient,
with the rapid fatal sinking and almost instantaneous loss of life
which but too often succeeds, to show that there can be  no analogy
whatever found between  the manifestations that take place in this
phenomenon and those that are ordinarily observed during the faint-
ings, swoonings, and prostration that are caused sometimes by pro-
fuse hemorrhage during operations, and that are thus as frequently
also the immediate precursors  of death.  We might dwell also on
another peculiar symptom which does not always exhibit itself, it is
true, when air has been imbibed  in the vessels, but which, when it
does, is equally removed in its character from what occurs in death
from exhaustion caused by hemorrhage.  This symptom is, as Dr.
M. has shown in the case of his own, described in his letter to M.
Amussat, (see Report  to the Paris Academy of Medicine, already
cited, and M. Guerin's Gazette Medicale of Paris,) that of convul-
sions of a most violent and peculiar nature, where the patient threw
himself on the floor, and  twisted and contorted his body and limbs
with spasms of the most  frightful description,  resembling  rather
the agonizing sufferings  of one  laboring  under hydrophobia, and
indicating certainly the most poignant distress, such as might  arise
from sudden strangulation or smothering, giving rise to  the  most
energetic exhibitions of muscular power.  A  very  different  and
opposite state, it must be confessed, from that of extreme exhaus-
tion, prostration, syncope, and  swooning from profuse hemorrhage
or concussion upon the nervous system, but imbodying results which
might rationally be explained by analogy, from the supposition that
the introduced air had, as it is proved to do in the  experiments on
living animals, penetrated into the right auricle and ventricle of the
heart, and thereby directly interrupted the vital functions of that
organ.—T.]

                § V.—Sang-froid of the Surgeon.

  When every thing  is in  order during  operations, the surgeon
rarely troubles himself, but many practitioners are disconcerted and
lose their self-possession  at  the  slightest untoward accident.  M.
Champion has instanced to me  a very distinguished operator, whose
sa,nf"froid is admiraDle wnen nothing particular occurs in the course
of the  operations he performs, but who is embarrassed with sur-
prising  facility in presence of every unusual obstacle.  He  aban-
doned one day, for dead, a female patient from whom he removed 
       THE CONDITIONS THAT ARE ACCESSORY TO OPERATIONS.      41

a tumor on the fore part of the neck, because she fell into  a syn-
cope, from which M. Champion soon revived her by placing her on
the bed and throwing a glass of cool water in her face.  I myself
know of one who operates with a remarkable composure, but who
quickly becomes discouraged when he sees any thing of a disquiet-
ing nature that he did riot anticipate.   I have seen this physician,
who is one that bears a celebrated name, and is justly esteemed,
faint at the sight of a simple operation  for empyema performed by
one of his colleagues, and at the extirpation of a tumor from the neck
in which he himself assisted.  These are moral peculiarities that
are very unfortunate, seeing that if it is  important that the surgeon
should reflect a long time, and analyze and weigh  every circum-
stance before commencing  an operation, it is also necessary that,
when he is once armed with the instrument, he should be discon-
certed at nothing; entirely absorbed in the work that he has com-
menced, he should have calculated all its chances and all its diffi-
culties, whether natural or  contingent, and be ready to  change
them, avoid, or remedy them, and foresee their consequences.  It is
under these circumstances  that the qualities of the  mind denomi-
nated composure and cool  self-possession are indispensable, and
merit the title of surgical intrepidity.
  When these qualities  are wanting, it is of great importance, as
it  is, in fact, in almost all the cases  where the operation involves
some serious responsibility, that the surgeon should  be surrounded
by skilful colleagues and assistants. Young practitioners, especially,
have n*.ed of assembling about them compeers of reputation when
they decide upon performing some important operation. They thus
procure for  themselves more  confidence and security, and  place
themselves under protection  from every harm if any unforeseen
event should happen.   There is instanced on this subject an exam-
ple which the great masters themselves should sometimes call  to
memory: Marechal wished to open an abscess of the liver in the
minister Leblanc ; but it was Morand,  who was then only a pupil,
who prevented him from plunging the bistoury on the side of the
abscess.  Some time after, the minister presented Marechal to his
family as the one who had saved his life.   The surgeon replied, as
he  pointed out Morand, " It is to this young  man that you owe it,
for but for him I should have killed you !"  (Leblanc, Precis de Chi-
rurgie, t.  L, p. 535.)
  In possession  of self-composure*  and of every kind of knowledge,
anatomical, physiological, and surgical, with which an erudite man
may adorn his mind, the surgeon has the right to undertake an in-
finity of operations, which  another should never attempt;  those,
especially, which are performed in regions where the compression of
the principal artery cannot be effected between the heart and the
seat of the disease.
  The operations required for diseases of the infra-hyoid and supra-
clavicular regions, and for those of the chest, abdomen, and peri-
neum, are, almost all of them, of this nature ; as to  the others, we
may readily conceive that  the agitation of the  operator, and his
  VOL. i.                    6 
42
NEW ELEMENTS OF OPERATIVE  SURGERY.
want of self-possession, would not prevent  the assistants from ar-
resting hemorrhage, and placing the patient out of the reach of all
real danger.

                  Art. III.—After Operations.

  Having finished with the use of the instruments, there  remain,
for  the  completion of the operation, many important things to be
done.

                  §. I.—To arrest Hemorrhage.
  The loss of blood being that which gives the most alarm, and
which may, in fact, the most speedily compromise the life of the pa-
tient, deserves to be considered first;  nevertheless, there  are an in-
finity of operations, which may, in this.respect, be neglected without
real danger.   Arteries of small calibre, those of the fingers, great toe,
scrotum, margin of the anus, neck of the womb, face, superior part
of the cranium, those of the skin, and of the subcutaneous tissue in
general, would rarely give place to serious hemorrhage in patients
not  previously enfeebled, if we could summon sufficient boldness not
to apply the ligature to them ; in other respects, as there is no incon-
venience in obliterating them when it is easy to seize them, it would
be imprudent not to close  them immediately ; it is only when they
have  ceased  to bleed,  and in  cases where all the  surface of the
wound may be covered, and more or less completely compressed
by small balls of lint, that I would advise abstaining from the ordi-
nary haemostatic means.
  A.  Various  Topical Applications.—We hear no  more to-day of
cauterizing the wound of  an operation with hot iron, boiling oil,
or melted lead, as was done in  the time of Paul  of Egina, and
Abu-1'Kasem ; nor of stuffing it with  tow, and enveloping  plasters
saturated with white of eggs, bole Armeniac, or  other astringents
pointed  out by Guy de Chauliac (Grande Chirurgie) and almost all
the  surgeons of the middle ages ; nor of having recourse to arsenic,
vitriol, and alum, (Borel, dans Bonnet, t. iv., p. 89,) still recommended
by Lavauguyon and Le Dran; nor,  in fine, of employing sponge,
or the agaric from oaks, as Brossard and  Morand proposed, long
time after Encelius, (Bonnet, Collect., etc., t. iv. p. 364,) towards the
middle of the last century.  Some, however, still  extol the remedies
that are included  in this enumeration.  M. Binelli says, that with a
water of his invention it is easy to arrest every kind  of hemorrhage ;
and some  experiments on  animals seem, in fact,  to give  support to
his  assertion.   M. Bonafoux  (Revue Med.,  1831, t. i., p. 49, 324)
composes with charcoal, gum,  and colophane, a powder  which, ac-
cording to him,  possesses the  same  properties.   In  fact, MAI.
lalrich and Grand (Bulletin de Therap., t. i., p. 137) have discov-
ered a liquid whose efficacy has been placed beyond doubt by a
great many experiments on clogs, sheep, horses, &c. ; but the appli-
cation ot these new means, which, in my opinion, are little to be 
        THE CONDITIONS THAT ARE ACCESSORY  TO  OPERATIONS.      43

relied upon, not having succeeded in man, it becomes unnecessary
that I should say any thing further of them.
   B.  The ligature is properly preferred to them.  Pare  is the au-
thor who revived and rendered new this important modification.  If
Galen, Avicenna, Tagault, and some others had already mentioned
it, it must be conceded that it was of no advantage to their succes-
sors.  Fabricius of Hildanus, Wiseman, and Dionis, who soon adopt-
ed it, did not neglect to bring it into general  use.  For more than a
century past, there are but some few exceptions in which we do not
use it, or substitute other means for it.   We begin with the princi-
pal artery, seeing that it is that which it is most easy to find, that it
is the one more important to be tied, and that afterwards the other
branches are more easy to be discovered, because they then carry a
greater quantity of blood.   We seize it with the forceps, called the
artery or dissection forceps, embracing it throughout all its thick-
ness, and taking care at the same time not to include the nerve or
vein.   Some persons, however, have advised to seize and tie at the
same time the artery and the vein together. Their object was to
avoid by that means the hemorrhages which the large veins may give
rise to.  The moderns have  rejected  this practice, first, because it is
useless, and also because it  is dangerous : useless, since the retro-
grade circulation of the veins does not allow the blood to  escape by
their mouths into the thick part of the stump, or because, if this acci-
dent happens, it is not necessary to recur to  the ligature to remedy
it; dangerous, because, as it is said, in tying.a large vein, we run the
risk of producing inflammation.  Others add, that it is proper to sepa-
rate the artery carefully from the surrounding tissues.  Experience
enables me to say that these are rules of  but little importance.
Whether we seize the artery alone, or deprived or not of its surround-
ing tissues, or embrace the whole of it, or insert one of the branches
of the instrument in its tube, while the other occupies the interior of
the neighboring vein, or that the ligature encloses the entire artery
only, or the artery and the vein, the operation will nevertheless have
nearly the same chances of success or failure.  The difficulties and
the dangers do not lie there ; and what has been said on this matter
is in no degree borne out by practice.  As to a simultaneous liga-
ture on the nerves, all recommend that it should be avoided.
  In the place of the forceps, Bromfield  and most of the English sur-
geons make use of a pointed  instrument, in form of a prolonged
arc, to which they give the name of tenaculum; but this tenaculum,
though it renders the application of the ligature more certain and
easy, is less convenient than the  forceps for seizing the artery with-
out tearing it; it is on this  account, without doubt, that it  is but
rarely employed in France.  The English themselves have recently
made such modifications of  it, that it resembles now our  hook for-
ceps, (pinces a crochet.)   Be  that as it may, having  once seized the
artery, the  operator endeavors to bring it out to the surface of the
wound; an assistant passes a ligature beneath, in order to unite ks
two extremities above, and to form a  circle, which he pushes beyond
the point of the forceps, which is then inclined  horizontally.   We 
44
NEW  ELEMENTS  OF OPERATIVE SURGERY.
tighten this ligature by embracing its extremities with the last fin-
gers of the two hands, and  by drawing upwards, while with the
thumbs, or the index fingers, we force the knot as deeply as pos-
sible into the bottom of the wound.   Some persons prefer drawing
on the ligature so as to  carry the extremities of it  backward be-
yond  the plane of the artery that we wish to tie.  If it is in the
bottom of a cavity where the vessel is found, it suffices, in order to
obtain the same result, that we support the  ligature outside the
knot with the index fingers,  which thus represent a sort of pulley.
But it is evident in this matter, that every one must adopt the course
which appears to him the most convenient and the most safe.  The
principal artery being  tied,  we  carefully search for the others, to
secure them successively in  the  same manner ; only that it is use-
less then to isolate them as carefully from the small veins and other
tissues which surround them : that is to say, if the direct ligature is
almost indispensable for the  large arteries, it is not as important
for the smaller ones.  Here  the tenaculum, grasping the vessel as
a hook would  do, brings it  out more  easily, and enables us with
greater  facility to surround it with the ligature.  If the artery is
deep or too difficult to separate, we  have recourse to the interme-
diate ligature ; that is, we include in the thread the entire organic
mass from whence the  blood  seems to come.  In those cases we
are sometimes  obliged to use a curved needle in order to pass the
ligature around the vessels.
  The threads that are used  are single for vessels of the second or
third  order;  a double or triple  ligature is preferred  for the large
trunks.  However, in England, where fine ligatures have been gen-
erally adopted in the treatment of aneurisms, they make no further
use of double or triple  threads even for other operations.  With-
out being indispensable, the French  method is, however, rather the
most safe.
  The principal artery is sometimes so hard, incrusted  with phos-
phate of  lime or diseased,  that, in applying a ligature  upon it, it
breaks like glass; in this case we may introduce into its interior a
small cone of linen, of cork, gum-elastic, or any other  substance,
or place between it and the ligature,  and of sufficient breadth to sur-
round it, a small cylinder analogous  to  that which is known under
the name of the rouleau of Scarpa.
  Sometimes the blood escapes from the interior of a bone, either
by simple transudation or by the trunk of its nourishing artery.  A
small graduated compress applied on the spot where the blood es-
capes, while  we are proceeding in the search for other vessels
generally suffices ; or sometimes it will be necessary to have re-
course to cauterization, or to insert in the medullary canal a piece
of wax, plugs of lint, or of agaric.
  There is a  crowd of arterial branches noticed during an opera-
tion, that soon after cannot  be found, but which sometimes  give
rise, a little while later, to a sufficiently abundant  flow of blood.
On this subject an explanation has been giYen, which to me appears
any thing but satisfactory.  I do not see that the momentary absence 
        THE CONDITIONS THAT ARE ACCESSORY TO OPERATIONS.      45

of the hemorrhage ought to be imputed to the spasm of the divided ar-
teries, nor to their retraction, nor perhaps to the instantaneous effect
that the action of the atmosphere exercises  upon them.   If they
seem to reopen themselves at the end of some hours, it is evidently
because the concentration of the organic  actions produced by the
operation finishes by giving place to an eccentric movement more
or less energetic, which brings back the fluid from  the interior to
the exterior.  The mode followed at first by Parish in America, by
Klein in Germany, by many  surgeons in England, and in France by
Dupuytren, a mode which consists in not  dressing the  wound until
after the expiration of some  hours, does not consequently appear to
me to be justified by reason, and I think myself  authorized to cen-
sure it as a general method.  Except in some rare  cases, it is al-
ways possible to guard effectually against hemorrhage immediately
after the operation.   The wound remaining open, undoubtedly gives
a better opportunity for placing new ligatures if they become neces-
sary ; but who  does  not know at the present time that we render
the ligature useless  upon an  infinity of  small arteries, by uniting
immediately the greater part  of the solutions of continuity.  Be-
sides, the patient, seeing that he is not dressed, becomes  restless, and
dares not trust himself to sleep.  In fact, it is  a practice  which,
though good in some cases, ought not to become  general.
  Since immediate union after operations has been proposed and
followed by a great number of operators, it has  been suggested to
leave in the wound as few foreign bodies as possible.   They thus
began by cutting off  one of the ends of each ligature very near  the
artery.  Veitch, who considers himself the inventor of  this modifi-
cation, strongly insisted, in  1806, on the advantages thereby pro-
cured.  He was in the habit of employing  very fine  ligatures of
silk, in order to be enabled to cut their two extremities, and to leave
their knot around the artery. Doctors  Wilson and Hennen fol-
lowed this practice for a long time before M. Lawrence had given
any account of it. MM. Collier, S. Cooper, and  Delpech, who have
also tried it successfully, declare that these ligatures often give rise
to abscesses, and  that it is better to leave their extremities out.  It
would appear further, that they were in the habit, in different coun-
tries of Europe, from the year 1780, of cutting the two portions of
the ligature very near the knot.  As silk and thread do not appear
susceptible of absorption, and act always like foreign bodies, an at-
tempt was made to use ligatures of another kind.  Ruysch had al-
ready proposed for aneurisms wide  strips of leather.   Beclard  re-
vived the use of them in France.  In America M. Physic tried liga-
tures of deerskin, and M. Jameson, (Journal des Progres des Sc. Medi-
cates, t. xl, p. 117; t. vii., p. 126; t. ix., p. 150,) who  has employed them
for a long time, speaks much in their favor.  Others have had recourse
to the gut of the silk-worm, to catgut, &c.  But  experience has not
yet decided upon the real and precise value of these different sub-
stances.  [Dr. Mott  has tried forms of  animal ligatures, catgut,
buckskin, raw-hide, &c, in the treatment of aneurism, and, from his
experience, it is preferable to leave  one end out, as abscesses will 
46            NEW ELEMENTS OF OPERATIVE SURGERY.

otherwise form in the wound.—T.]  At  Paris they generally use
ligatures of thread, single or double, according to the  size of the
artery.  When they are applied, and before proceeding to the dress-
ing, we cut one of the ends off near the vessel, in order to diminish
the bulk they would make in the midst of the tissues.  The other ex-
tremity rests without, to serve to draw out the knot which it forms
deep within, when that shall be detached from the artery.   As a
general method, it is the best in practice.
  C. Compression.—Kock, (Bulletin des Sc.  Med., t. xiii., p. 361,)
surgeon of the  hospital of Munich, affirms, that for more than twen-
ty years he has not in  any case had recourse to ligatures after am-
putations.  He confines himself to pressure upon the principal
artery of the limb, by means of graduated compresses, and a roller
bandage  extended from the  trunk to near the wound, which he
unites  immediately.  Numerous facts, he says, support  this prac-
tice, and prove that the arteries have no need of being tied to pre-
vent them  from  carrying  blood to the surface of the  stump.  A
serious question appears to me to lie at the bottom of these asser-
tions.   The annals of science  contain facts without number which
prove that the division of the  largest arteries  may not be followed
by any flow of blood.   Every one  knows that lacerated wounds,
amputations following gangrene, and wounds by fire-arms, have
often, in this  respect, astonished  operators.   S. Wood had his
shoulder torn off by the wheel of a mill, and got well without any
artery having  been tied.   De la Motte, Carmichael, Dorsey, and
M. Mussey, each one, relate a similar fact.  A child of nine years,
mentioned by Benomont, had the leg torn off, and  recovered in the
some  manner.   The  thigh violently  separated  from the hip,  in
another case,  was in like manner not followed  by  any flow of
blood.  Amputations of the thigh, related by Tcheps, Scharchmidt,
Theden, Thomson, MM. Taxil, S. Cooper,  Beauchene, Segond, and
Labesse, were attended with  the same phenomenon.  MM. Arbe,
Lizars, Mudie, Smith, and Flandin, have all stated the same of many
amputations of legs, arms, forearms, &c, as I have elsewhere shown.
(Journal Hebdomadaire, 1830,  1831.)  Similar  facts have also been
mentioned  by M. Briot, (Soc. Med. d'Emulat., t.  viii., p. 273,) by
Chabert, (Malgaigne, Thes. No.  55,  Paris, 1831,) by  M. Roux,
(Voyage a Lond., etc.,  1815, p. 53,) &c.  We thus explain the ideas
of Theuillier, (Thes. de Haller, extr., t. iii.,)  who, in place of ligatures,
prefers that, after operations,  we should  confine  our treatment to
diet, bleeding, and relaxants,  a practice since  revived here (Roux,
Voyage a Londres, etc.) by a surgeon of the provinces.  Although
the dangers of Kock's practice had been shown by the evidence of
M. Graefe, at  Berlin, and  even by M. Kock, his  son, (Journal des
Progres, t. xii., p. 248,) I have, nevertheless, thought it  my duty to
make  some experiments myself, of which the following are the
principal results.
   D.  Bruising.—The  bruising mentioned by M.  Briot  (Soc.  Med.
dEmulat., t. viii., p. 273) scarcely answers but for the small arteries;
if people who  make use of it, after having cut or torn off the cord 
        THE CONDITIONS THAT  ARE ACCESSORY  TO OPERATIONS.     47

 from new-born infants, if the animals who do  the  same succeed
 thus in preventing hemorrhage, it is because, as a general rule, the
 circulation naturally ceases of itself in  the  umbilical vessels after
 birth.   Nevertheless, having employed it successfully on the epi-
 gastric arteries, the tibials, and  the arteries of the fore-arm, I can
 imagine that Le Dran may have found it to answer after  the di-
 vision of the testicular cord of man.
   E. Plugging the Artery, (Fermeture.)—A cone of alum  or sul-
 phate  of iron, four to six lines long, inserted into the crural  artery,
 and even into  the carotid of a dog  or cat, becomes firmly fixed
 there,  and suffices in  general to stop the effusion of  blood;  except
 that from the kind of eschar which results from it, rendering the im-
 mediate union impossible, we run the  risk of seeing the hemorrhage
 reappear when  the foreign body falls out; it is proper to add, that
 its  introduction is not always easy except  in the larger arteries.
 Wax produces  the same effects, except that, being more slippery,
 and without any chemical action on the vessels, it becomes neces-
 sary to insert it deeper.   Nevertheless, if, when it  is introduced,
 the operator endeavors to push it from above down with a forceps
 or with  the fingers, across the walls of the vascular tube, which
 he holds firmly grasped,  there results from this a sort of swollen
 knob which  the blood cannot easily remove.   The small probe
 (stylet)  which   Chastanet (Gouraud, Principales  Operat,  etc.,
 Tours, 1815) appears to have used with the same intention a long
 time ago, though less safe, often effects a permanent obliteration
 of the  artery.   The point of a wax  bougie is infinitely better, pro-
 vided it is not allowed to penetrate  over an inch in depth.  Catgut,
 deerskin, or chamois leather, scarcely  acting as foreign bodies,
 have yet greater  advantages, inasmuch as they do not prevent
 our closing the  wound immediately.  These different means are at
 the best but a species of plugs, whose manner of acting is too sim-
 ple to require long explanations.
  M. Miquel d'Amboise (Journal des Connaiss. Med., t. iii., p. 3, 70,
 75, 102, 131) had made, at the close of the year 1828, observations
 similar to those of mine.  I  have proved, he  remarks, by thirteen
 experiments, that in introducing into the arteries of a dog a foreign
 body, especially the string of  an instrument, there is soon perma-
 nently developed there a morbid  condition, which renders them
 incapable of receiving the blood, though they may not be mechani-
 cally obliterated.
  F. Reversing, (Renversement.)—When it  is not too difficult  to
 isolate the artery, so as to reverse  it  upon itself, as Theden (Pro-
gres de la Chir., etc., p. 78) says he did on the intercostal, and Le
 Dran (Operat., etc., p. 193) on the whole cord after  castration, we
 almost have it in our power effectually to arrest the flow of blood.
 For that purpose it is sufficient, as  I have often done, to fold back
 the end of the  vessel, double it,  and then force it a  little into  the
 tissues, or immediately shut the outer wound, in order to maintain
 it  in the position that we have given it.  But as it is possible that
 without this reversing all those arteries would have equally ceased 
48
NEW ELEMENTS OF OPERATIVE SURGERY.
to bleed, prudence demands that we should wait before drawing any
conclusion from it.   In passing, afterwards, the inverted end across
the trunk of the artery itself, as M. Stelling proposed and did at Paris,
in 1835, (Gaz. Med., 1835, p. 367,) we should make of this operation
of reversing one that was difficult, dangerous, and very unsafe.
  G.  The Perpendicular Compression, which J. L. Petit, (CEuvres
Posthumes, t. iii., p. 152,) in the last century, wished to see prevail,
has not been adopted.  Inserting plugs of linen, agaric, sponge, or
lint, ami maintaining them, as this author directs, by the aid of a ma-
chine, on the arteries at the bottom of the wound, could only have
the effect to aggravate the consequences of the operation,  without
the certainty of preventing hemorrhage ; and in respect to the dis-
tinguished personage of whom he speaks, it would have been bet-
ter to have searched for  the  principal arterial trunk of the limb
above the solution of continuity,  than to have done what he did.
  H.  Torsion.—A subject  which naturally  arises out of the fore-
going experiments is that of torsion, as a substitute  for the  ligature
after operations.  I was led to this discovery in  1826,* in making
experiments on dogs of the various known haemostatic means.  I
had not, however, yet attempted it on the human subject, neither
had I  sufficiently varied my experiments on animals to permit  me
to speak of it to others than to the pupils who followed my lessons
in operative surgery at the close of the year 1827.   But on the 13th
of November, 1828, after having amputated the fore-arm of a girl
named Rohan, in presence of MM.  Al. Dubois and  Malteste, I
twisted the radial and ulnar arteries, reversed the anterior inter-
osseal, and immediately closed the wound; no hemorrhage super-
vened, and the cure was effected  in twenty-three days.  On the 4th
of December following I did the same  thing, and with the same
success, after amputating the first metatarsal  bone  in a strong and
vigorous adult.  Nevertheless, it was not until the 21st September,
1829, that  I performed the first amputation  of the thigh without
ligatures.   I had only to twist the femoral artery and two small
muscular branches.   There occurred no hemorrhage.   The young
girl, who was nineteen years of age, did well till  the fourth day,
but died on the twelfth.   The autopsy of the dead body showed nu-
merous purulent and  tuberculous abscesses (foyers) in her lungs.
The  ilio-femoral articulation was in a complete  state of suppura-
tion.  Some days later, on the 26th of the same month,  I did the
same, after an amputation of the  arm in a young man aged twenty-
three  years.  The brachial artery, the anastomotica magna, and two
branches of the external communicating artery, were twisted with-
out difficulty ; but many other branches caused  me  more trouble.
Perceiving, at the end of a quarter of an hour, that in spite of the
tourniquet the blood continued to flow, I took off the dressing. None
of the twisted arteries bled.  The  hemorrhage was from the bruised
(froissees) branches, and from three others that I had not at first per-
ceived.  I tied them all, and the bleeding did not return.  The pa-

   * Those who have since appropriated to themselves this discovery, did not speak of it
 till in 1829.               r                       "       H 
        THE CONDITIONS THAT ARE ACCESSORY TO OPERATIONS.      49

dent died on the  sixth day, and the necropsy disclosed no other
lesion  than extensive disease of the scapulo-humeral articulation.
Neither the arterial nor venous vessels showed any trace of inflam-
mation, and the ends of the arteries were firmly closed, and alike
lost in the midst of the other tissues, in both of these cases.
  Be that as it may, I had from that time the conviction that torsion
may succeed as well upon the arteries of men as on those of dogs,
and that, in truth, we might sometimes use it in  lieu of a ligature.
It remained to show  if it was better, or ought to  be preferred to it.
The experiments now known, without enabling  us to decide  this
question definitively, are sufficiently numerous, however, to allow
us to make an easy examination of it.
  Operative Processes.—Like every thing that depends on the hand
of man, the manner of twisting the arteries necessarily varies more
or less, according to  the ideas or notions of each.
  I. M. Thierry, wishing to do it parallel with the axis of the vessel,
is satisfied with  seizing the divided tube  by its extremity with a
valet a patin, of which the branches are more or less flattened, ac-
cording as  the calibre of the artery itself to be  twisted is more or
less considerable, and he afterwards turns it from four to eight  and
ten times on itself, without grasping the base of it.
  II. In Germany many other modifications have  already been  pro-
posed.  M.  Kluge, for example, warmly extols an instrument of his
invention, with which the  torsion is effected by loosening  a spring
which causes the forceps to turn on itself.
  III. As for myself, I most frequently employ a grooved forceps of
any description, or even an ordinary ligature forceps.   After hav-
ing seized the vessel crosswise by its extremity,  I separate it from
the surrounding  tissues, and immediately grasp  it near its root at
the bottom of the wound, with another forceps intended to hold it,
or with the thumb and fore-finger of the left  hand, whilst with
the first I turn it on  its axis from three to eight times, and not only
three times for the large arteries, as they have incorrectly made me
say.
  IV.  M. Amussat recommends  that after the artery has been
grasped with a forceps with rounded  branches, it should be pulled
out several  lines beyond the bleeding surface;  that after having
cautiously separated it  from the veins, and from the nervous  fila-
ments  and all the tissues  that surround  it, we should force back
the blood that it contains, and grasp the vessel  near its root with
another forceps, whilst  the  first, by means of gentle movements,
tears  its internal  and middle coats; that we  should  then, with
the last-named forceps, twist the end of the vessel from six to ten
times with a rapid motion, at the same time that the fixed  forceps
holds  it firm, without pressing too much upon the  sides  of the
wound; and that the separation of the internal  coats having been
effected, we are  to push them  back through the  cellular coat in a
direction towards  the  heart, as I have shown  under  the article
Aneurism.
  In place of pushing back the coats and leaving the twist of  the
  VOL. I.                        7 
50
NEW  ELEMENTS OF OPERATIVE SURGERY
artery at the bottom of the wound, we  may continue the  torsion
of it until it is completely detached, and leave only a simple shred
in the middle of the division.  Nevertheless, " we  are  obliged to
admit,"  says M. ^ilardebo, (These, No.  158, Paris, 1831,)  from
whom I cite these details, " that such manipulations are more easy
when the fingers limit the torsion than when we  make  use of
two instruments.  The second forceps is of use  only to break up
the artery and push back the coats. After this, we seize  the end
of the vessel with the  thumb and  fore-finger of  the left hand, on
a line with the tunics that have been pushed up, and we give the
first  series of turns with the forceps, which we  then bring the
fingers nearer to, in  order to continue the  torsion  during  another
instant; the  artery is then seized again still  nearer to the instru-
ment, twisting it all the time, and  so on successively.  The opera-
tion is terminated by twisting, after the manner of a corkscrew,
the spiral thus formed, and by crowding it into  the depths of the
tissues."
  Two things, as it seems to me, ought to be distinguished in this
matter : first, the isolation ; second, the torsion of the vessel.   The
first, which is applicable to the ligature  as well as to torsion, is in-
comparably, the most  difficult and delicate.  If the large  arteries
surrounded with healthy tissues, and themselves elastic and unalter-
ed, and all those that repose in the  muscular or cellular tissues, may
easily be divested of their coverings, elongated, and drawn out to the
distance of several lines, it is far from being always the case with
those that run into the substance of certain tendons and large nerves,
or that adhere by their  circumference or their outer side to the fatty
tissues that envelop them, that are fragile, scarcely  distinguish-
able, or crushed upon the least pressure, or which  we are in dread
of having escape from  us as soon as we have grasped them.   If it
were absolutely necessary, we might, nevertheless, in most  of these
cases, effect our object through force of time, address, and  precau-
tions ; but  to what purpose ?   It  is an  error a hundred times de-
monstrated, to believe that  there is  danger in  including  some
lamellae of cellular  tissue, or some fleshy fibrils,  in the  ligature
along with the artery.  The nervous  filaments,  even  the  small
veins strangulated  in  this manner, involve in reality no other in-
conveniences than that of causing  momentarily a little more pain.
One must be a stranger to the routine of practice in the large hos-
pitals, to impute to the defective isolation of arteries, the accidents
which too frequently follow operations.   It is then for torsion only
that these preliminary attentions are indispensable.  From whence
it follows, as we may at once admit, that, so far as regards  its prac-
ticability, the ligature  will always have the advantage.
   As for the rest, when the favorable conditions above mentioned
 exist, and we have given all necessary attention to the operation,
 the  twisted arteries are as solidly closed as if they had been tied.
 Inflammation, suppuration, external or internal, of the vascular and
 nervous tissues, do not appear to me more to be apprehended after
 torsion than from ligatures.  That the first should cause them more 
         THE CONDITIONS THAT ARE  ACCESSORY TO  OPERATIONS.      51

 than the second, must have been owing to its having been performed
 with one forceps only, and without taking the precaution of limiting
 its extent  inwards, as, for example, in the process of M. Thierry.
 Nothing at least proves, in the facts published at Berlin, Hamburg,
 and Paris, nor in all those that belong to myself, that these fears
 are well founded.   The  reproach which has been cast upon it of
 leaving the remnant of an artery that may act as a foreign body in
 the wound, does not appear  to  me to have any force.  In the two
 patients amputated upon by me at the  hospital of St.  Antoine, in
 1829, and  who died, the  vascular cone, still  recognisable, was so
 mixed up  with the surrounding  tissues,  that  it could not  have
 created  any inquietude in reference  to  the future, and I have not
 learned that other practitioners have positively established any inju-
 rious effects from it.   Thus the only indisputable objection in tor-
 sion is in not always offering as much security as  the  ligature, of
 not being  applicable to  all  cases, of requiring much  practice in
 order that it may  be well done, and of rendering the operation
 longer and more fatiguing; on the other hand, in permitting no-
 thing to be left of a foreign nature in  the stump, it presents the
 advantage of producing less irritation to the wounded surface, and
 of  favoring the cure without suppuration.  In this respect,  how-
 ever, the anticipations of practitioners will be rarely realized.   The
 patients operated upon by M. Amussat did not recover  faster, with
 the exception of one only, an infant, who was well, I believe, at the
 end of from twelve to fifteen days, than if they had been treated by
 the ligature.   Neither  was complete  union  by the first intention
 obtained in certain cases of amputation by MAI.  Fricke, (Rev. Med.,
 1831, t. iv., p. 62,)  at the hospital of Hamburg, Ansiaux at the hos-
 pital of Liege, Dieffenbach and Rust at the hospital of Berlin,  (Bull.
 des Sc. Med., t. xxii., p. 445,) Guerin at Paris, Bedor (Schrader,  Thes.,
 Berlin, 1830) and Fourcade (Lancette Franc., t. v., p. 56) at the hos-
 pital of Troyes, Lallemand and Delpech at Montpellier, and M. Key
 at Guy's hospital, (Journ. Hebd. Univ., t. vi., p.  400.)    That  being
 the case, torsion should not, in fret, be deemed of any importance
 except in certain operations which  are performed solely on soft
 parts.  In fact, ligatures properly applied may generally be removed
 from the sixth to the twe^n day ;  and a crowd of facts prove that,
 after their separation, eight to fifteen days, and sometimes less, suf-
fice to complete tb^ reunion; but we do not find that a wound
which comprises muscles,  bones, aponeuroses, &c, can be perfectly
cicatrized and  solidly agglutinated  in less than from twelve  to
twenty days.  To resume  : I consider that after operations it is not
advisable to twist  arteries that are difficult to isolate  ; that it  is
better to tie those that torsion  could not be practised upon, but
with every desirable degree of security,  and that we must not
 admit this haemostatic means in  such cases, but as a method liable
 to exceptions.
  I.  Conclusion.—The haemostatic means  ought, moreover, to be
 varied after operations according to circumstances.  The ligature
 is preferable wherever the blood escapes by jet  from a rather 
 52           NEW ELEMENTS OF OPERATIVE  SURGERY'.

 large artery, which can be easily secured.  In the breast, scrotum,
 and omentum, however, and in every part  where the arteries are
 long,  flexible, and surrounded with loose tissues, torsion  offers real
 advantages.  Bruising, and reversing, and pluggings (les bouchons)
 are of infinitely less value.  If the blood oozes out from small arte-
 ries, as  after extirpation of tumors of the neck, breast, and axilla,
 and we are not desirous of effecting immediate reunion, compres-
 sion by small balls of lint  (boulettes de charpie) is an excellent
 means which I cannot too much recommend.  [On the same princi-
 ple act  the  admirable styptic pressed sponge,  punk, cobweb, fur
 of hats, &c.—T.J  Compression on the course of the vessels through
 the teguments, as Kock  applies it, would  be practicable  on the
 limbs or head, if it should not be  possible to  tie or twist the  divided
 artery.  At  the bottom of certain moveable  cavities, such as the
 pharynx, mouth, and anus, the hot iron frequently should have the
 preference.  Liquids,  medicaments,  and  styptics ought  not to  be
 used but upon wounds already inflamed, or for consecutive hemor-
 rhages, and when it is  not proper to act mechanically on the wound
 itself.   We must add,  in, conclusion, that cool air, and cloths satu-
rated  with cold water, are after  a great number of operations suf-
ficient to arrest the  hemorrhage  in the space of an hour or two, if
there  have been no other than small arteries divided.


                     §. II.  The Dressings.
  After the  haemostatic means have  been employed, we attend to
 the cleansing and dressing of the wound.
  A.  We clean two things in operations,—the wound and its neigh-
 borhood, or  all the  regions which have been soiled by the blood.
 The wound should be  cleaned at. first, and while we are engaged in
 securing the vessels.  Here out manipulations should be more or less
 minute, according to two circumstances—according to the haemo-
 static means employed, and the kind of dressing that we  wish to
 use.  If we use only small balls of *nt, either naked or on fine linen,
 it is of little importance  that all the anfractuosities of the  wound
 are or are not perfectly freed of clots  of blood.  It is much the same
 where torsion  has been used, or where th«  two ends of each  liga-
 ture are to be cut off near the knot.   When each ligature remains
 with one of its ends entire, thorough  abstersion from the wound of
 all the blood that may have contracted adhesions with it is no lon-
 ger a matter of absolute  necessity, if we  are  going  to dress the
 parts  flat, (a plat.)   In every case, on the contrary, where it is desira-
 ble to effect the approximation of the edges of the wound imme-
 diately, it is important to free it  as completely as possible of ever v
 kind of foreign body.   To clean it, we use sponge and tepid water
 rather than  wet cloths.  In  pressing the sponge, we first  wash it
 freely with water, then  cleanse and detach all the portions of
 adherent fibrine, by brisk but gentle rubbing.  That done, we wash
 all the other parts, and then wipe them and  dry them with soft
 linen.  We return  then to the wound, to sponge up the exudation 
        THE CONDITIONS THAT ARE ACCESSORY lO OPERATIONS.       53

from it by a last wipe of the sponge, and proceed then to the dis-
tribution of the ligatures.

                B. Disposition of the Ligatures.

  When the hemorrhage  has rendered it necessary to employ
ligatures, and  the  ends of these ligatures have  been retained, it
is convenient to fold them outside, and to fasten them on the skin,
at some distance  from the wound.  Many modes of doing this
have been  proposed.  Most surgeons are in the practice of gath-
ering all the ligatures into one group, which they place near the
most depending angle of the wound.  But, by this method, some
of the  ligatures are obliged to occupy the whole extent of the
wound  before they reach  the  surface,  and there remains at the
bottom of the  wound a species of roller or network, which neces-
sarily increases the irritation and  suppuration, and by that means,
in fact, interferes with the agglutination.   Others, and I for one,
have for a long time followed this practice:  conduct each thread
separately in a straight line towards the point nearest to the sur-
face.   In this manner the ligatures represent rays as short as pos-
sible, which do not hinder the  surfaces from placing themselves in
contact, and becoming adherent to each other.   This last method
is incomparably the best when it is practicable to undertake imme-
diate reunion, without leaving cavities under the borders  of the
wound.  In the contrary case, as  after amputations of the leg, for
example, there is but little  inconvenience in following the ancient
practice, since then it is next to impossible to avoid the suppuration
of the  parts which are covered by the teguments, and brought to-
gether by the suture, or straps, or in any other way.
  These threads, folded outside, were formerly covered there by a
small compress known under the name of the ligature compress.  It
was then necessary for an assistant to hold his finger upon this com-
press, until the first portions of the  dressing were applied around
the wounded region, at least for amputations.  Now we prefer, and
I scarcely ever deviate from this course, a plaster of gum diachylon,
from one to two inches long, or the end of an adhesive strap, (ban-
delette,) in fact, which is applied over the extremity of each thread,
or each group of ligatures.  If there  should still remain any bloody
exudation, or should it be renewed, it must be removed for the last
time, and we then proceed to the dressing. The dressing after ope-
rations is a point of the  greatest importance.  Perhaps it has as
much to do with the success of many important operations,  as the
mode by which the operation itself has been performed.  Also, it
has been conceded from all time, that the dressing should be treated
of apart, and form  a special subject, in works of surgery.  I refer,
then, for all that relates to its details, to that portion of this work
which treats of minor surgery, not intending at present to  speak
of it but in its connection with the great operations. 
54
NEW  ELEMENTS OF OPERATIVE SURGERY.
                  § III.— Union of the Wound.

  There are two modes of treating wounds after operations.  Some-
times we approach the lips as exactly as possible, and endeavor to
keep them in the most perfect contact; sometimes, on the contrary,
they are kept apart by placing between them foreign bodies and
different kinds of dressing.  In the first case, we endeavor to obtain
what is called the  immediate union, or that by first intention; in the
second, we promote suppuration, and the cure or cicatrization is only
obtained indirectly, (mediatement,) or by second  intention;  I will add
to these, immediate secondary union.

     A.  Indirect (mediate)  Union, or that by Second Intention.
  As late as the termination of  the last century, indirect union (la
reunion mediate) is, to a certain extent, the only one of which sur-
geons have made  mention; but  this  is far from saying that it has
always been  performed after the same rules.
  The ancients had the practice  of filling the wound with com-
presses, or sponges, dipped in vinegar, and of treating it, in fact, like
all other solutions  of  continuity in which they wished to promote
suppuration.  Those who, like Archigenes, Heliodorus, and  Paul of
Egina, had recourse to cauterization to arrest the hemorrhage, made
use at first of garlic and salt, with  the view to make the eschar fall
off,  then cataplasms of honey, flour, or eggs,  or simply emollient
substances.   The  Arabs  have  particularly extolled  astringents,
styptics,  and  Armenian bole; they also frequently employed  the
balsam of sulphur. Fabricius of Hildanus thought he could  sim-
plify this dressing in  amputations by contriving a woollen purse,
with which he enveloped the stump after having padded it with dif-
ferent substances.  Wiseman preferred a beef's bladder to the purse
of Fabricius.   He  employed also the dry suture* to approximate  a
little the  lips of the  wound.  Sharp wished nothing more than the hot
iron ; but to hinder the soft parts from retracting, he had recourse,
like Pigray, to two ligatures applied crosswise.. It is thus we come
to the mode of dressing generally followed towards the close of the
last century.   At present it is done in the  following manner.  The
ligatures being arranged as we have above said, we place a fine
piece of  linen, covered with  cerate,  and perforated by holes, over
the whole extent of the wounded surface, whose edges are  brought
more or  less forward, so as to form, by means of these, a large cav-
ity.  Coarse lint fills this space ; some smooth pledgets are placed
over it;  long compresses, conveniently arranged, are then  made to
embrace the whole extent of this region; then, with a bandage of
sufficient length and width, the dressing is completed.
  In  the place  of applying  fine linen immediately to the wound,
some surgeons fill  it with sponge, agaric, or lint, as was done in the
t 1\.   Sutule s^Ae—a phrase of the schools for adhesive plaster—vide a few paces

■SbJo rther^T  """  Th6 phraSe t0°k '^ ^'^ ^^ S6Wing the edges °* 'h° 
         THE CONDITIONS THAT ARE ACCESSORY TO OPERATIC NS.       55

last century ;  except that they border the  circumference of it with
a liseret, or small bandage of linen, slashed (decoupee) on its outer
edge, and spread with  cerate.  The perforated  compress appears
to me to be preferable. As it is easy to turn it over  upon the edges
of the wound, we have no fear of seeing the lint or other material
of the dressing contract adhesions with the  cellular granulations,
and the living parts that  have been divided;  by means of this, in
fact, the second dressing can be performed without pain and with
the greatest ease, as soon as we judge proper.
  The Maltese cross, in such general use formerly, has  given place
to the long compresses, which are more convenient, and better ap-
plied to the form of the different parts.  We must take care not to
push back these compresses with too much force against the root
of the limb in amputations, for in doing so we should be certain to
crowd back the muscles and teguments whose retraction we are so
desirous of moderating.  It is for the  purpose of avoiding this  re-
traction, and to diminish  as much as possible  the protrusion of the
bone which results from it, that Wiseman, and especially Louis, have
recommended the  application of the containing (contentif) bandage
from above downwards, and not from below upwards.   I cannot too
strongly recommend on this subject the following method: We first
pass the bandage once or twice around the trunk, then  we bring it
to the root or upper part of the limb, conducting it by  turns mode-
rately tight to a level with the extremity of the bone, and proceed
afterwards to the rest of the dressing, as has been just described.
Another bandage,  or the  remains of the first, serve to fasten the
compresses by a second layer of turns, and to hold the whole firmly
together.   In this manner the muscles find difficulty in retracting.
The skin is pushed forward, and we moreover prevent, in a great
degree, the swelling of the stump, and the erysipelatous or phleg-
monous inflammations  of which it may become the seat, and  even
the phlebitis, which it is so important for us to arrest, the moment it
begins to be manifested.


        B. Immediate  Union, or that by the First Intention.
  The explicit direction to bring together  the edges of the wound,
and to close it immediately after  amputations, does not appear to
go back before  the time of Alanson, or  at  farthest to Gersdorf.
Adopted by Hey, and soon after by almost  all the surgeons of Great
Britain, it was not received among us ^ut with a certain repugnance.
except by Percy, who had frequent occasions of testing its  advan-
tages in the midst of  camps.  Pelletan,  M.  Larrey, &c., at first
stoutly opposed it; but Dubois, Boyer, Dupuytren, Delpech, MM.
Richerand and Roux, and almost all the distinguished operators of
Paris" and  of other cities of France, nevertheless, adopted it in a
majority of cases.  It appears, however, that Dupuytren had not as
much reason to approve of  it as he had believed at first, and that
M.  Roux  often thought it advisable to refrain from putting  it in
practice. 
56
NEW  ELEMENTS OF OPERATIVE SURGERY.
  To unite by the first intention, it is important, much more than in
the other method, that we should not leave in the wound any other
foreign bodies except those that we are not permitted to remove
from it.   We begin, then, by removing carefully the clots  of blood
and the threads that are not indispensable, and by cleaning the sur-
rounding parts with a sponge, and wiping the whole out with dry
and soft linen.  That being done, we approximate as exactly as pos-
sible the  divided  parts, endeavoring not  to  leave more space be-
tween them towards  the  bottom than near the edges.   While an
assistant  retains them in this  position, the operator puts on the ad-
hesive straps, (les bandelettes agglutinatives.)   By commencing with
those of the middle, it is  generally more  easy afterwards  to apply
the others.  Three or four almost  always suffice.  It is a rule to
leave some space between them, and  not to cover the  entire cleft
with them.  The  longer they are, all other things being equal, the
better they hold  on, the less inconvenience  are they  to the skin.
and the  better they attain the end we have in view.   To support
their action, it is often useful to have at the same time,  on the sides
of the wound, parallel with its largest diameter, graduated com-
presses of more or less thickness, or rolls  of lint, (faisceaux,) either
between the straps and the  skin, or otherwise, between  the remain-
der of the bandage and  the straps ; it is the only means  in some
cases of  hindering the fluids  from accumulating at the bottom of
the cavity, and of obtaining a free and regular union.
  If the ligatures have not been cut near the arteries, we fold them
back separately and fasten them between the adhesive straps*by
small strips of diachylon  plaster.  In the  place of bandelettes decou-
pees (vide supra) or the perforated compress that are placed on the
entire anterior surface of the  stump, some persons simply make use
of a large thin layer (gateau) of lint, smoothly spread with cerate :
in this matter each should act as he thinks proper: the important
point is to prevent  the too close attachment of the portions of the
dressing  with the neighborhood of the wound.  Soft pledgets (plu-
masseaux) of dry  lint are afterwards  arranged so  as to cover in a
convenient manner the  sides and  fore part of the stump.  For
that purpose two or three pledgets suffice: a greater number, from
the excess of heat which they might give  rise to, might be more
hurtful than useful.
   The long compesses vary necessarily in their number or length,
according to the  size of  the part or extent of the incision.   Their
middle part ought to rest precisely on the front of  the wound, and
their extremities  to be carried gently  towards the upper part of the
limb.  The one that some, after amputation, apply around or circu-
larly to the limb, to fasten the others a little above their place of
crossing, is, for the most part, useless.
   A bandage freed of its hem and ravelling, (fauxfil,) and which is
soft and rather narrow than too wide, completes the  dressing.  After

   * Strips of adhesive plaster, elsewhere called by the author bandelettes agglutina-
 tives, are here, designated ae rubans emplastiques. They mean the same thing.—T. 
        THE  CONDITIONS THAT ARE ACCESSORY TO OPERATIONS.      57

 having passed it, by circular turns, from the stump towards the upper
 extremity of the limb, we bring it back in the same manner to the
 side of the wound, on the fore part of which we may cross it several
 times, so as to shape it into a kind of capeline bandage, so frequently
 employed formerly;  and in order that we may thus obtain one that
 is more regular and neat, but which, however, augments  the per-
 pendicular pressure at the expense of the lateral.  As we  may
 thereby compromise the safety of the patient, this sort of affectation
 must be dispensed with, wherever we apprehend a deposite of mat-
 ters at the bottom of the wound.
   Suture.—In the place of plasters, or what is called in the schools
 the  dry suture, (la suture seche,) some operators  employ the bloody
 suture, the suture properly so called, in other words, sew the wound
 up.   This method, used by Pigray, Wiseman, Fabricius de Hildanus,
 Sharp, &.c, with a view of holding the integuments firm together,
 has been especially lauded, in latter times, by Hey, M. Benedict of
 Breslaw, and by Delpech, who asserts that he has derived the great-
 est advantages from it; at Montpellier they scarcely ever dispense
 with it after  amputations.  The interrupted suture, i. e. with inter-
 vals between the stitches, is that which is preferred in such cases,
 though the suture  of Pelletier  may  answer  as well.   For more
 safety, and to relieve the threads, we may also, after the manner of
 Delpech, place some adhesive straps* between them.  If the employ-
 ment of the suture of which  we are speaking was not necessarily
 accompanied with much severe pain ; if the union of the teguments
 was the most important part of the operation ;  and if the plasters did
 not effect the same object when they are properly applied, there is
 no doubt that it would have  been long ago adopted : but the  con-
 trary being generally admitted, every thing induces us to believe,
 that for the future, except in a small number of cases, the adhesive
 plasters will  continue to be substituted.
   When we begin like Louis,  Alanson, and M. Richerand, by fasten-
 ing a long bandage around the body, that it may descend afterwards
 by turns to the base of the wound, it is upon this that the straps ought
 to take their  point oVappui, and  with this difference from the other
 parts of the dressing, that it ought to be changed as seldom as  pos-
 sible.
   Open Dressing, (Plaie a Fair.)—Kern, Klein, Walther,  and most
 of the German surgeons, approve neither of lint nor pledgets about
 the stump, which they slightly cover with a few  compresses  wet
with cold water.  This practice has found many imitators in Eng-
land and America, even among hospital surgeons; and I learn from
M. Castello, physician of Ferdinand Vlfc, and professor in the  uni-
 versity of Madrid, that it has been a long time practised throughout
nearly all  Spain. In France, up to the present, it has counted but
 a small number of partisans.  This, as it appears to me, is to be re-
gretted, for nothing can be more satisfactory than the results that
  * The author, varying here from his two phrases above, denominates adhesive plasters
or straps, bandelettes emplastiques.—T.
  VOL. I.                       8 
58
NEW  ELEMENTS OF OPERATIVE SURGERY.
foreigners obtain from it.  Divested of a mass of useless dressings,
the stump is infinitely less heated.   In preventing or moderating the
inflammation which must invade it, we place the contiguous  sur-
faces in the best possible condition to obtain immediate union, and
the general reaction is reduced usually to  a small affair.    The
trials I have made of it have proved to me that cold water, though
often useful, is not always without its inconveniences.  In hot sea-
seasons, and when the patient is to remain in bed, I cheerfully fol-
low this practice, especially if the inflammation threatens  to be
intense ;  otherwise, it exposes us to real dangers, and is not as good
as the ordinary method.


C. Relative Estimate (appreciation) of Dressings by the First ana
                     the Second  Intention.
  The ancient method of treating wounds endangers, it is said, the
exhaustion of the patient, by the abundance and continuance of the
suppuration, and by the severe pains at each dressing: it requires
three, four, five, six, and even  seven or eight months to effect the
cicatrization, ordinarily produces only a small cicatrix, which is torn
upon the least exertion, and is almost always accompanied with a
considerable deformity upon the apex of the stump, after an ampu-
tation.  By the new method, say Alanson, MM. Guthrie, Klein, &c,
the patients suffer infinitely less; the fever  is always moderate;
there is no debilitating  suppuration ; the stump remains  rounded,
firm,  and well nourished; and at the end  of eight,  ten, fifteen,
twenty, or thirty days, the cicatrix is solid, and the patient in a con-
dition to use an artificial limb.
  Of ninety-two soldiers treated in this manner on the field of battle
by Percy, eighty-six were cured in twenty-six days : out of seventy,
Lucas did not lose but five.  But  while in France the chief of mili-
tary surgery defended immediate union with so much ardor, the
chief of civil surgery endeavored to cause it to be proscribed.   Out
of six persons operated upon by Pelletan, he saved only one.   In all
there were  effusions of blood and of pus between the lips of the
wound, in the course of the vessels, and among the muscles, and
the only  one that was saved owed his  life  to an effusion of pus
which forced off the adhesive straps : there is danger, then, says he,
in closing a wound which may bleed, or has need of suppurating,
either owing to the ligatures that irritate it, or because the bone, more
or less altered by the action of the saw, must necessarily exfoliate.
   The cure by the first intention  is more prompt, says M. Gouraud,
who adopts the objections of Pelletan, but it is more certain by indi-
rect union; (la reunion mediate:)  by being prolonged, the suppura-
tion prepares the person operated upon for the changes which must
supervene throughout his whole system ; and every time we operate
for an old disease, the secondary  reunion is the only one  which is
suitable.
   As for myself, I can aver, that  if the accidents mentioned by Pel-
letan often occur, it is much more for want of sufficient precautions 
         THE CONDITIONS THAT ARE  ACCESSORY TO OPERATIONS.      59

 than as an unavoidable consequence of the  operation ; allow that
 there may be some danger in drying up the source of a copious sup-
 puration of long date, and shutting in eight days the wound that
 results from the removal of a limb which the constitution had for
 a long time transformed into a secretory organ; but are not these
 exceptions ? and can reasons so feeble, and for the most part ques-
 tionable, weigh down against all the perils that we risk by indirect
 union 1
   In shunning one extreme, we should guard ourselves from falling
 into the other.  If the bleeding surfaces may be easily brought to-
 gether, if there remain in the stump nothing but sound parts, the
 immediate union has immense advantages ; and we ought to try it.
 In the opposite conditions, we may act otherwise, and  confine our-
 selves to approximating little by little the lips of the wound, after
 having placed between them small balls or pledgets (faisceaux) of
 lint, naked, or by the  intervention of the perforated compress.  It
 would be imprudent and even  dangerous to persist in  maintaining
 these in contact with it, if, in the course of  the first three or four
 days, blood or other fluids  should be  effused in  sufficiently large
 quantities to prevent the reunion from being freely made from the
 bottom towards the edges.  It is  then that it is proper to give a
 large and free issue to the matters accumulated behind the straps
 or sutures, and between the teguments and divided muscles, to clean
 cautiously the whole extent of the opening, (clapier,) and to dress af-
 terwards loosely, that  we may look no longer but to union by the
 second intention.  In acting thus  we will obtain most frequently,
 if not always, in the space of fifteen, twenty, or thirty days, a com-
 plete cicatrization, even after the amputation of the thigh, as I have
 many times myself experienced.

 D. Conclusions on the Relative  Value of the two Kinds of Reunion.
   To be understood on this point, we must consider the question as
 the moderns have laid it down.  Mediate [i. e. indirect.—T] union
 is no longer to-day what it formerly was.  By the present modes,
 we frequently obtain a perfect cicatrization in the space of three to
 six weeks.   The roller bandage with which we surround the stump,
 hinders the skin around it  from being  drawn backward, and suffi-;
 ciently favors the contraction of the wound to reduce it with great
 rapidity, as  soon as the ligatures  are  separated, and it is covered
 with vascular granulations.  When we can afford to wait for the
 formation of pus, the lint is detached without pain and without
 the least danger; the suppuration diminishes from day to day ; the
 suffering, the inflammation, and the fever have nothing alarming,
 and  have been  most  strangely exaggerated.  In permitting  the
 fluids to ooze out as they form, it renders their absorption more dif-
 ficult, and exposes less to inflammations, abscesses in the stump, and
 to phlebitis and metastatic deposites in the viscera, or serous cavi-
 ties, than immediate union does.  Moreover, the primitive adhesion,
such as it is daily practised, scarcely leaves the patient cured be-
fore three Weeks or a month. 
60
NEW  ELEMENTS OF OPERATIVE SURGERY.
    If it be true, that in spite of the contact of substances so different
  as bones, aponeuroses, muscles, cellular tissue, nerves, vessels, and
  the skin, the separation of some, the contusion of others, the con-
  tinual tendency of certain others to change, the almost absolute im-
  possibility of leaving neither clots of blood, nor lamellae, nor arteries,
  nor the least foreign matter, at the bottom of the wound in amputa-
  tion, for example,—the union has sometimes been achieved without
  any suppuration, and that this, therefore, is possible, then is it also
  true that on that account  we should concede to the dressing more
  care and time than is ordinarily given to it; that the section of the
  soft parts should be neat and regular; that the teguments should
  fall without effort on the front part of the stump, as if they were a
  head-dress; that the bones should  not  protrude  beyond the deep
  muscles ; that all the arteries liable to bleed should be immediately
  tied or twisted ; that the sides of the wound, freed of foreign bodies,
  should touch throughout their whole  surface, and be kept together
  in  the direction that  offers the least resistance;  that the straps
  should do no more  than preserve the coaptation, without pressing
  or exercising any drawing force, and  be also wide enough and suf-
  ficiently approximated together to  prevent  any slackening among
  them ; that the  suture should be added to them, or even preferred,
  if the  skin is thin or tends to  roll up inwards; that the  diseased
  part should be afterwards kept in the most perfect immobility, and
  that the inflammation should be moderated by every possible means.
  If blood or pus be deposited at the bottom of the wound, and if the
  adhesion of the  skin prevent their escape, they soon cause a local
  reaction; from thence, come swelling and redness, and then fever.
  finally a kind of abscess which develops itself in the centre of the
  stump, an abscess whose floor is represented by the section  of the
  bone, flesh,  and  vessels, while the tegument constitutes its dome or
  plafond.   Reposing on tissues newly divided, the  pus penetrates
  them, separates  them, insinuates itself into their interstices, extends
  more and more,  and spreads the  inflammation through the muscles,
  vessels, and periosteum, and even under the skin.  Then the veins,
  the lymphatics, and the absorbent system, and every thing else be-
  coming involved, it constitutes  a powerful cause  of phlebitis  or
^purulent fever,  and exists  in sufficient force to determine  those
  metastatic deposites which are so often followed by death.
   As soon as these  dangers threaten, we should at least  endeavor
  to remedy them.  If the ligatures do not answer sufficiently well as
  filters, we relax  one or more of the adhesive straps, which, in fact,
  must all be removed if the skin  is red or swollen.   We then treat,
  afterwards,  as  for  a subcutaneous phlegmon.  We now envelop
  in a large poultice  the stump, which latter must have been pre-
  viously leeched or not, as may seem necessary.  We also open one
  of the  angles or  points of the wound as soon as the presence of pus
  is no longer doubtful, taking care to make this opening sufficiently
  wide to prevent  the matter from stagnating afterwards at the bot-
  tom of the cavity which produces or retains it.  We do, in fact, all
  that can be done to  empty, cleanse, and cicatrize the part, the same 
        THE CONDITIONS THAT ARE ACCESSORY TO OPERATIONS.     61

 as if it were a true abscess, and to keep the teguments in the posi-
 tion which we had given them.
   It is, in fact, under such discouraging circumstances, and not under
 the brilliant forms that Bell represents, that we meet with immediate
 union  in practice.  This, however, does not infer that we ought to
 reject  it, but that it is not always convenient, and also has its dan-
 gers, and that it is often advisable to substitute for it the simple and
 incomplete  approximation of the lips of  the wound.  Thus under-
 stood,  it appears to me to include the  advantages of the secondary
 union.  In this sense, M. Serre, following his preceptor Delpech, is
 entirely right.  The error of their school  is to attach too much im-
 portance to the circumstance that there is no opening for matter to-
 wards the most depending part of the wound.  The suture, in truth,
 is rarely required, and there would evidently be danger in not mak-
 ing a passage for  the pus, as soon as it is collected in the stump in
 sufficiently large quantity.   It is easy to see from  these observations
 that Dupuytren, who placed a layer of soft lint between the lips of
 the wound, previously slightly approximated with straps of diachy-
 lon, and that M.  Larrey, who dresses even with pledgets  spread
 with resin of  styrax, differ  very little  in their dressing from that
 of union by the first intention, such as it is practised and adopted
 at the  present day.

                 E. Secondary Immediate Union.

   To reconcile the two preceding methods, it is easy to establish
 from them  a third, by applying to wounds  from  operations in gen-
 eral what O'Halloran advises for the flap operation in amputation.
 After having employed open dressings to the wound until it has be-
 come thoroughly cleansed and uniformly  covered with rose-colored
 cellular granulations, there is nothing to prevent our approximating
 its edges so as to effect secondarily immediate reunion.   I have used
 this  mode with success  in  a great number of  instances.   It is a
 practice which Paroisse  has strongly  recommended, and that may
 be qualified with the name of Reunion Immediate Secondaire.  Every
 thing being thoroughly cleansed,  it is generally easy to bring the
 edges of the wound in contact, either immediately or by degrees,
 and  thus, without incurring any inconvenience,  obtain a union in
 the space of a  few days.   I am of opinion that it is advisable, with
 very few exceptions, to undertake either the simple approximation
 of the edges of the wound, or even immediate reunion, taking care
 not to forget the  foregoing  precautions;  but that if accidents evi-
dently caused by it begin to be manifested, we ought not to hesitate
 reopening the wound, and deferring the union to a later period.   I
 would  add, that the results of this mode of dressing are much more
under  the control  of art than those of absolute  secondary union;
that consequently they will be favorable or unfavorable, according
to the skill or mal-address of the surgeon, according as the opera-
tor shall attach more or less importance to certain precautions that
 cannot be learned in books, and of which those only who have 
62
NEW ELEMENTS OF OPERATIVE SURGERY.
the opportunity of putting them into practice can estimate the value.
It must not be forgotten, moreover, that the preceding remarks have
much more reference to wounds from amputations than to any other
operations.
                       CHAPTER V.

          CONSEQUENCES OF  OPERATIONS.

              Article I.—Natural Consequences.

  After the dressing we attend to the removal of the patient, and
to the position which it is most proper that he should have.  If the
operation has been performed upon an ordinary bed, it is sufficient
to remove the  coverings and other objects that are wet or soiled by
the blood, and to replace them by dry linen.  In the contrary case,
the patient operated upon is borne upon a  litter  or upon the arms
with the least  possible motion, taking care that he receives no chill.
In cold seasons, it is desirable to place  him in a bed that has been
warmed; in other cases, this precaution is unnecessary.  Once  in
bed, the patient should be placed in a  position which will require
the least muscular effort; that  is, on the  back, having the head
moderately elevated,  and the lower limbs  slightly flexed.  As  to
the part which has been operated upon, we place it in such a posi-
tion that nothing can draw upon the lips of the wound or upon the
ligatures.   It consequently requires a position which must vary ac-
cording to each kind of operation.  If the wound is in a part of the
body which must remain in bed, the coverings are  raised from it
by means of hoops.  When the limbs are concerned, we are often
also obliged to place some cushions under them.  The patient, being
thus arranged, should be left quiet.
  Ordinarily he suffers sharp pains during the first hours, but these
afterwards diminish by degrees, and soon become quite supportable.
He also often appears pale and feels cold, or has even a slight chill
for  some time.  These phenomena, which  are accompanied  with
debility and with contracted pulse, soon disappear, or require  no
other remedy than one or two table-spoonfuls of wine, some warm
drink, or an anti-spasmodic  potion.   If every thing  goes  on regu-
larly, the inflammation in the wound is oeveloped in a moderate
degree only, and causes but a slight febrile  reaction of some three
or four days.   It is this period which requires the most precautions
in the regimen.  If the operation is really severe, little as we may
have to apprehend hemorrhage, it is advisable to leave a skilful
assistant near the patient for the first twenty-four hours, sometimes
even for some days.  This  precaution,  which the presence of the
pupil on  duty renders  almost  entirely unnecessary  in hospitals, 
CONSEQUENCES OF OPERATIONS.
63
ought not to be  neglected  in private practice ;  it inspires confi-
dence in the family, and powerfully contributes to the composure
of the patient.

              § I.—Regimen for those operated upon.

   Some practitioners  keep their patients who have undergone a
severe operation upon  a  rigid diet  from six to  ten days.   This
method, very generally adopted in France, has for its object to pre-
vent or moderate  the febrile reaction, to hinder  the formation of
abscesses in the vicinity of the wound, and the supervention of a
local inflammation in the digestive organs.  Bleedings, more or less
numerous, according to the strength of the individual, and emollient
drinks and anodynes, are united to this treatment.   Most foreign
surgeons strongly eulogize a course directly the reverse.  In Eng-
land, in America, and even in Germany, many practitioners admin-
ister large doses of opium, wine, and brandy to their patients, even
the same  day of the operation.   Kock allowed them coffee, strong
liquors, and nourishment the day after.   Benedict maintains that
instead of preventing  unpleasant symptoms,  bleeding promotes
their development; it is the most robust  subjects who best resist
morbific  causes, and with them inflammations are  most easy to
cure. ' The severe diet and copious bleedings prescribed by some
persons before or immediately after operations, are only of advan-
tage, he says,  where incidental diseases  and local  inflammations
supervene in those who have been operated upon.
  These two doctrines  appear to me equally objectionable.  The
severity of the regimen is in reality carried too far in France by a
great many surgeons; but it is evident that the course pursued by
the English and German practitioners must be liable  to many more
inconveniences.  For myself, I conform generally to the following
rules ;  if it is  a slight  operation, as that for  fistula lachrymalis or
amputation  of a finger,  I  scarcely change  the  customary  regi-
men of the  patient.  In the extirpation of tumors, and in all ope-
rations that do not necessarily disturb the  circulatory  functions, 1
diminish to one quarter or one half the quantity the patient takes
when in health, and I  willingly allow him water  slightly tinged
with wine, (de Veau rougie,) or some pleasant tisan  of  his own
choice for drink.  If the operation is more serious, or necessarily of
a nature that must seriously implicate the general system, I con-
fine my treatment to bouillons or very light broths (tres legers po-
lages) for  two or three days.  At the end of this time, if there does
not supervene an evident febrile reaction, I allow substantial broths,
then some of the white meats, eggs, and fried  fish,  with  a small
quantity of bread and wine.   I  thus manage  to allow the patient
the quarter or  half of his  customary  aliments in the course of the
second week.
  I do not recur to bleeding unless the operation  has required  an
extensive  wound, or involves a  delicate and important organ, and
where  the patient is naturally plethoric and sanguine.  Under such 
64
NEW ELEMENTS OF OPERATIVE SURGERY.
 circumstances I frequently prescribe bleeding, even the same even-
 ing  of the operation, which I sometimes repeat  the  next  day, and
 also the day after that.   I likewise employ venesection at the natu-
 ral period of the reaction, that is, from the third to the sixth day, if
 the fever seems to take  on too much intensity.
   The drinks which I  prefer after the eau  rougie, which is most
 suitable in simple cases, are the light infusions of the linden, if it is
 advisable  to favor  action upon the surface, the  poppy when the
 nervous system is much affected, chamomile in lymphatic tempera-
 ments, flowers of mallows or marsh-mallow when there is cough,
 borage, or buglosse, or elder when we wish to promote perspiration,
 Vegetable acids, citric, tartaric, &c, decoctions of barley or gruel—in
 fine, the different kinds  of acidulated  drinks—if the patient com-
 plains of too much heat and thirst.  But this  regimen must be un-
 derstood only in a general sense ;  for we must not forget that all
 the accidents that occasionally succeed to operations may require
 a change of regimen or  a particular treatment.
   Many patients, soon after  being operated upon, become constipa-
 ted.  This is owing to the necessary  want of exercise, the small
 quantity of food allowed them, or perhaps to actual  torpor of the
 intestinal canal.  As the accumulation and retention of stercoral
 matters, in such cases, must increase the general uneasiness, the
 cephalalgia, pervigilium, and febrile reaction, they must be reme-
died  in proper season.  We must not, however, forget that a patient
who  has undergone a severe operation may remain three, four, or
five days without stools, and without experiencing therefrom any ac
tual inconvenience.   The movements and displacements which the
 administration of enemata and the desire to void the excrements oc-
casion, expose the patient, in certain cases, to such serious dangers,
that we ought not to have recourse to these means unless they are
urgently required ; so that we may wait at least three or four days
before prescribing laxative injections or mild purgatives. Enemata
are proper when the  operation has been on  the upper part of the
body, since, in this case,  the  movement of the pelvis involves but
 little inconvenience.  For the other regions, unless it is contra-in-
 dicated by the state of the digestive organs, I prefer  giving a few
 glasses of Seidlitz water, or two or three glasses of water of pullna
 in the morning, or a draught composed of two ounces of castor oil.
 four  ounces of a weak infusion of mint, and  one of sirup  of lemons,
 to be taken by table-spoonfuls until it produces a  purgative effect.
   Changing the linen of  the patient  is a duty that must not be neg-
lected.  If  the  shirt  has not been removed on the bed where he
 was  operated upon, we must hasten, however little  soiled it may
 be, to change it before leaving him in his new position.  The nap-
 kins, sheets, and other parts  of the bed must be changed every two
 or three days, or  even more frequently, if they freely  imbibe the
 liquid matters that exude from the wound.   In other respects, the
 attention to cleanliness in those operated upon is not subject to any
 special rule. 
CONSEQUENCES OF OPERATIONS.
65
                § II.—Separation of the Ligatures.

   If the  flat mode  of dressing has been preferred, the ligatures
 placed on the arteries rarely fail of coming away between the fifth
 and tenth days.  When immediate  union has been attempted, they
 ordinarily hold on a longer time.  I have  seen them remain until
 the twentieth or even thirtieth day.  When  they are  too long a
 time in separating, it is generally owing to two principal causes:
 first, because some lamellae or threads of fibre are caught in the
 knot with the artery ; or, secondly,  that the knot itself  of the liga-
 ture is at the same  time imprisoned by the adhesion of the tissues
 at the bottom of a narrow passage.  In other respects, it is not un-
 common to see ligatures detach themselves on the  third or fourth
 day, and that without the slightest inconvenience following.  This
 is a fact that I have  often been witness to after the removal of tu-
 mors, and even of some amputations.  As for  the rest, I shall, when
 speaking of particular operations, point out the means of promoting
 the separation of the ligatures.


                     Article II.—Accidents.

       •                 § I.—Spasms.

   One of the most  frequent  occurrences  observed after capital
 operations, is spasm, or convulsive  tremors.   I do not  speak here
 of the spasm and momentary chill  which patients  almost always
 experience until they are warm in bed, but of the convulsive move-
 ment which is prolonged, or tends to be prolonged to an indefinite
 period, by affecting the wounded part with spasmodic contractions
 that are sometimes exceedingly painful.  We remedy this kind  of
 spasm  by giving  warmth to the  part as speedily  as  possible, by
 making strong pressure with the hand upon the muscles near their
 source, or by holding down the part by means of a bandage attach-
 ed to each side of the plane of the bed ; also, by giving antispas-
 modics and opiates internally, and by  keeping the dressings  thor-
 oughly wet with mallows-water and  laudanum.  In hot climates,
 these spasms cause great uneasiness, because they  are sometimes
 the preludes of tetanus.  In our temperate climates, it is rare that
 they are of a serious  nature.

                      § II.—Hemorrhage.

  After operations, the hemorrhage may still be renewed and excite
apprehensions.   This accident is owing to different causes.   In
some cases, the hemorrhage is owing to this :  that many of the ar-
teries, not bleeding at the time of the dressing, from being restrained
by the  revulsion of the blood to the interior, have neither been tied
nor twisted ; so that, dilating themselves in proportion as the circu-
lation recovers its natural action, they finally  commence bleeding.
It is generally at the  end of some  days that this kind of hemor-
  vol.  i.                       9 
66
NEW  ELEMENTS OF OPERATIVE SURGERY.
rhage takes place ;  and it is with the view to prevent it that some
surgeons have advised that we should wait two or three hours be-
fore proceeding to the final dressings.   Sometimes, also, the hemor-
rhage which supervenes the first twenty-four hours after an opera-
tion is excited by the irritation caused by the lint and other foreign
bodies collected in the  wound.  The blood, in such cases, rarely if
ever comes from such arteries as have been tied or twisted.   After
the first two or three days, the hemorrhage which is denominated con
secutive never takes place but by exudation,  the premature cutting
through of the arterial  trunks, or the loosening of the ligatures.   It
has been thus  seen from the eighth to the thirtieth day.  M. Guthrie
saw it on the twentieth, thirtieth, and even fortieth day.  It appear-
ed in one of M. Roux's patients at the end of the thirty-fourth day.
It is difficult to explain its appearance in such cases without ad-
mitting a diseased state of the vessels.  In fact, the ligature scarce-
ly ever requires more than two or three days for the effectual ob-
literation of the  arteries.  In my own practice, I have  seen the
ligature  of the radial  and ulnar arteries, of the  dorsalis  pedis,
and even that of the brachial, both after amputations and operations
for aneurism, come away on the third and fourth days without any
hemorrhage resulting therefrom.   The accident, then, in  the cases
referred to must  be  ascribed to an  exhalation from the  wounded
surfaces, or to some ulceration in the tunics of the arteries them-
selves.
  If the bleeding is not profuse, and the patient retains his strength,
we need be in no hurry to arrest it.  If  it is only from the  small
arteries,  they soon cease of themselves, and the bleeding from them
is a kind of  hemorrhage,  which is rather useful than injurious.   In
other cases we begin by cooling the part, and keeping it wet with
cold water.   If that is not sufficient, we apply the tourniquet, the
garrot, or some other means of compressing  the track of the prin-
cipal artery.   Supposing that even this  may not  be effectual, we
take off the dressings to clean the wound, and search and tie or twist
the vessel which gives  the blood.  After the first twenty-four hours,
the coats of the  artery  have undergone so much softening, (ra-
mollissc?nent,) that they are easily  cut through by the thread,  so
that the  ligature can no longer effect a solid obliteration.   It might
be advantageous then to imitate M. Sanson, by cutting all the tis-
sues around their bleeding extremity in a circular direction, so as to
make a cone, whose base would be formed by the wound, and whose
apex, to which the thread should be applied, would be formed by the
body of the vessel itself.
  When these means are insufficient, or impracticable, we may try
direct pressure, with agaric, lint, or sponge,  and by some means or
another  stop up the wound.   Plugs sprinkled with resin, or dipped
into Rabel-water,  (Veau de Rabel,) or some  other astringent liquid,
or, even if it  were possible so to do, the fingers of assistants, who
should  successively relieve  each  other, or some apparatus con-
 structed on the principle of that of J. L. Petit, and to be employed
 for the space of from  twenty-four to forty-eight hours, would oilen 
CONSEQUENCES OF OPERATIONS.
67
be found to succeed.  A last resource consists in searching for the
principal  artery of the part, and tying it at some distance above
the wound.  The kind of ligature that Delpech, Dupuytren, Somme,
MM. Roux, Ghidella, and  some others have used with success, has
nevertheless failed in  many cases cited by M. Guthrie, or reported
on the authority of M. Blandin.   Again, we should not class under
hemorrhages the exudation which almost always wets or soils the
dressing, the  napkins, and even the pillows, on  the first or second
day.  This exudation, which soon dries and produces  a great deal
of stiffness in the dressings, is composed principally of a viscid se-
rosity, rather than of blood.  Moreover, while the force of the pulse
is preserved, and the paleness does not increase, cold ablutions and
the tourniquet will be quite sufficient, if, in fact, any thing is
necessary.

                  § III.—Various Inflammations.

  If the inflammation which naturally ensues from the wounds of
operations should take on the character of erysipelas, angioleuci-
tis, or phlebitis, it comes under the class of accidents.
  A.  Ordinary Erysipelas is in  general announced by chills, rest-
lessness, loss of sleep, acrid heat of the skin, nausea, and much thirst.
We afterwards notice, in  the neighborhood  of the  wound, red
patches, with scalloped edges, (a bords festonnes,) slightly elevated
upon  the  surface of the healthy skin.  When  this kind of phleg-
masia is  not  traceable to the constitution of the patient, nor to
atmospheric influences, it is almost always  caused by morbific mat-
ters retained  or  stagnating at the  bottom of  the wound.   We
remedy it by removing the plasters  from the skin, if any have been
applied, and  by giving free issue  to the  offending  collection, en-
veloping the whole part, in its naked state, with warm poultices,
and observing the course  adopted in  the general treatment of ery-
sipelas.

 [New and successful Treatment of  Erysipelas Proper by Sulphate
                            of Iron.

  Since this edition was published in 1839, Professor Velpeau has in-
vestigated the nature and  treatment of erysipelas, properly so called,
or ordinary erysipelas, in a more special manner, the results of which
investigation are contained in a very recent paper published by him in
the journal of the Annals  of Surgery,  at Paris, for February, 1842 ;
from a copy of which, kindly transmitted to us by the author, express-
ly for this American edition of his work,  we make the following
abrege. or summary:

              I.—Nature and March  of Erysipelas.

  The experience which I have had, says  M. Velpeau, and the ob-
servations which I have collected during  twenty-five years  past,
authorize me to establish, among other facts: 
68
NEW ELEMENTS OF OPERATIVE  SURGERY.
  1. That in a surgical point of view, the predisposing cause of
erysipelas lies  much  more in inflammation produced by external
atmospheric or  meteorological influences, than in the condition of
the health or general  constitution of the patient.
  2. That the determining, or occasional cause, may almost always
be recognised in a wound, or in a crustaceous condition  (etat  crou-
teux) of the  part, or any irritation whatever, in some point  upon
the surface of the integuments.
  3. That its efficient cause  is  in general  a matter .coming  from
without, or from degenerate (denatures) tissues, and mingling itself
with the fluids  of the diseased region, either secondarily or  from
the beginning.
  4. That the fluids thus changed produce two orders  of morbid
phenomena, viz.:  general and local;  the first before the second
when there takes place at  first the introduction of  the fluids into
the general circulation; the second before  the  first if the change
is effected only  by direct absorption, (imbibition.)
  5. That in the diseased inflamed skin, the fluids changed by the
morbific element do not seem to circulate and advance but by en-
dosmosis; so that, progressing more and more, and extending super-
ficially and not  in depth, the  erysipelas  spreads  upon, or into, the
dermis, in the manner of oil on a flat surface.
  6. That a great proportion of the morbific matter remains,  even
to the termination of  the disease, under the epidermis, or in the
dermoid tissue,  mingled with  the blood in the inflamed organic re-
gion, (plaque.)
  7. That the totality of an erysipelas is almost constantly formed
of a number of small successive erysipelatous inflammations.
  8. That an isolated erysipelatous patch  (plaque) generally dis-
appears of itself at the end of four to  six or eight days.
  9. That the duration of the whole disease is thus extremely va-
riable, in consequence  of the number of erysipelatous patches which
succeed, or are  superadded to the others.
  10. That the  remedies, whether internal or external, intended to
remove  such a  disease, should have a special tendency  to effect a
modification of the blood.

                    Treatment of Erysipelas.

  M. Velpeau states that his experience, to the present, extends only
to external remedies.   He has treated one thousand  cases, or  about
sixty per annum, at his  hospital, of which he has taken  minutes of
only four hundred.
  Since the time he has drawn the line of distinction between ery-
sipelas  and  other inflammations, twenty-five of these cases  have
been treated by compression.   In these the erysipelas continued from
six and eight to twenty days.  The redness diminished under the
bandage, but the itching continued, and also the pain on the points
that were compressed.  The inflammation continued to spread.  If,
says M. Velpeau, I once thought  otherwise, it was because, like 
                   CONSEQUENCES  OF OPERATIONS.                69

the rest of the world, I confounded erysipelas proper with diffused
phlegmon, angioleucitis, and phlebitis.
  He made trial in thirty-three cases of the temporary blister, on the
centre, and to beyond or only on the margin of the diseased regions;
but in no case was the disease shortened ; and it can afford relief
only in the phlegmonous form, or in angioleucitis.
  The nitrate of silver, (azotate d'argent,)  in its natural state and
concentrated, and also in all its modes of application, gave no bet-
ter results.
  Twice only he used the hot iron, after the mode of  M. Larrey.
  In two hundred he used the Neapolitan ointment, and without ef-
fect.  " The mercurial ointment? he says emphatically, " neither cures
nor arrests erysipelas?  It may shorten it, perhaps, a  day or two, or
render it a little less painful, the only reason for which I still some-
times use it, and for which it would still be in use, but  for the re-
pugnance patients have to  it, the danger of salivation, and the soil-
ing of the linen.
  We find that hogs' lard  (axonge) in twenty-three cases moderated
the erysipelas, but did not abridge its duration—and was of less effi-
cacy than mercurial ointment.
  The disease in  twelve cases  was aggravated by an ointment  of
four grammes (seventy-two grains) of white precipitate  to thirty of
lard.
  Sulphuric acid in ten cases, applied as a lotion on the skin, had no
sensible effect.
  The hydrochloric (chlorhydrique)  acid in ten  cases  was not more
satisfactory.
  The citric and tartaric acids, the oxycrate (vinegar and water) and
salt and water, (eau salee,) or solution of chloride (chlorure) of sodium,
were  each employed in six separate cases and without effect.
  In six cases, the  nitrate acid of mercury, in three as a lotion and
in three as a caustic, proved useless.
  Camphor and the bird-peck punctures (mouchetures) were equally
unavailing.
  Professor Velpeau  had in despair renounced all the above reme-
dies, though  practitioners still  believe in the efficacy of the blister,
nitrate of silver, mercurial ointment and lard, until his attention was
drawn to the  changes effected upon the blood by the preparations of
iron.
                 3.—Special Local Application.
  Impressed  with the idea that  the  inflamed  tissues in  erysipelas
are impregnated with blood and altered fluids,  he asked himself the
question,  if ferruginous applications might not have some efficacy
upon  a  disease so  superficially situated.  In  forty cases he deter-
mined upon a formula of the  sulphate of  iron in solution of thirty
grammes (nine drachms) to about forty oz.  (par litre) of water,
or as an ointment of eight grammes to thirty of lard—after having
tested it in various other proportions.
  In forty cases the following were the results: 
70
NEW ELEMENTS OF OPERATIVE SURGERY.
  First, In  a man in the prime of life with  an erysipelas in the
front part of the leg, caused by an ulcer from operation for varices,
cloths wet with the sulphate of iron effected a cure on the third day.
  Second, Same cure in a man of forty, for erysipelas in the face.
  Third, In a young man with erysipelas  on the forehead, nose,
eyelids, cheeks, and upper lip, supervening on the tenth day, from a
very extensive pain in the head.  On the day after the use of the solu-
tion of iron the redness faded, the surfaces became wrinkled, and on
the third day the erysipelas had disappeared.
  Fourth, In an old man a vast erysipelas on the thigh and  hip,
above and below a sluggish abscess, (abces froid,) the solution of iron
was used on the first day, and the disease disappeared on the next.
  Fifth,  In a patient aged  thirty-two, with erysipelas on the right
side of the  face.  On the second day the solution ;  on the third the
part  wrinkled; the  solution is neglected;  on the fourth  day the
nose, eyelids, and forehead are involved ;  on the  fifth day the solu-
tion and the patches disappear, but the left cheek and ear are at-
tacked ; on the sixth the cure was effected, and the itching ceased.
  Sixth,  seventh, and eighth cases,  In  three women  the same
symptoms and results.
  Ninth, tenth, and  eleventh, The same  result in an erysipelas in
the neck of a man in whom M. Velpeau  tied the carotid, and in a
boy who had erysipelas on the arm and shoulder, and in a man who
had it on the thigh.
  Twelfth, thirteenth, and fourteenth, An erysipelas of one, two,
and three days on the lower half of the leg, with some outward ap-
pearances of angioleucitis, disappeared in twenty-four hours use of
the solution, in three young men.
  Fifteenth and sixteenth,  In a man—abscess in the thumb—an-
gioleucitis  in the forearm—solution of iron ;  on the second day
forearm  redder ; third day, erysipelas on  the arm and shoulder—a
measles-like eruption on the chest—solution;  on the next day there
was no redness but  on the  points which  had not been covered by
the compresses.
  Seventeenth and  eighteenth, An intense erythema, the  conse-
quence or effect of large burns in the hand in one case, and in the
foot in another, in two women, treated by the solution, disappeared
in twenty-four hours.
  Nineteenth, twentieth, twenty-first, and twenty-second, In these
four  cases the disease was also immediately cured,  but as it had
already existed for  many  days, the author could not say that the
sulphate of iron had any great part in the cure.
  Twenty-third and twenty-fourth,  In a woman recently operated
upon for a tumor in the breast, and in a man affected with varix in
the legs, erysipelas  of great extent, after four days of previous rest-
lessness, appeared on the thorax in the first case, and on the head
in the second ; in this latter the disease continued seven days, and
even reappeared on the twelfth day after some premonitory symp-
toms, but spreading  from one point, extended over almost the whole
of the head, chest, neck, and arm. 
CONSEQUENCES OF OPERATIONS.
71
  In these cases, as in the others, the new patches of erysipelas never
lasted over one or two days.  He adds that the  ointment,  which,
though less efficacious, is more  convenient  than the  solution for
large surfaces on the trunk, was used in these two cases.
  Every thing succeeded in the same way as in the sixteen other
cases.
  Unless, therefore, says M. Velpeau,  numerous and remarkable
coincidences have on  this occasion  deceived me, as so often hap-
pens to others, there is good reason to believe in  the efficacy of
sulphate of iron as a topical application in erysipelas.  In no case
did the inflamed surface resist this means over twenty-four to forty-
eight hours.  It is only strange that the spreading (ambulant) ery-
sipelas, extinguished at the point of its origin,  continued, never-
theless, under this treatment to develop itself, even upon regions
already covered and wet (enduites et imbibees) with the preparation
of iron.  Can it be that this remedy, like  so  many others, may be
curative but not preventive ?  Is it necessary, in order that the
inflammation should be modified, that it should be completely estab-
lished ?
  The researches I am continuing to make will, perhaps, enlighten
us on this subject.
  The learned professor remarks, that he has also essayed the sul-
phate  of iron in  angioleucitis, erythema, phlegmon, phlebitis, and
acute rheumatism,  and internally to reach the general infection of
the blood in erysipelas, but all without  any definite results.


           Mode of Application of the Sulphate of Iron.
  If cases occur where we must use the  less efficacious form or
ointment, the sulphate of iron should be first triturated, that it may
mix well with the lard, that it may be perfectly homogeneous, and
not give the sensation of sand when rubbed between the fingers  ; the
ointment should be applied freely three  times a day over the whole
surface of the inflammation, and  some distance beyond its margin.
  The solution is employed on compresses wet with  it every six
hours, and fastened on by a bandage.  The essential point is,  that
the skin must be kept constantly moistened with it.
  The antiphlogistic action of the sulphate of iron has hitherto failed
in no case where  M. Velpeau has used it.   An objection to  it in
hospitals, where economy is so essential, is, that it stains (rouille) the
linen to an excessive  degree, and that no chemical reagents yet
used have been enabled to remove this color without destroying the
texture of the linen.  A solution of sulphuret of potash (as suggested
by F. d'Arcet) does it, but its odor is too disagreeable.
  When the solution of the sulphate of the protoxyde of iron, accord-
ing to M. Quevenne, is exposed to the  air, it soon decomposes ; a
portion of its base gradually absorbs oxygen from the air and passes
to the state ofperoxyde;  but as any base whatever exacts so much
the more acid to become saturated, and to constitute it a neutral
salt, m proportion as it is more oxydized,  it results from this  law, 
72
NEW  ELEMENTS OF OPERATIVE SURGERY.
in this case, that the quantity of sulphuric acid primarily required
to constitute the  neutral  proto-sulphate, becomes insufficient to
effect the complete saturation of the base which is partly super-
oxydized : hence we have  new arrangements in the elements of the
salt.  The sulphuric acid  separates itself into two portions, one of
which rests in solution, combined with protoxyde and peroxyde, form-
ing thus a double salt with these bases, which remains in solution
in the liquor and gives  it a reddish color; the other portion of sul-
phuric acid, much weaker than the preceding, unites with a large
excess of peroxyde to constitute a sub-basic sulphate of iron, which
is precipitated in the form of an insoluble yellowish powder.
  Such, apparently, is the process of the decomposition of the proto-
sulphate of iron employed in a state of aqueous solution for dress-
ings :  the powder of the basic sulphate of iron (sulfate defer basique)
precipitates itself upon the vegetable fibre, to which it not only
adheres, but forms with it an actual combination.  It is to be re-
marked, also, that this  is found to be favored by the greater or less
proportion of the alkaline  ley which the linen retains, which latter
may give rise to  the evolution of a certain  quantity of oxyde of
iron, which also combines with the organic tissue.
  This combination is  so  close and so  tenacious when the linen is
strongly colored, that, in order to remove the iron, we are obliged
to employ water acidulated with 2^0  0I" sulphuric acid, and to favor
the reaction by means of ebullition a long time continued;  but
during this  operation the tissue  itself is greatly altered, and has
afterwards lost much of its solidity.   The portions of linen, how-
ever, which are not greatly rusted, may be bleached by boiling them
in water, containing T|F of sulphuric acid.
  M.  Velpeau made trial also of the  citrate, lactate,  carbonate,
and phosphate of iron, but without success.
  The sulphate only proved efficacious, though M. Velpeau modestly
says his trials, even of this,  have not been  sufficiently varied or
numerous to be considered absolutely conclusive—much, he says,
remains to be explored, and that his only object  in publishing his
experience has been to solicit the aid of chemistry, and to present
a new remedy to practitioners  for a  disease which has hitherto
baffled the efforts of medical skill.
  We are not aware that this  new remedy, which we trust  will
attract the general attention of the profession here, has as yet been
made trial  of  in our country. Recommended, as it now is, by the
great success  which has attended its application in the hands of the
eminent surgeon who had the good fortune and good sense to anti-
cipate its probable utility, by a  very natural course  of reasoning,
based upon his original and sound views upon the pathology of the
disease, we feel very confident  that its efficacy will very soon be
tested in America.  Especially may we hope for this, and also that
its  curative powers may  be fully corroborated  in  our  country,
where, from the extreme and  sudden vicissitudes of our climate
during the  long intemperate cold season, and from the intense dry-
ing heat of anthracite coal, in such general use for fuel in the north- 
CONSEQUENCES  OF OPERATIONS.
73
ern and middle states during that season, erysipelas in all its forms,
especially in the one under consideration, mere particularly in hos-
pitals, manufactories, &c, is probably of more extensive prevalence
than in any other country.  The late  researches of the celebrated
Liebig, on the iron of the blood, and its change from a protoxyde to a
peroxyde in the lungs in passing from venous into arterial blood,
favor the idea of M. Velpeau relative  to the antiphlogistic proper-
ties of the sulphate.  General antiphlogistic treatment by the lan-
cet and purgatives, &c, though  not named by M. Velpeau, must
necessarily be understood by him to be advisable in young, plethoric
subjects, &c.—T.]

                    [Leeches in Erysipelas.

  Professor Fergusson, of  London, in his  late work on Practical
Surgery, (London, 1842,) not only uses leeches with advantage, he
says, and without any bad  effect, on the  surface of raw ulcers, but
on parts affected with erysipelas.  These are certainly rather novel
modes  of application, and, in  regard  to erysipelas, appear  to be
specially contra-indicated from the well-known fact  that a formi-
dable erysipelatous oedema, or subcutaneous infiltration, particularly
in the loose tissues, as about the face, penis, scrotum, &c, is often the
consequence of leech-bites—and especially to be  guarded against,
as all forms of erysipelas have a natural tendency to gangrene.

            Suppurative or Phlegmonous Erysipelas.
  Professor Fergusson remarks, that he considers one of the char-
acteristic features of the suppurative form of erysipelas to be, that
"the matter is not surrounded by  an effusion of lymph, such  as
happens in the cellular tissue  in  common abscess, but, on the
contrary, the [purulent]  fluid seems to permeate in all directions
without restraint, further than is offered by the natural firmness  of
individual  texture,  and thus it will become extensively diffused
under the  skin or under an aponeurosis before it will burst through
either of those textures."  The remark is correct in so far as there
is no circumscribed boundary of effused  lymph enclosing the seat
of the  abscess, but,  nevertheless, lymph of a hard  consistence  is
more extensively and freely deposited, as  in long caky ridges  or
plates in the phlegmonous form and in angioleucitis, (in which latter,
the enlarged and indurated and inflamed condition of the neighbor-
ing lymphatic glands is a further evidence  of it,) than it is in ordi-
nary phlegmonous inflammation.  In the simple or superficial form
of erysipelas proper, Mr. Fergusson justly  observes, that one  or
more small  circumscribed abscesses occasionally form, surrounded
by condensed cellular substance from deposition of lymph, the same
as in ordinary phlegmonous inflammation.   After the inflammation,
too, has subsided, he remarks  with truth, that such  abscesses will
continue to form for some time.   We have,  however,  seen  cases
of what may be called a suppurative  diathesis of this kind in the
subcutaneous tissue, where such small abscesses of an elliptical  or
  vol.  i.                      10 
74
NEW  ELEMENTS  OF OPERATIVE SURGERY.
 oval shape would successively form from no apparent cause, and
 without at any time any preceding symptoms or outward  appear-
 ance whatever, of erysipelatous or other diffused inflammation on the
 surface or in the tissues.  I recollect  two such cases while I had
 charge of the Seamen's Retreat,  [Staten Island, New York,]  the
 patients being both colored persons and of adult age.  The abscesses
 in one forming at the upper and anterior part of the thigh below Pou-
 part's ligament, and in the other on the loose tissues about the upper
 eyelids.   In the first the patient had been mercurialized before
 coming into the hospital.  Neither, however, could be strictly called
 erysipelatous, except for this peculiarity of successive formation of
 small, regularly formed, circumscribed, purulent subcutaneous col-
 lections.  They were all speedily cicatrized by freely  laying them
 open to the bottom of their cavities, (a practice too much neglected,)
 and by generous treatment internally, and tonics.   The matter in
 these cases  appeared to be more attenuated, and more rapidly col-
 lected than healthy, well-digested pus.—T.]
   B. Phlegmonous  Erysipelas, or diffused phlegmon, which  takes
 place most frequently from the third to  the twelfth day, is mani-
 fested by a deep-seated, dull pain, heat and swelling throughout the
 whole thickness of the  part, while at the same time there super-
 venes a more or  less active fever, together with all  the symptoms
 of an unrestrained inflammatory reaction.  Here the inflammation
 sets out  from the wound  itself, and  extends to the cellular tissue,
 which unites, surrounds, or separates, the muscles, vessels, nerves,
 skin, and aponeuroses.
   As it is often also caused by the retention of pus, it is  important
 to give free exit to this secretion, and  therefore to make some de-
 pending opening for it, by removing  a  part of the  agglutinating
 dressings which may have been applied to the wound.  At the same
 time we must employ emollient cataplasms, and it is in this kind of
 inflammation that it may be necessary to recur to large bleedings,
 and to apply a large number of leeches to the inflamed parts.
   C. Angioleucitis, which almost all pathologists, and practitioners
 still more frequently, confound with one of the two  preceding in-
 flammations, or with phlebitis, begins like ordinary  erysipelas,  by
 irregular chills, much restlessness, heat, and dryness of the skin,
 burning thirst, nausea, or even vomiting, and also loss of sleep, and
 sometimes acute fever.   After these first symptoms, it is found that
 the neighboring lymphatic glands increase in volume and  become
 painful; then the vicinity of the wound  becomes surrounded with
 patches  and kernels, or reddish-colored bands, painful to the touch.
 Sometimes, also, similar striae extend from the wound to the painful
 glands, but this last symptom  is far  from being constant.  Angio-
 leucitis is distinguished from erysipelas in this, that  the inflamma-
 tion which characterizes  it is deeper seated, and develops  itself
 under the form of kernels, (noyaux,) rather than of patches, (plaques,)
 that it seems to extend itself from the parts within towards the sur-
 face, that it has no fixed and well-defined limits, nor  irregular mar-
gin elevated above the  skin. 
CONSEQUENCES OF OPERATIONS.
75
   Its causes are the same as those of erysipelas, or diffused  phleg-
 mon.  The  treatment  required  consists of  emollient  dressings,
 general  bleedings, and leeches in the neighborhood of the wound
 or the inflamed glands ; but all this more sparingly than in diffused
 phlegmon, while at the same time we are not obliged to give as
 much attention to the burrowings that may exist at the bottom of
 the wound.

                    § IV.—Purulent Infection.

   The most formidable accident,unquestionably, that can occur after
 operations, is that which is known at present under the name of
 purulent infection, and which comprises also phlebitis.  As it is
 seen  quite often after small, as well as large wounds, and as it has
 been the subject of numerous researches since I pointed it out to
 the attention of practitioners, in 1823, and afterwards,  in 1826 and
 1827,1 feel it incumbent on  me to treat of it here in some detail.
 What has been more recently said upon this subject by Mareschal,
 Dance, Rose, Legallois, MM. Arnott, Blandin, andTessier, not .dif-
 fering materially from the first descriptions and explanations wliich
 I gave of it, I shall, in consequence, have nothing to change in the
 substance of the article which I devoted to this kind of  accidents
 in the first edition of this work.
   A.  Symptoms.—The march of the symptoms in such  cases varies
 considerably.   Sometimes  they  commence  with a violent  chill,
 which amounts occasionally to shivering, (tremblement,)  and may
 last several hours ; at other times with horripilation, and in other
 cases with mere coldness of the  extremities.  The skin becomes
 pale,  assumes a yellowish  tint, somewhat livid or bluish,  and soon
 after  a more or less earthy aspect.   In contradistinction  to marsh
 intermittent fevers, which resemble this in Hiore than one point of
 analogy, this first period is rarely followed by a perfect  reaction.
 If sweating takes  place,  it  is unequal, and often unctuous, or
 clammy, (poisseuse.)  After these symptoms  have reappeared sev-
 eral times, under the form of exacerbations,  at irregular  intervals,
 they are  ordinarily succeeded by a state of putridity, or adynamia,
 of a  remarkable  character.  The eyes sink in their sockets, and
 become covered with a grayish blearedness, (chassie grisatre.) The
 conjunctiva, which is sometimes tumid, becomes yellow, as well as
 the circumference of the lips, while  the whole face appears more
 or less dull.  The tongue, which continues generally moist, without
 being very broad or pointed,  as  in  intestinal affections, does not
 become incrusted till at an advanced period of the disease.  The
 teeth  and lips become merely of a sooty color.  The pulse  is fre-
 quent and hard, without  being  quick, and afterwards  becomes
 smaller  and smaller, and more  feeble.   Tympanites, sometimes
 diarrhoea, rarely delirium, though almost always stupor, now soon
 supervene.
  In addition to these symptoms, we  find in some patients vague
indications of visceral inflammations.  Sometimes a livid redness 
76
NEW ELEMENTS OF OPERATIVE SURGERY.
 is observed at intervals upon one or both cheeks, accompanied with
 slight cough, or pains in  the  chest  and difficulty  of breathing ;
 sometimes a jaundiced suffusion, more or less developed, together
 with pain or uneasiness in the hepatic region or right shoulder ; or,
 what is more rare, desire to vomit, with inflamed papillae  (rongeur
 pointillee) on the apex and margin of the tongue, which then  be-
 comes dry, as in dothinenteritis, or typhoid fevers ; there  are also,
 sometimes, acute pains in some part  of the limbs, for example, in
 one of the larger joints.  Sometimes there forms, in remarkably
 rapid succession, at different points of the  surface, a  series of puru-
 lent collections, or gangrenous inflammations, with swelling of the
 conjunctiva and destruction of one of the eyes.   The thirst  is  not
 generally great.  The  breath, which  is often fetid, exhales some-
 times a strong odor of  pus.  The progress of cicatrization is also
 arrested  in the wound; the lips separate, and  also  become pale.
 like the rest of the surface.  Viscid and cream-like as the suppura-
 tion was in the  beginning, it now suddenly becomes grayish, gru-
 mous-like, or resembling vitiated serum.  It is not uncommon to see
 it wholly and instantaneously suppressed.  The swelling of the soft
 parts then subsides with the same rapidity, and they immediately
 assume a strikingly cadaverous aspect.  The muscles, bones, &c.
 separate  from one another, as if the  cellular tissue, which  united
 them in the healthy state, had been destroyed.  At a later period,
 blood oozes out in a more or less limpid state, which terminates,
when the disease continues a long time, by taking on the character
 of washings of meat, and by causing  hemorrhages which nothing
 can arrest.  The patient, finally exhausted, dies from the twelfth to
 the twentieth or fortieth day.
  B. Pathological Anatomy.—On opening  the dead body, we find
various lesions, all traceable to one cause.   They consist chiefly of
numerous points of suppuration in the tissue proper to the viscera,
 or collections, more or  less abundant, in the  serous cavities, of a
 grayish cream-like serosity, more of a. purulent character than mixed
with flakes.  In  some patients the  large articulations, such as the
 shoulder, hip, or knee, are also found filled with the pus, which sub-
 stance is likewise frequently met with, whether as a deposite or in-
 filtration, wherever there exists relaxed cellular tissue to a certain
 extent, and  also in all those localities where the least  degree of
 pain was noticed during life.   The  arteries  are almost always
 empty, or the blood they contain is found,  in general, in a state of
 great fluidity. That in the veins is more abundant in quantity, and
 is still more evidently changed.   The  small clots that are here and
 there found  in it, are  of a mixed  color, black,  yellow, white, or
 greenish, and of a granulated texture, which is easily perceived on
 cutting into  them, or  breaking them down between the fingers.
 They sometimes enclose globules of pus, recognisable to the naked
 eye.   Not unfrequently we find actual purulent centres (veritables
 foyers purulents) in the interior of the larger clots.  I  have  ob-
 served some of  these  in every part of the venous system ;  in  the
 iliac  and uterine veins, and in  the  inferior cava, chiefly under  the 
CONSEQUENCES  OF  OPERATIONS.
77
 liver and at its entrance into the auricle ; also in the superior cava,
 and in the  principal cavities of the heart, &c.   Many of these
 concretions are also'soft, and are evidently only of some few days
 formation.  Others have such a consistence, and are so dry, or fri-
 able, that  it is evident they are  not of recent formation.  In  the
 great  majority of cases they have no pathological relation to the
 state of the vessel, in the region which corresponds to them, in the
 interior of the  splanchnic cavities.   It is entirely the reverse in the
 vicinity of the  wound, where  nothing is more common than to see
 the  inflamed veins in a state  of complete suppuration, both in the
 interior and the exterior, and that to a greatly variable extent,  but
 never, however, or rarely, involving the two  cavas.
   I. Abscesses.   The small  abscesses  which I spoke of in the be-
 ginning have been observed in all the organs.  A subject which I
 examined at Tours, in 1818, had some dozens of them in the brain
 and in the tissue of the heart.   A young man who died at the  cli-
 nique of the faculty in 1825, from the effects  of amputation of  the
 ear, had them  also in the spleen and in the kidney.  The lungs and
 liver are not less frequently  the seat of them.  It is in these organs
 that they have always been recognised, and where they are found
 to exist when no traces of them are discovered elsewhere.  Their
 characters are  so well marked that it would be difficult to confound
 them with the results of an ordinary inflammation.  In  the first
 place, they scarcely ever exist singly, but most frequently  a  great
 number are found in the same part.   The superficies of the organs
 seems to be more favorable  to them than the deep-seated tissues.
 They but  rarely acquire large dimensions.  Under this  point of
 view, they vary from the size  of  a pin's head  to  that of  a  large
 walnut or a small egg.   By pressure we are enabled to distinguish
 them as so many tubercles, through  the parenchyma of the lungs,
 whose periphery is as it were  embossed by those that are more su-
 perficial.   Often they appear to have an ecchymosis for a nucleus.
 In the liver, they are enclosed in an  organic layer  of a blackish or
 livid color, which is sometimes of several lines in thickness.  They
 are more usually formed in the centre of the organ,  and are general-
 ly larger than in the other  parenchymatous structures.   The sub-
 stance of which they are composed is still more  diversified; very
 limpid, and greenish, flocculent, or of a milky whiteness  in  their
 centre, and very frequently grumose or concrete  throughout, espe-
 cially towards their surface.   In the lung, we are still better ena-
 bled to note their appearances.  In some points, we can distinguish
 only small spots like petechiae.  Further on, these  spots enclose a
 small drop  of  pus ;  in other places, the ecchymosis  no longer
exists, and the grumous purulent clots alone are observable. Then
we find nuclei, concrete, like the caseous  tubercles of lymphatic
ganglions, or of different degrees  of  fluidity, as in the liver.  The
substance of some of them  appears to have become confounded
with the surrounding tissues, and to have  penetrated and become
imbedded in them   Others are, as it were, encysted; in others, the
walls of the sac are villous,  and of a red lilach or hortensia color. 
 78            NEW ELEMENTS OF OPERATIVE SURGERY.

 Farther on, the organ is found again in possession of all the char-
 acters it has in a normal state ; and they are almost always sepa-
 rated by intervening sound texture.  In many cases, it  would ap-
 pear, after removing the matter and cleaning the cyst, that the or-
 gan had never been diseased, but had been under the action of a
 mechanical process, for the purpose of excavating its substance into
 separate compartments.
   II. The Effusions in the serous cavities are equally remarkable ;
 it is the pleura, so to  speak, which is their common rendezvous,
 though they may form also in the pericardium, the peritoneum, the
 arachnoid, the  synovial cavities, &c.  After some days, they be-
 come extremely abundant; the membrane  is scarcely  altered in
 character, and after being emptied, remains covered with a layer
 of greater or less thickness of genuine pus, while  the  rest  of the
 fluid, which is of an ashy or dirty color, is far from bearing any re-
 semblance to the milky serum found after extensive pleurisies,  (des
pleuresies franches.)
  In the articulations, we are surprised at the condition  of the tis-
 sues.  Neither the cartilages, capsules, ligaments, cellular envelopes
 —nothing, in fact, presents the least trace of inflammation ;  and on
 removing the pus from them, a simple washing has not unfrequently
 served to create doubts  if the joint had in reality been affected.
 Also, the cartilaginous surfaces may be partially destro}^ed  or ero-
 ded, and the synovial  membranes and  the ligaments perforated,
 without the contiguous parts having lost any thing of their pliabili-
 ty or natural color.   The same takes place with the subcutaneous
 or other deposites in the limbs.  . In other cases, these devastations
 are surrounded with ecchymoses, and more  or less evident traces
 of inflammation.
  If some patients who perish  exhibit all these different kinds of
 collections at the same time, and seem as it were  to be saturated
 with pus like a sponge, there are a greater number who have them
 only to a partial extent.   Sometimes there  are  found germs of a
 tuberculous character only in the lung and liver, and no effusion.
 Sometimes the collections exist only in the pleura ; at other times,
 they are only met with in  the  limbs, either  within or external to
 the articulations.  In many there are none to be found  anywhere,
 and we must then seek for the cause of  death in the  blood itself,
 more or less profoundly altered in its own vessels.   I  frequently
 observed this last fact in 1835, 1836, and 1837, in the dead bodies
 of subjects who had exhibited in the highest degree all the symp-
 toms of infection, or, as M. Tessier calls  it, purulent fever.
  C. Etiology.  Every wound that suppurates may give rise to the
 changes of which we are speaking ; the trephine, a simple incision
 on the head, the section of varices, ordinary bleeding, as well as
 lithotomy, amputation of the neck of the womb, excision of  hemor-
 rhoidal tumors, and amputation of the limbs.  But it  was not in
 our times that they were first noticed.  Pare (CEuvres, Lyon, 1633,
 p. 269, in folio) already had  made mention of them, and Pigrai
 (Epitom., etc., edit. 1615, p. 368) says that on a certain year, almost 
CONSEQUENCES OF OPERATIONS.                79
all the sick who died of wounds of the head had abscesses in the
liver.  Morgagni (De Sed. et  Caus. Morb., epist. 51, 52) describes
them with some detail.   Quesnay  and  Col  de  Villars (Cours  de
Chir., Paris, 1746, t. iii., p. 36 a 41) make formal mention of them.
J. L. Petit (Maladies Chirur.,  t. i., p.  6  a 11) gives  a very exact
idea of them, and many modern surgeons had pointed them out in
their lectures or in their writings ; but before I had described them
they had not sufficiently attracted attention to lead any one to an-
ticipate the importance that is now attached to them.  In limiting
themselves to saying that the  pus had fallen  from the wound into
the organ where it was found deposited, the  ancients reverted to
their favorite ideas of humoralism, and proved nothing.  The  sug-
gestion first made by Boyer and Dupuytren, that so much disorgan-
ization may result from simple idiopathic inflammations, which have
themselves been caused by sympathetic  revulsion (le retentissement
sympathique) from the wounded part to  the interior of the viscera,
or be produced by the antecedent existence of tubercles, or  by or-
ganic lesions that had not been previously noticed, was not calcu-
lated to awaken any very particular interest.
  Struck with their frequency and importance, when I was yet at
the commencement of my medical studies, I took an early occasion
to make them the special object of a series of researches.  Believ-
ing, from the first observation  I made  on this subject, at the hospital
of Tours, in 1818, that I had  conceived the true etiology, and  con-
firmed in my opinion by what  I afterwards saw of an analogous
character at  Tours and at Paris, I felt authorized to state my
opinions  in my public  lessons, in 1821  and 1822, and then in my
thesis of  reception, in 1823.   I  maintained then, that the purulent
deposites which  so often supervene in the viscera, after operations,
wounds, and suppurations of every kind, ought to be attributed, not
to so many  distinct  idiopathic phlegmasiae,  but to an alteration
of the  blood, from the entrance of pus  into the circulating mass,
and to its transportation into the midst of the  organs, whether it
came from the wound or was secreted by the  surrounding veins.
It required some courage to advance such ideas at that time, when,
in spite of the observations of Rodriguez, (Journ. Compl. du  Diet
des Sc. MM., t. x., p. 150,) Erdmann, (Dezeimeri's, Diet, de Med., 2d
edit., t. i., p. 100,) and Ribes, (Mem. de la Soc. Med d'Emul, t. viii.,
p. 614,) solidism reigned despotically in the midst of our schools,
from whence the partisans of  the doctrine denominated physiologi-
cal, thought they had driven humoralism for ever; in consequence
of which they were, for the  most part, unfavorably received.
Nevertheless, the conviction which I  had arrived at, and the  facts
which  daily came to its support, did  not allow me to renounce
them.  My residence at the Hospital of Perfectionnement furnished
me numerous  occasions of submitting  my first thoughts to  new
proofs, of calling the attention of my pupils to them, and of show-
ing how much they might enlarge the field of general pathology.
The two memoirs on this subject, which I published  in 1826, in
the Review, and what I had already written in the same journal, 
80
NEW  ELEMENTS OF OPERATIVE SURGERY.
while treating of the alteration of the fluids, and what I advanced
at the same time, or a little later, in the Archives, and in the Clinique
of the hospitals, and the discussions which took  place in the Aca-
demy, upon the  fundamental proposition upon which these labors
were based, finally awakened the public mind, and I soon had the
satisfaction of seeing  that Marechal, (These, No. 43, Paris, 1828,)
and M. Reynaud of Marseilles, (These, No. 232, Paris, 1828,) in their
excellent theses, and Legallois, (Journal Hebd., t. iii., p. 166 et 321,)
in a special memoir at the  same epoch, had  arrived at the same
conclusions as myself.  While in a work still more complete, Dance
(Arch. Gen. de Med.,t. xviii. et xix.) deprived opponents of their last
pretext, opinions supported upon facts of the same kind were  pro-
fessed at London by MM. Rose (Med. Chir.  Trans., vol. xiv.) and
Arnott, (Idem, vol. xv.).  M.  Blandin,  (These, No. 216, Paris, 1824,)
who, in the thesis he supported a year after mine, had adopted the
hypothesis  of pure and simple inflammations, and who gives the
name of  tuberculous masses to the abscesses in question, says, in
speaking of one of his observations, This is a most beautiful example
of tubercles developed under the influence of inflammation.   M. Ton-
nele and  M. Rochoux have since ranged themselves under the same
standard, although  their theoretic views are  not perfectly alike.
Finally, the pathological concours externe, which took place at the
faculty of medicine in the spring of 1831,  and which afforded an
opportunity to consider the question of metastatic suppuration from
traumatic  lesions, compelled  us—to  wit,  MM. Berard,  Blandin,
Sanson, and myself—to make known how public opinion then stood
on  this  subject, and to give unquestionable evidence that there
no longer existed any discordance of opinion on the nature of the
principle with which I had set out, and which I believe myself to
have been  the first to lay down,—namely, that the metastatic suppu-
rations and  abscesses caused by capital operations, are  the result of an
alteration of the blood.
  One problem,  however, still remains  to  be solved.   Marechal,
Legallois, and M. Rochoux, find  in the  absorption  of the  pus of
which the  wound forms  the focus, a sufficient  explanation of all
the phenomena  observed.  Dance, MM. Arnott, Blandin, and  Be-
rard, maintain, on the contrary, that an  inflammation of the veins
always precedes the general infection, and that the pus which enters
into the  circulation is  always the immediate product of the phle-
bitis, which M. Blandin, (Diet, de Med. et Chir. Prat, t. ii., art. Am-
putation,) like Cruveilhier, unhesitatingly places in the venous ra-
dicles, (veinules,) whether of the soft parts, the medullary canal, or
the spongy tissue of the divided bones, when the principal branches
of the venous system offer no traces of it.
  In the  place of admitting  a transfer without  decomposition, a
true metastatic deposite, these last authors think also that the blood,
profoundly  changed by its intimate mixture with the morbid secre-
tion, merely permits here and there the escape of some of  its par-
ticles that  have  become more irritating than usual,  and that these
globules,  deposited in the tissues, are there like foreign bodies, (role 
CONSEQUENCES OF OPERATIONS.
81
tTepines,) which immediately become the cause of as many centres
of suppuration.   This opinion, differing from mine only in this, that
it supposes that there always exists, that which, according to me,
happens only in some cases—it is difficult for me to comprehend
how anybody has imagined that they could adduce the opinions  of
Dance and of M. Blandin to  combat mine.  In fact, far, from  de-
nying the phlebitis  in  such cases, I had  already  said, in  1826,
(Revue  Med., t. iv.,) " The veins of the diseased limb are full of a
grayish and  very limpid pus, and inflamed from space to space, but
only  up to  the entrance of the great saphena  into the  crural."
Further on, I add: " The phlebitis was not sufficiently  extensive,
even admitting that  it was  primitive, to play an important part
here as inflammation.   In looking to the fluids, however, every thing
is explained  in the clearest  manner," &c.  In May, 1827,1 main-
tained (Clin. Qes Hopit, t. i., No. 5) that, " in this frightful affection,
(phlebitis,) authors have paid attention to but one of the causes  of
the danger, the facility with which the inflammation is propagated
from the wounded point towards the principal venous trunks, whilst
the pus secreted by the parietes of the vessel, and continually car-
ried along with the blood, which it alters and  decomposes, consti-
tutes in reality the whole difficulty," (en constitue reellement toute la
gravite.)  Finally,  in speaking of the same fact,  when no one
thought then of this etiology of infection of the blood by phlebitis,
(Tome'xxv., p. 504,) I  said, moreover: " There  the disease unques-
tionably was a phlebitis ; but is it to the inflammation of the vein
that we must ascribe all the symptoms ?   I think  not; the pus,
continually carried to the heart and distributed  with the blood to
all the organs, has produced the general infection," &c.
  As to the  formation of purulent collections, here is the theory
which I gave in 1826, (Rev. Med., 1826, t. iv.): " We may explain
in two ways  the origin of these collections, (foyers):  First—The
blood, more  and more changed from its  natural  composition, may
begin by disturbing the organism in general, and finish by establish-
ing a local phlegmasia of a particular species.   Secondly, The in-
flammation, developed at first under the influence of ordinary causes,
may, to  a certain extent, compel the pus to be  effused at the point
where the organ is most irritated.........It appears to me to  be
demonstrated, that the inflammation, when that supervenes, is then
only secondary; that  is, established by an effused particle of for-
eign matter,  which forms a source  of irritation,  (epine,) that it is at
least a phlegmasia, altogether peculiar, sui generis," &c.
  Thus, in my judgment, the question rested on two points: First—
The  mixture  of  the pus with  the  blood, as a cause of the visceral
alterations  observed; Secondly, The origin of this  pus, whether
from  the  blood or from the  organs.   The first head, which  1
anxiously desired to demonstrate the truth of, because it  may have
an immense importance in medicine, is generally now admitted  as
an incontestable truth.  The  other had not for me, I confess, the
same interest.  The aim of my efforts being to prove that the pus
may circulate with the blood, and infect the organism in the manner
  vol. i.                        11 
82
NEAV ELEMENTS OF OPERATIVE  SURGERY.
of poisons, it was of little importance for me at the time to show
that it entered into the  veins by absorption, or that it was simply
formed on the inflamed surface  of those canals, so long as it should
be conceded to  me that it is conveyed to a certain distance from
the point of departure.  The preceding quotations, however, suffi-
ciently show that I had not altogether neglected these secondary
questions.
  The effects of phlebitis on the composition of the blood are so evi-
dent, that it appeared to me almost superfluous to  enter into any
detail  to make them more apparent.  It was not  the same with
absorption, which many sensible persons still refuse to admit, so
that it is setting out from this point that a real difference seems to
exist between Dance and myself.  According  to this  author, phle-
bitis is the first and almost only cause of metastatic deposites, and
the veins alone have secreted the pus which change#the blood.  I
have said, on the contrary, from the very beginning, and I believe
so still, that the  inflammation  of the veins which we meet quite
often, either as a cause or as an effect, is not indispensable ; that
the pus and  other morbific matters of the wounded  surfaces enter
sometimes into the circulating fluids, whether by lymphatic absorp-
tion, by imbibition, endosmosis, or by orifices of the bleeding veins
at the  bottom, for example, of  a  wound from amputation.  The
proof, according to me, that this often happens  is,  that I have a
number of times found pus in abundance in the midst of the viscera,
though the veins  which led into the exterior lesions Mere scarcely
phlogosed, and that there was no trace of phlebitis on other points
of their course ;  it is since the possibility of this fact has been denied,
that I have again demonstrated its existence in a great number of
cases;  among others, in a woman who died in  consequence of a
deep traumatic  lesion of the foot, at the hospital  of  St. Antoine, in
1829, and who  was opened in  the presence of  M. Dezeimeris, a
declared  partisan  of the opinions  of Dance ; also  on one of the
wounded of  July, [i. e. in the Trois  Jours, 1830,] who died on the
20th day  after the amputation of  the thigh, at La Pitie, in 1830,
and in whom I  pointed out the total absence of phlebitis  to  M.
Berard, who had also adopted the hypothesis of venous phlegmasia
as the first cause of metastatic abscesses ; also since then on twenty
other different subjects.
  As to the nature of these abscesses themselves, I have said that
the pus traversing the tissues may be deposited there naturally, or
may by  its  presence irritate different points of the  viscera,  and
thus form as many different foci of inflammation or of pus, (aidant
de foyers phlegmasiques ou purulents.)   Dance rejects the former
of these two modes, and seems even to question its possibility.  In
spite of the  reasons and objections he urges, I cannot  yield to  his
opinion.   If, as appears to him,  the blood, rendered more fluid
and altered by the pus, always commences  by producing a small
ecchymosis, and soon after a true inflammation, before causing  the
production of an abscess, a process which I have myself admitted
in a majority of cases, it follows that he has not seen, like  myself, 
CONSEQUENCES OF OPERATIONS.
83
in the brain, spleen, kidneys,  lungs, and liver,  those  collections,
(foyers]) which are not larger than a hemp-seed,  around which the
most attentive and minute inspection does not enable us to detect
the slightest lesion of the organic  elements;  and that  he has not
seen those purulent deposites which I have so frequently met with
in the cellular tissue or in certain articulations, and which, after
having been emptied  and washed, do not leave the  slightest trace
of the ir existence in the midst of these tissues.
   If the venous radicles which come from each purulent centre are
sometimes inflamed, it is certainly far from being true that they are
always so, or that we can admit the capillary phlebitis mentioned by
M. Cruveilhier (Anat. Pathologique du Corps Humain, xi.  livr., in fob,
fig. col.)  to  be always present in such cases.  Moreover, as soon
as we admit the deposite of a molecule of morbid matter, there is no
reason to refuse the possibility of a greater number.  The pus min-
gled with the blood, is a heterogenous matter which  has a constant
tendency to separate  itself from it,  and to  make its way by some
channel  or  another towards the surface.  So long as it is shut
up in the large vessels, and the circulation has lost nothing of its
activity, it can escape nowhere ; but in the capillary system, where
the movement of the fluids is only a kind of oscillation, where nutri-
tion, the different  secretions, and a  thousand new combinations, as
well of composition as of decomposition, are elaborated, ought not
its elements to exhibit a tendency to become agglomerated and
united together, and  to cease to circulate  with  the other fluids ?
When this aggregation, which is altogether of a chemical nature, is
once commenced, does it not tend to establish a centre of attraction
for analogous molecules ?   Can more be required to determine the
nucleus  (noyau) of an  abscess?  There  is nothing in this  more
difficult to comprehend than in the  formation of bile, urine, saliva,
and mucus.   These latter are natural secretions and exhalations ;
the other, on the contrary, is a morbid secretion or exudation.  That
is all the difference that there is.                                 •
  It  follows, then, from these details, that Dance, M. Blandin, Le
Gallois, &c, have scarcely done  more than to  reproduce,  while
they have corroborated under  different  forms, what I had said of
purulent infection and phlebitis  in 1823, 1824,  1826, and  1827.
Let any one compare  what these observers have written in  1828,
1829, and since, with the  descriptions which I myself had given of
this kind  of lesions a long time before  them, and he will without
any  difficulty be convinced that their labors are little else  than
confirmations of mine.  Perhaps also I should  have a right to add
now, that the microscopic observations  of M. Donne on this  point,
and the  researches of another kind, to  which M.  Beauperthuis,
Adet de Roseville, Mande, &c, have  devoted themselves, come to
the support of my opinions ;  that the experiments of M. Bonnet and
of M. Denis stand in the same relation ; that while denying the
passage of  the pus from  the inflamed vessel  into the  circulating
mass, M.  Tessier, nevertheless, admits the purulent  infection, and
that  I alone  can, on  this question,  fall back, Avithout rejecting 
64
NEW ELEMENTS OF OPERATIVE SURGERY.
  the labors of any one upon the position I maintained in 18:23 and
  1826.
    Prognosis.  Be that as it may, or in Avhatever way we may explain
  it, the°metastatic collections of pus produced by serious operations
  are always traceable in their  origin to the  introduction or forma-
  tion of a certain quantity of pus in the general  circulation, and the
  prognosis is extremely unfavorable.  The term tuberculous, which
  I had given to them at first, had reference only to their form ; and I
  am surprised  that any one has imputed to me the intention of com-
  paring them  to pulmonary tubercles under any  other  relation.
  The obscure and often rapid march of these lesions rarely permits
  us to observe their commencement, and is the  reason Avhy, at  the
  moment when their existence is no longer doubtful, they are  in
  general beyond the resources of art.   As soon  as the surgeon sees
  violent chills, with change in the features, continued fever, pains
  or not in certain parts of the body,  or  that a diarrhoea supervenes
  or not in a patient who has been recently operated upon, or who
  has going on  in his own  system any suppuratiAre process whatever,
  accompanied with traumatic  lesion, he ought to expect the most
  serious accidents, and to apprehend that death may be the inevita-
  ble result.  Nevertheless, if such symptoms  reappear only for two
  or three days, and at the end of this time a general perspiration, or
  some other critical evacuations, bring about the solution of the fe-
  ver and arrest the organic derangements just pointed  out, we have
  still grounds not to despair.   I have seen many patients  recover
  from genuine chills of this kind, as Avell as from the other signs of
  purulent infection.  Such examples, it  is true, are rare, but they do
  occur, and the practitioner ought not to forget them.
    The  treatment of purulent infection  is not yet established upon a
  firm basis.  Bleeding, either by venesection or by leeching and
  cupping, is evidently proper  only in the beginning, and  in robust
  or plethoric subjects, unless there are certain pains  or local inflam-
• mation clearly defined.  I have used them and seen them used, and
  carried as far as possible, in a large number of persons  operated
  upon, without ever having been able to affirm any  real  advantage
  from them.  The  patients who have been seized with  hemorrhages
  from the Avound and from the  mucous surfaces haA'e not been more
  fortunate.   Purgatives opportunely given have appeared to me to
  succeed in some cases.   Large blisters to the legs  or  thighs, or  to
  the parts of the chest or belly that suffer  pain, are  not to be lost
  sight of.  The sulphate  of quinine, when there are intermissions,
  and the stomach is  not too irritable, is  also not Avithout  its  use.
  Tartrate of antimony in large doses, extolled first by Laennec, has
  not saved the patients whom I have subjected to its use.  It is the
  same with white oxyde of antimony, in  doses of from one to two
  drachms a day.  As to the preparations of opium, camphor, ether,
  acetate of ammonia, and other diffusible or exciting substances, they
  have always appeared to me to accelerate the  march of the symp-
  toms, and in many cases to hasten the  fatal  termination.
    In fine, when we discover the symptoms above indicated,  we 
CONSEQUENCES OF OPERATIONS.
85
 should hasten to recall the fluids to the wound.  We first envelop
 it, morning and evening, with a thick and large cataplasm of flax-
 seed meal placed naked on the skin.  At the same time  we  apply
 one or more blisters to the legs.  We give also a weak infusion of
 the linden or elder, to be drunk warm as a  tisan.  Bleeding, from
 eight to ten ounces, may be performed, if the pulse  is strong, and
 the patient has not yet been reduced.  In case the wound is pale
 throughout, and the tissues have no longer  their original firmness,
 we must wash it at each dressing with  a decoction of bark, and
 cover  it with lint besmeared with storax and balsam of Archaeus
 mixed with cerate.  Should it have swollen and inflamed, or have
 exhibited signs of  phlebitis from the beginning, a large  blister on
 the stump would also be indicated.  Compression  by means of a
 roller bandage, from the upper part of the  limb to  the  wound, is
 another means to be employed  so long as the disease has not  in-
 fected  the system, and continues to be  local.  After these first
 means, we may give Seidlitz water as a  purgative,  or pullna
 water  internally, provided the tongue remains  soft and is not red.
 Emetics in small doses ought not to be administered  till a later pe-
 riod, and after the accession of stupor, tympanites, or a  sooty ap-
 pearance of the  mouth.  Bark, in decoction or in substance, is not
 proper till the typhoid state is clearly established.  We  give  it in
 union  with gum or rice-water  when there is looseness, or the  di-
 gestive organs do not bear it well.  The sulphate of quinine, in the
 dose of from five to eight grains at once, at the end of each exacer-
 bation, would be more proper when there had been an intermission
 and sweat. [If  there were in  reality any  similitude whatever in
 the pathology of this terrific and peculiar disease, and that of fevers
 of an  intermittent type, then  might we hope for benefit from the
 quinine treatment  now after the proper preliminary steps of  deple-
 tion or otherwise have been taken, proved to be a positive specific
 in such fevers, and more entitled to the name of a specific than any
 other medicine whatever.  But recent experience has also  estab-
 lished the fact, that to be made a specific, and to give full effect to
 its virtues, it must be administered, not in small, futile, and  tanta-
 lizing,  if not irritating doses, but to  the extent  of at least twenty-
 five, and more frequently fifty  to  one hundred grains at once, twice
 in twenty-four hours.  In the intervals, the paroxysm  never returns,
 and the only inconvenience following is a slight ringing or deafness
 in the one or both ears, and occasionally a little giddiness.   This
 practice was first introduced by myself while I was Physician to
the Seamen's Retreat Hospital, N. Y., 1831-2-3, and is now gene-
ral in Europe, but  more  so in this country, and especially in our
 army.__T.] The drinks ought, moreover, to be varied according
 to the predominant symptoms and the desire of the patient. Vege-
 table and  mineral acids, acidulated decoctions of tamarind, &c.,
will be preferable if the thirst is considerable.  In the contrary
 case, infusions that are  slightly bitter or aromatic agree better.
Decoctions of rice, barley, gruel, and rhatany, and the  white decoc-
tion  diascordium,  gum kino, and the cashew nut, and extract  of 
86
NEAV ELEMENTS <.F OPERATIVE  SURGERY.
rhatany,arealsoto be used Avhen the bowels afe loose, or a copious
diarrhoea is exhausting  the  patient.  In fact, the Avhole of this
treatment, being the same exactly as that of phlebitis and purulent
absorptions  in general, cannot be  but imperfectly  given in this
place.   It is in treatises of pathology that Ave must seek for its de-
tails.   My object has been to give only the summary of it, Avhich
was necessary in order to excite the solicitude of the practitioner,
and to  Avarn him against the  dangers of a  false reliance upon a
mode of cure AA^hose fficacy is yet so  unsettled.
  For details relative to alterations  of the blood in general, I must,
in respect to my own researches, refer to the theses which I sup-
ported in 1823 and  1824, to  the memoirs AAmich  I inserted in the
Archives de  Medecine in 1824,  1826, and 1827, and in the Revue
Medicate in  1825, 1826, 1827, 1829,  as Avell as in  the Clinique  des
Hopitaux for the year 1827.
  [Mr. Mayo remarks, that Avounds  from dissection are less  apt to
produce the  peculiar train of distressing symptoms from this source
than wounds from post mortem examinations, because the subjects
in the former case are more usually in a considerably advanced state
of decomposition, the absorption of the products of which lead ordina-
rily to a series of much milder symptoms than the poison from the se-
cretion of inflamed serous membranes, in existence, even sometimes
a few hours after death.   Mr. Mayo recommends the student, if he
should prick himself, to wash the wound, suck it strongly Avith his lips,
and bind a  strip of adhesive plaster an inch  wide tAvice round the
part, and not to remove it for three days ; and if the subject be re-
cent, or have died of puerperal  fever, phlebitis, or peritonitis, it is
well, also, after cleaning and sucking the wound, to touch it Avith
the  point of  a probe that has been dipped in  nitric acid.   Medical
Gazette, Dec. 17, 1841.—T.]
  [Late Experiments of M. D'Arcet,  M. D., on Purulent Infection.
  M. D'Arcet (These—Recherches sur les Abces Multiples, &c, Paris,
1842.—See also British and Foreign Med. Review. Jan. 1843) seems
to think that purulent infection is agreed on all hands to be OAving
to the presence of pus in the blood.   According to his experiments
however, the opinion, that Avhere these purulent deposites are found
none of the  usual eAddences of inflammation are  present, but that
the  pus seems as  if deposited without  any previous process of the
kind, is entirely erroneous.  On the  contrary, he says a red spot of
inflammation precedes their appearance—and  where pus is actu-
ally present, coagulable lymph is deposited  around it, which be-
comes organized and resembles a cyst, the internal surface of which
is as flocculent as that of the chorion.
  M. D'Arcet found that healthy pus of phlegmonous inflammation
absorbed through living intestine, a volume and a half of oxygen gas
producing only a. fifth of carbonic acid gas—and that the pus-globules
then ran together and formed an amorphous coat, or layer, floating
on the subjacent  liquid.   By exposure to air  the whole became of-
fensive and  putrid, without the layer becoming redissolved, which 
CONSEQUENCES OF OPERATIONS.
87
last, separated by the filter, left a yellowish green fluid, blackening
silver, and evidently containing sulphureted  compounds upon Avhich
a portion, yet not all, of the poisonous properties depend, seeing that
these remain Avhen the former have been removed by mixing lith-
arge with the fluid.   Injecting the above insoluble inert amorphous
layer, after it had been repeatedly washed,into the jugulars of rabbits
and dogs, the effects, where it did not kill immediately, Avere hur-
ried respiration, hard, frequent pulse, and death Avithin forty-eight
hours, quietly and without diarrhoea or vomiting.  Phlyctcenai were
found  in the lungs,  sub-pleural  ecchymoses  penetrating into  the
parenchyma Math a  nodule of well-marked hepatization  in their
centre.  In two instances (dogs) where the lungs were  covered
with ecchymoses, a circumscribed purulent  deposite, identical with
those met MTith  in man, was found in several of them.   In both
cases,  also, there was effusion of serum in the cavity of the pleura.
None of those terrible symptoms seen in man were present. There
was disease and death,  but no diathesis.  These effects, correspond-
ing to those  from  injection of quicksilver by Cruveilhier and Gas-
pard, of powdered charcoal byMagendie, of cerebral substance by
Dupuy, of the blood of the slug by Gaspard, and of particles of gold
by D'Arcet himself, he attributes to a common cause—the insoluble,
amorphous, and pulverulent nature of the substances  injected, ren-
dering them incapable of elimination, and, from their  size, of circu-
lating in the capillaries.   The effect Avas always  a  local lobular
phlegmonous inflammation In the part.  On injecting, howeA^er, after
freeing it of  all insoluble matters, the  yellowish, green, putrid fluid
aboA^e, which resulted from the spontaneous decomposition of the
pus, the results Avere, first, hiccup, vomiting, diarrhoea, rigors, fever,
dyspnoea, folloMred by marked adynamia, depression,  stupor, invol-
untary evacuation of urine and faeces,  pale appearance of the mu-
cous membrane, different hemorrhages, abdominal pains, and  the
most complete  prostration, and death in five hours.  On  dissection,
the lungs were found of a violet color,  infiltrated and indurated as
in oedema, their surface  coArered with small spots of sub-pleural and
interlobular ecchymoses. Similar ecchymoses existed in the spleen,
liver,  and intestines; the  inner membrane of the aorta was  red-
dened ; the blood fluid, black, greenish, containing grumous portions
which broke down under the fingers, without communicating the sen-
sation  of fibrine.  These effects show  a  general diathesis and dis-
ease of the Avhole system, the poisonous liquid, like a leaven, having
communicated its deleterious properties to the whole  blood.  In in-
jecting healthy pus before it is decomposed, M. D'Arcet only twice
in eleven  or twelve experiments obtained purulent deposites.   In
most of the cases the putrid symptoms alone supervened, Avhether
the pus was human or of the animal.
  He finds in the above results an entire correspondence with those
in man, and considers purulenA absorption, phlebitis, purulent infec-
tion, and purulent diathesis, a complex malady of two distinct classes
of phenomena often confounded :
  1. A disease of the respiratory, hepatic, or other organs; a local 
88
NEW  ELEMENTS  OF  OPERATIVE SURGERY.
inflammation dependent on a mechanical cause, the capillary tis-
sue being embarrassed by insoluble or pulverulent principles devel-
oped  in the pus by its exposure to the oxygen of the air, (in the
lungs,) and not producing  other constitutional effects than those of
phlegmonous inflammations of the  same organs.
  2. A miasmatic poisoning, caused by the absorption and circula-.
tion of some principles of the pus, itself becoming putrid, acting on
the blood in a special manner, and producing grave general symp-
toms, especially characterized as  adynamic—such as indicate a
class  of diseases where the entire organization is intimately de-
ranged, as the plague, typhus fever, purpura, glanders, &c.
  M.  D'Arcet thus explains the chemico-organic mechanism of this
process:  The purulent matter in  the vessels  reaching the lungs
undergoes such changes,  by the action of the oxygen, as Avould
happen to it as an unorganized substance out of the body.   Its ele-
ments separate into two parts—the globules absorbing oxygen in-
crease in size by their reunion, and become incapable of traversing
the capillaries, the caliber  of which they obstruct, in the same way
as mercury, gold, or charcoal, and hence the phenomena from those
substances introduced into the circulation.  The liquid part, under
the same  influences, acquires putrid properties, which produce
the effects as described in  those of  the simultaneous circulation of
blood and putrid matter.   He does not think pus in substance can
be absorbed by the capillaries—the laws of endosmosis allowing
only soluble substances.  But the purulent  serosity of the pus, de-
prived of its pus-globules, is readily absorbed,  and hence, in addi-
tion to inoculation, there  is another road opened for putridity en-
tering the system.   M. D'Arcet had noticed, in cases where puru-
lent deposites were found  to have existed, that the urine had been
albuminous during life ; and to this  last organic process he imputed
the dispersion of such abscesses Avithout producing harm.   This
sufficiently accounts for the  serous or largest  portion of the  pus.
The pus-globules are supposed to  remain in the part, constituting
the greasy, putty-like substance met with by Dupuytren and others
in the seat of chronic abscesses which had spontaieously disap-
peared.—T.~\
                       TITLE  II.

                   MINOR  SURGERY,

                       (Petite Chirurgie.)

  Operative Surgery, such as  we understand it in common lan-
guage, is divided into two great  sectmns:  Minor (petite) or auxiliary
Surgery, (chirurgie ministrante,) ancr Great Surgery.   This division
has nothing logical in it, and would, in truth, be difficult to justify on
principles of reasoning; but it is tacitly admitted, and seems to have 
THE ART OF DRESSING.
S9
for a long time assumed a place in practice.   It is, besides, impos-
sible to establish natural limits  betAveen small and great surgery.
Guy de Chauliac, whose book was one of the  first, if not  the first,
to take the  title of Great Surgery, says nothing of what we are
to understand by petite surgery, (small or minor surgery ;) and the
Bertheonee or small  surgery of Paracelsus has no resemblance to
any that we to-day call minor surgery.  Since La Faye especially,
authors haA*e appeared  to understand under  this last  name, the
surgery which in practice we allow to be performed by pupils.
   In this  section, therefore, are  consequently  given  the most ele-
mentary principles of surgery ; it is under this form that the ele-
mentary book of La Faye, that  of Mouton, and also that of M.
Legouas haAre been given to the public.  In our day petite surgery,
confined to the  mechanical part of the most simple processes, has
become the subject  of  works still more exclusive, and  of   a
nature that  requires almost of necessity that it  should occupy  a
place at the  head of treatises upon operative surgery.
  The  embarrassment which a great number of pupils experience
in the duties about the sick or in  the hospitals, induces me for that
reason to return to the plan which I had traced out in the first edi-
tion of this work.   I have felt more and more that minor surgery
was scarcely less indispensable than greater surgery, and that we
cannot in reality, in  a didactic work, separate these  two branches
of operative surgery.
  In other respects, without restricting myself to a rigorous defini-
tion, I shall include under the name of Minor  Surgery, (petite chi-
rurgie]) every thing  that relates  to the dressings,  bandages, ele-
mentary operations, and the employ of the means which we are in
the habit of confiding to the  care of pupils, whether  out-door (ex-
terncs)  or in-door, (internes) attached to the hospitals.
                        PART FIRST.

                      ART OF DRESSING.

  •We  understand by Dressing, every  methodical application of
the mechanical and topical  means, Avhose object  is the cure of
surgical  diseases.   They are the little operations that the pupil or
the surgeon is obliged to practise every day.  The  art of dressing
is, perhaps,  the most useful  in surgery.  Wounds badly dressed,
simple as they may have been, become serious.  Without a correct
application of the dressings,  operations that have been performed
in the  best  manner succeed badly.  It is also important that we
should study these kinds of processes with care, and devote a long
time to them, if we Mash to practise the profession of surgery Math
advantage.  Lecat (Prix de VAcad. Royale de Chir., edit. 1819, t. i.
p. 103) and  Lombard have shown  by their writings that this sub-
ject Mras not unworthy  of the meditation even of great practition-
  vol. i.                       12 
90
NEW ELEMENTS OF OPERATIVE  SURGERY.
ers.   If students of medicir.<?  better understood the real value oi
dressings properly applied, they would occupy themselves with the
subject Avith more ardor and perseverance than they generally do.
We would not then see them hurrying through this duty in hospitals
as quickly as possible, as if it were a tax, thereby neglecting its most
simple requirements.
  The dressings are made with the aid of instruments, topical appli-
cations, and various bandages.
CHAPTER I.
        INSTRUMENTS REQUIRED  FOR DRESSING.

  The articles which serve for
dressing, and which every sur-
geon  ought to carry with him,
are usually collected in  a sort
of port-folio known under the
name of the pocket-case (etui or
trousse) of the surgeon, (Fig. 1.)
The form of this case and its
dimensions vary  according  to
the taste or wants  of  each.
We arrange it in such a man-
ner as to contain conveniently
a ring forceps, artery forceps,
scissors, spatulas, a porte-cray-
on,  probes, sounds, a grooved
sound, a porte-meche, thread,
needles, and lancets, (Fig. 2.)
  Among these instruments, to
which a razor should be added,
there are none which a pupil
may not stand in need of, even
for the slightest kind of  dress-
ing.   I will not, however, speak
in detail of the sounds, needles,
and lancets, until when treating              (Fig. 2.)
of catheterism, and of sutures and bleeding.

                     Article I.—Forceps.

                     § I.—Dressing Forceps,

Better known under the  name of ring forceps, (pince  a anneaux,)
the dressing forceps, always composed of two branches which cross
and are jointed to each other  in the manner of scissors, presents
nevertheless some varieties  in its form.   The rings of the modern
forceps, instead o. being borne, as was formerly the case, (Fig. 3,)
 
INSTRUMENTS REQUIRED FOR DRESSING.
91
  (Fig. 3.)   on the extremity of each branch, are now placed entirely
          without their axis, (Fig. 4.)  It results from this   (Fig- 4}
          that, when shut, the instrument is reduced to a /^,
          cylindrical stem, and that in opening it, we do |   jj
          not want  as  much  room  to  obtain the  same V-J(|
          separation.
            It is well not to have the point too blunt, and
          to see that the inside is cut into grooves, that it
          may have  a better hold upon  the objects.  In
          other respects, we must take care that the joint
          works easy, that the instrument may be used
          without effort.  Whether there should be any
          chasings near the place of union or  not, is a
          matter that must be left to choice.
           The ring forceps serves to remove the portions
of dressing Avhich cover the wounds, to carry different ob-
jects to the bottom of cavities, and to extract from caATities or the
depth of wounds all  those substances that should be removed.  In
fact, it is an instrument designed to replace the fingers in situations
which  the latter cannot reach  without difficulty.
               § II.—Artery or Dissecting Forceps.

  The artery forceps, which are the same that we use in dissecting
rooms, resemble scarcely in any thing the ring forceps.  Separating
themselves by their own  spring, and  unable to shut without the
pressure of the fingers, which generally  grasp them as we do a
writing pen, the artery forceps should be sufficiently pliable not to
(Fig. 5.) fatigue the hand, and sufficiently elastic to open readily ;  also
     grooved like a file in the middle  portion, (Fig. 5,) that they
     may not slip through the fingers.  Those whose two branches
     are smooth and convex towards the middle outside are now
     scarcely ever used.
        The forceps called valet a patin, (Fig. 6,) and (Fig. 6.;   (Fig. 7)
     which, by means of  a cross piece  and double
     button, are kept open at such space as we de-
     sire, are also rarely now in use.   I shall, how-
     ever, have frequent occasion to speak of them
     in the course of this work.
        The same  remark applies to the different
     kinds of spring forceps, (pinces a  ressort,) and
grooved forceps, (pinces a coulisse,) (Fig. 7,) that are
designated at thepresent day  under the name of tor-
sion  forceps.                                        a
  The  artery forceps, still known under the name of  i
the ligature forceps, are at first designed to seize hold
at the bottom of wounds of the different vessels which
we intend to tie or twist.   They afterwards serve to remove shreds,
eschars, and foreign bodies, of which it is proper to free the M'ound
or injury. In fine, we employ them to maintain or to fix in a deter-
 
92
NEW ELEMENTS OF OPERATIVE SURGERY.
minate position the edges of certain wounds, the borders of certain
natural folds, and the different layers of tissues that we find it use-
ful to divide in the course of operations.  It is true that we can, in a
great number of circumstances substitute the ring forceps for them,
in the same way  as this latter might be sometimes replaced by
the dissecting  forceps.  Only that we soon find from practice that
this last is better adapted to objects that are  loose, (delies,) slip-
pery,  or moveable, and the other for cases which require less force,
attention, or address.
  A dissecting forceps ending in three small mouse-like teeth, two
on one side and one on the other, is, in a number  of cases, of ex-
treme advantage.   It  would be advisable, therefore, to add this to
the others in the common pocket case.
(Fig. 10.)
                     Article II.—Scissors.

  After the forceps, the most indispensable instrument in dressing
    .  8    is that Avhich is  called scissors.   I do not
          mean to speak here of the specific kind of
          scissors required for hare-lip, staphyloraphy,
          excision of the tonsils, and  certain polypi,
          or, for example, for the different operations
          practised on the eyes.  Those which serve
          for dressing are of three principal kinds: the
          straight scissors, (Fig. 8,)  (ciseaux droits])
          the scissors curved on  the flat part, (Fig. 9,)
          and those curved on the edges, (Fig.  10.)
            Formerly the  ring of all  these kinds of
          scissors was, like those of the dressing for-
          ceps, fixed at its middle to the extremity of
          the handles.    At present, good  workmen
          do not any longer make them in that way,
          and they are now placed on  the outside of
          the handle.  These instruments, Avhich, as
with forceps, may be made  of steel, silver, or even gold, ought to
     (Fig. n.)      be very sharp, and not catch (se macher) upon the
                blades.  As the objects placed between their blades
                tend to escape by pressure, a cutler  named  Meri-
                cant has contrived a scissors, one of whose cutting
                edges has a great number of  small indentations
                upon it,  (Fig. 11,) similar to those of a sickle, the
                object of which  is to prevent the slipping spoken
                of.  It is a  modification that I  have  made use  of,
                but it appears to me  of  little  value.  It does not
                absolutely hinder the  tissues from  escaping, and
                the cut the  instrument  makes is not so neat.  The
                sliding that the artist Mericant  wished to prevent
                is besides often more advantageous than hurtful.
                  The straight scissors are used to cut  the  differ-
                ent portions of linen, lint, or plaster  that we have
^Fig. 9.)
 
■
                instruments required for dressing.             93

need of.  It is to these, also, we have recourse for the section of
the tissues that  are not to be divided  with the bistoury.
   We use the scissors that are curved on the flat of their blades, to
remove excrescent growths that we  wish to excise at the surface
of the skin, or at the bottom of some cavity.  They may also prove
of use  for making holes in certain compresses, and for  giving a
particular form  to certain wounds.
   As to the  scissors that are curved on their edges, they are now
scarcely ever used.  Formerly they were frequently used, by guid-
ing their convex branch upon a grooved sound into cavities whose
external opening it was desirable to enlarge ; but we have every-
wbere substituted the straight scissors and bistoury for them, and
with advantage.
   There is no necessity of pointing out  the manner of holding the
scissors. Natural instinct alone, and the example of all women, suf-
fice to enable us to understand it.   Besides, we  shall speak briefly
of this under the article on incisions.

                      Article III.—Razor.
   Almost all dressings require the use of the razor.  In men espe-
cially, there are few parts of the body where the skin is not cover-
ed with hair.  Whether Ave are  treating a wound, or, for some
cause or other, have occasion to apply a fatty substance, unguent,
or plaster, &c,  to the teguments, these hairs collect in irritating
masses, or are glued together  to portions of the dressing, so as to
render each dressing more or less painful.  It  is easy to see from
this, that it is always proper to shave the regions destined to receive
the portions of the dressing, or that are to be  operated upon.  If
the customs in use formerly, which, so to speak,  forced the pupil of
medicine to learn with a perruquier the art of handling a  razor,
tended to degrade the profession of the surgeon, do not those of to-
day, which do not exact of the student  any exercise of this nature,
possess the disadvantage of rendering him  less dexterous ?

                     Article IV.—Spatulas.

  The spatula is a metallic blade, (Fig.  12,) slightly curved.
That which we generally use  in France, terminates at one
extremity, after the manner of an  elevator, in a beak with
which, as with a lever of the first kind or with a scraper, we
may displace  certain hard bodies.   The  other extremity
represents a blade  in  form of a  sage-leaf, Avith the  edges
a little blunt, and shelving on both sides.
  The uses of the spatula are to extend and equalize in all
directions topical applications of a soft consistence, Avherever
they are placed.  We  also use it to remove plasters  and
other objects which may adhere to the  skin, and to relieve
this latter of scabs and fatty matters, and all other impurities
which it may be desirable to take away. 
94            NEW ELEMENTS OF OPER kTIVE SURGERY.
  Myrtle Leaf and English  Spatula.—Formerly the (FiP-,3-.' (Flg-
blade of the spatula resembled rather a myrtle leaf,
which name some surgeons  gaAre to it; but  under
this  form it Avas evidently less useful than the modern
spatula, (Fig. 13.)
  Grooved Spatula.—Still more  to increase its utility,
M. Yidal  (de Cassis) proposed to hollow out a grooAre
in the spatula on its concave side, (Fig. 14.)   Under
this form it  is an  excellent director  in  releasing the
stricture in strangulated hernia.

             Article V.—Porte-Crayon.
  The cases which require the employment of nitrate
of silver in surgery are so numerous, that  this sub-
      stance is almost as necessary in the pocket-case of the ^ ►
      student, as  the  spatula and forceps.   As it consists of
  S small cylinders that are brittle, and may tarnish the linen or
      skin, it is necessary to enclose it in a protecting instrument.
      This instrument, which is a species of case made of ebony, ivo-
      ry, silver, or gold, contains a sort of cleft tube, opened or shut
      by means of a small mo\Teable ring, and intended to hold the
      cylinder of  the caustic, (Fig. 15.)   Some porte-crayons are
      much more complicated; but in that case, the intention is to be
      enabled to change them at pleasure into a writing pencil or
   !U  portable pen, and they are made with a second cavity in their
   i|  upper part to hold the pieces of nitrate of silver.  It is near the
   J|  middle of the instrument-case that the porte-crayon is generally
   Ij  placed. It should never be put there after the nitrate has been
   |  moistened, until we have  carefully dried it; otherwise, the
   I caustic salt which it consists of might, in decomposing, corrode
   "  the instruments near it.  The manner of using it, after re-
      moving the  case, is the same  as in  holding a writing-pen.
We touch Avith it the parts that are to be repressed or excited, fol-
lowing the rules that cannot be conveniently pointed out but in de-
tail, under the head of each special article.


                      Article VI.—Probes.

                    §  I.—Ordinary Probes.

  The probe is a metallic rod,  designed for exploring the bot-
tom of Avounds, or the somewhat deep passages that are found be-
Ioav the solution of continuity  of the skin.  Almost all  probes are
blunt pointed : that is to say, one of their extremities terminates in
a small, rounded head.   Some, however, are entirely  cylindrical,
(Fig. 16,) and end merely in a blunt point.  They should be  suffi-
ciently pliable to  adapt themselves easily to  the  curvatures Ave
may wish to give them.   The iron probes, however, are infinitely
less serviceable than those of silver or gold.  This instrument takes
 
fnstruments required for dressing.
95
;FifM6.) (!•*. 17.) (F,e. i8.)tlie name Qf eye or needle  probe, (stylet a fenetre
                ou en aiguille]) when it has  at its other extremity a
                large eye, (Fig. 1 ^.)   Under this form it is used to
                pass a mesh of scraped linen or small strips through
                wounds or openings in the skin, or the different
                kinds of ligatures under vessels.   It is  called the
                grooved probe and whitlow probe, (stylet a panaris])
                when, in place of an eye, it has on its upper sur-
                face a groove, which converts it into a kind of
                grooved sound,  (Fig.  18.)  Then it may serve to
                direct the bistoury into very small openings, and
                become a useful guide when  we wish  to  explore
                narrow passages, or to  have a sort of  axis by
                which to introduce with safety  certain kinds of
                tubes  to a considerable depth into the organs.
                  In fact, the probe is an instrument of Avhich the
 Fig. 19.) name should be changed, because of the terror it creates in
       the minds of most patients.  If it were possible to have an
       understanding on a subject of so little importance, I would
       propose to substitute for it that of cylinder, which could also
       be qualified as  the  probe-pointed cylinder, the eye cylinder,
       and the grooved cylinder.

                       § II.—The Chest Sound.

         The ordinary probe, being only five or six inches long, does
       not answer in all cases. Occasionally, when it is desirable to
       reach to the bottom of extensive devastations, or into some
       deep cavity, we feel the want of a much longer probe.  The
       one we employ in such cases bears the name of the chest
       sound, (sonde de poitrine.)   It is about a foot  in length, and
       to render it portable, it is divided into two halves, (Fig. 19,)
       which may be  screwed together or separated at pleasure.
       Its name, which was  doubtless given to  it when it was
       a rule to probe wounds of the chest,  would lead to error at
       the present day; for any surgeon M'ould be censured  who
       should attempt to insert it into the thorax through a wound
       of this cavity.


             Article VII.—Catheters (Algalies) or Sounds.
        We apply the name of catheters, or holloAV sounds, to tubes
       of different kinds, designed to draw  off natural or morbid
       liquids  from certain cavities.  These  tubes  serve  also to
       conduct medicated substances to the bottom of certain or-
       gans, as Avell as to explore the interior  of certain  viscera.
       Surgery, for this purpose, has sounds for the Eustachian tube,
the nasal canal, the larynx, oesophagus, and bladder, and even for
the rectum.  These instruments are of gum elastic or metal. They
take, however, the  name of catheter only when  they have been 
96
new elements of operative  surgery.
constructed for  the  purpose of being introduced into the urinary
bladder.  Before discussing  in  detail the use of catheters, when
speaking of vesical catheterism in the male, I will confine myself
for the present  to some remarks upon the catheter, which the stu-
dent sometimes has  need of  in the business of dressing.

                     § I.—Female Catheter.
   The female catheter, so called, is  a metallic tube of about six
fFig.20) inches length,  and two to  three lines in diameter, cylindrical,
     (Fig. 20,) slightly curved at its blunt extremity, pierced with
     two lateral openings on that end,  and at the other extremity
     slightly widened like a funnel, and  furnished with  a small
     ring on each side.
        This catheter, constructed for the female  bladder, serves
     also to drain the liquid  contents of certain deep and extensive
     abscesses, to explore the interior of the nasal fossae,  and  to
     introduce,  in   the manner of a probe, into the bottom of any
     burroMang wound.
        Thus made, the vesical  catheter is an instrument that can
     rarely be dispensed with.   In pregnant women, and when-
     ever' the bladder is forced up into the hypogastric region from
     some disease in the pelvis, it is neither long enough nor suf-
ficiently curved  to be introduced with  ease.   In those cases, the
male catheter, Avhich may equally be  substituted for it in ordinary
cases, is manifestly more convenient.

                   § II.—The Male Catheter.

  The  male catheter differs  from the preceding only in being a
  (Fig. 21.)  third or a half longer, and in having a much        (Fig. 24.)
         greater curvature.   This form, which ren-
         dered it difficult to place it in the  instru-
         ment-case until a mode was found of divid-
         ing it, renders it applicable to a great varie-
         ty of uses.   At the present  day, it may be
         said that the catheter, with which  every
         student should provide himself, is composed
         of three pieces : one the stem, and two be-
     |    longing to the beak.  The first, common al-
   ^•|    so to the two others, resembles in some sort
         a sleeve, (Fig. 21,)  that is, the straight por-
   ~ m    tion  of the instrument.  The other varies
   ^    according as it is a female or male catheter.
         For a female, it consists only of  a segment
of a circle of two inches in length, (Fig. 22.)   For  a
male, this segment may extend  to five inches, (Fig.
23.)  In screwing the stem upon one of these portions,
we obtain at pleasure a short and almost straight ca-
theter,  that is, a female catheter, or a long and curved
one, (Fig. 24,) that is to say, a male catheter.
j[>
J 
                instruments required for dressing.             97

   In the instrument-case, it should be carried in the form of a fe-
 male catheter, while the curved half of the male catheter is kept
 separate.
   This catheter should have Avails sufficiently  thick and solid to
 prevent its being easily indented.   The orifices  known under the
 name of eyes, and which are placed near the beak, should be at a
 certain distance from one another, and sufficiently M'ide to giAre free
 issue to the liquids.  The place of division is a point that should be
 guarded.   When the two pieces of the male catheter  are loosely
 screwed together, they lead to  an  inconvenience which it is impor-
 tant to understand, and of which I shall again speak in treating of
 vesical calculi.   The beak of  the instrument, Avhen obstructed by
 some resistance in  the bladder, is unscreAved at  the bottom of the
 urethra, while we are endeavoring to turn the broad end in another
 direction.   There is then noticed a sound which might readily con-
 vey the idea of a calculus, and induce  us to  believe that we had
 explored all the regions of the bladder, when, in fact,  the curved
 part of the  catheter had not moved at all.  It  is true that, by means
 of a particular kind of grooving, the artist named  Charriere  has
 contrived to remedy this inconvenience.  But however  improved
 Ave may suppose them to be, the catheter in two pieces  can never
 have, under a given volume, the same strength  as ordinary cathe-
 ters ; so that if it is advisable to have one of the first kind for con-
 tingent cases, this is no reason  for  neglecting the others when Ave
 have it in our poAver to choose.
   The species of punch (mandrin, called stylette in English) or little
 probe that eArery metallic catheter has connected Avith it, being of no
 other use than to clear cut the  eyes of  the catheter when they are
 stopped up, should  ahvays be withdraAvn before sounding the pa-
 tient, or at least when we  desire to ascertain the absence or pre-
 sence of calculi in the bladder.  To conclude, I   cannot  here con-
 veniently point out the  manner of employing  catheters.   I Mall on-
 ly remark that gum elastic catheters should  be  added to those of
 metal in the surgeon's instrument-case.
                                                         CFig. 25.)
        Article VIII. —Director, (Sonde Cannelee.)

   The instrument known as the Director, resembles in  no
 respects the catheter,  properly so called;  it is a stem  of
 steel, silver, gold, or silver gilt, which has scarcely one  to
 two lines in diameter, and but four to six inches length.   It
 is rounded  upon its loAver side, and has channelled upon
 the other a groove of  considerable depth, (Fig. 25.)  One   .
 end  is shaped into a cleft plate  with blunt edges, to be
 used in securing certain bridles, such as the frasnum of the   |
tongue, which we are obliged to keep in a state of tension,
 while the surgeon  divides them.   At  the  other end, the
 channel of  the  grooved sound ends sometimes in a cul-
de-sac,  at  other times  without  any  stop.   This sound,
which is often substituted for the probe  as an exploring
  VOL. I.                     13
% 
98
new elements of operative surgery.
instrument, is principally used for directing the bistoury or the
scissors into incisions in the neighborhood of organs which it is im-
portant to avoid.  We then hold it in the left hand as a lever of
the first kind, the thumb being applied to the flat plate, and the fore-
finger extended upon the middle portion,  while the point serves to
support or raise the parts, (Fig. 26.)  It is used also to break down
those tissues that make but little resistance, or to detach  and re-
move certain vessels.   In this case, the point of the sound ought to
be a little curved on its concave part; and the surgeon holds it as
he Mould a pen, taking care to keep it horizontal, and to commu-
nicate to it, while pressing it firm, slight motions backwards and
forwards.  Upon this  instrument, also, we  pass the  porte-ligature
probes, and different meches, and cylindrical stems which it is im-
portant to introduce through  certain passages.  It is,  in fine, the
most useful director instrument we have in surgery.
  The director  also presents numerous varieties.  Some persons,
for example, approve of having it perforated near the point  with
 (Fig. 27.) several holes.  Others give to its groove a consider- (Flg. #, ^
      able depth and a form nearly square, while, accord-   vV/
      ing to some others, this  groove should be triangular
      and nearly superficial; and  others again prefer hav-
      ing it in form of a gutter ; but none of these differ-
      ences are worth discussing.
         English Director.   In place of terminating in a
      bifurcated plate, the English Director (Fig. 27) has
      on its extremity a lateral ring, situated like the ring
      on one branch  of a scissors.  It is evident that under
      this form, the director is less convenient in handling,
      gives less  power to the surgeon, and loses some of its
      advantages.

                  Article  IX —Porte-Meche.
   The instrument called Porte-Meche (Fig. 28) is a sort of
 probe, terminating at one extremity in a  small fork, and at the 
instruments required for dressing.
99
other in a lenticular button.  Its use is very limited, and might be
more so, seeing that the ring forceps may, in most cases, be easily
substituted for it.  To use it, we  fix the bifurcated  extremity on
the middle of the meche, whose flattened extremities ought to cover
it, so that it can push them before it to the depth that is desired.
The right hand also embraces its other extremity in two different
ways.  Sometimes, in fact, the button, fixed in the palm of the
hand, permits  us to hold the stem with the two middle  fingers and
the thumb flexed, while the  fore-finger is  extended and placed in
front.
  In other cases, and this is the mode  I prefer, the two middle fin-
gers reach and press the meche against the instrument, while the
thumb, supported on the button, (Fig. 29,) makes it advance in the

                            (Fig. 29.)
direction of the organs.   The button of the porte-meche has also
the advantage of enabling us to introduce certain portions of dress-
ing into the midst of resisting tissues, and of thus replacing an in-
strument formerly employed under the name of 'Meningophylaz.

               Article X.—Needles  and Thread.

  We must have in the case  ordinary  thread and needles, to sew
different pieces of linen; silk threads, and  some  that are waxed.
to serve for ligatures, as accidents may require; suture needles,
straight and curved, of different sorts, for the union of wounds; but
it will be under the head of particular  operations that  we shall
treat of these objects. 
100           NEW ELEMENTS OF OPERATIVE SURGERY.
                        CHAPTER II.

                             LINT.

  Lint is among the articles most frequently required in dressing.
ft is a spongy and pliable substance, made out of linen that has
been partly worn.  To make it, it suffices to destroy the texture of
the linen, and to separate its threads from each other.   Lint is seen
under two forms: one composed of threads extracted from  small
pieces of old linen, and the filaments more or  less intimately min-
gled with them; the other, obtained by scraping with  a knife or
some other metallic blade portions  of the linen extended between
tAvo fixed points, or on some solid body, (Fig.  30.)  The first is lint
properly so called, and the  second takes the name of scraped lint.

                             (Fig. 30.)
  Lint is employed in a crude  state, or in masses of particular
forms.   Crude lint exists in the form of unequal masses, made up
of threads intermingled in every sort of M'ay, such, in fact, as it ap-
pears Avhen taken from bags or other places where  it is kept.   To
have it good, it is necessary to select such as is pliable, porous, and
white, deprived of all mixture Avith crude substances, clean and not
too old, Avith the threads not too large, and  made of linen neither
neAv nor too much Mrorn.
  Some have supposed that lint made of  new linen absorbs  better
and quicker than such as I  have just described.  Not only is this
erroneous, but lint of  new  linen is too irritating to  the surface, by
the hardness of its threads and its roughness, ever  to deserve the
preference over lint made of old linen.
  When Ave employ lint, it is  to cover certain wounds, or to favor
uniform pressure by padding certain vacuities, or to absorb morbid
fluids,  or to compress  some surface  or  cavity, or to keep asunder 
LINT.
101
the lips of a wound which Mre do not wish to cicatrize.  If it is  to
fill up certain depressions upon the surface of the body or limbs, we
confine ourselves to the crude lint, taking care  to equalize the pe-
lotons.  In other respects, the lint  is arranged in pledgets (plumas-
seaux), or in layers  (gateaux), in small balls (boulettes), dossils (bour-
donnets), cushions (pelotes), rolls  (rouleaux), wicks  (meches), plugs
(tampons), or tents (tentes).

    Article I.—Pledgets (Plumasseaux) and Layers, (Gateaux.)

                       §  I.—Plumasseaux.
   Plumasseaux are so formed as to give them a shape conformable
to the surface that we wish to cover.  Generally they are in pledgets
      (Fig. 31.)     (plaques)  of an  elliptical form,  (Fig. 31,) of
                 thickness and dimensions necessarily very varia-
                 ble, so  constructed however, that they may ex-
                 tend in every direction beyond every part of the
                 circumference of the wound,  and  be sufficient for
the absorption of all the fluids that may exude  from it in the space
of twenty-four hours.   The plumasseaux are  made  of the lint  pro-
perly so called, and the surgeon arranges them in the  following
manner :  holding in his right hand a mass of crude lint,  he places
the loose end of it between the  upper portion of the fore-finger and
the thumb.  Held firm by the pressure of these  two last-named fin-
gers,  the threads thus pinched become detached from the others.
The common mass,  thus treated successively for a great number of
times, finally parts with all its fibres,  and produces  a regular
layer of nearly parallel threads, and  of the thickness of from three
to six lines or  an inch.  In general, the plumasseau ought to be a
little thicker towards  the  middle than at the circumference.   To
add to its regularity, some surgeons trim its edges with a scissors,
while others merely fold over the edges or loose ends with their
hand.  All this is a matter of but little importance.   Provided the
contours of the plumasseau are freed of borders (bourrelets) or knots,
(nodosites,) it is all that we  can desire.  Whether  they  are after-
wards trimmed with scissors or merely turned  back, is left to the
option of our taste.  Their regular form itself, also, is a matter of
fancy rather than of real utility.   It is nevertheless true, that the
pupil who would desire to arrange speedily and in a proper man-
ner a plumasseau  which shall be  soft, uniform, and sufficiently
porous, should practise the art frequently and with care.
  Arranged in this  manner, the lint readily receives the different
kinds of greasy substances and ointments that we wish to apply to
it.  Applied upon wounds, it covers without irritating them,  pro-
tects  them against  the action  of  atmospheric  air  and the shock
of foreign bodies, preserves them in a mild temperature, and guards
them from all painful pressure, at the same time that it imbibes
their  secretion in proportion as it is given out. 
102
*EW ELEMENTS  OF  OPERATIVE SURGERY.
                        § II.—Gateaux.

   In reality, the plumasseaux of lint might well bear the name of
gateaux also.   We reserve, however, this name for the pure  and
simple agglomeration of coarse lint that we wish to apply to wounds
under the form of layers (plaques) of more or less regularity of
                 shape.   To make a gateau, we take a sufficient
                 number of masses of crude lint, spread them out
                 without altering the irregular mixture of their
                 threads, thin them so as to  increase its pliancy,
                 and give nearly everywhere  the  same thickness
                 and density to the layer, so  that the whole may
                 resemble in character a slice (lame) of sponge.
                   At the present day, when lint is scarcely ever
                 applied naked to the edges of a wound, the form of
the gateau is generally more suitable than that of the plumasseau.
We obtain by it an arrangement more porous,  pliable, and advan-
tageous in every respect, than by placing the threads of the lint in
any systematic order whatever.  The gateau presenting an areolar
aspect, which  manifestly resembles that of the sponge, is more  ab-
sorbent and less irritating than the plumasseau, which is but slight-
ly changed from the fibrous form of the linen.   It is, however, pro-
per to recollect that the gateau does not answer so well for the ap-
plication of ointments and unguents, and that the plumasseau only
is conveniently adapted to receive those matters.


        Article II.—Different Rolls (Rouleaux) of Lint.

  In place of arranging lint in layers, (plaques]) there are also other
forms given to it.

                  § I.—Boulettes, (Small Balls.)

  Boulettes of lint, a sort of small globes, (Fig.  33,)  that are made
  (Fig. 33.)   by rolling this substance between the palms of the hands,
          should in certain cases be made extremely soft and  po-
          rous, when, for example, we wish to  fill up suppurating
          cavities, or the bottom of a fresh wound that does  not
need compression.   In that case, they  should  resemble so many
small pieces of sponge, which should be made as uniform as pos-
sible as to their density at every point.  At other times, on the con-
trary, the boulette should be sufficiently solid to become rather a
compressing than an absorbent body.  They are used in this form
when we apply them in greater or less number upon vessels that
we do not wish either to tie or twist, at the bottom of cavities that
it is important to support, and upon  points whose exuberance  we
desire to repress.   Different sizes are given to  them, according as
they are to be  applied to such or such a surface.  In general, how-
ever, the size of boulettes is scarcely ever less  than that of a pea,
and rarely reaches that of an egg.  Having the  advantage  of
 
LINT.
109
moulding themselves with ease to all the inequalities of the wound
or cavernous passages, the spongy boulettes are of frequent use in
surgery.

                 § II.—Rolls properly so called.

  We may give the name of rolls  (rouleaux) to masses of crude
lint gently rolled into a cylinder, (Fig. 34,)  or into the form of a
                   spindle.   Sometimes, however, these rolls are
       (Fig-34)        a little  more flattened on  one side than  on
                    another, or contracted at some point of their
                    length.  We apply them between the edges of
any large wound, or along the lateral grooves of certain abscesses,
at the bottom of any wound  from amputation, between  the  labia
majora  and the upper part of the thighs, and on the sides of the
scrotum in certain diseases.   As  in the  construction  of boulettes,
the lint, when  their object is to absorb the fluids, should be rolled
in a manner  to resemble rather an elongated sponge, or like a cyl-
inder of linen when we wish, on the contrary, to establish a certain
degree  of compression.

                  § III.—Bourdonnets, (Dossils.)

   Formerly surgeons made frequent use of bourdonnets.   Now they
are scarcely  ever employed.  They are a kind of hard boulettes, a
little lengthened, bulging in the middle, (Fig. 35,) where they are
                 frequently  tied  by a thread.  Also they should be
     (Fie 35)   .*«.   made of crude lint,  and their principal purpose is
                 to make pressure from the  centre to the circum-
                 ference, or from  before  backwards, from below
                 upwards, or from above downwards,  also upon
                 the interior of certain natural passages, the nasal
                 fossae  for example,  or some morbid cavity, such
as that of an abscess.

                         § IV.—Pelote.

   We apply  the name of pelote to a mass of lint enclosed and press-
ed in a  piece of linen, which  is tied in  the  manner of a  sack, and
which has thus the appearance of the larger extremity of a gourd,
or of a  head  included in a narrow collar, (Fig.  36.)   To make a
         oelote, it is sufficient to place  on the middle of a square
         niece of linen a mass of crude lint, according to the size
         we  wish to give the pelote.   After  having raised up  the
         linen on every side, it is tied by several turns of a thread
         between the free portion of  the linen and the  cul-de-sac
occupied by  the lint.  In some cases, it is made in another  way:
the lint, beingpreviously introduced into the cavity where we wish
to place it, remains  free outside.  We then, piece by piece, force
 
104
NEW  ELEMENTS  OF OPERATIVE SURGERY.
into the bottom, as into a purse, all  the lint required, until there is
enough to prevent its coming out, and to give it the form of a col-
lar, when we draw upon the portion outside. With this precaution,
we introduce without difficulty pelotes of a  sufficiently large  size
within openings of the most narrow and difficult character.  It is
when we wish, therefore, to obtain pressure from the interior to the
exterior, to arrest hemorrhage, in wounds of the intercostal artery
for example, or operations on the lower extremity  of the rectum,
that the pelote of lint is specially indicated.

                    § V.—Tampons, (Plugs.)

  When boulettes or numerous masses of  crude lint are to be ac-
cumulated, either at the bottom of a wound to distend  it, or at the
bottom of some cavity to compress it, Avhether they are naked or
enclosed in linen, they generally take the  name of tampon.   We
see, then, that tampons may in turn resemble boulettes, bourdonnets,
rouleaux, or pelotes of lint.


               Article III.—Meches and  Tentes.

                         § I.—Tentes.

  We give the name of tents to rolls which are  sometimes cylin-
drical, sometimes conical,  (Fig. 37,) or  a  kind of lint-stopper.  In
                 general, the lint is, in that case, rolled between
jgssw/'         the fingers, so that its threads, which are at first
f§l|ll|^i22i^s> parallel, are thus made to twist around each
pSpi|illiB*^^  other in spirals.   The  most  common Avay  of
                 forming a tent consists in folding  double a bun-
dle composed of a greater or less quantity of the  filaments of  this
substance.   There results  from this a cone whose base ansAvers to
the point of flexion, and  the  apex to the free  extremity of the
threads.
  We also sometimes form tents by rolling up a piece of old linen,
or by cutting out some pieces of prepared sponge, or some porous
root, like that of gentian, for example.  Though  formerly much
used, tents at  the present time are scarcely ever employed.   De-
signed for keeping open fistulous passages, and to dilate certain open-
ings  that are too narrow, and to prevent the too rapid adhesion of
certain circular apertures, they have the inconvenience  of obstruct-
ing the exit of fluids, of painfully compressing the parts, and per-
forming the office of a stopper.   We should do  wrong, however,
absolutely  to  proscribe them in practice, since there are cases
where the effects which they produce are precisely such as we wish
to obtain.  Lint is much more suitable when we desire to  have a
gentle pressure.    Sponge, on the  contrary, should be preferred
when our object is  to dilate speedily some opening which is .too
contracted, particularly the neck of the uterus.  Tents of  gentian
and  of carrots hold in some sort an  intermediate place in this re- 
1-lNT.
105
spect between sponge and lint.  The  tent of gentian may also be
replaced in  some cases, either by the  extremity of a sound or of a
gum-elastic bougie, by a bit of bougie-plaster, or a  piece of com-
mon taper,  called by the vulgar name of rat de cave. Finally, we
may substitute for all these articles a cone of diachylon cerecloth,
rolled  upon the surface Avhich is free  of  the  plaster.   It is in
this manner, for example, that we may keep open the meatus uri-
narius in certain cases  of wounds, and that we might compress a
vessel opened by a puncture through the  walls of the abdomen.

                         § II.—Meches.
  There are three principal kinds of meches in  surgery—meches
of lint, meches of ravelled linen, and those of cotton.
  A. To make a lint meche, we take a bundle of greater or less
size  (according as is required)  of the threads of this substance,
Avhich we double after  the manner of an ordinary skein cut off at
one of its extremities.  A band restrains  the whole at the point of
flexion, and prevents the  threads of lint from being displaced. We
thus obtain a regular cylinder, which is now scarcely ever used but
for dressing diseases of the anus, or  to dilate the nasal canal in
some operations for fistula lachrymalis.   We, however, use meches
of lint for some other  fistulas, for certain kinds of abscesses, and
also for certain cases of diseases of the urethra.   Sometimes these
meches are drawn by means of the thread which is tied to the loop
—more frequently they  are introduced  by means  of the  porte-
meche.
  B.  The linen meche  is made with  a strip of pliable linen, half-
Avorn,  raArelled on the edges, so  as to leave  a
breadth of two to four  lines of fringe, and a middle
and unaltered portion of three to six lines wide, (Fig.
38.)   This meche, whose edges are very pliant, is em-
ployed under the form of a seton in a great number
of cases.  When one extremity only is to rest in the
(Fig. 390  interior of a cavity, whether  that cavity is
        natural or the  effect of disease,  it is often
        unnecessary to ravel the edges.
          C. The cotton meche is  nothing else than
       a cord of threads of the same kind, arranged
       in the manner of wicks for bougie or other
       candles, and for small oil lamps, (Fig. 39.) We
       find  them, therefore,  all prepared in  com-
       merce, and their use is the  same as that  of
       the preceding.,

                  Article IV.—Scraped  Lint.

          Though  it is  taken from linen, either of flax or hemp, the
       scraped lint differs  nevertheless  in  essential particulars
from ordinary lint. Deprived of threads and every kind of filament,
  vol. i.                      14
 

 106           new elements of operative surgery.

it is in reality composed only of down or  hairs.   So also is it very
absorbent, and infinitely more pliant than ordinary lint.  Applied
to wounds,  it becomes speedily glued to them, and tends to dry
them much more than the other kind. For this reason, it evidently
irritates the edges of the wound, and cannot be used but in a small
number of cases, as, for example, for suppurating surfaces in flabby
tissues of pale color.

                  Article  V.—English  Lint.

  For a long time the surgeons of England and of many northern
countries have substituted for our lint (charpie) a particular tissue,
               which they call lint, (patent lint, Fig. 40,) and which,
               according to them, they have had much reason to
               extol.  This  tissue, in some  respects  resembling
               wadding, (ouate,)  is villous, like  ours,  on one of
               its sides, and smooth or  glossy,  (lustre,) like  fine
               linen, on the other side.  Under this form it appears
               in commerce, in rolled bandages  like linen. When
               we wish to use  it, we cut off portions of it of such
               form  and  dimensions as we desire.  The plumas-
               seaux  and gateaux are thus made with care and
               despatch.   We  may compare this tissue, as to its
               form,  to velvet, whose  villous surface has  been
               much thinned out, or to those mats of down used in
               our rooms for wiping the feet upon.
                 If it is admitted that the patent lint is more con-
venient than the French, it is also true, from its thickness not being
susceptible of increase or diminution at pleasure, or in one point
more than another, that  it cannot accommodate itself so well to
the form of parts. Moreover, its glossy face renders it less adapted
than ordinary lint for the drying of the wounds, the absorption of
pus, &c.;  so that, every thing considered, the patent  lint is not so
good as ours, or in reality preferable to simple  pieces of linen.

                     Article VI.—Filasse.
  The difficulties that are sometimes experienced in obtaining good
lint, have induced persons to  seek for substances  that might  take
the place of it.  Flax, (la filasse]) wool,  (la bourre]) tow, (fetoupe,)
moss, (la mousse,) employed  on all occasions  by country people,
when they have nothing better,  were the first that offered.
  It is true  that filasse really represents lint under its two princi-
pal forms. In the state of prepared flax it is similar in some meas-
ure to lint in the form of plumasseaux.   In that of'tow, (Vetoupe])
it would be coarse lint, or the same as gateaux.   The difference is
this, that tow and flax have not been made pliable by friction, or
that they retain a spring, and  elasticity, and hardness  in each of
their fibres, which render them at the same time irritating, and not
sufficiently well adapted to the absorption of liquids.
  M. Ganal, it is true, thinks that  we may remove  these defects
 
lint.                         107
of flax by beating it and then submitting it to chlorine gas.  But
the trials to which I have subjected this kind of lint, called Vierge
by its inventor, have convinced me that it was far from being equal
to ordinary lint.   In respect to the skin and wounds, tow and flax
are to good lint, what coarse new and rough linen would be to that
which is fine and half-worn.  Those  substances, however, answer
very well for lint when we wish to pad or fill up certain voids or
cavities in the neighborhood of parts that  require gentle pressure.
Thus, in the apparatus for fracture, or beneath certain compressing
bandages, or to distend some natural cavity, we may employ them
under the form of pledgets, rolls, tents, and gateaux, in the place
of lint, which, in  all  such cases, has the disadvantage of knotting
(de se pelotonner)  and  lumping (de se grumeler) more  easily than
tow or flax.   In fine, these substances being cheaper and easier to
procure than lint, it is advisable to use them among the poor, when-
ever lint is not indispensable, or where we can do no better. Wool,
or the hair of the single-hoofed animals, the ox, camel, &c., is much
inferior to flax, and ought not consequently to be used, except where
nothing better can be had.

               Article  VII.—Typha,  (Cat-Tails.)

   The plant known under the name of typha bears upon its free
extremity, when fully grown, a sort of cylindrical mass, whose ef-
florescence furnishes a down somewhat analogous to  lint.  Other
plants afford a similar down; but typha is that which furnishes by
far the greatest quantity. This plumage of typha, which may serve
for making cushions, and even small paddings, has been for a long
time in use, in place of tow or lint, among the peasants in the marshy
districts of France.   Nevertheless, surgeons have not attempted
to employ it until it was ascertained that it cured with sufficient
celerity certain wounds of the skin.  It appears, also, that in the
department of the Aube, typha, among others, (Vignal, These, No.
152, Paris, 1832,) has been for twenty  years the domestic remedy
for different kinds of burns. Knowing that this substance had been
used in some of the hospitals of Paris, particularly by M. Cloquet, and
that much success was imputed to it,  I wished to make trial of it
myself.  Unfortunately, I soon became convinced that the fibrils of
the typha were more  irritating and evidently less absorbent than
lint; that if  it was possible to substitute them for any thing, it
could be only for scraped lint.   If we had neither lint nor flax, ty-
pha would be better than nothing, or even better perhaps than
wool; but certainly lint and tow, where we are permitted to choose,
should always be preferred.

                     Article VIII.-Cotton.

  Cotton, like lint, is seen in commerce under two principal forms
—carded cotton  (cardt)  and the  crude  (ouate) or glossy cotton,
(coton lustre.)  It is a substance whose introduction into surgical
practice ought to be encouraged. 
108
NEW  ELEMENTS OF OPERATIVE  SURGERY.
  The crude or glossy cotton could be easily substituted for English
lint—[that is, Avhat is commonly known as patent lint]—and would
certainly in many oircumstances ansMrer much better ; being more
fibrous and pliant, it would have the advantage  of more readily
imbibing fluids, and of not so readily rolling itself up on the surface
of Avounds. Carded cotton has yet more resemblance to crude lint,
and like this, lint may be adapted to the construction of gateaux
or plumasseaux, intended as coverings for all kinds of wounds ; it
is also undoubtedly practicable to form it into tents, rolls, bourdon-
nets, pelotes, and tampons.
  As cotton is  cheap, and to be procured everywhere, the question
has been proposed, whether it should not everyAvhere be substitu-
ted for lint.  An American surgeon, M. Anderson, has maintained
that it  is a sort of specific in burns, and M. Larrey was in the use
of it for a long time  in many of his dressings ; but no one has more
strongly  insisted than M. Mayor (Nouveau Systeme  de Deligation
Chirurgicale. etc., p. 71, Paris, 1838)  on the virtues of this material.
If we may believe the surgeon of Lausanne, cotton  is much better
adapted for use than lint; once  put on, it does  not become dis-
placed, and adheres so exactly to the wound that we may dispense
with a bandage ; furthermore, that  it is found everywhere, and is
so well adapted to  all  purposes, that nothing can be compared
with it.
  Cotton is preferable to typha, and to  wool and flax ; it may al-
most always take the place of scraped lint, and can often be sub-
stituted for ordinary  lint in making gateaux and plumasseaux.
  In the treatment of extensive burns upon the surface, it is of un-
questionable advantage ; applied to the suppurating surfaces, it
becomes  adherent to them, and protects them from contact  with
the external air; absorbs the fluids and  preArents all painful pres-
sure, and finally transforms itself, by combining with the excreted
matter, into a crust, which dries and permits the cicatrization of
the wound to go on underneath.  Nor has it the  disadvantage of
rolling or lumping,  (se  tasser,) or  of readily forming into small
balls  (pelotons) and hard  and irregular knots,  under the action
of the  humidity which  escapes from the skin or wounds ; com-
posed,  however, of a sort of down of extremely fine short  hairs, it
becomes too closely adherent  to the surface of wounds, so that it
is more difficult to  remove than lint, and also irritates and  dries
faster.
  In fine, without sharing all the enthusiasm of M. Mayor, I am
bound  to declare that cotton  is preferable to lint in some cases  ;
that it may be substituted for it in  an infinity of others ; but that
it is less adapted to  ordinary dressings, or to ulcers  and wounds in
general.
  [With all due deference, we  must beg leave to differ altogether
from the too favorable recommendation  of the author on the pro-
priety  of substituting cotton for  lint.   He has been rather mis-
led, we judge, by the warm eulogies of others than enlightened by
his own personal experience   So far  as the experience of Dr. 
I
LINT.                          109
Mott goes, and it accords fully with mine, cotton never should be
used as a direct application to any  incised,  abraded,  or wounded
surface whatever, whether in a state of suppuration, ulceration, or
otherwise.  In this cotton-growing country its uses are familiarly
known; and if it is in general employment as a common applica-
tion, the most readily to be had in sudden emergencies of scaldings,
burns, &c, so frequent  in steamboat  explosions, that does not
prove that the same  surfaces would  not have done  much better
under the use of lint, or whatever soft substance there may be of a
similar nature to lint, and fabricated out of fax, or even hemp.  It
is unquestionably true, that there is  something peculiarly irritating,
acrid, and unfriendly, either in the  short mechanical form of the
spicuhe themselves of cotton down,  or in the qualities of the plant,
to all wounded surfaces ; and no better test of this could be given
than the manifest injury and inflammation almost  always excited
in the wound in the vein in the arm after ordinary bleeding, if we
apply a pledget of cotton cloth, or cotton itself, instead of linen—
even avooI or tow of flax or hemp  being, as is Avell known among
the poor and in our dispensary practice, greatly preferable to cot-
ton.  As to the possibility of substituting cotton  for English 01
patent  lint, that Ave think entirely out of the question, as much so
as the  latter is of fine fibrous threads and down of linen, &c, and
the other of cotton;  in truth, it  is far more probable  that the con-
venient, light, smooth form of prepared patent lint will, on the con-
trary, from its great and manifest  utility, (as far as we can judge
from much use of it,) entirely supersede the employment of scraped
or crude lint.   Another evidence of the  injurious effects of cotton,
and the more injurious  from  its external application  over large
scalded surfaces, is, that, in those disasters where there is  so wide
a field for testing its value, it  has now for the  most part been to  a
great degree laid aside, to give place to the mild, soothing applica-
tion of pure  sweet oil, or other  equally  pure oil.  Even the lubri-
cating qualities of spirits of turpentine,  it  is found in such cases,
better  compensates for  its stimulating  properties, than the more
soft feel or lightness of weight in  cotton coverings can neutralize
the chemical or mechanical irritation of a very acrid and heating
nature, produced by the -minute short spiculae  of the  cotton down,
which in truth, from their close juxta-position and variant direc-
tion, give a peculiarly confined interstitial texture to the cotten
fibre, and by thus  making  it a powerful non-conductor of caloric,
as all the world familiarly knoAv it to be, add  greatly to the reten-
tion and increase of heat  in the wounded surfaces.  Many persons
in truth, as is familiarly knoAvn, in summer, in our country and in
the more permanently heated latitudes of the West Indies,have their
skin naturally so sensitive that they cannot endure the  heating, ir-
ritating effect of even a  cotton shirt, or sheet, or pilloAv-case.  We
must for ourselves proscribe cotton in any shape in surgery, except
occasionally only as an  external covering, or padding, or matting,
as the author has indicated, and then Avith this reservation, that  it
must never come in contact  with  the naked surface, and must be 
 HO          NEW ELEMENTS  OF OPERATIVE SURGERY.

 used chiefly for warmth or wadding, or, as we term it, filling—
 taking care to dispense with  it in hot weather, or wherever much
 inflammation exists in the wound or reaction in the system.—T.~\

               Article IX.—Substitutes for Lint.

                          y I.—Silk.
  Silk, which  some persons have  also  advised, might, in case of
necessity, be also employed;  but its  high price  on the one hand,
and its long compact threads  on the other, and its Mrant of porosity,
will never permit it to be compared as a dressing to lint, cotton, or
even tow, (etoupe.)

                     § U.—Wool, (Laine.)
  The extreme fineness and  irritating qualities of wool, joined to
the high price of this article, are alike  obstacles to its ever being
substituted generally  for the substances of which we have been
speaking; so that fine lint, as it appears to me, will triumph over
the objections that have been directed against it for years past, and
maintain, as an article of dressing, the preference which it has en-
 joyed for near a century.

                        § III.—Sponge.

  Some  other substances, however, are still employed in certain
 cases in the place of lint; sponge, for example, separated into frag-
ments, serves for small balls, bourdonnets, or plugs, when we wish
to compress or dilate  the  interior of a wound, and to absorb the
liquids of certain openings.   By selecting wide and  large sized
sponges, we may effect moderate pressure upon certain flaccid or
uneven regions of the  body—for example, the abdomen ; neverthe-
less, sponge cannot be compared to lint but in a very few points of
 view, and it is scarcely other than  in the first dressings that it can
 be indicated.   [It is, in the opinion of  Dr. Mott,  a  valuable  and
powerful absorbent, and very serviceable  in  extensive  suppura-
tions, compound fractures, &c.—T.]

              § IV.—Agaric and Punk, (TAmadou.)

  ►These substances are nearly similar in character.  They are  use-
 ful for equalizing the contour of the articulations, and as a filling in
 for all uneven surfaces, and of more decided advantage still when
 it is desirable to repress any large or projecting part—the mamma,
 for example, or some point which is exceedingly circumscribed; but
 are rarely suitable, after the first dressing, for covering wounds
 properly so called. In using them, we must select such pieces as are
 smooth, pliant, and of uniform  consistence throughout, and also in
 good preservation.  They are shaped  into pieces of different dimen-
 sions—sometimes very small, sometimes very large ;  at other times
 applied in a single piece on the diseased part, more frequently by
 piling pieces together, placing one on the top of the  other, so as to 
                            LINEN.                         HI

form a sort of pyramid, the apex of which either rests on the skin,
or is situated externally.  In general, we use agaric or punk to
replace the different kinds of graduated compresses, while  sponge
is rather intended as a substitute for cotton or masses of lint, ga-
teaux or boulettes.
                        CHAPTER  III.

                            LINEN.

  The kinds of linen that we employ in dressing are the same as
those used in domestic life. Thus we  use the tissues of thread, flax,
cotton, silk, and wool.
  Hemp cloth is that in most frequent use.  It should neither be too
thick nor too fine.  That of coarse thread, like the new, would be
too irritating  and inconvenient.  The very fine, or that which has
been too much worn, has not sufficient strength and tears too easily.
Linen cloth would be better than all, if its price made it attainable
by  every body.  Ordinary  linen, therefore, when  made pliant by
being worn, is the best, and in general best adapted for use.
  It is generally thought  that  linen for dressing should  not be
washed with ley, except in some cases, since, when thus prepared,
it draAvs (tire)  the humors with more force and dries up the wound
too much.  This common opinion is based on a fact which the pupil
ought to be acquainted with: linen washed in pure water is much
harder and rougher and  infinitely less porous than that washed in
ley; so that it does not so easily allow fluids to penetrate it, and is
better adapted to serve as  a plaster to the wound.   It is easy, in
fact, to conceive that the alkaline salts dissolved in the ley must re-
move from linen which has been soaked in it many of those impu-
rities that cannot be got rid of by washing in ordinary Mrater.
  Other things being equal, white linen, which has been soaked |n
ley, is the best for dressing; and we ought not to use any other but
from necessity.
  Cambric muslin, calico, and all the tissues of cotton, may  also be
used for that of hemp in a  great many cases.   People who attrib-
ute to cotton cloth (linge du coton) poisonous qualities, and are re-
luctant in applying it to wounds, are not  so entirely in error as one
would at first think.   We find in fact  in cotton cloth  a fine and
penetrating down, of which I have just spoken.   Owing  to this
texture, the cloth quickly becomes adherent to the wound, and is
certainly  more irritating to its  edges than ordinary  linen.   This,
however, only holds true if the textures be applied directly to the
wounds themselves; for, if they are  to be employed as an enve-
lope, filling in, or bandage, we may very well substitute cotton tis-
sues for those  of hemp, and vice versa.   [See inserted note  on cot-
ton, page 108—supra.] 
112
NEW ELEMENTS OF OPERATIVE SURGERY.
   Wool in the state of cloth is used but in few instances, and al-
most always under the form of flannel.  In this form it is used only
for applying to a part, by means of friction, the oily  substances
known under the name of liniments; it is thus used  for embroca-
tions, oily, emollient, or mucilaginous ; in other cases for the pur-
pose of maintaining a sufficiently elevated temperature about the
part; but in no case is it directly applied to wounds.

                Article I.—Dry or Wet Linen.

  Ordinarily portions of linen for  dressing are applied in a dry
state.  It  is thus they serve for wiping the skin, cleansing off the
matters formed on the  surface of Avounds, and in this A\ray are  in
daily  use  in most dressings.    Sometimes, however,  we use Mret
linen.  Then it may be moistened in different ways—sometimes by
merely dipping it  in tepid or cold Avater, that it may shape itself
better to the parts, or press them gently as it dries.   I will speak
further on of the virtues of moistened linen in the treatment of surgi-
cal diseases. When the linen is not wet until after  MTe place on
the dressings,  it  cannot be compared with that above mentioned,
but belongs evidently to the description of dry linen.  A point not
to be forgotten is, that the pressure is less under linen that has been
wet before  applied, AArhilst it  increases under that which  is wet
afterwards ; and this is because the fluids, by swelling the threads
of the linen, necessarily shrink and thicken this substance, (s'epais-
sissent]) which, for the same reason, must  resume its original di-
mensions,  and become thinner [and looser] by drying.

      Article II.—Perforated and Fringed (Decoupe)  Linen.

  There is now consumed an extraordinary quantity of perforated
linen, (linge troue.)  This is  nothing more than pieces of the finer
      (Fig. 41.)       kinds of old linen that are perforated with holes,
   _______„,___  ______   so as to give the appearance of a skimmer  or
                j  Avatering-pot.  These holes are cut out by scis-
   WggC.       4l  sors,  or by means of a punch,  (empoite-pieces,)
   lBw_J.!p_lltfB  or  by machines  constructed  for this  purpose.
                  The manner of doing this is, in  other respects,
very simple, and has no other inconvenience than requiring a good
deal of time and causing considerable fatigue.  We take a piece
of linen, folded twice or four times, and cut out with the scissors
each  angle that is thus made upon the principal fold.   We may
accomplish the same by cutting, by means of the flat curved scis-
sors, portions of this linen on one of its sides, (faces.)  The way to
make this perforated linen with most precision, is to draw out from
space to space two or three threads, first in one direction, then  in
another, so as to convert it in this manner into a sort of net-work,
having a great number of square holes.
   This kind of dressing is of very great utility ;  greased with ce-
rate,  or clothed with any fatty substance whatever, and  placed 
LINEN.
113
upon wounds, this does not prevent their being covered Math absorb-
ent gateaux and plumasseaux, while it protects them from painful
adhesions and from too rapid a desiccation. By this means, Ave run
no risk of leaving a painful traction upon Avounds in dressing them.
The holes by A\oiich it is pierced permit the suppuration to escape;
the oily matter which  covers one  of its surfaces  hinders it from
drying, and sticking, and forming  a crust Avith the  edges of the
Avound;  the lint AAath AArhich Ave cover it is thus freed of one of its
most serious incom-eniences.
  Latin, gauze, or muslin, AAOiich, in  case  of necessity, might be sub-
stituted for the perforated linen, have not, hoAvever, all its advanta-
ges.  Forming a simple net-Avork, these  tissues can retain no fluid,
and are incapable  of preArenting the  desiccation and agglomera-
tion of the dried matters, as the lint that Ave often have occasion to
apply to them does ; but  (as I shall mention farther on) they are
better adapted than perforated  linen to the surface of cataplasms
that Ave do not wish to  apply next to the skin.
  Fringed linen (le linge decoupe) is  a small bandage of six lines
to an inch in Avidth, Avhich is cut by the scissors from space to space
upon one of its  edges, so  as to convert  it into a     (Fig 42)
species of fringe or border,  (Fig.  42.)  This small
bandage, previously coArered Avith cerate, is applied  _§|
upon the edges of Avounds, so that its fringed bor-
der extends outside, and the  other overlaps by a line or tAvo the
edge  of the Avound.   The gateaux or plumasseaux, applied over it,
are thus prevented from the possibility of unpleasantly adhering to
the edge of the suppurating surface.  Within the last half century, the
perforated linen has superseded them in almost all those cases where
they Avere formerly employed.  I think  they have  been too  much
excluded from use; for they are better than the perforated linen for
ulcers and wounds of  a pale and flabby character,  and for  all
wounds that require the use of scraped lint or carded cotton.

  Article III.—Linen spread AAara Ointment, (Linge  enduit de
                          Pommade.)

  We no longer use noAV, in the dressing of Mrounds, those numerous
medicated compounds to M'hich  so many virtues Avere ascribed in
former ages.   Thus the linen applied on  wounds is scarcely eArer
covered Avith any ointment, unguent, or plaster.   At  the present
time Ave use it in the natural state, and either dry or wet; or if we
desire to prevent its adhesion to the subjacent parts, it is with ce-
rate only that we besmear one of its sides.  The  linen, which then
takes the name of cerated  linen, (linge cerate]) exists under  three
forms—in the natural state, when we wish to cover an inflamed or
naked portion  of the integuments Avhere there is no wound; in the
state of perforated linen, as I have just described it, and in that of
fringed bandelettes.
  vol. i.         .              15 
114           neav  elements  of operative surgery.
CHAPTER  IV.
                         COMPRESSES.

  The name of compresses is given to various pieces of linen used
in covering wounds.  They are also of very different forms. They
are made of the cloth of hemp, flax, or cotton, or of silk, or flannel,
but especially with linen.

               Article  I.—Form of Compresses.

  When the linen which takes the name of compress has the same
             dimensions in its two principal diameters, (Fig. 43,) it
             is called a square compress.   If this linen is  twice as
             long as it  is broad, so as  to form  a square when
             doubled on its length, it is called an ordinary com-
             press.  We call it by the name of long compress (lon-
             guette) Avhen  it ex-              (Fig. 44.)
             ceeds by twice or
(Fig. 43.)

iWpil^Vi'j.i'l'jItll	:.ri!!i:p,|||^!ri'i;';lf "" ]!f.l!fjl
thrice in one direction its other
diameter, (Fig. 44.)  The trian-
gular compress is made with a square piece of linen, folded so as to
     (Fig. 45.)       bring tAvo of its angles together, (Fig. 45.)  If this
                 triangle is afterwards twice or thrice folded from
                 the apex to the base, it is transformed into /Wi„ ...,
                      r  .           ,                ,    (rig-46.)
                 a cravate compress, (compresse en cravate—
                 Fig. 46.) The fichu compress, (compresse en
fichu,) requiring more pliancy, is ordinarily of silk, cotton, or
muslin.   All these forms of compresses having a special ap-
plication, I shall be obliged to recur to them again.

                Article  II.—Divided  Compresses.
(Fig.	47.	>
jij,iir'lii|l:i1i,|f	jlji	
	1..	■ | _| F.!
  We are sometimes obliged to divide, to greater or less ex-
tent, the free edges or extremities of compresses.
  The Cross of Malta. If we cut upon a small square piece
of linen, formed of four folds, in a direction from the most
salient free angle to within some lines of its folded angle, we
              obtain a Maltese cross, (Fig. 47.)  This cross,
              which it may be useful  to  perforate in the
              middle, to fix it by its centre upon the ex-
              tremity of projecting parts of the body—upon
              the extremity of the fingers, for example, or |\ j
              on the wound Avhich succeeds to the opera- \W
              tion of phymosis, or from amputation of the
              penis, or upon the apex  of the mamma, or, as was
formerly used, on the stump in most cases of amputations—ought
to be small, and not  to have a diameter greater than from four to
five inches. 
I
COMPRESS
115
(Fig. 49.)
   The half-cross of Malta (Fig. 48) is a piece of
linen divided like the preceding, but after having
been doubled once only.  It  is particularly adapt-
ed to the stump of the shoulder.
   Cleft  compresses, (compresses fendues.)   If  we
merely divide into two equal halves the extremity of a long com-
press, which is either single or double, to the extent of a third or half
of its length,there results a compress cleft into
two heads, (Fig. 49.)  This compress, one of
the  halves of M'hich remains undivided, is
chiefly used to draAV up the flesh in amputa-
tions of the limbs, at the moment when the
surgeon performs the section of the bone. In
some cases  it is necessary to divide it into
three heads, (Fig. 50,)  as in amputation of
the leg or forearm. The middle head is then
passed through the interosseous space, Avhile
the two lateral heads are drawn up outside the bones.   [This last
is  the retractor of English and American surgeons.—7.]
   Sling, (fronde—Fig. 51.) The long, narroAV, single compress takes
the name of sling, if it is divided throughout its Avhole length, with
                             (Fig. 51.1
(Fig.	50.)	
iffiSHHgf	_	~~\- _-_-. __i
t_._____"._. "	1\T	___;^«fe;=l
s^»&=	:_--"	^HK==J
the exception of a feAV inches of its middle part which are leiu un-
cut ; it is often useful to pierce a hole through the central point of
this  middle part.   It  is  scarcely ever used but in diseases of the
chin and of the lower jaw.
   The window compress,  (compresse fenetree.)  Some  persons un-
derstand by compresse fenetree the perforated linen (le linge troue)
of which we  have already spoken; but it is better to reserve this
name for compresses which are to have large perforations on one
or more points of their extent, in order to be adapted to particular
kinds of ulcerations.  We have thus compresses Avith circular open-
ings, (compresses en  lunette—Fig.  52,) those with
               square openings,  (Fig. 53,) rhom-
               boidal, ellipsoid, &c.; for example,
               for the  dressing of blisters upon
               the arm, the  application of some
               kinds of caustic, and the  dressing of certain ulcers,
(Fig. 32.)
(Fig. 53.)
                Article III.—Folded  Compresses.

  All compresses that are not folded may be denominated single.
They are used in this manner in a great number of cases where 
I
116
NEW  ELEMENTS  OF OPERATIVE SURGERY.
(Fig. 54.)
the linen is not separated from the skin or wound by any other sub-
stance.   But the compresses most  generally employed are once or
several  times doubled.  If the linen is folded only once, the com-
press is  said to be only doubled ; if this double is folded upon itself,
the compress has two doubles; and so on in succession.
  A kind much used is the graduated compress ; it  is made with a
square double, or with a Avide long compress.   The  linen is  then
folded a great number of times upon its base, so that each new fold
                       is a little less in width than that Avhich pre-
                       ceded it, (Fig. 54.) In order to maintain the
                       shape of the graduated compress, it must
                       be immediately  moistened,  or  its centre
                       stitched together by means of thread from
space to space.  The graduated  compresses  which have much
more length than breadth, resemble a kind of prisms, pyramids, and
                        staircases, (Fig. 55,) and  are intended to
                        fill up cavities, or to compress certain
                        parts of the circumference of a limb in
                     3  the manner of Avadding.
  [Amadou, or Punk.  Mr. J. Wetherfield recommends amadou, (or
punk,) from its soft elastic nature, as a graduated compress in um-
bilical hernia in children, and over fistulous ulcers.  Also, when
spread with  soap plaster, it is, he says, a good application 0Arer the
sacrum and ilium, to prevent inconvenience from long confinement
in one position.  Also, in this way, it forms a good  corn plaster,
and to support varicose veins.—T.—Vide  Med. Gaz. 1841.]
(Fig. 55.)
                        CHAPTER V.
                    BANDS,  (BANDES.)
  The  name of bands, in the art of dressing, is given to certain
kinds of ties which  are used for fastening the other pieces of the
dressing, (appareil,)  and which ordinarily make many turns on the
diseased part.   These portions of the dressing may be of different
tissues.  They  are  made of tissue of hemp, or flax, or of muslin
calico, flannel, or caoutchouc.   For a  piece of one of these  sub-
stances to acquire the name of band, (Fig. 56,) it is necessary that
                            (Fig. 56.)
its length should be at least six times greater than its breadth;
otherwise it would only be a bandeau or long compress. 
BANDS.
117
     The length of bands is extremely variable.  Some are not over
   a yard; others  exceed ten; nevertheless, they are most generally
   from three to six yards—that depends upon the size of the diseased
   part, and upon  the number of turns or circuits we wish to make
   with it.   The width of bands is rarely less than that of the finger,
   and rarely exceeds that of four inches.  The wide bands of three
   fingers breadth are the most common, and at the same time the
   most  convenient.  The narrowest are only used for the fingers,
   ears, or penis.   The  widest are employed  about the belly  and
   chest.
           Article I.—Linen Bandages, (Bandes en Toile.)

     Being designed to hold the other parts of the dressing, or to make
   pressure on some region of the body, these bandages require a cer-
   tain degree of strength.  The ordinary linen  cloth (toile ordinaire)
   also has the preference. Only it is necessary, as for compresses,
   not to make use either of new linen or that which is of too coarse
   texture.   Old linen  is the best:  we cut it in the direction of the
   warp, (a droit fil]) and we thus cut up into strips our sheets, shirts,
   napkins, and table-cloths, that have already served their household
   purposes.
     As the strips  resulting from this division of the pieces of linen
   are rarely sufficient for each of them to form a bandage, it becomes
   necessary to unite several of them together by their ends. This
   union, which might in cases of necessity be made by means of pins
   placed crossA\dse, ought to  be effected by means of a whip-seam
   pressed  down,  so that  as little  inequality as possible may result
   from it.   The linen bandage thus prepared should be freed of its
   hem  and of every other seam.   Then, hoMrever, it has  the disad-
   vantage of readily unravelling on its edges, and of incommoding
   the bandage with troublesome filaments while we are unrolling it.
   If, to avoid  this incomenience, we protect the edges by a hem, it
   becomes hurtful in another respect.   Each one  of its edges thus
   arranged, presenting a greater degree of firmness and resistance
   than  the middle portion, is  sure  to compress and restrict, in  the
   manner of a cord, the points that  it embraces.  If in the place of a
   hem we merely have a selvage, (un faux fil,) we avoid the unrav-
   elling of the bandage ; but there still results from it a compression
   less regular and less uniform than with a bandage that  is entirely
   plain.  It is, however, true, that the employment of bandages Avith-
   out selvage or hems involves serious difficulties for certain kinds
•  of dressings; it would be  desirable,  therefore, that an article of
   such general use might be made in some other way.
     It appears that in Germany surgeons  have contrived a way of
   making  bandages without being obliged to use linen, properly so
   called.   They are made like the ordinary bandage, but with a softer
   and more porous thread.  They are so arranged that the transverse
   thread leaves, at intervening spaces,  small loops on the edges of
   the bandage, by which means nothing is more easy than to attach
   the edges of such bandages together.  I cannot conceive Avhy  in 
H8           NEW ELEMENTS OF OPERATIVE SURGERY.
     France art has not yet profited of this contrivance.  The only rea-
     son that can be given is, that bandages, such as arc used amongst
     us, may everywhere be made as Ave want them.  It  is neverthe-
     less true, that if Ave had not contracted the habit, it would be much
     more handy to take from a roll of bandage the portion that Ave re-
     quired for dressing a wound, than to cut it from a sheet or napkin.

       Article II.—Bandages of Cambric Muslin or Calico,  (Bandes en
                          Percale ou en  Calico.)

       The  tissues knoAvn under the name of cambric muslin, or calico,
     being finer than ordinary linen, have, therefore, appeared to some
     persons more suitable for bandages.  This  is but partially true.
     Before  having been washed or used, this tissue is not sufficiently
     porous to answer the principal indications that we have in view;
     it also slips too readily for  the bandage  to be easily kept in its
     place.   If Ave do not employ it until after it has been softened by
•    use or washing, it has no  longer sufficient firmness, and plaits or
     rolls  up into a cord with extreme facility ; whence it follows, that,
     with few exceptions, the bandages of cambric muslin or calico are
     not so good as those of ordinary tissue.
       Cotton bandages would be preferable, if their down was less irri-
     tating,  and if old cotton cloth retained the solidity of linen.

                    Article III.—Woollen Bandages.
       Woollen cloth, which  is but rarely employed under the form of
     compress, would often be preferred to linen for bandages, if it was
     less  dear.  Though we  might for  this purpose make use of any
     kind  of woollen cloth, or stuff, Ave generally, however, prefer flan-
     nel, and that  almost exclusively, for woollen bandages.  Pliable,
     porous, and resistant at  the same time, flannel bandages ha\re the
     advantage of adapting themselves exactly to the parts, and with
     very  little tendency to become  displaced, or to plaifc or roll up upon
     themselves ; also, they increase the  temperature of the part, and
     readily absorb all its fluids; they are, besides, very extensively used
     in England.   There is, however, the objection, that they keep up a
     certain degree of irritation upon the skin, uselessly heat the parts,
     and  soon become badly soiled; also, that they do not answer as
     well  for the establishment of reverses (renversees) as linen banda-
     ges, and are, besides, too distensible, and of a kind that cannot be
     readily had on all occasions.

                   Article IV.—Caoutchouc Bandages.

       Gum elastic, or caoutchouc, which has been a long time used in
     commerce under various forms, and advantageously  employed in
     the making of suspenders, gaiters, cinctures, corsets, &c., may also
     be used for the construction of bandages.  A young physician, M.
     Barthelemy, (Theses, No. 322, Paris,  1836,) has discovered a mode
     of flattening and attenuating (filer) caoutchouc, so as to convert it
     readily and at pleasure into pieces as thin, wide, or long, as may be 
BANDS.
119
 desired.  He has shown me bandages made in this manner, and I
 have remarked that they roll and unroll with the same facility as
 those of linen.
   The pliancy and elasticity of caoutchouc would seem to ensure for
 it a more uniform compression upon all the parts without any re-
 striction anywhere.   There is no necessity of reverses or folds, and
 we have no trouble  from creases, (les godets;) if any reaction takes
 place under the bandage, its flexibility permits it to yield on a given
 point, while it is making the proper resistance required upon the
 others.   There is no  doubt  then that the caoutchouc  bandages
 would be an  incalculable acquisition in practice, if they could be
 brought into use, and if it were possible to procure them at a cheap
 price.  They are  nevertheless not free of disadvantages.  Liable  to
 relax under the influence of heat, and to contract during cold, they
 easily give  rise to dangerous inequalities.  Yielding, too, without
 difficulty to muscular action, and to the different movements of the
 articulations, they might, in elongating themselves in an unequal
 manner, fold  over crosswise, and in a great number of dressings
 not ansMrer the purpose  intended.
   [Caoutchouc ligatures and bandages.  In addition to what is given
 in the text, we must add here some further details: Mr. Thomas
 Nunneley, of Leeds, England, has introduced caoutchouc ligatures,
 and extols their advantages over all others. Their superiority con-
 sists in these particulars : They may remain on  a much longer time
 without producing irritation  of any kind ;  from their elasticity, they
 hold the divided parts in contact with  much less stretching and in
 a more natural  manner, and at the same time  keep up an equal
 degree  of tension, for, if the  part swell, the ligature gives way in
 proportion  to the pressure;  so, too, when the parts contract, they
 also contract, and an  equal  approximation is  maintained.  From
 their smooth and  unirritating properties, also, a greater number may
 be applied,  and as they do not induce ulceration, the scars left are
 much smaller than after silk ligatures, Avhich is an important con-
 sideration in wounds of the face and neck.
   As they  become  smaller  by stretching, they  should  be larger
 where much pressure is  to be used.  The  ends should be knotted
 three or four times to  prevent  their giving Mray,  and to effect that
 better,  the  cord  should  be .Masted tMace  before making the first
 knot.   But the very properties of caoutchouc ligatures which give
 them the advantage for wounds, obviously make them most unfit
 for tying vessels.
   The  thickness  of the thread should be one-sixteenth of an inch in
 diameter when cold.  The application of the warmth of the hand
 contracts it to one-sixth  its length.  In his experiments, Mr. Nun-
*neley found that a cord of one-sixtieth of an inch diameter, when
 stretched out to eleven feet long, contracted by warmth (of 90° F.)
 to eighteen inches, but no farther by any addition of temperature
 up to 212°.  Hence, before the suture is applied, he recommends it
 to be immersed in warm water of not less than 90° F.  A uniform
 degree of elasticity  is thus obtained, and  we thus adapt it to the 
120           NEW  elements  of  operative surgery.
tension required by the part. Thus, if we apprehend much swelling,
it should be drawn so tight only as to keep the parts in apposition ;
if, on the contrary, there be much tumefaction, it  should be drawn
so tight as to anticipate the subsidence of the swelling.  The dan-
ger, however, is of drawing the ligature rather too tight than not
enough so. If they make too great tension, they soon cut their way
out. The eye of the needle should be large, and of the character of
the seton needle, as the cord Moien contracted is bulky.  The su-
tures  should all be introduced with one thread, which is to be after-
wards cut into the separate ligatures.
  Mr. Nunneley thinks the  caoutchouc ligature especially advan-
tageous for dressing wounds Mrhere the adhesive plaster cannot be
retained, or is too irritating to the skin, and where it is desirable to
apply lotions.  In  lacerated wounds of limbs, Mr.  Nunneley pro-
poses to bind up the wound with caoutchouc thread, thus dispensing
with sutures and plasters, M'hile intervals  are left for the free dis-
charge of matter and the application of emollients and lotions.  In
the event of using cold lotions, goldbeater's leaf may be interposed
upon the raw surfaces  of the wounds. Mr. Nunneley suggests that
this method of bandaging might  be of great use in reducing old
hernias when the  ring is large.  The turns of the thread should
commence  at the bottom of the hernia, and pass uninterruptedly up
to the neck. The thread should be double the thickness of ordinary
sutures, and also wound around the hernia spirally. He thinks this
mode of graduated pressure much preferable to the taxis, the irri-
tation of which latter, he is of opinion, often does great injury.—T.
Vide London Lancet, March  13 and July 3, 1841.]
  [Caoutchouc bandages. The same properties of caoutchouc which,
in the opinion of Mr. Nunneley and others, should  induce us to give
a preference to cord or tape ligatures of this new, useful, and re-
markable material in  the  art, may, in the opinion of M.  Rigal, of
Gaillac, be urged in favor of caoutchouc bandages under certain cir-
cumstances.  He has used both for some years, and he particularly
instances hare-lip and  operations for the restitution of lost parts as
adapted to the ligature ; while  he remarks that the  elastic banda-
ges are very useful in maintaining oblique fractures of the lower
extremities in perfect  apposition, opposing a force in constant op-
eration to the irregular action of  the displacing muscles.  In this
way, also, they may assist in the replacement of parts after tenoto-
my.—T.—Vide British and Foreign Med. Review, July, 1841.]

             Article V.—Thread-Riband Bandages.
   There are ribands of common thread, also those of flax or cot-
ton, and of all sorts of tissues, and of different thicknesses.  Among
these ribands, which in domestic  life have altogether a  different
destination, there are some sufficiently wide to use for bandages.
These riband bandages, however, are generally unpleasant, hard,
and stiff, as if glazed by ironing, or by the starch  with which they
are impregnated.  They are Avithout porosity,  and slip so easily
that they can scarcely ever be kept in place.  Their edges, like 
BANDS.
121
cutting instruments, wound the skin; the reverses with these are
difficult to be made, and they generally adapt themselves badly to
the form of the parts.  I should not advise them, therefore, unless
no better can be had.
                Article VI.—Roller Bandages.
  Almost all bandages are presented to the surgeon under the form
of a cylinder; they are then called  roller bandages.  One of the
extremities is found on the  surface of the cylinder, while the ether
occupies its centre.   Bandages are thus rolled up into one head, or
into two.  Every bandage has two extremities or heads and a mid-
dle part, (le plein.)  The manner of rolling a bandage is an essen-
tial point for the student of medicine.  It is important, in fact, that
he should perform this small operation with ease, quickness, and
some degree of dexterity, if he does not wish to be excelled by the
nurses.   For that purpose, we are to fold the internal extremity or
central head of the  bandage four or five times  upon itself, that it
may form a sort of  axis.  We then hold this nucleus of the cylin-
der between the thumb and fore or middle finger of the right hand
by the two extremities of its greatest diameter.   The loose portion
of the bandage, being throMm across the radial side of the fore-finger
of the left hand, is held flat in that position by the thumb of that
hand, while  the other hand, draAving the  bandage toAvards it by
half-turns, successively winds  it upon the  initial pivot, and thus
forms it by degrees  into an entire roll of bandage.   Two methods
may be followed to arrive at this result—in one the belly or bulging
part of the first cylinder looks downwards, and the right hand rolls
it from the beginning to the end by drawing it from below upAvards
and from behind forwards, (Fig. 57.)  In the other, on the contrary,
                            (Fig. 57.)
the free  part of the cylinder looks upwards, and the hand which
moves it draws it from  above doAvmvards, and at the same time
from before backwards.  The bandage thus wound up to its termi-
                              16
VOL. I. 
122
NEW  ELEMENTS OF OPERATIVE SURGERY.
nation is said to be rolled into a head, (globe—Fig. 58.)   ("g.se.
                    To roll a bandage Avith two heads,
                    (Fig. 59,) it is held as in the prece-
                    ding manner, only we stop for the
                    first cylinder at the middle of the
                    length of the bandage, so as to do
                    the same with the other extremity.
In this case, the bandage with its two ends in the centre has no free
extremity.  The portion of the bandage Avhich unites the two heads.
and holds the place of its outer extremities, takes the name of the
middle (plein) portion.  We generally give less volume to one of the
rolls than to the other.

                 Article VII.—Wet Bandages.

  Bandages are  ordinarily applied in the dry state;  it is generally
preferred, however, to have them a little damp.  If it be true that
dry bandages are very generally employed  at the present time, it
is also true that  damp ones are likewise often useful.  We dampen
bandages by dipping them into various kinds of liquids.
  With water.  Impregnated with water only, they adapt themselves
to the parts with more facility than in the dry state.  Adhering
slightly to the skin, they render the reverses more uniform, and are
less liable to puckers. The wet bandage, howeA'er, unravels easier,
and  soon shrinks a little by drying.   [Bandages tighten or shrink
when Avet, and vice versa.  See aboA'e, Avhere  M. Velpeau admits
these Avell-known facts.  So in ships Avith ne\v rigging, it has to be
slackened when  Avet, or it breaks.—T.]
  With medicated solutions.  If Ave dip the bandage into medicated
fluids, it transmits their properties to the diseased parts.  It is thus
we may make it  emollient by impregnating  it with marsh mallows,
or slightly resolvent  and  anodyne with the aid of lead Avater, still
more resolvent and desiccative by spirits of camphor, and narcotic
by preparations of opium.  We, hoAvever, rarely employ bandages
dampened in this way, because it is generally preferred to sprinkle
the medicated liquor upon the bandage, after the latter is once ap-
plied, than  to saturate the different pieces of the dressing with it
beforehand.

       Article VIII.—Glutinous Bandages, (Bandes Collees.)

  It may become useful to impregnate bandages with matters which,
in drying, harden and glue them together in such manner that the
whole bandage becomes converted into one homogeneous substance.
We shall see, farther on, that bandages applied in this manner are
suitable to almost all kinds of fractures, as well as to a great num-
ber of other dressings.  The materials that  are used in such cases
vary much.
   White of Egg.  A- mixture of the white  of eggs, spirits of cam-
phor, and lead water, beaten together, soon gives to the tissue a lig-
neous hardness.   It is the liquid eulogized by M. Larrey. 
BANDS.
123
  The essence of turpentine, with which linen is easily impregnated,
has the same effect.  Veterinary surgeons have long used it in their
dressings.  It is a substance Avhich has the disadvantage of sticking
with  tenacity to the skin and hair, and of being more difficult to
detach than the liquid of M. Larrey.
  Flour. Rve, and all other flour dissolved in vinegar or water, so
as to  form a* clear bouillie or glue, also causes the turns of the ban-
dage  to become adherent to each other and to acquire a great hard-
ness.  This application, which I have  employed,  and which was
shown to me by M. Bretonneau  at the hospital of Tours, was used
as the base of the plaster  called calotte, of Avhich  I gave the for-
mula in 1823, (Theses de Paris, No. 16.)  It may be substituted for
the other applications I have  mentioned,  and also, in cases of ne-
cessity, for those of which I am noAV going to speak.
  Glue, (colle.)  A solution of gum in  Avater, or a solution of Flan-
ders glue, produces a result nearly similar.
  Starch.  It is the same with starch, boiled in the  manner it  is for
the purposes of AvasherM'omen and for starching.  It is in that case
well to besmear the turns of the bandage  with it, as we unroll it.
  Dextrine. In the place of starch we may use a  solution of dex-
trine.  One part of dextrine, gradually diluted in as much pure wa-
ter, or in a mixture  of water and brandy, cold or  hot, furnishes a
solution into which we may dip  and saturate the bahdages, which
afterM'ards glue together and harden,  in the space of  two days, to
the point of acquiring the  solidity of  wood.  Thus prepared, they
serve to form all kinds of immoveable bandages, and  are destined,
if I am not deceived, to be of great utility in surgery. Up to the present
time,  diluted dextrine has the advantage,  over all other substances
that I have tried, of being at a low price,  of requiring no prepara-
tion, and of gluing the linen when cold; and the power, also, of
penetrating it like M'ater, of hardening rapidly, and of allowing it-
self to be readily softened again by means of hot Avater.

   [Dr. Van Buren on Glutinous, Starch, and Dextrine  Bandages.
  A very interesting paper on the different  kinds of glutinous, starch,
and dextrine bandages, the history of their origin, and their present
modes of application, was published in the American Journal of
Medical Sciences, (Philadelphia,) for May,  1840, by  William H. Van
Buren, M.  D., formerly an eleve of M. Velpeau,  and now of the
city of New York.   We avail ourselves with pleasure ot the val-
uable practical remarks in Dr.  Van Buren's learned paper, an ac-
curate summary of which is here subjoined.— T.
  It is not only of late years that the attention of the profession
has been directed to  this subject.  The inefficiency of the ordinary
aoDaratus for fractures was asserted by Hippocrates:   Nam neque
in quiete ut putant,  crus  continent, neque dum rehquum corpus in
hanc vel'illam partem convertitur, canales prahibent quominus crus
sequatur, nisi homo ipse diligenter advertat, (Hippocrates: DeFhze-
turis,)-nna by a later and more familiar  authority, Boyer:   Mal-
gre l'opinion generalement adoptee, ll est facile de demontrer, que lea 
124
neav elements of operative  surgery.
bandages ne servent que tres peu, ou meme point, a maintenir lea
fragmens dans leur rapport  naturel."—(Dictionnaire des Sciences
Medicates, tome xvi., p. 535.)
  We have eAridence that the Arabians, and some of the eastern
nations, were in possession of an " immoveable apparatus" Avith which
they treated fractures.  It is generally believed that the idea Avas
first suggested, in modern times, to M. Geoffroy, on the inspection
of some ancient Egyptian relics.   M. Sedillot, in the early part of
the past year, exhibited before the  Royal Academy of Medicine, of
Paris, an apparatus used by the Arabs for fracture of the fore-arm ;
it consisted of numerous narrow splints made of split cane, each
less than an inch  in AA'idth—these were firmly attached to a sheep-
skin Avith the M*ool on it, and bound to the arm.   Of this the splint
recommended by  Benjamin Bell (Bell:  Surgery, Philad. ed.,  1814,
App. p.  15)  is but a modification; it is  a thin strip of light Avood
glued on leather, and afterwards split longitudinally at intervals of
half an inch.
  A splint  consisting of strips of whale-bone, attached by linen in
the manner of women's  stays, formerly much used by the English
surgeons, is also  on the same  principle. This plan calls to mind
the instructions of Ambrose Pare, when suffering from a fractured
leg, to his  friend  Richard Hubert, who attended him :  " You  must
fortify," said lie, " the sides of my limb with junks made of tents or
little sticks, and lined with linen cloth." (The Works of that famous
Chirurgeon, Ambrose Pare, translated by T. Johnson, London, 1612.)
According to M. de Bouqueville, (Voyage dans la Grece, Paris, 1820,)
the modern Greeks habitually use a consolidating mixture for curing
broken bones—gum mastic is said to form its principal ingredient.
A similar though essentially different expedient is adopted in Spain,
Corsica, and the Brazils, introduced most probably by the African
Moors.
  The Italians have long made use of an immoveable apparatus,
which has been brought into notice by Assalini, in the modifications
which he applied  to it, consisting chiefly in the substitution of moist-
ened pasteboard for the original materials.  The itinerant boneset-
ters  of Switzerland and the  southwestern provinces of France,
some of whom have become quite notorious for their success in the
treatment of fractures and sprains, employ pasteboard and avUIoav
splints, and solidify their apparatus by means of resin, pitch, mas-
tic, and other varnishes.  Guy de Chauliac, one of the earliest Avri-
ters on surgery in France, speaks  of a  composition  he employed,
consisting of slaked lime with  different  gummy and resinous sub-
stances.  Ambrose Pare (Op. Citat, p. 584) recommends at length
the following " Plaster to holdfast restored bones:—ty. Thuris. mas-
tich, aloes, boli armenii, ana, I j ; aluminis, resinae pini sicca?, ana,
 3iij ; farinae, 5 jss;  albi  ovorum, q. s.—make thereof a medicine,
and let it be applied all around the leg."
  Among the English surgeons, Cheselden (11th ed., Lond., 1778, p.
38) is the first who makes mention of an apparatus.  In his "Anato-
my," he speaks of a bonesetter of  Leicester, who employed a mix- 
BANDS.
125
ture of wheat flour and whites of eggs, Math which he smeared his
bandages  to  render them  solid; subsequently he  adds: "I  think
there is no better way than this to treat fractures, for it maintains
so perfectly the position of the limb"*
  Mr. Lawrence,  the  celebrated surgeon of London, in a lecture
which I heard him deliver on this subject, (Jan., 1839,) ascribed the
first employment of whites of eggs and powdered chalk, as a solid-
ifying mixture, to a namesake of his, a  Mr. L., of Brighton, Eng.,
Avithin a few years past.  He recommended the practice very highly,
and Avent through the process, before his class, of applying the ap-
paratus.
  Mr. Alfred  Smee has lately published an account  of certain
" moulding tablets for fractures," consisting of a composition of gum-
arabic and whiting interposed betAveen two  layers of coarse  linen.
(V. Phil. Med. Exam., vol. ii., No. 14, from Lond. Med. Gaz.)   These
appear  to be equal, if not  superior to  those splints made of felt
soaked  in gum-shellac, Avhich, on account of their being patented
by  the  inventor, are placed, to  a certain degree, beyond the  reach
of" the profession.  Lecat, a French surgeon, in the year  1735, in* an
essay on the treatment of fractures, to which a prize was awarded
by  the Acad. Roy ale of Paris, asserts that a "simple fracture, when
reduced, requires only to be maintained ;  and need be examined but
once before its consolidation—oftener is  unnecessary."  In 1768, M.
Moschati, acting on these principles, presented to the notice of the
Academy seA^eral cases of fracture which  he had treated success-
fully by means of an apparatus consisting of compresses and ban-
dages saturated  Avith the whites of eggs. The idea was again neg-
lected until resumed by Baron Larrey, in his  well-known apparatus
employed with  so  much success after the battle of Moskwa, (Lar-
rey's European Campaigns;) this consisted  of cushions and com-
presses, retained by the 18-tailed bandage, and rendered immoATeable
by saturation Avith camphorated spirits, acetate of lead in solution,
and Avhites of eggs ; this apparatus, thus applied, remained undis-
turbed until the consolidation.  Of its efficacy and adA-antages, es-
pecially in military surgery, Larrey speaks in the highest terms.
  The use of plaster of Paris, made to set around a limb, generally
in Europe  ascribed to  Dieflenbach, who employed it extensively,
was originally derived from the Moors of Spain, (Eaton's Travels in
Arabia,) and  first noticed in Europe  by Prof. Kluge, of Berlin, in
1829, and  Drs. Muttray and  Rauch, (Muttray—de cruribus fractis
gypso liquefacto curandis, Berlin, 1831,) Avho wrote  theses upon the
subject.  I saw several cases of club-feet, M'hich had been operated
upon by a section of the different  tendons, retained thus in a plas-
ter-mould, in Middlesex Hospital,  London,  under the care of Mr.
  * In GataJcer's translation of Le Dran's Operative Surgery, with observations by
Cheselden, p. 543, the latter surgeon recommends the same mixture for contorted or club
feet. He' also gives a case in which he applied it to a fracture of the fore-arm which
happened to a gentleman while travelling: he continued his journey, and, at the end of
forty days, the bandages were removed, and the cure found perfect.  At a much later
period, John Bell recommends the  same materials, under similar circumstances.  Vide
Principles of Surgery, p 137, New York, 1812. 
 126           NEW ELEMENTS OP  OPERATIVE SURGERY.

 Mayo.  This plan has some advantages, but many inconveniences.*
 In the year 1834, M. Seutin, Professor of Operative Surgery in the
 University of Brussels, and  Surgeon of the Hopital  St. Pierre,
 having under his care many of those wounded at the siege of Ant-
 werp, made  trial of the different varieties of the immoveable ap-
 paratus, and finally chose starch  as the material best adapted for
 surgical purposes.  His practice and success are published.  This
 material has been variously used  by different  surgeons since its first
 application by M. Seutin; for instance, M. Laugier, of Paris, em-
 ploys stout wrapping-paper, cut  in the form  of the eighteen-tailed
 bandage,  in  place of linen or cotton rollers; M.  Lafarge de St.
Emilion uses a mixture of boiled starch and plaster of Paris, and
others substitute tin,  lead,  zinc, and carved wooden splints for
those of pasteboard.  M. Seutin called his starch bandage I'appareil
amidonne.   Among the surgeons of  Paris  who gave to the im-
provement of M. Seutin the fullest and fairest trial, the celebrated
Velpeau stands first; and after much experience, he has substituted
for the starch a substance knoMm by the name of dextrine, as being
superior in many respects, and equally firm.   (For a description of
the dextrine, vide Dr. Van Buren's paper—ut supra.)  Dextrine is
one of the proximate elements entering into the composition of all
amylaceous vegetables and plants, in combination with fecula, ami-
dine, diastase, gum, &c.; it is used to a considerable extent in com-
merce and  manufactures,  especially  in Paris.   It is sold  by the
quantity in Paris, at about eight sous per pound.
  The following is the manner  in which M. Velpeau applies it:
 For a fracture of the tibia, about  1 iv of the powder of dextrine are
necessary; this  is to be moistened Math camphorated spirits, and
dissolved in sufficient water to  form a  solution of the consistence
of molasses.  In applying the apparatus to the leg, after reducing
the fracture,  a dry roller is passed from the toes to the knee; tM'o
splints cut from the common binders' board,  and previously moist-
ened, so as to mould themselves exactly to the inequalities of the
limb, are  then  placed  one on either side ; these are smeared OAer
Math the mixture, and then a second roller, thoroughly soaked in the
solution, is applied over them, and afterwards  perfectly covered ex-
ternally by a coat of it.  The limb should then—in the case before
us—be suspended from a fracture-bridge, and surrounded by vessels
of hot water to dry the  apparatus, Avhich, in  about six hours, will
become as firm as a case of sheet-iron.  When  the period has
elapsed necessary for consolidation of the fracture, it is easily re-
moved by soaking for a few minutes in Avarm water.
  In the use  of dextrine in this manner, M. Velpeau has been grat-
 ified with excellent success.  During a period of eight months of
 constant attendance in his Avards, in which  time upwards of fifty
 cases of fracture came  under his care, I saw there no apparatus
 but that of dextrine, and the bandage of Scultetus for immediate

   Strange  as it may seem, two English  surgeons, Messrs. Beaumont and Sweeting,
 were contending a year or two  since for the honor of having first used the plaster. The
 latter gentleman speaks in the highest terms of his success. 
ADHESIVE TLASTER.
121
use in compound fractures. Part of the time I was actively engaged
in his service, and had frequent  opportunities of applying the ap-
paratus under his inspection, and of closely watching its action
during the whole progress of cure.]
                        CHAPTER VI.
             ADHESIVE PLASTERS, (BANDELETTES.)
  The word bandelettes seems to imply a mere diminutive of bandes,
[or bandages.]   It is true that we might give the name to ribands
of linen of the width of the finger, and from one to three feet long,
for example ; but use confines the application of the word almost
exclusively to certain strips of plaster, (lanieres emplastiques.)
           Article  I.—Plasters op Vigo or Diapalme.
  The Vigo plaster and the  diapalme plaster, spread upon linen,
known under the  form of cerecloth, (sparadrap]) may be cut into
strips or ribands of variable length and width.  Strips obtained in
this manner may be applied around the  limbs and upon all  parts
of the body.  The diapalme does not adhere with  sufficient firm-
ness ; and it breaks and falls too easily into scales to have any great
efficacy under this form.
   The Vigo plaster, more adhesive, and  of a  closer texture in its
composition, would be better for compression and to fasten certain
parts of the dressings.   Perhaps, also, it  irritates the skin less, and
favors less the development of erysipelas, than  diachylon plaster.
But its greenish color, and tendency to liquefaction by heat, and the
difficulty of removing it from the skin, will always render its em-
ployment inconvenient.
    Article II.—Adhesive Plaster, (Bandelettes de Diachylon.)
  The cerecloth with diachylon is almost the only one Ave use at
present.  The strips of this plaster are employed in the treatment
of ulcers, in the folloAving manner: they ought to  be sufficiently
long to make a turn and a half upon the  part, and we giAre them a
breadth of from eight to twelve lines.  The first strip is applied one
or two inches below the  ulcer, and without its being as important,
as some surgeons pretend, to place its middle portion (leplein) on the
side where the ulcer is, rather than on the opposite. We then succes-
sively apply the others from below upward, and in the same man-
ner, taking care that they lap  over each other by two-thirds or at
least a half their width on their inferior  edge, like  the tiles of a
roof.  The highest must also be an inch or two above the  suppu-
rating surface.   An important precaution here is, that each  strip
should be applied in a direction exactly perpendicular to the surface
that they are to  compress or  embrace.   It is  also  necessary that
they exercise a uniform moderate compression, the  same as an
ordinary bandage, and that they should, when they are all applied,
act like a kind of gaiter or buskin, as regularly as possible. 
128
NEW  ELEMENTS OF  OPERATIVE SURGERY.
  These strips of diachylon are also used as a means of union for
most Avounds, and after a multitude of operations;  they are also
knoAvn under the name of adhesive plasters, (bandelettes agglutina-
tives.)   I shall return, then, to the manner of using them in treating
of dressings, properly so called.
  There is another mode of using strips of diachylon: as a means
for fastening the pieces of linen which serve in the dressings, they
are ready substitutes for bandages.   Thus, strips of diachylon, of
sufficient length to go several inches beyond the limits  of all the
compresses or gateaux with which a wound is  covered, attaching
themselves to the skin, take the place of every other sort of ban-
dage, because we may apply thus any number of them, and cross
them in various directions.  It results from this, that the portions of
the dressings cannot be misplaced, and that no compression is made
on the diseased part. This is an important advantage, upon the face,
cranium, chest, and abdomen, and also in some cases of wounds of
the limbs.  Under this form, the strips, which may also be made to
make the entire  circuit of the part, have  nevertheless the disad-
vantage of favoring the development of erythema and of erysipelas
upon the skin, and of  causing in some patients an insupportable
itching.  The bandages imbued with dextrine  may, as it appears
to me, often be substituted for adhesive plasters.
  [Isinglass Plaster.—Mr. Liston has been in the habit of using,
for many years, a plaster  made with  oiled silk coArered Avith  a
coating of isinglass.   An  ounce of isinglass is moistened by tAvo
ounces of water, and let to stand for an hour or two till quite soft;
then add three  ounces  and a half of rectified spirit, previously
mixed with one ounce and a half of water.  Plunge the \ressel into
a saucepan of boiling water, and the solution will be  complete  in
a few minutes.  Having  perfectly  stretched  out  and securely
fastened the piled silk  on a board, apply the isinglass smoothly and
uniformly with a brush, as in applying  a  coat  of varnish.  When
hard and dry, apply another layer in an opposite direction, and  so
on to a fourth or fifth; the last layer should be reduced in strength
by adding a little more water.  The isinglass must be well soaked
in the water before the spirit is added.  The brush used is a flat
hog-tool.  The  solution, when cold, should be of the consistence of
blanc-mange.  Gelatin will not answer as a substitute for isinglass.
Mr. Liston has  now substituted for  the oiled silk, the peritoneal
covering of the caecum of the ox, rubbed down and carefully pol-
ished in the manner of goldbeater's skin.   Mr. Ancrum, assistant
of Mr. Liston at the North London Hospital, states that, from the
extreme thinness of the membrane  plaster, the wound can be ex-
amined without its removal—that it adheres much better than when
the isinglass is spread  on oiled silk, and becomes firmly joined im-
mediately—that its tenuity makes it as unirritating as goldbeater's
leaf, and when once applied, it is so accurately adherent that it
need not be changed for many days—finally, that ample experience
proves it to be the best uniting material ever produced.  In making
it, the same precautions are observed as above  for the oiled silk, 
VARIOUS ARTICLES.
129
except that a layer of drying oil is to be spread upon the other side
of the membrane.—T.—Vid. Pharmaceutical  Transactions;  also
Med.  Gazette, Oct. 15, 1841.]
                       CHAPTER VII.
                    VARIOUS ARTICLES.
  Dressings demand also some other  articles  for certain special
cases: for example, in treating diseases of the bones or joints.  It is
for this purpose that they have devised fanons,the false (faux) fanons,
cushions, splints, fracture-boxes, (gouttieres,) tapes, (les lacs,) cords,
hoops, (cerceaux,) and also beds that might be called surgical beds.
                      Article I.—Fanons.
  Fanons comprise three principal varieties: 1. The drap fanon ;
2. The fanon properly so called ; 3. The false fanon.
  § I. The name of drap fanon, or splint-holder,x (porte-attelle,)  is
given to a piece  of linen  somewhat longer than  the  fractured
limb, and upon which the other parts of the dressing are first laid.
Properly speaking, this is a simple aleze, or a napkin, destined to
envelop the different objects  that are placed about the fractured
leg  or thigh.  In other respects, the use of the drap fanon is easy
to understand.  If,  for example, it is the leg we are treating, Mre
spread out  a  napkin, deprived of its hem ;  upon this napkin M'e
place the strips of Scultetus;  and upon these strips we place, op-
posite to the fracture, some long compresses.  When these latter
are  placed upon the limb, and then fastened by the strips of Sculte-
tus, we roll up the lateral splints, from right and left, in  the edges
of the primitive napkin, or drap fanon; we thus bring each splint
by degrees, up to the distance of an inch from the surface of the
limb ; the cushions are then introduced between the limb and the
      splints  thus arranged; the  cushion and the splint in front
     '; are  also placed; and we then fasten the whole by  means
      of circular bandages.
         It is easily conceived, that  in treating a fracture  of the
       thigh, the drap fanon must be of much greater length, and
       also that less length would be required for the arm or fore-arm.
         Meanwhile, the drap fanon is nothing more than the en-
       velop of linen  (la toile d'enveloppe)  which we sometimes
       have occasion for in dressings somewhat complicated.
  ';i    § II. The  ancient surgeons frequently made use of fanons,
  II  properly so called.   They understood  by them, cylinders  of
       coarse  straw, (de forte paille,) (Fig. 60,) designed to take the
       place of splints, in fractures of the inferior extremities, espe-
       cially of the leg, still employed in our day by some practition-
       ers, especially by M. Larrey, senior.  These cylinders, Avhich
       have the advantage of bending and accommodating them-
       selves easily to the elevations and depressions of the parts,
       while they  at the same time present a certain degree  of
 vol. 1.                        *7 
130          NEW ELEMENTS OF OPERATIVE SURGERY.
(Fig. 61.)
resistance, have been for a long time past generally abandoned.
Their tendency to be displaced, their cylindrical form, the pressure
which thcv necessarily make upon a very narrow space, their Avant
of solidity'Avhen it is important to guard against powerful causes of
displacement, are the reasons Avhy the splints
used  at  the present day are almost always
substituted for fanons.
  § III.  The false fanons (Fig. 61) are nothing
but linen folded upon itself a certain number of
times ; in a Avord, a species of graduated com-
presses.  These faux fanons, chiefly  employed
for the leg, serve at the same time for cushions
and fanons, but principally for cushions.  That
which has been preserved in practice  under the
name of the anterior tibial compress, was placed
in front, and a little to the outside,  while the
others were introduced  on each side, between
the bandage  of Scultetus  and  the drap fa-
non, the splints, or the bandages.  They Avere
made to reach, the first, from the tuberosity of
the tibia to the instep, the two others, from
the sides of the knee to below the ankles.  In
reality, the fanons and  the false fanons cannot be  useful but in a
very small  number of cases, since cushions or splints are Avith rea-
son everywhere preferred.  Noav, however, Avhen the dressings for
fracture have  undergone a complete revolution, it is  to be hoped
we shall no more have occasion to call these  objects to our aid but
for certain kinds of dressings of an altogether peculiar description,
and Moiich I have not now under consideration.
            •   Article II.—Cushions,  (Coussins.)
  We employ in surgery two kinds of cushions, or mats, (paillassons.)
Sometimes we place cushions beneath the diseased parts, or between
the bed and other portions of the dressing. These are a species of
pillows, filled with the chaff of oats; in a case of necessity we could,
instead of oat-chaff, use feathers, wool, cotton, bran, sand, cows' hair,
or leaves of certain plants; but  the cat-tails, (typha,)  and the oat-
chaff, are infinitely better than the other substances.   The form of
these paillassons varies with that of the parts they are intended to
support; that of a simple square, (Fig. 62,) or  of an oblong, (carre
long,) (Fig. 63,) however, is the most convenient.   It  is important
        (Fig. 62.)
(Fig. 63.) 
                        VARIOUS ARTICLES.                     131

not to fill  them too full, but only about one-half,  for Ave  almost
always find it necessary to increase or lessen their thickness, some-
times on one part, sometimes on another, so as to place them, in
fact, in perfect relation Avith the form of the part that they are
intended to support.  To prevent their irritating the skin, it is Avell
to enclose them in a single or double fold of linen, a sort of aleze,
or tick, (taie,) before insinuating them under the wounded part.
   At other times, the object of cushions is to adjust and protect cer-
tain parts which Ave think require to be supported by means
of more solid substances, or by a  considerable degree of
pressure.   Thus, according  to  the  ancient mode, they
alMrays placed some between the bandage and the splints
around the fractured limbs. Avhile they arranged one  be-
tAveen the  chest and arm in fractures of the clavicle, or
neck of the humerus, &c.  Then they resembled a kind
of Avedge, (coin,) or cylindrical sacks, a little longer than
the broken limb, and from three to six inches in diameter,
(Fig. 64.)  As it is scarcely ever found necessary to pkice
them in contact Avith the integuments, there is no  absolute
necessity to have them  enclosed, as  the others should be,
in a linen case.
   The neAV method of treating fractures  Avill soon also
do aAvay Avith this kind of paillasson.  It is right to say,
hoA\rever, that certain wounds, also certain diseases of the
joints,  and  some kinds of inflammations,  requiring one
side of the  limb to be exposed at pleasure, while the other
is left in a state of perfect immobility, will make it neces-
sary to retain them in practice.
  As to cushions  of  sand, or  bran,  or  ashes, substances  em-
ployed formerly to increase the  heat of .the parts,  and designed
to prevent limbs operated upon for aneurism from becoming cold,
they have  scarcely any value  at  the present  day.   Like the
satchels  (sachets) of medicated powder  of herb  leaves,  they will
continue to be used remedially for certain cases, but not among
the usual  articles  employed in  dressings.   In  fine, paillassons
are in truth pillows, either square-shaped, cylindrical, elongated,
         (Fig. 65.)                            (Fig. 66.)
rounded, spectacle-shaped, (Fig. 65,) or  cuneiform,  (Fig.  66,)
adapted, in a word, to the  part  which we desire to raise up,
 
132
NEW ELEMENTS OF OPERATIVE SURGERY.
envelop, or support, and,  when they  are  small,  denominated
coussinets.
                     Article III.—Splints.

  Already used in ages past, under the name of ferules or edisses,'
splints acquired a great reputation under the patronage of the Royal
Academy of Surgery, and  in the school of Desault.   They  are
pieces of wood Avhose form  would be sufficiently well represented
by a portion of bandage.  Destined to maintain in a state of immo-
bility the fragments of the broken bone, and to serve as a point of
support to the bandages used to envelop the  fractures, and to sup-
port certain diseased parts that we are fearful of  disturbing,
splints, like cushions, present a number of varieties.
  Some are plain, (Fig. 67,) that is, entire (pleines) throughout their
length, and devoid of notches, (echancrures;)  others have at one or
                                       the  other of their extrem-
                                       ities,  and sometimes on
                                       both ends, a notch in the
                                       shape of a half moon, of
                                       greater  or  less  depth.
These latter often have also one or two  mortices (Fig. 68)  in  the
                (Fig. es.)                  vicinity of each notch, in

                                     r  the same manner as some
                    "iil'riyiH            others are furnished Math
                                       similar  openings   from
space to space throughout their whole  length, or  at least in their
middle portion.  These notches and mortices serve for the passage
of bandages, and to keep these latter from being displaced.
  In fractures, the splints should, as far as it is  in our poAver, be
made to  extend a little  beyond  the length  of the affected limb.
Their width varies from tM7o to four or five fingers' breadth.  Their
thickness should scarcely be less than a line  and  a half, nor have
more than three to four lines.   If too narrow or too thin, they would
have the disadvantages of fanons; if too thick or too broad, they
would have too  much Aveight,  and Avould  sit badly on the parts.
All this, howeATer, is applicable only to  splints of wood, iron, or tin;
for those of pasteboard, leather, or lead, must be considered under
another point of A'iew.
  Leather splints, which some  English surgeons make use of, mould
themselves admirably upon the organs;  but  they have  the disad-
vantage of not making  sufficient resistance, and  of  being- at too
high a price to come into general use.
  Lead moulds itself to the parts  still better than  leather; but as it
retains the inflections that are g_Aren to it, and is destitute  of any
spring, it does not fulfil, or at least but very imperfectly, the object
Mre have in view in using splints.
   Pasteboard (carton) is free of all these objections ; by Avetting it,
we can mould it like lead; when once dry, it becomes hard and re-
sisting like wood.  It is in very general use, and may be had every-
where cheap; and, unless there should be  immediate necessity of 

                       VARIOUS ARTICLES.                    133

considerable resistance in the dressings of the fracture, the paste-
board, in my view, will for the future supersede Avooden splints, in
the small number of  cases  where  these latter  might still  offer
certain advantages.
  It is easy to conceive that the pasteboard of which the splints are
to be made should be of variable thickness, and that it is necessary
to dip it  in water so as to  soften  it properly before applying it.
[Felt, says Dr. Mott,  made into slabs, sheets, &c, often half an inch
thick, is  much better than pasteboard, and when wet in warm wa
ter, or over steam, perfectly soft and flexible.   When dry, they are
as hard as a board,  and harder than pasteboard.  They are very
cheap and serviceable.—T.]

            Article IV.—Trough-Boxes, (Gouttieres.)

   Troughs  (gouttieres—literally, gutters or troughs) are a sort of
half-tunnels  (demi-canaux)  designed  to  support some  parts of
the limbs.  They  are made for the  forearm,  arm,  leg, and thigh.
Some have extolled  them as a substitute for splints in the treatment
of certain fractures; but they are  chiefly intended to place the
diseased  articulations in the  state  of immobility, in  which  it  is
proper that they should be preserved.  It is impossible to  conceive
how advantageous it is for patients laboring under arthritis, whether
from gout, rheumatism, syphilis, or other cause, to have the painful
part  supported in a properly padded trough. This contrivance,
from which M. Champion, of  Bar-le-duc, has for so long  a period
derived such important advantages,  has procured for me also ex-
tremely fortunate  results.  Enclosing half the circumference of the
limb, trough-boxes have over splints  the advantage  of not being
displaced, and of  exacting no compression,  serving at  the  same
time, in some degree, as a cushion and splint to the part.  In other
respects, the troughs that are made  of tin, iron plates, (tdle,) paste-
board, or  even wood, should be as light as possible, and sufficiently
long to extend at  least to the  middle of the limb, above and below
the diseased articulation.  Those  which the  natives of Brazil or
America make with flexible stalks or reeds, and, which have been
improved upon by M. Smith, have the advantage of being widened
or narrowed  at pleasure, and of even  being transformed into a
cylindrical  canal; but  they  are not so convenient as ours of
pasteboard.

  Article V.—Hand-Board (Palettes) and Foot-Board, (Semelles.)

   In connection with plain and grooved
splints and trough-boxes, are to be con-
sidered the articles  known under the
name of palettes  and soles.
  The palette is a plate of wood (Fig. 69)
designed to support the hand and fingers.
Ordinarily divided like the fingers when
they  are  expanded,  it ought to be  of
 
134           NEAAr ELEMENTS OF OPERATIVE SURGERY.

sufficient length to be prolonged in the form  of a splint to near
            . 7())             the elboAV upon the side  of the fore-
                            arm.  The semelle is  another plate
                            (Fig.  70)  perforated  Avith morticed
                            openings near its edges,  and shaped,
                            it may be  said, to the sole of the foot,
                            which it  is  intended  to support or
protect in certain cases.

        Article VI.—Tapes (Lacs) and Strings, (Cordons.)

  Certain dressings  require the  use of cords.  These generally
consist  of ribands, and pieces (des bouts) of bandage or  strings.
Tapes (les lacs) of riband or thread, in fact have the same uses in
surgery as in domestic economy.  They are designed to fasten the
different pieces of certain apparatus, as, for example, in the case of
fractures.   At other times their purpose is  to  stretch, Avhile  they
retain uniformly in their place, particular portions of the bandages,
such, for example, as the suspensory, triangular, and  square ban-
dages, and the clavicle cushion.   For  this purpose Ave generally
make use of ribands of coarse thread, or such as are new  or half
used, according as they are to press next the skin or not. We may
employ also the common riband;  the important point is, that  they
should be sufficiently strong to resist the traction that we may haA'e
occasion to use upon them with the hands.   We also use bands
made of bandages, sheets, or napkins folded cravat-fashion, wher-
ever we desire to make extension or counter-extension, as, for ex-
ample, in the reduction of fractures or luxations.  In that case it is
necessary to choose bandages sufficiently strong, or to double them.
  Cords may be made of bandages or ribands rolled  upon their
axes'; but it is more easy to  employ merely the ordinary cord. This
kind of cord is rarely employed to  retain the dressings about the
limb, but for want of better.  But they are used with advantage in
fastening certain parts, either to the edge  of  the bed, or to some
solid substance in the  neighborhood.   We have recourse to them
in the strait-jacket, to secure patients whom Ave wish to restrain
Avhile laboring  under a furious delirium, also to exercise extension
when using  tackles or pulleys, in cases of luxations, for permanent
extension in certain apparatus for fracture, &c.  Finally, Ave may
use them Avherever it is desired to  employ great force, and where
the band (le lien) cannot be  applied directly to the body itself.

                  Article VII.—Surgical Beds.

  Almost all patients should be  dressed in bed.  In general, they
are dressed in the ordinary  bed;  if, however, it were permitted to
the surgeon  to make choice  for this  purpose of the most convenient
bed, he should prefer one that is narrow rather than wide, that the
surgeon and his assistant, being placed  one on either side, might
act without  being fatigued, or obliged to move the patient.
 
VARIOUS articles.
135
  Metallic beds, being light, and less liable  to  bugs, and more
favorable to ventilation, are infinitely better than those of M'ood.
The upright  and horizontal shafts  with which  these beds  are
constructed, resemble a kind of arbor-work with large AvindoM's,
Avhich is of great  advantage where a  number of assistants  are
obliged to Avork together upon the same Mounded limb. Extension
and counter extension may be thus made permanently, and secured
upon the frame of the bed, without the necessity of recurring to a
special apparatus.   It is the same with all the  articles that we
wish to preserve immoveable about the patient.
  It is important that the bed of the patient should be sufficiently
firm to prevent it from being easily depressed ;  and that the bottom
be furnished with a thick straAV bed, unless we can procure those
elastic mattresses which have been introduced into commerce for
some years past.  Above this mechanical hair quilt,  or straAV bed, Ave
place one or two ordinary mattresses, and not a feather bed. If it were
desirable to have still greater solidity, and  to  prevent every kind
of projection or depression upon the plane which is to support the
wounded part, Mre might, as is  still practised  sometimes for frac-
tures of the  lower extremities, slide a wooden board betAveen the
mattress and the straw bed.  But it is rarely that  this last precau-
tion is indispensable, and the surgeon should  keep in vieAv that a
too great hardness  of the bed fatigues and disturbs the repose of
the patient.
  If the surgeon had constantly  at his disposal  a sufficient numbei
of assistants, or persons capable of understanding him clearly, the
bed  of which Ave have just  spoken Mrould  fulfil every indication.
But  as the  contrary is too often the case, and as  it is essential in
certain patients that we should  be enabled to change them with
the least possible disturbance  or movement, there ha\re been de-
vised certain mechanical beds, Mrhich might be denominated Sur-
gical Beds, (lits chirurgicaux.)  Among these  beds, there are tAvo
that are distinguished at the present day  above  all others:  that
of Daujon, and that of M. Nicolle.
  Daujon's bed is a sort of sacking bottom, (fond sangle]) supported
by four cords which  suspend  it to so many pulleys, and Avhich may
be raised entire at the head, or the foot, or at one or the other of its
angles, or on the right or left side only.  Having also a part Avhich
is a kind of moveable cushion towards the seat, it allows the  pa-
tient to have his stools without moving him the least from his place.
Its simplicity, and the*real advantages it procures for the patient,
have contributed in a remarkable  degree to bring it into general
use for the last twenty-five years.
  It is  nevertheless true, that the newly devised bed by M. Nicolle,
is manifestly still more useful.  With this,  in  fact, Ave may have
successively, and temporarily or permanently, all the  comforts of
a chair, or an arm-chair, upon a plane more or less inclined, and
in whatever direction we may wish; we may raise or lower  the
head or foot Mdthout being obliged to incline the rest of the body.
With this bed, we displace  this or that part without difficulty, and 
136
NEW  ELEMENTS  OF  OPERATIVE SURGERY.
nothing is more convenient for  patients who  suffer, and whom we
do not wish to disturb.
  Many other mechanical beds have been constructed; but those
of Daujon and M. Nicolle, up to the present  time, appear to unite
all the best qualities in this kind of article.
               Article VIII.—Hoops, (Cerceaux.)
  After the dressing is finished, it is sometimes required to proteot
the wounded parts from the pressure of the sheets and bedclothes.
In such  cases, we use an apparatus known under the name of Cer-
ceaux, and whose design is, to keep all the surrounding objects at a
distance from the dressings.   In the country, or where it is neces-
sary  for us to  construct one  on the spot,  and  to have it immedi-
ately, we generally use a cask hoop, cut off at one of its extremities;
this allows the two extremities  to be separated and fixed between
the  edges of the bed and the sides of the straw  bed or mattress;
while the ordinary hoop (Fig. 71)  rests upon the bed.  We have
                            (Fig. 71.)
thus a large or a small arc, (Fig. 72,) which sufficiently well sup-
ports the bed-covering that wo wish to surround the patient with,
leaving the wounded part in a kind of void.  If a single  arc, thus
arranged, should not suffice, nothing would be more easy than to
place a second, or even  a third, at some distance above.
  The hoop, arranged as in figures 71 and 72, is, in part, the pre-
ceding one -systematized. It is  made with rods of metal, or some
splittings of a bushel mea.sme,(quelques plaques de boissellerie,) joined
together by transverse pieces somewhat more solid, so as to resem-
ble two or three  arcs fixed  together, and  which should rest with
their base upon the mattress on
each side of* the injured limb;
other cerceaux resemble more a
kind of square, (Fig. 73,) which
is constructed in the shape of
a box or cage.  The important
point is, that they should be of
height, width, and length suffi-
cient effectually to  isolate and
protect the diseased part.  It is
also evident that the cerceaux
ought  to be divested,  at their
 
BANDAGES.
137
base, of every kind  of cross-piece, that we may raise or  remove
them without being obliged to disturb the  rest of the dressing.
[ Common wire, says Dr. Mott, makes an excellent cerceau.   Take
three or four pieces, and  bend them into semicircular arcs, and
then fasten them at the base  with a piece  on each side running
horizontally ; and this makes  a light and capital cradle in a few
minutes.—T.]
                       CHAPTER VIII.

                          BANDAGES.

  It would be quite difficult in the present day to give a definition
of the term bandage.   We indifferently use, in fact, the words ban-
dage and appareil to designate the same thing.  It, hoAvever, seems
to me that we ought, by the word appareil, rather to understand the
ensemble of the articles which we may have occasion for in the
dressing, while bandage should be applied to the containing pieces
only, or to all the portions of the dressing, after their definitive ad-
justment.
  However this may be, the bandages  are intended to fasten, and
retain in their place, the different portions of the dressing, or of the
diseased part. Moreover, bandages haA'e been divided by surgeons
almost to infinity, according to the purpose  for which they are to be
used, or the  form or  figure they present.  There  are  those which,
fulfilling every indication, are applied in every case, and merit the
name of general bandages.   Others, having been rather designed
for certain parts or regions, should  take the name  of special ban-
dages.

                 Article  I.—General Bandages.

  We find, in works that treat of this matter, uniting, preservative,
dividing, expulsive, compressing, retaining, (retentifs,) suspensory,
and containing (contentifs) bandages ;  but it is evident that a  great
number of bandages may serve, at  the  same time, for all these in-
dications.  There are none of them, for example, which may not be
preservative and have other qualities at the same time.
  The uniting (unissant) bandage,  Avhich is intended for  approx-
imating divided  parts ; the dividing, (divisif,) which is for keeping
them separate ; the retaining, (retentif,)  for restraining their protru-
sion ; the expulsive, (expulsif,) which is intended to expel them;  all
exercise, at  the  same  time, a certain degree of compression, and,
therefore,  come, more or less,  under the compressing (compressif)
bandage.                                    .   .
  The suspensory, (suspensif,) the object of which is to give gentle
support to parts that are naturally pendent, is moreover preserva-
tive,  (preservatif) and containing, (contcntif.)  This last, intended to
  vol. i.                         18 
138
NEW ELEMENTS OF OPERATIVE SURGERY.
fasten the other pieces of the dressing, is found equally comprised
in all the others.  It differs from the compressing  bandage, how-
eA*er, in this, that it has no other use  than to preA'ent the displace-
ment of the parts.  All these bandages may be made out of bands,
(bandes,) from  Avhich,  in  fact, they receive their name.  Some of
them may be made Avith  simple  pieces of linen or compresses, as
there are others in whose construction enter ribands, tapes, (des lacs,)
or twine, (des cordes.)  Certain bandages, such, for example, as are
employed for containing hernia, include also other substances, such
as steel springs, pieces of leather, gum-elastic, or caoutchouc, &c.
In fact, the ancients had so multiplied the number of bandages, that
they  created confusion,  while Ave seem to  haA*e  fallen into  the
opposite extreme.  If it is true, that it is useless to haAre fifty spe-
cies of bandages for the head alone,  as in the time of Galen, it is
no less certain,  that the pupil who knows how to make useful ban-
dages properly, dresses better and quicker, and is more serAaceable
to patients, than he who acts Avithout rule and without principles.
  In the application of the dressing, we must not sacrifice the use-
ful to the agreeable ; but, if it be possible to  give  some elegance
to the bandage, while Mre haAre made it at the same time better,
why should we  not do so ?  If it belongs to the surgeon to manipu-
late the objects Avhich he uses with more address than the world in
general, why should he not seek to distinguish himself also from the
vulgar in the matter of dressings ?

                   § I.—Containing Bandage.

  In more  general use than any other, the containing bandage is
employed everywhere.  Applied  around Avounds, its intention is a
very moderate compression, which has no other object than  to fix
the compresses, lint, &c., in their  place, Avhile it renders them im-
moveable.  This bandage sometimes represents a spiral around the
limb,  (Fig. 74,) and sometimes lozenge-shaped turns, (losanges,) or a

                            (Fig. 74.)
double spiral crossed, (Fig. 75,) as the  ancients often made it:
sometimes a true roller bandage.
  It  is the containing bandage that Ave apply after luxations : al-
most all hernia bandages are of this description ; we may say the
same of certain pessaries supported in the vagina, and of some pe-
lotes that are kept in the anus.   Many of the dressings of fractures
are also containing bandages.   There is  scarcely, properly speak- 
BANDAGES.
139
ing, any other in surgery but the containing and compressing ban-
dage.
                            (Fig. 75.)
§ II.—Compressing Bandage.
  We apply the term compressing to a bandage, as often as, in ad-
dition to its constraining qualities, it is intended so to act upon some
points of the diseased region as to cause pressure upon it, and ap-
proximate some of its tissues.  This bandage comprises the simple
compressing  bandage, the expulsory,  the  retaining, the uniting,
and the dividing bandage.   By it, we effect on the circumference
of the  limb, a  pressure sometimes circumscribed, sometimes dif
fused, often partial, and occasionally general.
  When the pressure is exercised only upon a circle of the part, it
takes the name of strangulation, (etranglement,) or ligature.  Com-
pression, in fine, has for its general object, to force the fluids into the
interior—to moderate their afflux to the part—to flatten and re-
press vegetations and tumors, and to bring  into contact parts that
have a tendency to separate—to destroy morbid  growths  from
openings or  dependent parts where they tend to accumulate—to
restrict  others  of them to the cavities where we have confined
them—to  arrest  or suspend the circulation in  certain vascular
trunks, and to cause mortification by producing an eschar upon some
point of the skin. But the compressing bandage may, like the con-
taining, assume an infinity of different forms.  Hence we employ
it under the form of a circular, roller, crossed, (croise,)  or recur-
rent bandage, that of a T bandage, or cruciform, (bandage en croix,)
suspensory, sling-shaped, (fronde,) or special bandage.

                   § III.—Circular Bandage.
                                              (Fig. 76.)
  If, with a bandage of greater or less
width, we make several circular (Fig.
76) turns around any part whatever,
so as to giAre it the appearance of a
collar,  as  is  sometimes done at the
wrist, arm, bottom of the leg, and un-
der the  knee, at the inferior part of
the thigh, and at the elbow, whether
for the  dressing of certain wounds,
blisters, or cauteries, the bandage takes
the title of circular bandage ; it is with
this also that we begin a great number of other bandages; but it
then soon loses its primitive name.
 
140
NEW ELEMENTS OF  OPERATIVE SURGERY.
   The circular bandage  alone  is suitable to all  regions  that  are
throat-shaped, (en forme  de gorge,) that is to say, to all parts of the
body that increase in size above  and below the region which we
Avish to dress.   For the purpose of a compressing bandage,  it is
scarcely  suitable to  any part, seeing  that its action may be so
quickly changed into that of strangulation ; in  that case, it Mrould
be necessary to associate the roller bandage with it.


                     § IV.—Roller Bandage.

  The  most common of all bandages, the roller bandage,  is, in
respect to dressings, in some sort what the bistoury is to operative
surgery;  therefore I shall describe it with more detail  than any of
the others.
  By roller bandage, (bandage route]) we mean  a series of turns of
bandage which lap over  each other by the half or two-thirds  [their
breadth,] and which, in their ensemble, constitute a sort of stocking,
or gaiter.
  This bandage answers all kinds of indications;  often  it is only
containing, at other times uniting, and  it may equally be  dividing,
expulsory, or retaining; but the purpose which it best fulfils is
compression.
  To be enabled to apply the roller bandage well,  it is  necessary
that Ave  should have been much practised in the  expert use of
bandages.

A.—Rules which should govern in the application of Bandages in
                            general.

  Thebandage rolled into a cylinder, (globe,*) and the only one almost
in use at present, should  be held in the hand by the two extremities
of its axis.   Its end, that is, its  head, which is free—and which we
often  find in hospitals, by  a reprehensible custom, fastened  Avith
several pins to  the other part of  the roll—should be applied by its
outer surface on the point opposite to that on which the wound is
situated.  While the fingers or thumb  of the left  hand retain this
head in its place, the right hand draws moderately upon the rolled
 head to unroll it while traversing the circumference of the limb.
   To prevent the free head of  the bandage from slipping, or being
 displaced, it is well to fasten it by two  or three circular turns, or,
 what appears to me better, to fold it back on the first turn, in order
 to cover it by the second,  that we may afterwards have no more
 trouble with it.  In continuing to unroll the rolled head of the ban-
 dage, Ave must take care to  hold it as little distant from the surface
 as possible, and never to unroll more of it at one time than is re-
 quired for half a turn.
 * Though the term globe may be specific enough in French, it is, in our language, too
constantly and intimately associated with the'mathematical idea of sphericity, tt> bo used
in English for the true cylindrical shape of a roUer bandage.—T. 
BANDAGES.
141
(Fig. 77.)
(Fig. 78.)
   We proceed in this manner until the cylinder in the hand is ex-
 hausted, and that the central head becomes free.  Then we have
 only to  fasten that, and it is ordinarily by means of pins that  the
 operation is terminated.
   In this respect, we may adopt three modes :  1. With a single pin
 on the middle of the length of this edge, we attach it to  the subja-
 cent turns ; in this case, the pin should always have the head turned
 toward  the free  side of the edge ; otherwise it would constantly
 tend to  be displaced, and its point would soon  become entirely
 detached before the  next dressing.  2. If the bandage  has more
 than two fingers' width, the edge of its free extremity being fastened
 only at the middle part, soon
 turns up at  the  angles, and
 gives it  a  disagreeable look.
 It is better, therefore, to  place
 a pin near each extremity of
 this edge, (Fig. 77,) or still bet-
 ter, after doubling in  its two
 corners, so as to shape it into  a
 triangle, to fasten on the point
 (Fig.78)  as in the  first case.
   3.  Some  persons prefer attaching two strings to the end of the
 bandage, Avith a  view of fastening
 this  latter by a bow knot,  in the
 manner of ribands. When the band-
 age  is narrow, like that, for exam-
 ple, which is  used for the fingers, it
 is easy, by slitting its free extremity
 to the extent of four to six inches, to
 convert it into tAvo strips, Avhich Mall
 ansAver for  ribands, and Avhich we
must  take care to cross  under each
 other, (Fig. 79.) before tying them.
  4.  The student also  should not  forget,  that  in placing the pins
crosswise, (Fig. 80,) or the head turned towards the middle of the
bandage, (Fig. 81,) he proves
(Fig. 790
(Fig. 81.)
(Fig. 80.)
that he  has never  studied
the art of bandaging.
  In  unrolling  a bandage,
Ave make—1. Circular turns,
when the turns  are  placed
directly over each other; 2.
Portions  of a spiral, when,
acting on a conical part, we proceed from one end to the other of
the surface of the limb, by making all the points of the outer surface
of the bandage  bear perpendicularly upon  the  limb;  3. These
turns, which are also called oblique,  and by means of which we,
form crossed (croises) bandages, take the title of doloircs when they
lap by a third, two-thirds, or a  half [of their width.]
  To make the manner of applying the roller bandage understood, 
142
NEW  ELEMENTS OF OPERATIVE  SURGERY.
 I Avill suppose that we are treating the loAver extremity.  We must
 procure a bandage of the proper length, rolled into a cylinder, three
 fingers Avide, dry or M^et, according to the indication, and begin by
 surrounding the foot Avith it.  If the surgeon is  accompanied by
 assistants, one  of  them holds the heel fast with one of his hands,
 and the digital extremity of the foot with the other, Mrhile a second
 assistant, placed near the pelvis of the patient, supports the ham,
 or lower part  of the thigh,  so  that  the whole leg is sufficiently
 raised to  permit the different turns  of the bandage to be  freely
 passed around it.  If we are deficient in assistants, it is necessary
 that the heel of the patient should be supported upon the knee of
 the surgeon, on the edge of a chair, or some other insulated prop.
 These precautions being taken, we throw the free head of  the
 bandage upon one of  the malleoli,  the  external  malleolus if it
 is  the right limb, on the  internal, on  the contrary, if it is  the
 left, on the supposition,  meanwhile, that the surgeon uses  his right
hand better than his left. Arrested upon this point by the left hand,
the bandage is passed  by  its free surface upon the dorsum,  the
inner edge and sole of the  foot, and brought to the root of the little
 toe. We then make a first turn ; then a second, which covers two-
 thirds of the first; then a third and fourth, following the  same
 rules, till we approach  the instep.  There the bandage is carried
 back by the inner side, and  passed by the outer side around the
 lower part of the leg, on a level with, or a little above the ankles,
 so that the turns upon the  foot resemble the figure of 8 in their
 connection with those of the leg.
   Here difficulties present, which practice alone  enables us to
 surmount.  The malleoli  and  the heel form three projections,
 separated by unequal depressions.  If the roller bandage is to be
 purely a containing  one, we can proceed without  any real incon-
 venience ; but however little may be  the compression it exercises,
 these parts are to be covered by it uniformly; the best mode, then,
 is  to employ a glutinous bandage, (bande collee)—(Vid. supra.)  In
 this case we always unroll the bandage perpendicularly to the sur-
 faces ; and the reverses  (renverses) that we are obliged to make to
 change  its direction having  no longer a tendency to slip,  M'e are
 thus not compelled to  leave any vacant  space, but  cover every
 point of the entire  region without difficulty.
   Supposing that we do not wish to have recourse to the linen satu-
 rated with glue, we must fasten the bandage, in proportion as Ave
 unroll it, to the turns over which it laps, and that by using  pins at
 each circular turn where we  wish to change the direction.
   There is also here a difficulty of which young surgeons should be
 advised ; it is, that the  instep, from the metatarsus to the base of
 the malleoli, represents  a sort of neck, which necessarily requires
 a  great number of turns, (doloires,) and Avhich, being the  point of
 departure to a great number of compressing radii, seems to accu-
 mulate  upon it a more considerable share of pressure than any
 other  part in  the  neighborhood.  Hence it is there that patients
 chieny ieel the pain; that phlyctaenae, sores, (escarres) and  gan 
BANDAGES.                       143
grene form, if the bandage has not been  properly applied.  It is
necessary, therefore, to be careful that we press as little as possible
on this spot, and to endeavor not to concentrate upon it the differ-
ent turns of the bandage that are to envelop the heel.  It is a point
of practice on which I cannot too much insist, so often has it hap-
pened to me to see it neglected by pupils, even by those who have
been the best instructed.
  Reverses, (renverses.)  Before arriving at the instep, and espe-
cially in order to  continue the* bandage in  the direction of the leg,
we are obliged to make reverses, (Fig. 82.)  In the act of bandaging,
                            (Fig. 82.)
they give the name of renverses to a  fold which makes the upper
edge of the  bandage become the lower, and its outer surface, the
inner one.  To render them as little incon\renient as possible, these
reverses should be abrupt, that the  oblique edge  they make may
not be  much longer than the width of the bandage ;  otherMase, it
would represent a species of cord, Avhich would wound the parts by
rendering the compression unequal.  To make these folds, Avhether
from above doAvnward,  or from below upward,  according to the
place where we apply them, the surgeon fixes the last point of the
bandage that has been unrolled, to the surface of the limb, Avhile
with the other hand, which has not separated the cylinder but to
very little extent  from the bandage,  he turns it suddenly upon
itself, without drawing  upon it, and as if to cross its tAvo edges.
That being done, he continues to unrol it, until he comes back to
the same point, following the rules above indicated, so as to repeat
the same manipulations a certain number of times, if the form of
the limb requires it.
  These reverses  are everywhere indispensable  where the parts
contract in the form of a cone.  In fact, whether it be at the foot,
leg, or fore-arm, the parts enlarging, from the inferior extremity
towards the upper portion, render it necessary, in order to bear per- 
144
NEW ELEMENTS OF OPERATIVE SURGERY.
(Fig. 83.)
pendicularly on all the points of their surface, that the turns of the
bandage should be made to stretch Sut in a spiral manner. To ob-
tain, then, a regular roller bandage, it is necessary, in these regions,
that the upper turn, which otherwise would fly off in a diagonal di-
rection, should be brought back by a fold, made as quickly as possi-
ble, to the inferior turn, which latter is to remain in a circular posi-
tion, if Ave desire that it should be in part lapped over by the other.
  Puckers, (godets.) The  pupil who, in  a case  like this, fails in
                   making reverses, produces what  are  called
                   puckers, (des godets—Fig. 83;) that is to say,
                   the bandage, applied  circularly, does not then
                   bear or press but by one of its edges, while
                   the other edge flares out, and  remains open,
                   and  tends to be displaced.  These puckers not
                   only take away from the bandage every thing
                   that it  might possess of elegance, but they
                   also  cause  the limb  to be strictured  from
                   space to space, and  the dressing to become
                   displaced from  the moment of its application.
                   Thus, to arrive at the roots of  the  little toes
                   on the  instep,  it is absolutely necessary to
                   make three or four reverses. From the mal-
                   leolus to the loMrer part of the  calf these re-
                   verses may not be  necessary,  but thence to
                   some fingers'  width  below the  tubercle  of
                   the tibia they  are absolutely
                   necessary and require  extreme
care.  In approaching the knee, the limb, becoming
cylindrical, or rather somewhat contracted, does not
exact the same precautions. To give some elegance
to this arrangement, we endeaA'or to place the re-
verses on the same line, on the anterior surface of
the limb, for example, from  the small toes to the
knee ; there results from this a crossed appearance,
Avhich gives the bandage some resemblance to the
ancient buskin, (cothurne—Fig. 84,)  or to the stalk
of an ear of wheat.
  Nevertheless, we must  guard against making un-
equal pressure on any part, merely for the purpose
of giving greater regularity to the dressing. As the
cylindrical or conical form of the part  is  not the
same in every individual, it Avould be manifestly in-
jurious to  wish  to submit  the  application of the
roller bandage  to rules too precise.  The law
which ought, above all other things, to govern the
surgeon in such a case is, that the plane of the ban-
dage should always press perpendicularly upon the
skin; add to this, that the compression should every-
where be equal; that there may be no void between
the turns of the bandage  ; that these turns  lap over
(Fig. 84.)
 
BANDAGES.                        145
each other in the manner of tiles or slates upon a roof; and you
then have, for every intelligent person, the key to a roller ban-
dage.
  Padding, (remplissage.)  The  roller bandage, when used also for
compression, often requires that paddings  should  be associated
with it.
  The leg.  If it is the foot, we place, first, on the sole, at the inner
part and middle ;  secondly, on the dorsum, upon the outer part and
in front, pliant compresses, pieces of lint, cotton, tow, (Vetoupe,) or
agaric; the same precaution is necessary between the heel and the
ankles, and on the sides of the tendo-Achillis.  Without this, the
compression, in fact, would bear almost entirely upon the edges of
the foot, and would soon fatigue all the articulations of the metatar-
sus, at the same  time that it  would favor the engorgement of the
tissues directly beneath.  In the tibio-tarsal region, it would be the
heel, malleoli, and tendons of the ankles, that would be compressed
precisely in that part where the compression is useless, whilst  the
intermediate portions, the only  ones which we  generally desire to
make pressure upon, would remain perfectly free.  It is apparent
how the tendo-Achillis would be pressed towards the posterior face
of the tibia, if we  did not take the precaution to pad its sides.
  I will  add,  that with the roller bandage,  as  Avith  all  others, an
equal amount of pressure produces infinitely less effect,  on the re-
gions abundantly supplied with flesh, than on  those that are depriv-
ed of it;  therefore it is well, Avhen Ave wish to have exact pressure,
to increase its force about  the calf, and to place upon this region a
large compress folded four to six times, while around the tibio-tar-
sal articulation the compression should be much more moderate.
  Fore-arm. What I have said  of the roller  bandage, in regard to
the  leg, is precisely applicable to the fore-arm, except that the hand,
being Avell covered with flesh  on both  its sides, does not, therefore,
involve as many difficulties as the foot, and has no tibial crest, like
the  leg, endangering too severe a pressure upon  the teguments in a
right line.
  In conclusion, when we wish the roller bandage to remain  in  its
place for a certain length of time, it is often necessary to fasten the
looser turns of it  by a  few stitches or  pins; but if this fastening
should be a matter  of  much importance, nothing could be com-
pared in this  respect to a solution of dextrine, or Flanders glue,
with whi,ch the bandage should have been previously saturated.
  The roller bandage is of such general use, and yields so many
advantages when it is Avell made, that I cannot too much urge upon
pupils to practise themselves in  it.  Let those who have it not in
their power to practise upon it in hospitals, get a manikin, or, Avhat
is as well, procure some bandages, and among themselves, on their
own limbs, familiarize themselves to the use of it, so that they may
comprehend and overcome all  its difficulties.   Being the only dres-
sing for a great number of severe diseases, and associating itself to
almost all other bandages, and  to a great variety of dressings, it
rarely fails to make a part of even those that are the most trivial.
  vol. i.                       19 
146           NEAV ELEMENTS  OF  OPERATIVE SURGERY.
         § V.—Tail Bandages, (Bandages a Bandelettes.)

  Tail bandages are of two kinds—one composed of tails of greater
or less Avidth and number, and which are fastened by the middle ;
the other formed of  narroAver tails, simply imbricated  or lapping
over each other.   To the first kind belong the different sorts of
cleft compresses,  and especially the bandage Avith eighteen tails,
and that of Pott; the second comprises, at the present day, scarcely
any other but the bandage of Scultetus.

           A.—Bandages with eighteen tails, (Fig.  85.)
                            (Fig. 85.)
  Though frequently employed formerly, the bandage with eighteen
tails is now almost totally forgotten ;  it is composed of three pieces
of linen nearly square, and laid over each other; they are after-
wards slit on each side into three portions—a middle, a loAver, and
an upper one: we have thus nine compresses, each with tAvo tails,
consequently, in all  eighteen tails.   With  this division of three
whole pieces of linen Ave may envelop the leg in a uniform man-
ner, Avithout making either puckers  or  perceptible folds, because
the lower tails slightly coATer  over  the  middle tails when  they
are brought  forward, and the  same with  the  upper tails when
we bring them  round from the  loAver part of the calf to the  crest
of the tibia; but this bandage has this disadvantage, that Ave
cannot remove it but as a whole, and of presenting ends of com-
presses that are too wide. The bandages that haAre been substituted
for it  are manifestly better.

 B. 2?Bandage with the tails united, (Bandage a bandelettes reunies.)

  Desiring to unite the security of the  eighteen-tailed bandage
to the regularity  of the bandage with  separate bandelettes, some
surgeons have  devised a dressing composed of Avide bandages of
three  to four fingers' width, and sufficiently long  to make a turn
and a half around the limb.  These bandelettes, previously arranged
upon  a drap fanon so  as to  lap over one another to two-thirds of 
BANDAGES.
147
their width, should be seAved together along the whole median line
on the back of the bandage, (Fig. 86.)   We obtain thus, Avhen it is
                            (Fig. 86.)
applied, a species of roller bandages, whose parts, fastened behind,
cannot in any manner be displaced, and which, being sufficiently
narroAv, do not oblige us to make any fold or pucker capable of
irritating the parts.  This bandage, neArertheless, has not come into
general use ; from the union of its  portions behind, preventing us
from changing the bandelettes  separately, the bandage with sepa-
rate bandelettes, or that of Scultetus, is generally preferred.
  C. Bandage of Scultetus.—Next to the roller bandage, the dressing
of Scultetus  is the one most employed in surgery, when  we are
healing wounds of the limbs ; that of Pott, or the  preceding, differs
from it only in the stitches which fasten the different pieces behind.
It is made, therefore, like the  bandage of Pott, with a  variable
number of tails.   These bandages being designed to make a turn
and a half upon the part, will necessarily vary also in their length
and breadth,  according  to the size of the limb.   If it is the thigh,
Ave give them a breadth of four fingers, and a length  of twenty to
thirty inches; for the leg, they ought to have at least six inches in
length, and only three fingers breadth.  Vie take  care  also  to make
them a little shorter opposite the narroAv parts  of the limb.  All
these tails (bandelettes) being prepared, we place them on the drap
fanon, or on a napkin spread out.  We commence by the upper
                            (Fig. 87.)
one, and the others are afterwards arranged from above downwai d,
so that they may lap over each other two-thirds, (Fig. 87.) 
148
NEW  ELEMENTS OF OPERATIVE SURGERY.
   Most generally it is useful to place on  this dressing some long
 compresses, half as wide as the bandelettes of Scultetus, and which
 are the first that are raised around the wounded part.
   To apply this bandage, we roll up its sides on two splints, which
 connect the Avhole into a  species of cylinder, which are easily re-
 moved Avithout displacing any thing.  If we are treating a fracture,
 we first surround this bandage with the  ties which  are thought
 necessary.  The diseased limb being raised, the surgeon slips  the
 whole underneath, loosens the ties, unrolls the splints, and then
spreads out all the bandelettes  of the dressing.  After  having
lowered the part as exactly as  possible upon the middle of the ban-
dage, he proceeds to the dressing.   An assistant supports the foot
by the  heel and the roots of the toes, while  a second assistant
fixes the knee.  The perforated linen, the  lint, the compresses, and
the cataplasms, are immediately arranged, if the state of the wround
requires it; nothing more is left to be done than to apply each ban-
delette  of the  bandage;  an assistant, who  should be in front,
stretches the extremity of  one  of  these bandelettes, in proportion
as the surgeon draws on the other, and  raises it.  We  must begin
with the long compresses, and  always at the lower part.  We then
 come to the bandelettes of Scultetus, properly so called, beginning
 also with that  from below.  In fact, the pieces of linen of the whole
 bandage ought to be applied in an inverse order to that of their
 position on the drap fanon.  Below, we cross them so that their
ends reach the plantar surface of the foot. Upon the  leg, on the
contrary, it is necessary that each of their extremities should be
pressed against the side of the tendo-Achillis, or upon  the calf, be-
tween the teguments and the fanon.  We continue thus to the last
of the bandelettes, that is  to say, up  to the knee if  it concerns the
 leg only, or to the hip if the thigh is to  be  included.
  Composed of a multitude of  pieces, the bandage of Scultetus ac-
 commodates itself to every A'ariety of form and size of limbs.   It
 has the Aery great advantage of enabling us to arrange the dressings
 without obliging us to disturb the  part, Avhereas, in  order to raise
 the part up to  apply the roller  bandage, we are forced  to hold the
 limb in the air.  Moreover, this bandage may be put  together or
 taken apart in portions.  Should some of its pieces become  soiled,
 and require to  be taken away, they are removed Avithout disturbing
 any thing.  By fastening, by means of a stitch or pin, a clean ban-
 delette to the extremity of that which is soiled, we  draw with the
 same movement the first into the place of  the  second.   It is then
 the containing or compressing  bandage par excellence, for all parts
 that require to be  dressed frequently,  and which it is important
 should be disturbed as little as possible.

                      § VI.—T Bandages.

   The T bandage is composed of two portions, one horizontal, the
 other vertical.  The horizontal branch of the T, a portion  of the
 bandage M'hose length ought to be in relation with the size  of the 
BANDAGES.
149
part to be  embraced,  is  nearly  always arranged  in the  same
manner.   The vertical branch
of this  bandage  presents,  on
the contrary, many varieties.
Ordinarily  single, it  may  be
double up to its root, or only
to within some inches from the
horizontal  branch,  (Fig. 88.)
Formerly,  surgeons used also
a T, with three or four vertical
branches ;  but, at the present
time,  we no longer use those
complicated  bandages.    In
short, it is  a bandage which
is made by sewing, or simply
fastening by pins, one or two
ends  of bandage  upon  the
middle  of  another  portion of
bandage. The T. bandages are
never employed now, but  for
diseases of the anus, perinaeum,
and genital organs.  We shall
see, however,  that  they  are
useful also for other regions.
(Fig 88.)
            § VII.—Square and Triangular Bandages.

  A piece of linen, of medium  strength, cut into a square shape,
and having a riband at each  one  of its angles,  constitutes the
square bandage, (Fig. 89.)  This bandage, which may be suitable

                            (Fig. 89.)
for certain diseases of the breast, hip, upper part of the thigh, and
sides of the chest, is so simple that  it has no need of being de-
scribed. 
15U
NEAA' ELEMENTS OF OPERATIVE SURGERY.
It is the same Avith the triangular bandage, (Fig. 90,)  which
                             Ave employ on the same regions,
                             and sometimes on the scrotum.
                                  § VIII.— Uniting Bandages.

                                  Since adhesi\re plasters  haAe
                                been modified and improved so
                                as to be  made applicable to
                                the greater number of Avounds,
                                the uniting bandages have  al-
                                most entirely disappeared  from
                                practice.  With some strips of
                                diachylon  and the simple  con-
                                taining  bandage, Ave fulfil, in
                                fact,  the greatest  part of the
                                indications that gaA*e rise  to
                                these  different  sorts  of band-
                                ages.
                                  It is,  however, necessary to
                                know some of them: 1. Because
                                adhesive strips cannot be borne
                                on the  skin  of  some persons;
                                and 2. Because the approxima-
tion of the lips of certain wounds is, in reality, better effected by
a bandage than by plasters.

           A.  The long uniting Bandage for wounds.
  To unite a wound, whether of the limbs or trunk, in a direction
parallel to the great axis of the body, we have need only of a bandage;
excepting that it is necessary that this bandage should be rolled into
two unequal cylinders.  In arriving at the sides of the wound, after
haAdng placed, for a point d'appui, the middle part of the bandage
on the region diametrically opposite, the two heads should be  con-
ducted in such manner that the smallest passes through a slit pre-
viously made in the bandage of the other.  They are thus crossed
in front of the wound, whose two lips are  drawn together. They
are afterwards  conducted backward, where the small head must
be made to terminate, and in such manner that  there are still
some turns to spare of the larger one.   It is often, also, useful to
place under this bandage a graduated compress, of greater or less
thickness, on each side, and at some distance from the wound.  We
thus force the deeper tissues to come into  contact  as well as the
superficial layers.
  A more  regular bandage  than the preceding, is that which is
made  with a long bandage, the  extremity of Avhich  is converted
into two strips,  (Fig. 91,) and which present, at a variable distance
from each  other, two kinds of long openings.   We make a small
head with  the divided extremity  of the bandage, and a large one
with the other portion.  The measurements ought to be so made,
 
BANDAGES.
151
that Avhile the middle of the bandage is supported on the point op-
posite to the wound, the openings and the root of the strips may

                            (Fig. 91.)
be found united together on  reaching near the wound.   Passing
through each other, and properly crossed, the two portions of the
bandage are  then  drawn upon, unrolled, and fastened, as in the
preceding case.
  With this arrangement, the strips fill  up exactly the holes pre-
pared beforehand, and the whole makes in reality but one piece,
which draAVS in an equal manner, and in an opposite direction, upon
the parts that we wish to keep in contact. It is to this, then, that
we must have recourse Avhen  we wish to undertake the immediate
union of a wound of some  length,  in those cases where adhesive
plasters do not seem applicable or sufficient.
  When the wound is narrow, or where it is of no consequence to
effect a perfectly exact coaptation of its lips, we may make use of
a more simple uniting bandage ; that is, of one somewhat narrower,
and rolled like the  other into two  heads, and whose two  portions
are obliquely crossed without being slit, or without crossing upon
the front part of the wound.  This form of bandages is useful when
we are treating parts,  for example, of small dimensions, as the
fingers, where we make use of bandages extremely narrow.

           B.  Uniting Bandages for transverse wounds.
   To approximate  the edges of a transverse wound, we must draw
upon it in directions parallel to the axis of the body. The bandages
then necessary not being enabled to act  in a circular direction, wc
are obliged to employ special pieces, that are fastened by means of
a roller bandage.  Thus, we  have  an  upper piece  represented by
the extremity of a bandage of greater or less length and width ; in
the portion of this bandage  which is to rest on the wound, we make 
152
NEAV ELEMENTS  OF  OPERATIVE SURGERY.
long slits or openings; Ave then have a  second  piece of linen, of
nearly the same dimensions, and Avhose upper  extremity is to be
divided into two or three strips.  In joining and crossing the divided
parts of the  tAvo pieces of bandage, we obtain  nearly the same
figure as by the uniting bandage  for longitudinal wounds.
  When we Avish to apply this bandage, Ave fasten the inferior part
to the lower part of the leg if we are treating the abdominal ex-
tremity, and the superior portion around the thigh, by means of
circular turns, (Fig. 92,) taking care to  fold the unperforated ex-
tremity under  each turn of the  bandage, in order  to fasten it as

                           (Fig. 92.)
firmly as possible.   When the roller bandage reaches both above
and below to the neighborhood  of the wound, the surgeon, having
charged two assistants with  the head of each bandage, passes the
strips of the lower piece into the openings of the upper piece, slips
the graduated compress underneath and across, draws upon these
two pieces in an opposite direction, and applies to the wound the per-
forated linen, lint, or any other object he judges necessary; when all
the parts of the dressing are properly crossed, and each one prop-
erly applied in its place, he continues to unroll the upper bandage
from above downward, until  it is entirely exhausted.  He  does the
same with the lower bandage, which enables him thus to complete
the roller bandage, by enveloping  what may remain uncovered
of the  uniting slips.  This  bandage might be replaced by  tMTo
bandages in T, with two to three or four vertical branches.   But
then it would be necessary also to use a bandage of great length, in
order to establish a  roller bandage  from the extremity of  the limb
to its upper part;  it  would, also, have the inconvenience of too
strongly pressing upon the parts at the root of each T.  The uniting
bandage for transverse wounds  is still employed by some for frac-
tures of the patella and of the os calcis,  and for rupture of the
tendo-Achillis; but  in those cases  it should be replaced by some-
thing more simple  and full as efficacious.  On the arm and thigh
we add to its solidity by fastening the superior portion with one or
tAvo turns of the spica bandage  on the upper part of the limb. 
BANDAGES.
153
Article II.—Special Bandages, or such as are adapted to those re-
          gions OF THE BODY IN WHICH THEY ARE REQUIRED.

  The form of the different parts of the body, obliging us to vary its
bandages and portions of dressings, makes it proper that Ave should
examine special bandages successively from the head to the foot.

                § I.—Bandages for the Cranium.

  The ancients had become so practised in the application of ban-
dages, and had  so  diversified their forms, that for the head alone
Galen describes, an upper divided bandage,  one  cut  in front, an-
other general bandage, also divided, a covercle cut in eight divis-
ions, the covercle with three heads, and three other varieties of co-
vercle, tAvo rhombs, a half-rhomb, the scapha, with many A-arieties,
the thais of Perigenes, the anonymous thais, the discrimen, the tie
of Glaucius,  the royal bandage, different sorts of chevestres, the
hare without ears, the upper joint, the helmet, &c, &c. These ban-
dages, of which  Vidus Vidius (De Chirurg., lib. quat. in fob, pp. 46-
72; lib,, tert. Venet., 1611) has carefully given us the figures, are
at the present day abandoned.  There is scarcely a wound of the
cranium that cannot be conveniently dressed with the aid of a ker-
chief, (couvre-chef)  a bandeau, triangular handkerchief, a T ban-
dage, a bandage Math six tails, the sling bandage, the packer's knot,
and the capeline.
  Even among  these last there are many that are generally dis-
pensed with in practice. The great kerchief, (le grand couvre-chef,)
for example, which  is formed with a  napkin folded double, but in
such manner  that one of its edges extends  some  fingers' breadth
beyond the other, and tAvo heads of which are tied under the chin,
while the other two are carried upwards towards the occiput, is no
longer thought indispensable.   The head-dress which country wo-
men sometimes wear, to protect them from the cold or sun, would
give a tolerably  correct idea of it.  The head-dress, called serre-tete,
would equally well replace it.
  A. The bandage with six heads,  (Fig. 93,) or the poor man's ban-
dage of Galen, is more  worthy of preservation.   It is, in some re-
spects, like one of the bandages with eighteen tails.  The  middle
part is placed on the vertex of the head ; the two middle heads are
then brought down and fixed under the chin, after which we bring
forward horizontally the two posterior heads, and  carry backward
its tAvo anterior heads.  We have, in this way,  a bandage suffi-
ciently simple and firm, and which allows of our making a certain
degree of pressure on almost every part of the head.
  B. The sling  bandage, (la fronde—Fig. 94,) of the  head, differs
from the preceding by only one piece less.  It may serve, for exam-
ple, for dressing  blisters on the neck, provided two of its heads may
be easily fastened on the forepart of the forehead, while the tAvo
others circularly embrace the nape.   We  perceive how  this sling
  vol. i.                     20 
154           NEW ELEMENTS Or OIXRATIVE SURGERY.

bandage, when placed on the anterior portion of the cranium, might
readily take the  place of the great couvre-chef bandage, and also
of the bandage with six heads.
  C. The T bandage, single, double, or triple, often formerly em-
ployed in the treatment of wounds of the cranium, is almost totally
(Fig. 93.)                             (Fig. 94.)
rejected at present. So also with the discrimen, the figured, (figure,)
and the knotted, (noue,) bandages.
  D. The packer's knot, (nceud d'emballeur.)  When bleeding by the
temporal artery was much practised formerly, they had recourse,
in order to stop the hemorrhage, to a  sort of compression, which
was rendered exceedingly solid by forming, upon graduated com-
presses, different crossings called  the  packer's knot,  (noeud d'em-
balleur.)  For that purpose, it Mras necessary to have a bandage of
five yards in length, about an inch in width, and rolled up in tAvo
heads.   The middle of the bandage was placed on the sound tem-
ple, in  order to bring its two heads, the one in front, the other to the
occiput, opposite the point of compression.  Here they Avere crossed
in order to change hands, making each perform a half turn, and
bringing them back on the sound temple by conducting  one to the
vertex of the head, and the other under the chin. Crossing  them then,
as before, they were brought horizontally back to the wounded
temple to be crossed again, and so on till the two heads were ex-
hausted.
  This bandage, which could be of no use at present,  had ako the
inconvenience of making painful pressure by its knots,  and of be-
coming readily loosened, in consequence of the little security of its
vertical turns.
  E. Capeline.  The head bandage most in vogue is that which is 
BANDAGES.
155
still known under the name of capeline, (Fig. 95.) To make it, the
surgeon placed on the forehead  the  middle  part of a bandage of
ten yards length, rolled into  two
heads. On reaching the nape, the              (Fis-95>
heads change hands; after having
made a reverse with the smallest,
it  is brought to the forehead, fol-
lowing the median line; it is fast-
ened there by a circular turn with
the other head ;  it is then carried
to the back  part of the  head, fol-
lowing  a line a little upon  one
side ; again fastened behind, then
brought forward upon  the other
side, and so on in succession till
the whole cranium is covered Math
it, this head of the bandage is ex-
hausted in bandelettes, having the
appearance  of the ribs upon a
melon, whose terminations, in fact,
are concealed by means of the cir-
cular turns of. the larger head of
the bandage.
  The capeline, which we shall meet with again in speaking of
bandages  for the clavicle, shoulder, and thigh, is a bandage of great
regularity, and of extreme elegance; but one which is deranged
with great facility, difficult to make compression with on the vault
of the cranium, and by its lower folds and numerous circular turns
is, to a considerable degree, oppressive to  the forehead, occiput, and
temples ; moreover, we can substitute for it, without any sort of in-
convenience, the most simple bandages, and it could only arise from
affectation, that  a preference, in any case, should still he aM^arded
to it  at the present day.
  F. The handkerchief. All bandages that were  formerly used for
the head have, at the  present day, finally yielded to the triangular
handkerchief, (mouchoir.) Applied by its base, either upon the fore-
head, or under the occiput, this bandage, the point of which is fixed
in an opposite position by bringing  it up from under the edges
which are to make the circular turn  of the head, has the immense
advantage of being everywhere accessible, of being capable of ap-
plication by every one, of possessing  great security, and of permit-
ting moderate compression, whether by one of its turns only, or over
the whole surface of the cranium, if we take the precaution of draw-
ing in an  equal or unequal manner upon  the point or lateral edges
of the triangle, after its base is properly fixed.
  For some cases, a simple bandeau  might also replace the hand-
kerchief bandage—in all cases where the uniting bandage on the
cranium is  not indispensable.  The  triangular handkerchief may
take the place of all the others.  If we really required bandages for
any wounds of this region, it would be rather one of  the forms of
 
156
NEW ELEMENTS OF OPERATIVE SURGERY.
(Fig. 96.)
 the chevestre, than of the capeline, or bandages with six or four
 heads, that it would be most proper to use.

                  § II.—Bandages for the Face.

   There are four regions of the face, the nose, eyes, lips, and chin,
 for Moiich particular bandages have been contrived.

                  A.—Bandages for the Eyes.
   The frequency and number of the diseases to which the  eye is
 subject, and the great number of operations that we are obliged to
 perform on this organ, sufficiently explain the  number and variety
 of bandages which surgeons have contrived for it.   It is neverthe-
 less true, that  all the dressings required by diseases of the  eye or
 eyelids may be  reduced down to four or five—the handkerchief,
 the bandeau, the eye bandage, (I'asil,) single or double,  the mono-
 cle, (le monocle,)  and the T bandage.
                           I. Handkerchief and bandeau, (Fig. 96.)
                         When  we wish  only  to  attach  gently
                         upon  the forepart  of the orbit some
                         pieces  of  linen,  or lint, the handker-
                         chief, in form of a  triangle, applied in
                         the way we have mentioned in  speak-
                         ing of bandages for  the head, is gen-
                         erally  quite sufficient.  It is evident,
                         that by lowering the base of this  tri-
                         angle to the point  of the  nose,  the
                         two eyes must be  completely covered
                         by it.
                           The handkerchief, covering, as it does,
                         at  the  same time, the whole  head, and
                         pressing too much on the bridge of the
                         nose, is advantageously replaced by the
                         bandeau.   We give the name of ban-
                         deau to a piece of linen,  which is a
                         long compress of  five  to  six  fingers'
                         width,  and  sufficiently long to make
                         a turn round  the   head,  to  be  fast-
ened behind with pins.   This bandeau differs  in no respect from
the handkerchief, except that it sends off no point  from the forehead
towards the nape. To render it more useful, it  is well to make a
T-shaped hole in it near the middle and close to its edge. For that
purpose we fold it double, and, with the scissors,  cut its fold to the
extent of about an inch  through, and at the distance of about half
 an inch above its lower edge.  Another incision, perpendicular to
 the first, and which is to represent the vertical branch of the T, is
 also made, from below upwards, upon the upper  edge of the hori-
 zontal incision.  This cleft, which is to receive the nose, when once
 in its place, prevents the bandage from either rising  up towards
 the forehead or  descending towards the mouth, and allows of its
 being applied  much better  upon the surface of  the oye-lid.   We
 
BANDAGES.
157
 should, therefore, prefer it in most cases.   Also, in arranging either
 the handkerchief or bandeau obliquely or diagonally, in place of ap-
 plying it circularly about the head, we convert it into a kind of
 monocle in place of using a bandage for the two eyes.  •
   These bandages, however, which are almost the only ones that
 are used at present, are not  suitable, if the object is to make direct
 pressure, and with a certain degree of force, upon some points of
 the contour of the orbit, rather than upon others. It is in such cases
 that the monocle, or the bandage called the  eye bandage, single or
 double, might still be of some  utility.
   II.  Monocle.  To make the monocle, we apply the free extremity
 of a bandage, two fingers wide and four to five yards long, upon the
 angle of the jaw.  This extremity of the  bandage should hang
 down to the extent of three quarters of a yard in a direction towards
 the chest; we then carry the  rolled head of the bandage upon the
 cheek, the internal angle of the  eye, the parietal bone of the oppo-
 site side, and to the nape, that we may circularly surround the base
 of the cranium.  Brought back to the nape, this rolled head is passed
 under the jaw, in order to fasten the pendent head, which we then
 immediately raise to the forehead, where  another circular turn
 fastens it, while it alloAvs us to  bring it under the jaw and fix it
 there by another turn, that  we  may bring it up for the last time
 upon the forehead, where it is to be finally attached by some addi-
 tional circular turns.   We have, thus, four oblique bandelettes im-
 bricated upon the front part of the orbit—bandelettes which, firmly
 fixed on the forehead and  under the jaw,  cannot in any manner
 slip ;  so that, after the bandeau, the monocle  is, in fact, the most
 secure of all  the bandages of the eye ; only it has the disadvantage
 of impeding  the movements of  the lower jaw, and of making a
 greater degree of pressure on the forehead and supra-hyoidean  re-
 gion  than on the forepart of the  orbit.
   III. We  may advantageously substitute for it the single or double
 eye bandage.   To make the  single eye, the bandage, having passed
 round the base of the cranium, is brought back upon the angle of
 the jaw, and conducted thence towards the upper part of the nose;
 then  upon the parietal of the opposite side, and again on the nape.
 After having thus made three  or  four diagonal circulars, which
 must lap over each other half their width, as in the roller bandage,
 we let out the  rest of the  bandage by horizontal circular turns
 around the head.
   IV. If we  wish to make the double eye, we proceed in the same
 way, Avith this difference, that we pass the diagonal circulars upon
,the right and left  eye alternately, and in such a manner that the
 whole represent an X on the forehead and  occiput; that is, an X,
 or sort of cross,  (croise,) which is encompassed besides by a certain
 number of horizontal circulars.
   V. The  new eye, (azil  nouveau.)  The  single or double eye, such
 as I have just described it, is very liable to be displaced. Its diago-
 nals  scarcely ever fail to ride up by their lower portion towards the
 ear, or to slide  either upward or downward in their parietal por- 
15S
NEW  ELEMENTS  OF  OPERATIVE SURGERY.
tion.  We may, however, make it sufficiently secure, by modifying
it in the follov\ang manner;  that is to say, by fixing the free head
of the bandage near the ear, so as to leave a portion of it hanging
down like  the  monocle.  The rolled head of the bandage is then
passed under the jaw, and to the  nape, and passing under the ear
upon the opposite side, and going circularly around the base of the
cranium, and aftenvards brought from the nape to the angle of the
jaw upon the outer surface  of the free head, then repassed diago-
nally upon  the internal angle of the eye and to the  opposite parie-
tal  bone, is afterwards carried back to the nape, then to the angle
of the jaw, to the front of the eye and on the parietal bone, and in
this manner  successively for three or four times.   By this means
Ave obtain a single eye, which may easily be made immoveable, by
bringing back the free head of the bandage, in the form of a bridle,
upon the outer surface  of  the turns of the ear, under  the  jaw,
and in such manner as to make a vertical circular, which is fastened
by means of a pin upon the fold or root of the bridle.  If Ave wished
to have a double eye, the two free portions of the bandage should
be brought down towards each  other, and tied together, by a knot
under the chin.
  These three  varieties  of  bandages for the eyes,  howe\"er, are
rarely demanded.  To make a moderate degree of pressure on the
forepart  of the orbit, it would be much better still to use circulars
from the upper part of the forehead to a level with the cheek
bones, taking care  to protect the bridge of the nose by padding,
rather than to attempt the monocle, or the other bandages which I
have described.
  ■The T bandage which some  surgeons, David, for example, for-
merly applied in place of the monocle, merits in reality the disuse
into which it has fallen.

                   B. Bandages for the Nose.
  The principal bandages for the  nose still in vogue, at  the  com-
mencement of  this century, Avere, to judge of them by Thillaye's
book, (Traite des Bandages, etc., 2d edition, Paris, 1809,) the double
T, the haAvk, (epervicr,) the  drapeau, the sling, (fronde,) the  rele-
veur, the tAvisted nose, (le nez tortu]) and the fossa (fosse) of Amintas.
   I. The double T  deserves to be retained; its A*ertical branches,
each from eight  to tAvelve  lines  in breadth, should be separated
near an inch apart at their root. We begin by placing its transArerse
branch upon the  upper lip; Ave then raise its  two  vertical heads,
first upon the sides, then to the upper part of the nose, Mrhere we
 cross them to carry them to the nape by passing obliquely oA-er the
 parietal bones.   The two  heads of the horizontal  branch, Avhich
 are made to  fasten them there, enable us to raise them again, and
 then return to the forehead, to fasten them there again, and to be
 completed by one or two circular turns.
    II. Epervier, or Drapeau.   With the T bandage we easily dress
 wounds on the sides or upper part of the  nose ; but for wounds of
  the point  of the nose, (lobule,) it is better to have  recourse to the 
BANDAGES.
159
epervier, which is nothing else than a kind of purse, the tAvo late-
ral ribands of which are passed from before backward under the
occiput, to fasten the upper riband of the  bandage (drapeau) at
this point, and to be brought back to the forehead.  We have thus
a small sack, more or less exactly fitted to the nose, which enables
us to apply upon this  organ all the portions of dressing we may
have occasion for.
  III. The sling  (fronde) of the nose should have only  an inch
width, and be provided with a hole  in its middle to hold the point,
(lobule.)  Its two lower heads are raised up, and carried above the
ears towards the occiput, while the upper heads are brought down
towards the nape.  This small bandage does  not close the nares
like the preceding, but it  has the disadvantage of being less secure,
and of tending to flatten  the nose.  No person, at the present time,
attaches any further importance  to the releveur of the nose, or to
the tMdsted nose bandage, nor the fossa of Amintas, nor to the
seventeen varieties of bandages figured in the book of Vidus Vidius.
With the aid of the double T, that of the  epervier, Avhose lower
part may also be  easily perforated near the nares, and with the ban-
deau perforated at the point of  the nose, we have enough to satisfy
all the wants of practice.  At the present day, moreover, when the
adhesive plasters are attainable by  all surgeons, we rarely feel the
necessity of bandages for the nose,
               C. Bandages for the Lips and Chin.
  Diseases of the lips scarcely require  any other than the uniting
bandage; but as this bandage, which comprises the three kinds above
described, will be referred to again, under hare-lip, I will only re-
mark here, that we often associate pe-
lotes with it, to  compress  and push for-
ward the anterior part of the cheeks.
  In some cases, however, we use the
sling for diseases upon the contour of
the mouth.  This sling should be slit, in
fact, or notched,  on a level with the
mouth, and cut  out  in a  crescent un-
der the nose.  Its two inferior heads are
carried obliquely under the ears to the
projection of the occiput, where they
are crossed, and then brought forward
and united on the forehead.  The supe-
rior  heads, also passed under the ears,
may be fixed upon the nape, or crossed
at this point, and afterwards  brought
to the forehead.
   Wounds in the interior of the mouth
scarcely ever requiring dressings, pre-
sent, on that account, no occasion  for
the employment  of bandages.
   Wounds of the tongue only, have claimed some attention under
this point of view, and the small purse (bourse) of Pibrac, (Fig. 97,)
(Fig. 97.)
 
160
NEW ELEMENTS OF OPERATIVE  SURGERY.
 which, enclosing the apex of the tongue, has at its base two silver
 threads, Avhich are turned under the chin, and to which ribands are
 attached, which should go to the nape and return on the forehead,
 is the only dressing Ave can in such cases require.
  Bandages for the Chin.  It was in some measure for the chin that
 the sling was contrived; so also is it the only bandage used at pres-
 ent for Avounds of soft parts of this region.  Sometimes perforated in
 its middle portion, at other times entire, the sling for the chin ought
 to have about four fingers' width.  Its two inferior heads are raised
up in front of the ears, to be crossed at the vertex of the cranium,
and afterwards brought down to the temples.  Its upper heads,  on
the contrary, are passed horizontally under the  ears to the nape ;
crossed on this point, they are then  brought to the forehead, Avhere
they are crossed again,  to  be returned  to  the  nape, and  there
fastened.
                        D. The Mask.
  When it is necessary to  cover many parts of the  face at the
 same time, we  use, under the name of mask, (masque]) a piece  of
 linen shaped to the face, cleft into  a T, or perforated opposite the
 eyes, nose, and mouth, and having attached to it four ribands, tA\ro
 above and tAvo below, for the purpose of fixing it  around the head.

             E. Bandages for the region of the Ear.
  Wounds of the ear, or the parotid  region, are  dressed with the
 aid of the ecusson, the T bandage, the oblique, the sling, or the
 chevestre. ,
  I. The Ecusson.  A piece of linen, sufficiently large to cover either
 the expanded portion of the ear (pavilion) only, or both the pavilion
 ajtid mastoid region, and to Avhich three ribands are attached, behind,
 above, and below, constitutes the ecusson for the ear.  This bandage,
 which is fastened by a vertical circular turn by means of the upper
 and loAver ribands, and by a horizontal circular turn by means  of
the posterior  riband, conveniently holds the lint, or other portions
of dressing that Ave wish to apply, either upon the irregularities of
the pavilion  of the ear, or betAveen the pavilion and the mastoid
process, or even in the parotid fossa.
  II. T Bandage.  When we Avish to leave the ear free, and the
disease is in front of the  pavilion or the mastoid region, or if we
have to dress a* blister, for example, the T bandage is preferable  to
 the ecusson.  We fix the horizontal branch of it  around the base
 of the cranium ;  then bring doAvn its vertical branch either behind
 or in front of the ear, according to the-seat of the wound, in order
 to pass it under the jaw in the form of a bridle, and thence to fasten
 it to the horizontal circular  on the  opposite  side.  This bandage,
 though without contradiction the most simple that could be applied
 to the ear, is, nevertheless, but little employed;  this is because it
 does not ahvays answer, and that Ave can substitute for it, without
 inconvenience, temporary bandages, or, what is  as well, a simple
 cravat to be fastened on the  top of the head. 
BANDAGES.
161
  III. Oblique Bandage for the Ear.  If the dressing of the auricu-
lar region requires some degree of security and many turns of the
bandage, the oblique bandage is  indicated,  which  is  made as
follows: a bandage,  five yards long,  is first fastened circularly
around the base of the cranium, then brought from the nape under
the ear and jaw; it is then  carried up perpendicularly in front of
the ear upon the sound side, to be brought down upon the diseased
ear, and to return under the jaw; then around the cranium on the
sound side, to return obliquely from the occiput to the affected ear;
then under the jaw, and vertically to the top  of the head, to make
a new vertical circular; then another horizontal circular, and so
on, successively, three or four times.
  The oblique bandage  of the ear, which we should  not restrict
ourselves to  making with too much precision in one mode rather
than another, is decidedly preferable to all the preceding, and may
be, in almost every case, substituted for them.
  IV. JOhevestres.  Of the  seven chevestres represented in figures
16, 17, 18, 19, 20, 21,  and  22, of Vidus Vidius, there remain but
three in modern practice: the simple chevestre, the double with
one rolled head, and the double with two rolled heads.
  These bandages, whose object iatto support the pieces of dress-
ing that may be required  for fractures  or luxations of the lower
jaw, do not differ sufficiently from the oblique bandage for the ear
to require that they should be any longer separated from it, at least
if Ave take care to simplify them, as I shall presently point out.
  a. The simple Chevestre, (Fig. 98,) requires  a bandage of three
fingers' width and five  yards long.
Two  compresses, cut in the man-
ner of a sling, are first applied upon
the chin and  under  the jaw.  The
bandage, being  fixed by a  circular
turn around the cranium, is carried
obliquely behind the ear and the an-
gle of the jaw on the sound side ; then
under the jaw and in front of the ear
on the diseased side, to the top of the
head, behind the sound ear, under the
angle of the jaw, and so on, in succes-
sion, so as to make three ATertical cir-
culars open in front.   We then pass
the bandage circularly around the up-
per part of the neck, then on the front
part of the chin, so as to fasten the
sling compresses, after  which  we
make another vertical circular, ter-
minating Avith a horizontal circular, Math which the  bandage is
permanently  fastened.
  b. The double Chevestre requires a bandage eight yards long.  We
apply it first  like the preceding one, and are then careful to pass
it  obliquely and vertically,  alternately to the posterior part and
  vol. i.                         21
 
162
NEW  ELEMENTS OF OPERATIVE SURGERY.
front of each ear, and  as  many times to the right as to the left.
The circulars designed  to  envelop the chin being terminated, Ave
make, as Avith the simple chevestre, one or two vertical circulars,
and terminate it by one or  tAvo horizontal circulars.
  To obtain a double chevestre as regular as possible, it would be
much better  to make use  of a bandage- with tAvo rolled heads.
We place the middle of this bandage on the forepart of the fore-
head, then cross the two portions of it upon the nape; avc then
bring them out under the ear on each side to cross them under the
jaAv, and to pass them vertically betAveen the ear and the orbit Up
to the top of the head; there we cross them again, to carry them
back to the nape, change hands Avith  the heads, bring them under
the ear, cross them, repass them to the vertex as  at  first, and thus
recommence a third vertical circular.  We proceed  afterwards  to
form the circulars of the neck and chin, and then to make tAvo more
vertical circulars, in order to terminate in like manner Avith one or
two horizontal circulars.
  These bandages, often employed formerly for fractures and com-
plete luxation of the jaAV, are scarcely ever used at this day in such
cases ; but something similar is still frequently found useful for cer-
tain wounds or diseases of  the parotid, masseter, temporal, auricu-
lar, and mastoid regions.
  c. Chevestre of the Author.  Without restricting myself, then, to
the exact representation of one form more than another of the ban-
dage which is used, I believe the folloAving will answer for all the
wants of practice, and render useless the oblique bandage, the ecus-
son, the T bandage of the ear, and the different sorts of chevestres.
of Avhich, in fact, it is only a more  simple modification. I fix the
bandage by a circular upon the base of the cranium; I afterwards
pass it from the nape under the ear and under the jaw, either upon
the  sound  or diseased side—it is generally a matter of no conse-
quence  Avhich;  I then carry it upward, as Avith the chevestre,
towards the temple on the  sound side, in order to pass it directly
over the vertex to the temple of the diseased side ; I thus multiply
its vertical circulars, inclining them  sometimes in one direction,
sometimes in another,  so  that they soon cover the whole of the
dressing.  Those which I  pass upon the forepart of the chin are
made to cross each other upon the nape ; when  it is necessary to
place some under the jaMr, I cause  them to  pass in a spiral line
around the vertex of  the head, in order to bring  them  back to the
nape, and afterwards to make more vertical circulars;  I finally ter-
minate with one or tAvo  horizontal circulars.
  It is evident that the bandage may be applied in this manner a
little more behind or before, on one or on both sides  of the head
and face, and that nothing  is more easy than to space out, (espacer,)
or to gather together the turns of the bandage a little more on one
point, or a little less on  another, according to particular indications.
I Avill add, that in making this bandage glutinous, we  may form a
dressing, as simple as it  is solid,  for all kinds of fracture of the
loAver jaw, and that, Avith this modification, nothing is so easy as to 
BANDAGES.
103
establish a permanent compression on Avhatever part Ave desire in
the regions above mentioned. It is the only one that I have retained
of all those that Galen speaks of, and of those that have been pro-
posed since.
                  §  III.—Bandages for the Neck.

   The region of the neck generally renders the dressing of its dis-
eases someM'hat difficult, at least as respects wounds, operations,
and deformities.   For inflammations,  tumors, and  other diseases,
which require only  containing bandages,  the neck  accommodates
itself very Avell  to the  circular bandage,  or that  in  the form of a
cravat.  It  is in this manner  we dfess a  seton, blister, moxa, or
cautery, Avhich Ave  occasionally find it necessary to apply to the
nape.   But  in  order to unite a transverse Avound, or to keep open
the lips of a Avound of that kind, situated upon some part of the cir-
cumference  of the neck, we occasionally feel the want of certain
bandages of a particular description.

          A.— Uniting and Dividing Bandage, (Fig. 99.)
  Longitudinal wounds on the neck re-
quire only adhesive plasters of diachy-
lon, or the circular bandage. Transverse
Avounds, Avhere Ave do not wish  to recur
to the suture, but prefer to approximate
their edges,  require a bandage  Avhich
should keep the head inclined to the side
of the Avound.
  The most convenient uniting bandage
one can employ in  such a case is the fol-
loAving :  We fix securely upon the head
of the  patient a cotton cap, or a serre-
tete, kept in place  by a chin-cloth, (men-
tonniere;) we afterwards  fasten upon
this cap, by means of a sufficient number
of circular turns, a bandelette slit in tAvo,
to some distance from its fixed point, and
from Avhich the two halves are left hang-
ing down upon the diseased  side.   The
Avound being properly dressed, Ave de-
press the head of the patient by drawing
upon the two  bandelettes,  Avhich act
upon it like a double hook; then we at-
tach them upon a body bandage Avhich
surrounds the chest, and Avhich  latter
has been made secure above by a scapu-
lary, and below by bandages under the
thighs.
  If it  concerns the anterior region of the neck, the bandelette
should have its fixed point upon the occiput; and its two branches
coming out  in front, and brought down to the external orbitar an-
 
164
NEW ELEMENTS OF OPERATIVE SURGERY.
 gles, should be made to descend to a level Avith the mammae, Avhere
 they are to be fastened  to the body bandage.  For a wound of
 the opposite region, it is upon the forehead that we must fix the
 root of the bandelette, and behind and betAveen the  shoulders that
 we should attach its branches to the body bandage.   A wound of
 the lateral region would require to have this kind of dressing fixed
 upon the temple of the sound side, and to attach its tAvo branches
 on the body bandage, the one before, the other behind the shoulder
 of the wounded side.
  It has always appeared to me, that this  bandage could also re-
 place the dividing bandage for the neck.  It is evident, in fact, if
 it Avas required to keep apart the lips of any wound in this region,
 that it Avould be sufficient to  draw the branches of  the bandelette
 backward when the wound is in front, and forward  when  it is be-
 hind, &c, &c.  This indication might possibly be presented  in some
 cases of Avounds of the larynx or trachea, or  after the destruction
 of certain bridles and accidental cicatrices.  Nevertheless, we must
 not deceive ourselves by supposing that this bandage can be made
 to keep in  place for any length of time, or that the patients will
 endure it without inconvenience or fatigue.  Supported upon a col-
 umn extremely moveable, the head almost always finds means, by
 inclining itself in one direction or another, or by  turning on its
axis, to escape from the  torsions made by  the dividing or uniting
bandelette.   All that we can say is, that it is less  fatiguing, and
wholly as efficacious, as the extremely complicated bandages which
haA_e been contrived to fulfil the same indications.

                 B.—Redressers of the Head.

  Winslow, Thillaye, and some others, proposed  bandages for
straightening the head in cases of contortion of the neck.   At the
present time, when the section of the retracted muscles or tendons
is performed with surprising  facility, bandages proper for righting
the  head Avill not fail to come again into much use. As I do not
wish to occupy myself in this place with the different  apparatus
known under the name of machines, I will confine myself to saying,
that, with a simple bandage fixed around the  head by some circu-
 lar turns, and passed from the inclined side to the forepart of the
forehead, then to the temple of the  opposite side, then to the nape,
we are enabled to straighten,  M'ith a considerable degree of force.
the  cervical region of the spine, while  we elevate the face  and
chin.
  The  end  of this bandage may afterwards be fixed upon a body
 bandage  under the arm-pit,  or  the bandage passed  over the arm-
 pit  itself, properly protected, to be  afterwards brought above the
 shoulder upon the posterior part of the neck, then in front, under
 and behind  the other arm-pit,  then  again  around the head  and
 under  the arm-pit behind the shoulder  of the inclined side; if
 these bandages be interlaid Math pieces of pasteboard saturated
 with dextrine, they become extremely solid. 
BANDAGES.
165
  The bandages used after  opening the jugular vein, and after
bronchotomy, will be described in the chapter on those operations.

                § IV.—Bandages for the Thorax.

  A.  Body bandages, (bandages de  corps.)  The chest, properly so
called, rarely requires any other than this bandage,  (Fig. 100.)  It
is the only one employed as a containing bandage in the treatment
                            (Fig. 100.)
of wounds.  Fractures of the ribs, and all diseases that require the
employment of any topical application, or any portions of dressing,
equally well adapt themselves to this bandage.   It is made with a
napkin folded thrice, or, if we wish to have it prepared beforehand,
by sewing, in the form of a  napkin thus folded, two folds of linen,
of sufficient width and length, upon their free edges. This bandage
is applied  circularly.   We  should take care to tighten it  a little
more below than aboATe, in order that it may be displaced as little
as possible, and that it may not pucker into a cord from movements
of the chest or arms; we fasten it on its upper edge by a scapulary,
and on its lower by sub-crural bandages, [i.e., under the thighs.] The
scapulary, formerly, was  a piece of linen slit so as to let the head
pass through, and attached, on the anterior and posterior parts of
the chest, to the  body bandage.  At the present time, we  replace
this bandage by  the end of a bandage Moiich is doubled, the fold of
which is fixed, between the shoulders, to the body bandage, and its
two heads brought, in the manner of suspenders, upon each side of 
166
NEW ELEMENTS OF OPERATIVE SURGERY.
the neck, to be attached in front, either separately or together, upon
the circular bandage.   It is e\en better, when it is desirable that
the patient should be as little moved as possible, to attach this ac-
cessorv piece to the body bandage before passing the  latter around
the chest; so also, in renewing the dressing, we may confine our-
selves to detaching these suspenders and the bandage in front only,
without taking them entirely off.

                  B. Quadriga for the Thorax.
  If Ave should require a more equable and diffused  pressure, and
a more uniform constriction than it is possible to procure by the
aid of a body bandage, Ave should, in the place of the bandages de-
signed by Butet for supposed  luxations of the  ribs, and by David
for  luxations and  fractures of  the  Arertebrae, and  fracture of the
sternum,  have recourse to the bandage called the quadriga of the
ribs.  In  short, Ave no longer employ at  present the quadriga Avith
two heads, nor the different  sorts of stellated bandages (etoiles) of
Kiastres, &c, as used by the ancients.
  The bandage Avhich  I  am about  to describe differs, also, essen-
tially from the quadriga or chariot of the ancients; composed  of a
kind of posterior stellated bandage (d'etoile posterieur) and  thoracic
circulars,  it  resembles, in some measure, the cataphrast of Galen.
A long bandage of three fingers' width answers, in  this respect, for
every purpose.
  In place of applying it in the manner of the roller bandage, from
beloAv upwards, afterAvards to terminate by one or two figures  of 8
around the arm-pit and shoulder, it is better to proceed as follows :

                  C. Cataphrast of the Author.
  We  leave hanging behind the thorax about half a yard of the
free end of  the bandage,  the  rolled  head of  which is  passed
to the shoulder of the  sound side, in front of the chest, under the
arm-pit of the diseased side, and back of the thorax, so as to make
circulars which, in passing over the free head of the bandage,
should, while they lap  over each other to two-thirds their width,
extend upwards to the  hollow of the arm-pit in the manner of a
roller bandage.  We afterwards surround the arm-pits with a pos-
terior figure of 8, to terminate upon the chest by a circular, either
from below upwards, or from above downM'ards. '  We then raise
the reserved  head  of the bandage to the shoulder  opposite to that
Avhich first received it, in  the  manner  of suspenders, to  fix  it in
front upon the lower circulars, (Fig. 101.)  We thus prevent the
separation of the turns of the bandage, and give great solidity to the
whole dressing.

                  D. Bandages for  the Mamma.

  Subject to numerous diseases, and frequently requiring serious
operations, the mammary region has suggested the contrivance of
a great number of bandages, which may, however, be replaced, in
most cases, by the body bandage, or by the preceding quadriga. 
167
  I. Square Bandage for the Breast, (Fig. 102.) There are two spe-
cial bandages which are occasionally used for diseases of the mam-
(Fig. 102.)
mary gland—one the square bandage, which is a piece of linen six
to ten inches in diameter, having a riband or a band at each one
of its angles; in order to  fasten this bandage, Ave pass its two lat- 
JOS
XEAV ELEMENTS OF OPERATIVE SURGERY.
 eral ribands, the one above and the other under the arm-pit of the
 affected side, to tie them behind with those of the sound side, which
 should also pass, one above and the  other under the shoulder.
  In place of the  square bandage, we  may use  a triangular one,
whose horizontal part should be fixed around the chest, while its
vertical should be  made to join the  other behind the diseased side,
in the manner of suspenders.   A double  T bandage, with large
branches, would fulfil the same indication, but with less regularity.
  II. The suspensory bandage for the mamma is also made with a
square piece of linen, from which we cut off a triangle, in order to
sew the two edges of the division, and thus speedily form a kind of
purse  Mrith a large opening to enclose the mamma.  The angles of
this suspensory, being  also supplied Avith straps, are then applied
and fastened like the square bandage.  But these bandages, though
suitable for supporting a simple dressing, are not sufficient when
we Avish to make pressure, or undertake the  approximation or sep-
aration of the lips of a Mround.
  III.  Uniting and compressing  bandage for the  mammary region.
Wounds of the mammary region may be united by means of adhe-
sive plaster,  or simple uniting  bandages, like  those  for any other
region.  If, in addition, the approximation of their edges should be
clearly indicated, it.would be  sufficient, in order to effect this object
without  difficulty,  to make some regular turns of the cataphrast
in their neighborhood, and to arrange at a certain distance gradu-
ated compresses.
  To suspend the mamma by means of a bandage, we may do as I
have described in speaking of the quadriga, except that some turns
of the bandage ought then to be passed in a diagonal direction from
the lower part of the diseased breast over the  shoulder of the op-
posite side.   If these diagonals were only on the diseased side, we
should have only a siagle suspender ; in applying them on the two
 sides,  we would have the double suspender.  Some circular turns,
 placed first above, then  below the breasts, secure the turns of the
 suspensory. The head of the bandage, Avhich has been left free be-
 hind,  being brought in front in the manner of suspenders, forms,
 altogether, one of the most simple and secure dressings.
  The compressory bandage  for the mamma does not materially
 differ from the preceding; for whether we do  or do not apply at
 first pieces of agaric or gateaux of lint upon the organ to  be com-
 pressed, there is, if the mamma be large, not the less necessity of
 diagonals, the same as in the suspensory, and also of a greater or
 less number of circulars, as with the roller bandage, and of an ex-
 tremity of the bandage to serve as a suspender to restrain the Avhole.
   The compression of the mamma might also, in certain cases, be
 effected by means of strips of adhesive plaster applied circularly, and
 from before behind, about the chest, when the gland is, as it were,
 flattened (plaquee) on the thorax, or Ave  may apply the strips circu-
 larly around the breast itself, and from its base to the nipple, when
 the organ is extremely globular, pendent, and easy to be separated
  from the thorax; Avith this exception, that  Ave rarely find that the 
BANDAGES.
169
 conformation of the parts allows us to give to this dressing all the
 firmness which it requires.
   We see, then, that, in adding a posterior and an anterior figure
 of 8, a single or double turn of the spica, and one or two diagonals,
 the  roller bandage  of the  chest is  converted at pleasure into a
 quadriga, a cataphrast, a figure of 8, a star, (etoile,) or a spica ;  so
 that it may,  in reality, answer for all the dressings of the mamma-
 ry, axillary, sternal, dorsal,  and supra-clavicular regions.

                § V.—Bandages for the Abdomen.

   Whether we desire to make pressure upon the abdomen, to dress
 or unite its wounds, or to make any dressing whatever upon this
 region, it is  always  possible to effect this object by the aid of the
 body bandage, the roller, the cincture, corsets, or uniting bandages.
   I. The body bandage {bandage de corps) itself is more frequently
 employed than all the others put together, for the purpose of sup-
 porting the portions of the dressing around the belly; only that we
• have to give it a little more width for this region than for the chest,
 and are more frequently obliged, also, to secure it by bandages un-
 der the thighs, (sous cuisses.) This bandage is adapted, at the same
 time, to diseases of the epigastric,  umbilical, and hypogastric re-
 gions, and.to the sides and loins.
   II. The roller bandage. It would not be necessary to substitute
 the  roller for  the body  bandage, except where it should appear
 requisite  to  make  a uniform pressure, or pressure on distinct and
 numerous points, in the different regions upon the anterior part of
 the abdomen.
   III.  Cincture and Corsets. When it is required to make upon the
 abdomen a uniform, unchanging, and permanent pressure, the cinc-
 ture or the corset  sometimes replaces the body or roller bandage.
 The cincture, which, in fact, is  nothing but a  stuffed body bandage,
 somewhat narrow, and ordinarily supplied with leather straps, or
 other elastic materials, is peculiarly adapted to support the different
 kinds of ATentral or abdominal hernias.
   Corsets may be very useful for dropsical patients, and for certain
 females Avho  suffer in the  hypogastric region.   For this purpose,
 Monro devised a kind of bandage which enveloped the Avhole belly,
 and which was laced behind like a corset,  and the object of M'hich
 was to compress the abdomen  in the operation of paracentesis, to
 prevent the  too sudden  relaxation of the  digestive organs.  Now
 generally no longer used in such cases, Monro's corset might,  nev-
 ertheless, be  exceedingly well  adapted for producing compression
 of the belly to promote absorption  (a titre de resolutif) in ascitic
 patients.
   IV.  Suspensory, or Cincture of the Hypogastrium.  Women who
 have had many children, and  those who have the uterus inclined
 forward, with a very large pelvis, often experience uneasiness,
 drawing-down pains,  and Aveight, in  the lumbar region, kidneys,
 iliac  fossae, groins, and hypogastrium, sufferings  for the relief of
 which they are often subjected to all kinds of useless treatment, 
no
NEW  ELEMENTS  OF  OPERATWE SURGERY.
but which generally yield to the use of a suspensory to the hypo-
gastrium, (Fig. 103.)  But this suspensory  may be the ordinary cor-
set, provided, in place of being Avidened below, it bends inward (se
recourbera) in the direction of the pubis,  so that, when applied, it
(Fig. 103.)
moderately presses upon the loAver region of the abdomen  from be-
low upwards and from before  behind,  instead of pressing from
above downward, as it usually does.  The busk of this corset would,
moreover, answer, better than any other bandage, to secure  a pe-
lote or graduated compresses upon a fistulous opening, or some tu-
mor, that would require to  be compressed upon the median line ; an
artificial anus, for example, (of which I have had an instance,) and
that without occasioning any uneasiness.
  In general, women put their corsets on over their chemises; if it
is necessary that the bandage should press directly on the skin, it is
better to have one made especially.  In  this  case, I use a sort of
belly-band, (Fig. 103,) shaped to the hypogastric region, furnished
with or without stuffed pelotes, and which are fastened about the
trunk on the side of the loins, or in front, and then below, by the aid
of bandages under the thighs, (sous-cuisses.)
  In truth, the suspensory of the hypogastrium should be used much
more frequently than it is; it is the means of preventing miscar-
riage in a great number of pregnant women.  Many indispositions,
attributed to the condition of the womb or  intestines, Mrould be
made to disappear entirely, purely by its mechanical action,  and
without any medical treatment.
  V.  Uniting bandage. In  no part do wounds that  we wish to unite 
BANDAGES.
171
immediately, more imperiously require the suture than in the ab-
domen.  Supposing that this  means should not be applicable, Ave
should, at least, have the resource of adhesive plasters. If, how-
eATer, we preferred making trial of uniting bandages, we have only
to recall what I have said of them above, to understand hoAV, by
giving them a breadth proportionate to the extent of the MTound or
region, and having care to fix them by a scapulary above, and sub-
crural bandages (sous-cuisses) below, we possess all that is necessa-
ry to know on this subject.

             § VI.—Bandages for the Genital Organs.

   The diseases of the genital organs have suggested but a very
small number of bandages, to wit: Some fqr the penis, others for
the scrotum.
              I. Bandage for the Penis, (Fig. 104.)
   Whether  we  wish  to  dress  a             (Fig. 104.)
wound, or an ulcer of the penis, or
to compress this organ, the Maltese
cross, or the roller bandage, with or
without lint, are generally quite suf-
ficient.  Sometimes  the  Maltese
cross is merely perforated opposite
the urethra; at other times it is pro-
vided with a hole, which alloM^s  it
to embrace the glans penis, and to
push back the prepuce.   A narroAv
bandage serves  to fasten it by its
circulars, and to cover the whole
extent of the penis with a roller
bandage, which should terminate  at the pubis, either by a knot by
means of the bifurcated extremity of the bandage, or by the aid of
a pin, or, better yet, by attaching it to a suspensory.

        B.  Bandage for fixing the  Catheter in the Urethra.
  When it is desirable to leaAre a catheter in the urethra, or blad-
der, it is indispensable to retain it  there by means of bandages ; it
is  a precaution that pupils rarely  know how to carry into effect in
a proper manner; which, however, it is very useful not to neglect.
We possess for this purpose a great number of peculiar processes:
the best of all consists in fastening, near the handle of the catheter,
by means of a double knot, and by their middle portion, two cords
of cotton wick (cordons de coton a meche) about thirty inches long ;
the two branches of each of these cords are then taken, pair by
pair, and brought two of them forward and two behind, or, what is
as well, tAvo of them to the right and two  to the left, to a level
with the base of the glans penis, (de la racine du gland.)  We then
connect the two branches of one side with each other to form a
noose, (anse]) then the two heads of this noose are exhausted in cir-
 
172
NEW  ELEMENTS OF OPERATIVE SURGERY.
culars upon the teguments behind the glans, and fastened by a boAV-
knot, (rosette;) the same is done with the tAvo cords on the opposite
side.  We thus obtain four rays, united by their apex near the han-
dle of the catheter, and fastened on the penis by their base, (Fig.
105.)
      (Fig. io5.)          To give greater firmness to this  little ap-
                    paratus, and to render it less inconvenient to
                    the patient,  Ave may previously include the
                    penis in a small double compress, as we may
                    also fasten the four heads by some  circulars
                    of adhesive plaster.
                      Those who recommended fastening the ca-
                    theter by two cords under the prepuce, and
                    around the corona glandis, made use of linen
                    fibands ; but it is a practice too objectionable
                    to be retained.
                      Many surgeons,  fearing  pressure on the
                    penis, fix the four cords, of which I have been
                    speaking, to the cincture of a suspensory,  or
                    of a T bandage, (Fig. 106,) above, and to the
body of the suspensory, or  to the sub-crural bandages of the  T
below.
  Finally, there are those who begin by fixing to the root  of the

                            (Fig. 106.)
penis, on the front part of a suspensory or T bandage, a ring slightly
wadded; it is to this ring, (Fig. 107,)  which remains fixed in this
position, that the four cords of which I have just been speaking are
attached.
  The process which I have first described is unquestionably the
most convenient of all.  When properly applied, it causes, in most
patients, no inconvenience;  if, however, the state of the penis, or
some other special reason, should deter us from using it, the wad-
ded ring could be most advantageously substituted for it.
  When it is requisite to fasten a catheter in the bladder of a fe-
male, we can only do this conveniently by attaching the four cords,
 
BANDAGES.                        173
that are fastened near its handle, to the cincture and sub crural.
branches of the T bandage.
(Fig. 107.)
                § VII.—Bandages for the Scrotum.

   Bandages are used to support the scrotum or testicles, even where
there are no wounds of these parts.  They are also used as a means
of compressing them, and for dressing their wounds.

                         A. Suspensory.
   We give the name of suspensory of the scrotum to  a kind of bag"
designed to sustain gently all the parts of the dressing we may have
occasion for in  the  treatment of diseases of the testicles, or of its
envelopes.  This purse, which should vary in size or depth, accord-
ing as it is  to enclose a greater or less number of objects, is com-
posed of a piece of linen fastened aboA7e to a'bandage of sufficient
length to go twice  around the pelvis.  Below, the suspensory has
two  cords called sub-crural, (sous-cuisses;)  near its  upper part it
has an opening through which the penis is  to pass.   To  apply it,
we first neatly adjust all the dressing ;  then, by means of the cinc-
ture, we fasten it  around the body ; the two sub-crural branches
are then .passed into the  sub-ischiatic groove, then on the side of
the great trochanter, and  fastened by a bow-knot, or  by the aid of
buttons, to the cincture  of the bandage near the hip.
   This manner of applying the suspensory has, in a great number of
cases, the inconvenience  of pressing or crowding the scrotum to-
wards the anus, or against the  upper part  of the thighs.  I  have
also been in the habit,  as practised also by other surgeons, when
there is nothing to be done but merely  to support the scrotum, and
there is no particular indication to the contrary, to bring the sub-
crural bandages forward along the groins, (Fig. 108,) in place of
making them pass behind.  In this manner the  testicles are kept
gently suspended, and free from all traction or painful compression.
   When the dressing is for wounds, the arrangement  of the suspen
sory is difficult.  In that case, in fact, it is convenient to give to it 
174
NEW  ELEMENTS  OF  OPERATIVE SURGERY.
 sometimes the form of a triangular or square piece of linen slightly
 hollowed out, Avhile at other times it must represent a sort of child's
                               bonnet, or a purse, of greater or
             (Fis-loa)            less  depth.  It is  rare, also, that
                               they are well made in hospitals,
                               and Ave often find ourselves obliged
                               to substitute  extemporary  band-
                               ages for them.
                                 When we have  only to support
                               the scrotum, to prevent its becom-
                               ing fatigued or involved in disease,
                               we generally find in the shops sus-
                               pensories that answer sufficiently
                               well, some being of hemp cloth, lin-
                               en, or cotton, others of caoutchouc,
                               or even leather, or in form of a bag-
                               net or truncheon, (de tricot.)  The
                               only inconvenience of these suspen-
 sories, is that of their presenting a harder border than the rest of the
 dressing, and which often irritates the parts in the manner of a cord.
   We sometimes replace the suspensory by a long compress, Avhich
 embraces the scrotum under its middle part, and which is fastened
 by its  extremities to a cincture  around  the hypogastrium.  A
 more convenient mode still, consists in folding a pocket handker-
 chief into a triangle, the base of which rests on the root of the
•Jscrotum, while the extremities are brought in front of the groins, to
 be attached to the cincture of the hypogastrium, and the apex of the
 purse raised in front, to be fastened at the median line on the same
 cincture.  But these substitutes are in reality neither as secure or
 convenient as an ordinary suspensory which has been properly made.
   B. When  we have to dress wounds of the scrotum, after the
 removal of the testicle, Ave may find it useful  to employ the T
 bandage.  We may also use, equally well, the triangular bandage
 in place of the suspensory; if Ave have to make unequal pressure
 on various points of the scrotum, we may have recourse to a kind of
 quadriga for the pelvis.  In the  tAvo first, Ave pass the horizontal
 portion of the bandage around the lower part of  the  trunk; Ave
 then depress the vertical branch of the T, or the triangle of linen,
 on the  diseased side  of the region, in order to encircle the  upper
 part of the thigh Avith it, and thus fasten it to the cincture on the
 side of the body.
   Certain engorgements of  the  testicle,  blennorrhagic  orchitis
 among others, are advantageously treated by  compression.   But
 to  make exact  pressure on the testicle, nothing is more  commo-
 dious than adhesive plasters made with diachylon.  Depressing the
 swollen part with one hand, as if to detach it from the ring, the
 surgeon surrounds it with adhesive strips of the width of the thumb,
 so that all the parts of the  tumor may be covered or enveloped as
 by a sac,  the opening or apex of which should be  arranged Avith
 care around the root of the cord, (Fig. 109.)
 
BANDAGES.
175
  [A scrotum bandage, which I contrived while phy-
sician to the Seamen's Retreat, (New York,) where
the class of patients and diseases Avere such as to
require great attention to this part of surgery, and
in which I found this apparatus of eminent service
in completely supporting this part  in an isolated
manner,  giving great relief, and  neither pressing
on or wedging between the thighs, nor drawing back
painfully, as in the  ordinary clumsy suspensory,
was the following, (Figs. A and B,)  which I would
recommend  to general use :
                   (Fig. A.)
(Fig. B.)
  Fig.  A represents the suspensory as  applied, being  a bag of
brown holland, (hemp tissue,) of four trapezoidal pieces, tapering
downward, and firmly sewed, with the seams outside, as seen in
Fig. B.#   There  may be six or eight  strips of narroAv bandage,

  * Brown holland is mentioned as a cheap tissue for public institutions, and easily
attainable everywhere.  When made of that or similar stuff, (always excepting cotton,)
large eylet-holes, in rows, should be worked into it, each one at least a third of an inch
in diameter, to admit of ventilation.  A more perfect mode of attaining ventilation, as
preferred by Dr. Mott, would be to  make a netted bag  of flax, hemp, or silk cord, as
being far cooler, and equally well calculated to answer the object. 
176
NEW  ELEMENTS OF OPERATIVE SURGERY.
about an inch wide, attached at pleasure to the corners and sides.
Each one of the two coming from the middle portion of the  upper
edge of the two lateral sides of the bag, is to pass backward under
and around the  thigh, to be fastened to the cincture  around the
waist, farther back than the others, which latter four or six, ac-
cording to  the number the  bag has, are all to be fastened on the
broad girdle  of brown holland in front, in the space on  the belly
betAveen the  hips, the patients shifting the  same  as  they  Avould
the rigging of a ship, (and which the  sailors at the Retreat Hos-
pital above mentioned did with great expertness,) until each band-
age Avas  arranged to  suit their feelings, in such manner that they
all dreAV Avith an easy and consentaneous force upon the bag, which
latter, Avith the contained testicles, is thereby raised gently upward
and forward, or to one or the other side, at pleasure,  and, at the
same time, kept in a firm and steady  position, especially by the
two straps going backward, which, to use a nautical phrase, might
be called the back-stays.  The great superiority of this suspensory
OA*er all others was effectually established by me at the Seamen's
Retreat, as it has been in private practice since.  The size  of the
bag must be proportioned  to the dimensions of the scrotum and
testicles, Avhether the  latter  are diseased or not.  It is  of eminent
use and  comfort to patients with  hydrocele, varicocele, and espe-
cially scirrhous and hydatid testicles, which, by their weight and
size, are so distressing upon the cord.  The floor of the bag may be
made so as to be slightly concave within.—T.~\
    § VIII.—Bandages for diseases of the Anus and Perinceum.
  The  T bandage is  almost the  only one in use at the present
                              time for dressing affections  of
                               the anus and perinaeum.   It is
                               almost always the double T that
                               we require.   As it  is from the
                               lumbar region that  Ave set out
                               with the vertical branch, it is ne-
                               cessary to give  to this  portion,
                               which  should be from four to six
                               fingers wide, a length in its undi-
                               vided portion  of from six  to ten
                               inches,  in order  that the tAvo
                               branches may not be separated
                               from  each other  except  in the
                               neighborhood  of  the  anus. We
                               apply it first around the trunk.  It
                               is advisable, in fact, to fasten it in
                               this manner before commencing
                               with the dressing.  The wound be-
                               ing dressed, we bring the T down
                               upon the portions of the dressing;
                               we then cross the  branches on
the perineeum, so as to bring that on the right between the scrotum
(Fig. 110.)
 
BANDAGES.
177
and the left thigh, and that of the left between the scrotum and
the right thigh, in order to fasten them by a knot or by pins to the
cincture above the groins.
  The triangular bandage, which  was used formerly for certain
wounds in the neighborhood of the anus, and which is in frequent
use at present for diseases of the inguinal region,  (Fig.  110,) is  in
fact the same  as that of which I have  spoken in pointing out the
bandages for the mammary region.  It is, therefore, unnecessary to
recur to it here.

          § IX.—Bandages for the upper part of the limbs.
  The upper part of the arm is subject to so many diseases, that it
has giAren rise to the suggestion of a number of bandages.  Among
these, hoAvever, there are scarcely any other than the figure  of 8,
the different varieties of the spica, the stellated, (etoile,) and the cape-
line, which it can become necessary for us to be acquainted Math
at the present day.
  A.  The bandage,  called Figure  of 8, was formerly  employed  in
the treatment  of fractures of the clavicle,  (Fig. 111.)    We place

                              'Fig. 111.)
under each arm-pit a long compress, whose ends are crossed on the
apex of each shoulder.   We then, by means of a bandage of three
fingers'  Mddth, make an 8, which surrounds the upper part of each
arm, and crosses between the shoulders, to be repeated thus three
or four times, while an assistant, having his knee fixed against the
dorsal portion of the spine, forcibly draws the two shoulders back.
In order that the turns  of the figure of 8, thus made, might rest se-
cure, some  surgeons placed under their point  of crossing a long
compress, or a strip of bandage, the extremities of which were
  vol. i.                      23 
178
NEW  ELEMENTS OF OPERATIVE SURGERY.
Of
112)
turned back upon the median line.  This bandage irritates, and is
altogether useless.
  B. Spica. (Fig. 112.)  The bandage knoAvn under the name of Ear
  Wheat, (epi,) or Spica, is a kind of figure of 8 Avith unequal turns,
                           Avhich are applied on the upper part of
                           the arm, the apex of the thorax, and on
                           the upper part of the thigh and pelvis,
                           also on the root of the thumb.  On the
                           arm and thigh the bandage requires
                           to be from five to ten yards in length,
                           and at least three fingers' Avidth.  To
                           render it secure, and  to prevent its
                           displacement, I am  in the habit of
                           making it thus: I pass the free head
                           of the bandage around the arm-pit or
                           thigh of the diseased side, either from
                           before backward, or from behind for-
                           ward, and then continue it in an op-
                           posite direction, so as to leave a por-
                           tion of it hanging doAvn about two
                           feet long.   This  precaution  being
                           taken, Ave pass it over either surface
                          I of the chest, under the arm-pit of the
                           sound side, and bring it back by the
                           other surface of the chest to  the dis-
                           eased shoulder.   We then  pass it
                           under the arm-pit to  make  a turn,
                           and thus cross it on  the shoulder,
carry it  back under the other arm-pit, and bring it in the same
manner upon the  shoulder and under the arm-pit of the diseased
side, repeating this manipulation four, five, or even six times, ac-
cording to the extent of the surfaces Ave wish to cover.  It is then
that the  reserved head of the bandage should be raised 'up. in the*
form of a bridle, to the Avhole dressing, as I have said in  describing
the cataphrast.
  This bandage bears the name of the descending spica, Avhen the
turns Avhich compose  it lap over each other from aboAe down-
wards, that  is, from the shoulder towards the arm.  It takes, on the
contrary, the name of ascending  spica when the turns go upAvard
from the arm to the loAver part  of the neck. If it should be necessary
to prolong it doAvmvards to a level A\Tith the insertion of the deltoid, it
would be much better to make some circular turns upon the hume-
ral portion of the  shoulder, than to give it the form  of spica in its
whole extent.
   Finally, to make the spica in the groin, it suffices  to apply to the
pelvis and upper part of the thigh what I have said of the  chest
and shoulders.
   The spica which I have described is the simple  spica.  If it was
required to  have it double, we may understand, Avithout the neces-
sity of a particular description, that it Avould be necessary to make
 
BANDAGES.
179
on each side Avhat I have said of one of them.  The roller bandage
Avith two rolled heads, Avhich was formerly employed for this pur-
pose, is Avholly useless; surgeons of the  present  day are, for the
most part, satisfied with the bandage Avith one head  for the differ-
ent kinds of spica they may have occasion for.
  C. The Stellated, (etoile—Fig.  113.)   The stellated bandage is a
sort of figure of 8, crossed in front of the chest, and associated Avith
some turns of spica.  Thillaye describes three varieties of it—the
single stellated, the double stellated, and the stellated with a  band-
age of two rolled heads.
  To make the first, we place the free end of the bandage  under
one of the arm-pits—that of the right, for example—then pass it in
front of the chest and left clavicle, behind the shoulder, and under
the arm-pit of the same  side, to return in front upon the claAricle,
behind the shoulder, and under the arm-pit of the right side, so as to
complete the  8 ; after having repeated  this crossing two or three
times, we carry it in front of the arm-pit, on the clavicle, and behind
the corresponding shoulder, in order to reach the posterior part of the
opposite arm-pit, as in the spica. We at length terminate by repeat-
ing the figure of 8  and spica turns, till the bandage is exhausted,
unless we should prefer unrolling it circularly around the chest.
  This bandage, which advantageously replaces the quadriga and
the spica,  has  the  inconvenience of being very easily displaced
Embracing the upper part of the arm in front, it slips with the least
movement, and readily becomes  detached, in the manner of the
sleeves of a dress that opens behind. 
180           NEW ELEMENTS OF OPERATIVE SURGERY.
  The double stellated is composed of anterior and posterioi figures
of 8, AA'hose scapular  crossing is  not unlike a double spica.  We
make it Avith a long  bandage, proceeding first as aboAre.  After
havino- made one or two figures of 8 in front, and carried them in
the rear, the bandage serves to make an equal number of figures
of S behind.  In continuing thus, Ave soon have three or four turns
of the 8 crossed on the top of the  sternum, on the  posterior part of
the thorax, and on  the clavicular portion of each shoulder.
  This bandage, which is much more solid than the preceding, con-
veniently retains the dressings Ave may require under the two arm-
pits, or on the supra-clavicular regions.  It is, in fact,  only the
quadriga bandage  without the thoracic circulars.  But it is evident
that the single spica is much better for one arm-pit, or one shoulder
only; also, that, for a double lesion, we ought to prefer the double
spica  to this ; and  that,  for diseases of the front part of the chest,
or for the back, the cataphrast is preferable to the stellated.  It is,
in fact, therefore, a bandage comparatively useless. The making it
Avith a bandage Avith two rolled heads renders it neither better nor
more  solid, and generally interferes with its construction.

                 § X.—Bandages for the Hand.
  Diseases of the hand may all be dressed with the roller bandage,
the circular,  or the spica.   The  spica answers scarcely for any-
thing but the thumb, which in that case represents the shoulder,
Avhile the Avrist corresponds to the chest.   By the  aid of this band-
age, the thumb, the thenar eminence and metacarpal bone, which
corresponds to it, as well as the wrist, may be dressed without the
hand participating  in it.  The fingers have a kind of bandage adapted
only to them, and  bearing  the name of gauntlet, presenting two
varieties : the gauntlet,  properly so called, and the demi-gauntlet.

                        A. The Gauntlet, (gantelet,) (Fig.  114.)

                          The object of the gauntlet is to surround
                       each finger Avith a kind of roller bandage.
                       It is always useful when we wish to make
                       a certain degree of pressure, preArentive or
                       curative, on each of the fingers separately.
                       A mode  of doing this, which I have found
                       very convenient, is as follows: take a ban-
                       dage of about an inch or one finger's width,
                       and eight or ten yards long ; fix it securely
                       by tM'o circulars on the wrist; then bring it
                       diagonally on the back of the hand to  the
                       root  of  the  little  finger;  then wind it
                        around this finger to its free extremity ;
                       then make turns which lap over each other
                        two-thirds, in proceeding from the nail to
                        the metacarpus; return  to  make a circu-
                        lar about the wrist, then'by the  doisum of
                        the metacarpus, to do on  the "ring finger
 
BANDAGES.
181
what has been done on the little finger;
proceed a second time to the wrist; bring
the bandage to the middle finger, which is
to be surrounded like the preceding; re-
turn a second time to the wrist, to surround
also the forefinger.  There is then nothing
more to  do but to  pass some transverse
circulars upon the  metacarpus,  and  to
finish by fixing  the bandage  upon  the
wrist.

  B. The half-gauntlet .(Fig. 115) differs
from the preceding, in being limited to one
turn of the bandage upon the root of each
finger, and fastened by the like  number
of circulars upon the wrist.  It is a sort
of multiple of the spica, sometimes dorsal,
at other times palmar, but scarcely ever
used at present.


              C. The Scarf, (echarpe—Fig. 116.)

                           (Fig. 116.)
  Almost all diseases of the upper extremity require the bandage
commonly knoAvn under the name of the scarf.  Formerly there
(Fig. 115.)
 
182
NEW  ELEMENTS OF OPERATIVE SURGERY.
Avas a large and a smaller scarf, the medium scarf and the grand
scarf of J. L. Petit.
  The ordinary scarf is made Avith a triangular piece of linen, gene-
rally with a napkin, or pocket-handkerchief, folded from one angle
to the other.   The forearm is placed in the middle of this piece, so
that the point of the triangle is  directed toM^ards the elbow.   Its
t\Aro extremities are raised up, one in front, the other behind, as it
Avere to form a loup (anse) at the root of the neck ; the extremity
of the triangle passing from below upward, and from before back-
Avard, under the healthy armpit,  in order to return to rejoin the an-
terior extremity in front of the shoulder of the diseased side, would
make a diagonal, as in the preceding bandage.   After haAdng fast-
ened the two ends of the scarf by a knot or a pin, the middle por-
tion of it is spread out under the  forearm ; we afterwards  raise up
the point in front or behind, to fasten it upon that portion  of the
triangle which is situated in that part.
  The scarf, which in fact is nothing but a suspensory of the fore-
arm, and which the diagonals of the preceding bandage could in a
case of necessity replace, may be arranged in a great many other
ways.  Thus, in place of being turned in the direction of the hand,
its base may be carried backward; and in place  of mounting to
the neck, it may be attached to the forepart of the vest or coat;  it
is thus Ave obtain the different kinds of scarfs which I have noticed
above.  Provided that it  supports, in an equal  manner, the elbow
and the Avhole length of the forearm, and permits the  parts to be
easily withdrawn from, or replaced in it, it is all that we can ex-
pect of it;  the rest is only a matter of taste.

           § XI.—Bandages for  the Lower Extremities.

  The different bandages which  the diseases of the abdominal ex-
tremities may require, are the roller, the circular, the bandage of
eighteen heads, and that of Scultetus.  The stirrup (etrier) will be
described in speaking of bleeding in the foot.   The uniting band-
ages for longitudinal and transverse wounds, have no special ar-
rangement  for these parts.  The figure of 8, the kiastre,  and the
bandage  of Ravatan, like all other kinds of bandages  devised for
fractures of the patella, have no claim to our attention at present;
so that the Hbwer extremity has, in fact, no special bandage.

                § XII.—Bandages for Fractures.

  It is in treatises  upon surgical pathology, that we can properly
discuss in detail the different  kinds of dressings designed for the
treatment of fractures; but as  the  bandage necessary for these
descriptions of disease is, owing  to the neAv improvements, nearly
everywhere the same, I propose  to speak a few words of it in this
place.  Thus, in every case it is the bandage of Scultetus, the body,
clavicular,  or roller bandage.   Wherever we- desire compression,
and do not wish to remove the  dressing frequently, the bandage
must be previously saturated in a solution of dextrine.  To do this 
BANDAGES.
183
we pour, little by little, into a large vessel, one portion, a tumbler
full,*for example, of dextrine in poAvder, then a portion of Avater to
dilute the powder.  When Ave have carefully diluted  the dextrine,
breaking  it up by means of the fingers  and by trituration,  we
pour into  the mixture, gradually, a third of brandy or alcohol;  the
unrolled bandage is then dipped into this liquid.   When it is satu-
rated Avith it, and we  are ready to make use of it, we  roll  it up
as we do a wet bandage, without rolliftg  it too tightly.  If it is
the bandage  of Scultetus, we should saturate it after  it is in its
position with the  same mixture.  It  is in this solution, also, that
we must dip  the graduated compresses, or the pieces of pasteboard,
if it should be found advisable to  make use of them.
                   A. Fractures  of the Hand.
  I. Fractures of the fingers.  In the case of the fingers, after hav-
ing properly reduced  the  portions of the  phalanges,  we surround
the part with a piece  of fine linen, then with turns (plan) of  the
roller bandage which has  been saturated with dextrine ; a gradu-
ated compress, or a long, narrow strip of pasteboard, is then placed
on the palmar and dorsal  surfaces, from one extremity to the  other
of the fractured finger. We then  apply over this a second or third
series  of turns of the roller bandage, after which we conduct  the
bandage to the back of the hand, to make two circular turns there,
and then  proceed to  form it into a collar around the root of  the
finger.  Left exposed  to the air, the bandage thus arranged dries
and acquires the hardness of wood in twenty-four hours. Thus it
is protected from all displacement, and has  no necessity of being
reneAved before the consolidation is completed.
  II. For  the metacarpus, Avhether it concerns one or more of its
bones, we proceed nearly in the same manner: a dry piece of linen
being applied on the part, is immediately attached there by one or
two turns of the  bandage.  The surgeon  proceeds  then to the
reduction, if he has not effected it  before, and applies immediately
upon the back of the metacarpus a square piece of linen folded upon
a piece of pasteboard saturated with dextrine, (carton mouille]) then
a similar square, or one a  little thicker, on the palm  of the hand,
which .latter must be fastened by some additional turns of the band-
age.   After having surrounded the wrist with turns,  the bandage
is brought back to the root of the finger, which corresponds to  the
fractured bone as in the gauntlet. It remains then  to  place the
graduated compresses upon the palmar'and dorsal surfaces of the
finger and of the metacarpal bone.  One or two series of turns of the
roller bandage, which should envelop the whole length of the finger,
then the Avhole hand, and also the wrist, complete the dressing.  The
important point  here, is to make pressure in a very gentle manner
upon the edge of the hand near the root of the fingers, and to avoid
all strangulation at the wrist.
                  B.  Fractures of the Forearm.
  I. Fracture of the lower extremity of the radius.   Having restored
to the wrist its natural direction, the surgeon applies upon the  linen 
184
NEW  ELEMENTS OF OPERATIVE SURGERY.
which is to go next to the skin, a portion of roller bandage, from
the root of the fingers  to the elbow; over that he places theftAvo
graduated compresses, the anterior and the posterior, folded upon
pasteboard Avhich has been saturated Avith dextrine, (doublees de
carton mouille,) doAvn to the corresponding  surfaces of the  hand;
a second and then a third series of roller bandage, from the elbow
to the root of the fingers, and  from the  root of the fingers to the
elbow, terminate  the bandage.  The solidity of this bandage, and
its desiccation being effected by degrees only, allows of the inferior
portion of the forearm, during the first days of its application, be-
ing gradually adjusted, and with as much exactitude as we could
wish.
  II. Fractures in the body of the limb.  The coaptation being made,
and the limb surrounded Math linen, it is enveloped in one series of
turns of the roller bandage.   The graduated compresses, Avith the
pasteboard, are applied before and behind upon this layer of turns,
(plan de bandage;) a second layer  of turns of bandage is brought
from  above, from the elbow to the Avrist; the bandage is then
passed once or twice around the metacarpus, between the thumb
a,nd the root of the fore-finger, and then terminated by a third series
of turns with the  roller.  For greater security, if we were treating
an intractable subject, or a fracture Arery high up, it would be Avell
to prolong  the layers of bandage, the limb being flexed, to some
inches above  the elboAv; because, when it has become dry, the
humero-cubital articulation  is by this means rendered altogether
immoveable.
  III. Fractures of the  olecranon.  No bandage hitherto proposed,
can with certainty prevent the  separation of the fragments of the
bone in a fracture of the olecranon; unless this separation exceed
an  inch,  it causes very little inconvenience.  The best thing to
do in such a case, is to keep the limb in a very moderate state of
extension, and completely immoveable, for  about  a month.  We
obtain this result  in the most perfect manner possible by means of
a bandage saturated with  dextrine ; nothing then preA^ents our de-
pressing  the  fragment  of the  olecranon by placing above it  a
transverse graduated compress, then some oblique turns (arcs) of
the bandage, provided we take care to make but little pressure, and
to place over the  Avhole, in a uniform manner, the roller bandage,
with two large pieces of pasteboard saturated with dextrine, ex-
tending from  the  root  of the fingers to the neighborhood of the
shoulder.
                  C. Fractures of the Humerus.

  For the humerus, properly so called, there is no need of graduated
compresses; the simple roller bandage, attached above by some turns
of the spica, Avith tAvo pieces of pasteboard, suffices, Avithout any
other precaution,  for all the  fractures of the  body of this bone.  If
it is its lower  extremity, we must  place  a graduated compress in
front on the bend of the elbow, and  another behind upon the ole-
cranon.  One  of the assistants making extension by draAving upon 
BANDAGES.
185
the hand, the  other counter-extension and coaptation by pushing
the olecranon forward Avith his thumbs,  and drawing the  loAver
fragment backward with his fingers, enable the surgeon to apply
the saturated bandage in the form of a  roller with three layers, (a
triple plan]) with the saturated pasteboards, and to multiply its cir-
culars around the elbow;  here, as at the wrist, we must take care
to Avatch the desiccation of the bandage, and by making the proper
degree  of pressure upon  the parts, gradually to restore  them to
their natural position.
  I have already said that the fractures of the neck of the humerus,
Avhether in an anatomical or surgical point of view, do very well
with the bandage for  the clavicle, described further on; I will add,
that the roller bandage, accompanied Avith four or five turns of
spica, provided Avith a thick piece of linen, or Avith any other material
adapted to filling the cavity Avhich  separates the  two principal
Avails (parois) of  the axilla, is still more convenient, and ought
generally to be preferred.

           D. Fractures  and Luxations of the Clavicle.
  Of all the bandages contrived since the time of Hippocrates to
the present day, to remedy fractures  or luxations of the  clavicle,
scarcely any  now remain  but  the bandage  of  Desault  and the
single scarf.   The bandage of Petit,  those of Duverney, Boyer,
Boettcher, Brasdor, and Meslier, the sling (fronde) of Flamant, the
ancient brassiere of Ravaton, and a great number of others, in no
Avay answering the  end proposed, merit  the  oblivion into  Avhich
they ha\Te fallen.
  I.  The bandage of Desault itself is scarcely any  longer employed.
The difficulty of applying it Avell, the  necessity, so to speak, of re-
placing it every day, and the irritating pressure which results from
it, upon the chest and brachial plexus, have caused it to be generally
discarded ;  Avhich is so much the less to be regretted, as it  scarcely
eArer prevents the riding upAvard (chevauchement) of the fracture, and
the deformity of the callus.   This bandage, which seems  to have
taken its origin in the spica of Glaucius, delineated in figures 75,
76, and  77, of Vidus Vidius, deserves, therefore, no further mention.
  The scarf that  M. Mayor desires to have  substituted for it, is
not sufficiently solid, and  permits too much motion to the limb, to
have any other advantage than that of supporting the elbow and
forearm, and of leaving the cure of the injury to  nature.
  II. Bandage of the  author, (Fig.  117.)  There  is no doubt that
a simple scarf is much more valuable than the bandages and differ-
ent machines extolled of late.  It causes infinitely less fatigue, while
it accomplishes full  as  regular a union.  But I haA'e  contrived a
bandage, by means of a  simple band, which  is adapted both to
sternoclavicular luxations, for which I had at  first designed it, and
also to acromio-claAdcular luxations, fractures  of the clavicle, acro-
mion, and scapula, and even to fractures of the neck of the hume-
rus.   For this purpose Ave procure a bandage of eight to ten yards
in length.  The head of this bandage  is first applied under the
  VOL. i.                      21 
18t'»           .\EW ELEMENTS OF OPERATIVE SURGERV.
armpit of the sound side, or behind, as with the cataphrast;  it is
then passed diagonally upon the back and shoulder to the clavicle,
upon the side affected.   The hand of the patient is then placed
(Fig. 11
upon the acromion of the sound shoulder, as if embracing this last.
The elbow thus raised is brought in front of the point of the ster-
num, and the affected  shoulder is pushed upM^ard, backM^ard, and
outward, by the action of the humerus, Avhich, taking its point 'd'ap-
pui on the side of the chest, acts like a lever of the first kind, or by
a swing-like motion, (mouvement de bascule.)   While  an assistant
keeps the parts in place, the surgeon brings doAvn the bandage upon
the anterior surface of the arm, then  outside and under the elbow to
bring it upM'ard and forward under the sound armpit.  He repeats
this  three or four times, in order to  have that number of diagonal
turns, which obliquely traverse the wounded  clavicle, the upper
part of the  chest, and the middle portion of the arm.  In place of
bringing back the bandage to the affected shoulder, it is afterwards
passed horizontally upon the  posterior surface of the thorax and
brought back upon the external surface of the arm,  elbow or
torearm, m  the form of circulars, Avhich are repeated until'the
hand Manch  is on the  sound shoulder and the stump of the affected
one  alone remain uncovered.  We finish by one or two more diago-
nals, and by a similar number of horizontal circulars. 
BANDAGES.
187
   Another bandage, well saturated AAdth dextrine, and applied ex-
 actly in the same manner over the first, makes a kind of immovea-
 ble sac, in Avhich the elbow rests without effort, and without  hav-
 ing the power to moAe itself either backAvards, outAvards, or for-
 wards.  I  have already employed it a great number of times, and
 it has appeared to me so simple, and of such easy application, that
 I do not hesitate to offer it as preferable to all those that have been
 hitherto proposed.  It is unnecessary to add, that some paddings
 and thick compresses may be placed under it in the supra-clavicu-
 lar region, sometimes nearer the sternum, at other times nearer the
 acromion, according as  it seems proper to make pressure on one
 point rather than another.   It is Avell, also, in order to avoid exco-
 riations of the skin, to place a piece of linen folded double between
 the chest  and arm ; and it will be also  necessary to adjust a  kind
 of Avedge into the arm-pit, of half the thickness of that of Desault,
 if it is a case of fracture of the  neck of the humerus.

             E.  Fractures  of the Ribs and Sternum.
  All fractures of the ribs  and sternum may be dressed with the
 body bandage, (le bandage  de corps]) or equally well  with three
 layers of the roller bandage, or, better still, with the cataphrast satu-
 rated with dextrine.  The first ansAvers Avhen the fracture is  sim-
 ple, and without  displacement;  the second or third Avill be prefer-
 red in other cases, because it  enables us to increase or  diminish
 at pleasure the pressure on this or that point, and, consequently, to
 force back, during the desiccation, and in such direction as we  may
 desire, the  projections that we wish to flatten down.

             F.  Fractures of the Lower Extremity.
  All the fractures of the abdominal extremity,  like those of the
thoracic, may be treated by the bandage of Scultetus, or the roller
bandage, saturated with the desiccatory glue ; on which account, I
have, for the last three years, discarded all extensor and containing
splints, and the dressings of Desault, Boyer,  &c, &c, in the treat-
ment of fractures of the leg and thigh.
  I. Fractures of the Foot.  For  the foot wo proceed as Avith  the
hand ; that is to say, a dry piece of linen is  first applied upon the
 skin; the reduction being well effected, the anterior external de-
 pression of the dorsal region, and the posterior internal hollow of
 the sole of the  foot, are adjusted with graduated compresses  and
 pieces of pasteboard; and the whole is afterwards  covered with
 two or three  layers (plans) of  the roller bandage, Avith which we
 surround both the lower part of-the leg and the malleolar regions.
  II.  Fractures of the Leg. In complete fractures of the leg, one as-
 sistant, seated at the foot of the bed, grasps the heel Math one hand,
 and the digital extremity of the foot with the other, in  order to
 make the  extension ; a second assistant, having his back turned to-
 Avards the face of the patient, grasps the lower part of  the  thigh,
 and the posterior surface of the ham, to make the counter-exten-
 sion : the two together, thus holding the leg slightly raised up, ena- 
188
NEW  ELEMENTS OF OPERATIVE  SURGERY.
ble the surgeon to effect the coaptation ; to surround the limb Avith
dry linen—then with a layer of roller bandage reaching from the toes
to above the knee ;  to apply a long graduated compress on the an-
terior inter-osseous fossa, and another on each side of the tendo-
Achillis,  and behind the malleoli; or to substitute three pieces of
pasteboard for these compresses—one behind and one on each side—
to descend again Avith a layer of turns upon these compresses, or
pasteboards, and to pass another layer of them upAvards to the knee.
This being accomplished, Ave may, in order to have a more rapid
desiccation, suspend the leg upon loops of bandage, (anses de bandc,)
or by straps fixed to the circles of the hoop which is to support the
bed-coA'erings.   If the direction of the parts should not seem cor-
rect, avc must carefully look to it, and adjust it, in proportion as the
bandage hardens and dries.
  III. Fractures of the Tibia.  Fractures of the tibia being scarcely
ever accompanied with displacement in the direction of the length
of the bone, are still more easy to dress than complete fractures of
the leg.  We proceed in the same manner as I have just described,
except that, in most cases, we may dispense with the anterior and
external, and even with the internal, graduated compresses.
  IV. Fractures  of the Fibula.  There are three principal kinds of
fractures of the fibula: those of the three upper fourths  of the bone,
those of the external malleolus, and the  fractures opposite to the
tendo-Achillis.  The first and second require only the simple roller
bandage, with the bandage saturated with dextrine.  Those of the
third kind, or the supra-malleolar fractures, and which interest sur-
geons the most, require that the foot should be forcibly raised up
and directed inward by the assistant, who makes the extension, that
the hollows (gouttieres) of the tendo-Achillis, that is, the malleolar,
as well as those  of the anterior inter-osseous fossa, should be Avell
adjusted with graduated compresses, and that the pieces of paste-
board should accompany the rest of the bandage; they  require that
we should, from  time to time, take care to adjust the inclination of
the foot inward and forwards, until the desiccation of the dressing
is completed.   We  thus procure, without any effort or fatigue on
the part of the patient, all the advantages of Dupuytren's dressing,
united to those of the bandage of Scultetus, and the ordinary splints
and compressing bandage.
   V. Fractures of the Patella. Like those of the olecranon, the frac-
tures of the patella  are scarcely ever united by immediate contact;
like them, also, they allow the limb to resume  its functions when
they are  not followed by a separation of more than an inch.  I haAe
even seen fractures of the patella accompanied Avith a separation
of two or three inches, and which had not prevented the functions
of the leg from being re-established.  If, on the other hand, avc con-
sider that all bandages, without exception, and all the methods
adopted for this  injury, lead to a great number  of inconveniences,
we should be alloAved, as I conceive, to subject it to the application
of a bandage which causes no fatigue, Avhich permits  the patient
to take considerable exercise, and procures a definitive result as 
BANDAGES.
189
satisfactory, at least, as any of the others.  This bandage we have,
and it is no other than the roller bandage saturated with dextrine,
and provided behind with a piece of pasteboard, which may go from
the upper part of the thigh to the heel.   The only precaution to be
taken in employing it  consists in this, viz.: To hold the two frag-
ments of the patella as  closely approximated as possible ; to apply to
their unfractured (adherent) margin graduated compresses placed
crosswise ; to draw them towards each other by means  of turns of
bandage passed obliquely  under the ham ; to prolong the roller
bandage to'the upper part of the thigh, and to re-descend  to the
foot.
   VI. Fractures of the Thigh.  The thigh, when it is fractured in
the body of the femur,  accommodates itself still better than the leg
to the roller bandage saturated with dextrine.  The fractures in the
neighborhood of the trochanter do, also, exceedingly Avell Avith it.
So also do those of the loAver part, provided Ave take care to place
graduated compresses  in the hollow of the ham.  In all cases, it is
requisite that the bandage should be prolonged as high as possible
in the direction of the hip, and that it should be carried many times
around the pelvis, in the form of spica, upon  the upper part of the
limb.  To increase  its solidity still more, we must not forget to
place two large splints of pasteboard, one before and the other be-
hind, between  the great trochanter, or  the ischium, and the knee,
or, Avhat is as well, one on the inside and the other on the outside,
extending  up to the iliac fossa.  If the necessity of holding the
limb raised during the application of the roller bandage should dis-
quiet the surgeon, or  seem to fatigue  the patient too much, we
might, Avithout any difficulty, substitute for the roller bandage that
of Scultetus.
   VII. Fractures of the neck of the Femur.  If it is true  that intra-
capsular fractures of the neck of the femur cannot be consolidated,
it is useless to  subject patients who are afflicted Avith them to the
employment of any fatiguing application.  Thus I have, for a long
time, been in the  habit of permitting such patients to leave their
bed  and move  about  on  crutches, after the  tenth or fifteenth day
of the accident.   On the supposition, howeATer, that there may be
reason  to  hope for consolidation, a bandage,  saturated with dex-
trine, (bandage dextrine,) when properly applied, in the form of
spica, and associated with a roller bandage, which  should  extend
from the foot  to the  ischium, Avould assuredly be better than the
bandage of Desault, or that of Boyer, or than the half-flexion of
Bell or Dupuytren; in fine, than the thousand modes M'hich have
been proposed, and which are still at this day proposed, Avith the
 intention of curing fractures of the neck of the femur without short-
 ening the limb.
   If, after all,  it were necessary to keep the  limb extended during
 the desiccation of the dextrine bandage, nothing would be more
 easy.  A bandage, passed  as a noose (en anse) above the heel and
 instep, serves to make the extension by fixing it to a cross-piece at
 the foot of the bed, while another bandage, passed under the thigh 
190
NEAV ELEMENTS OF OPERATIVE  SURGERY.
and ischium, serves to make the counter-extension, by being fixed
to a post at  the head of the bed.  As  soon as the dressing is com-
pletely hardened, these accessories are useless, for the limb is no
longer susceptible of any displacement, and the patient is at liberty
to turn and move himself Avithout danger.
  G. Thus, then, have Ave all that concerns the bandaging (deliga-
tion) of fractures at the present time, if all practitioners Avould im-
itate what I have done at La Charite since the month of January,
1837.  In every case, we perceive that the bandage saturated Avith
dextrine answers the purpose.  When we  consider that, by this
means, the patient is enabled to move and to turn himself in bed,
even to raise himself up, and to walk with crutches from the third
or fifth day,  it may be asked if henceforward there Avill be any need
of cushions, splints, fracture-boxes, (gouttieres,) inclined planes, leath-
ers, ties, and foot-boards, in the bandages designed for fractures.
  [With every degree of deference due to so high an authority as
M. Velpeau, the unqualified preference given by him to the appareil
amydonne, or dextrine, as first adopted and lauded to so great an
extent by M. Seutin, of Brussels, should, in the opinion of Dr. Mott,
be taken with considerable alloAvancc, or subjected to important
exceptions.  There is no question, ceteris paribus, of its superiority
over all other modes in effecting and preserving perfect coaptation
and immobility.  But there is unquestionably, and lamentable ex-
perience proves it, great danger in its immediate application.  For
its unyielding nature  under such  circumstances must, in every in-
stance, aggravate the consecutiA'e local inflammation, or inflamma-
tory reaction, (often violent,)  Avhich must necessarily, and should,
by every sound curative principle in pathological and therapeutic
surgery, take place as a consequence to the injury, and an essential
remedial process for  the accomplishment of consolidation.  The
memorable and recent instance of Prof. Dubovitsky, of St. Peters-
burg, Russia, Avherein this appareil amydonne Avas immediately ap-
plied, and the deArastating effects of which Dr. M. Avas himself an
eye-Avitness  to at Paris, has been descanted upon at length, as also
all  the objections to Seutin's  mode,  in  Dr. M.'s recent  book of
" Travels in Europe and the East."  This case, if no other existed
on record, Avould demonstrate the danger of the immediate applica-
tion of this method of treatment of fractures.  Among the dreaded
results Avhich the inelastic character of the dressing produces upon
the inflamed parts, and which may be developed insidiously to the
most mischievous and alarming extent under this masked battery,
and be thus concealed from the possibility of inspection by the sur-
geon, are great augmentation of pain, heat,  and every other symp-
tom and consequence of inflammation, from the inability  of the
parts to have free distension ;  and thence follow quickly ulcerations,
abscesses, sloughing, gangrene, and sphacelation, or, should the vi-
tality of the parts survive, permanent and incurable thickening and
contraction of the tendons, aponeuroses, and fasciae, and hypertrophy
of the bones and callus, and total destruction often of the use of the
limb.  After the reduction of the primary inflammation, there is no 
PROVISIONAL DRESSING FOR FRACTURES.
191
doubt that the apparatus may often be eminently beneficial and
decidedly indicated ; but, until all preliminary inflammation is sub-
dued or past, the open mode of dressing by the modern improved
methods of jointed splint-boxes, with Avell-regulated means of ex-
tension and counter-extension,  and especially the flexible cylinders
of straAV, as improved upon and sanctioned by the Baron Larrey,
should be rigidly persisted in. We shall recur to this subject of the
dextrine bandages under the head of Tenotomy.—X1.]
                       CHAPTER IX.

           PROVISIONAL DRESSING FOR FRACTURES.

  For all the different portions of linen which  I have hitherto
spoken of—that is to say, for bandages, compresses, straps, &c.—a
surgeon of Lausanne, M.  Mathias Mayor, proposes  to substitute
simple pocket handkerchiefs.   Square pieces of linen, pocket or
neck  handkerchiefs,  folded in the form of a triangle, cravat, or in
any other manner, are sufficient, says M. Mayor, for all our wants.
These articles, which Ave have always at hand, have, moreover, the
ad\rantage of being afterwards restored to their uses, as portions
of dress in the domestic economy.  With them we have no need
either of bandages, bands, (liens,) or compresses ; all the dressings
may be applied by the first person who comes. Without sharing in
the repugnance which M. Mayor has to bandages and compresses,
or concurring  exactly in all the praise  he bestows upon handker-
chiefs and square pieces of  linen, I ought to declare that Ave may,
by means of these articles of dress, extemporaneously and without
difficulty, make a much greater number of more simple, convenient,
and even more solid bandages than with the ordinary kinds of ban-
dage.   I will add, that for all kinds of dressings, we may, in a case
of necessity, in fact, substitute  for the bandage  the  handkerchief,
folded in different ways, as a provisionary dressing. If it Avere only
then under this last  point of view, the method of dressing by the
surgeon of Lausanne deserves to come  into general use, and to be
better known.  It  so frequently happens  in the army, in campaigns,
and on the occasion of sudden accidents, that we are under the ne-
cessity of dressing the wounds immediately, without having at our
command either bandages or compresses, that the surgeon will find
himself fortunately situated, if he can have it in his power to borrow,
either from the assistants, or from the patient himself, Avhatever can
be made into a temporary dressing.

              Article  I.—Bandages for the Head.

  We have already remarked, that the  handkerchief, folded in tri-
angle, was frequently employed for covering the dressings designed 
\
192           NEAV ELEMENTS OF OPERATIVE  SURGERY.

for Avounds of the cranium ;  it is, therefore, useless to recur to that
at present.

             Article II.—Bandages for the Face.

  Having shown how, in lowering the base of the triangle, on one
or both sides, or upon the eyes  or nose, Ave obtain Avith the hand-
kerchief a bandage preferable to the different bandages of the nose
and  orbitar region, I have only to  call attention to the facility of
applying the same processes to diseases of the temple and ear.
  For hare-lip,  or any other division of the upper lip, Ave obtain a
uniting bandage by bringing  from the occiput  under the nose the
two heads of a handkerchief, (Fig. 118,) the point of which has been
                         fastened  to the cap.  These two por-
                         tions are then crossed on the front part
                         of the  lip, and passed, one  above or
                         through the other by a button-hole, and
                         to be then passed in the opposite direc-
                         tion towards  the temples,  where they
                         are to be fastened Avith a pin.  We may
                         also place the  middle portion of the
                         handkerchief  upon  the forehead, and
                         carry  the tMro heads  to the occiput,
                         crossing them there, then bringing them
                         back on  the front part of the lip, and
                         fastening them  as  in the   preceding
                         mode. In adopting this last mode, there
                         is no use in placing  a cap on the head,
                         for the handkerchief, whose point is ex-
                         tended to the nape behind, answers that
                         purpose sufficiently  well.

        Article III.—Sling (Fronde) for the Lower Jaw.

   To coArer the wounded portions of the cheeks, lower jaAv, or even
the lips—to take the place, in fact,  of the sling  or chin-cloth, (men-
tonniere)—we adjust the triangle towards the vertex, with its point
turned forAvard.  After having brought  down  and crossed its two
branches under or before the chin, we carry and fix the extremities
of this triangle toAvards the temporal regions.  By placing the mid-
dle of the handkerchief, Avhich is on the top of the head, a little far-
ther forAvard, it is easy to bring doAvn its tAvo halves upon the paro-
tid regions, cross them under the jaAv, (Fig. 119,) and afterwards
raise  them toAvards the temple.  In this  case, we may place  the
middle part of the triangle on the auricular or on the parotid re-
gion itself, in order to fix its two extremities upon the opposite tem-
ple.   But,  the handkerchief,  folded as  a cravat,  is  manifestly
much better fitted for diseases either of the cheek, ear, o» parotid
region, than the handkerchief in the shape of a triangle.  Applied
by its middle, portion under the jaw, the cravat intended for this
(Fig. 118.)
 
PROVISIONAL dressing for fractures.
193
use is afterwards raised, either directly upward, or obliquely back-
ward, and carried towards the vertex of the head, where it is fast-
ened, either by a knot or by the aid of pins.
                             (Fig. 119.)
              Article IV.—Bandages for the Neck.
  The ordinary dressings for the neck are made by a neck hand-
kerchief, (mouchoir en cravate;) this has been the practice for ages.
                             (Fig. 120.)
If this kind of lesions require  a certain degree of solidity in the
width of the bandage, nothing  is more easy than to adjust,  after
  vol. i.                        25 
194           NEW  ELEMENTS OF OPERATIVE SURGERY.

the manner of M. Mayor, a thin piece of pasteboard or of coarse
paper betAveen the folds of the handkerchief.
  The uniting, dividing, and straightening (redresseurs) bandages,
for the neck, are made by means of a handkerchief, the middle part
of which is placed on the vertex, (Fig. 120,) if it is necessary to in-
cline the head forward; on the forehead (Fig. 121) in the contrary
                            (Fig. 121.)
case ; and on one of the parietal regions, when we wish to incline
the head towards one of the shoulders.  We afterwards bring doAvn
the extremities of the handkerchief to attach them, before or behind,
upon a body bandage, or,  on  the  side  to a  sub-axillary cravat,
of which we shall speak presently.

             Article V.—Bandages for the Arm-pit.

  The diseases of the arm-pit (or axilla) may be easily dressed by
the aid of a handkerchief, folded cravat fashion.  We place the
middle of the cravat under the holloAv of the arm-pit itself, in order
afterwards to cross its two halves upon the corresponding supra-
clavicular region.  We then conduct one of these in front, the other
behind,  to  beneath the sound arm-pit,  where  they  are  fastened
(Fig.  122.)  If the handkerchief should be too short, we lengthen it
by means of pieces of ribands, or, what is as Avell, by placing under
the sound arm-pit a second cravat, Avhich we should then tie to the
first on the shoulder of the diseased side.  We  may also, Avith the
same facility, make a figure of 8 with  these two  sub-axillary cra-
vats ; each one represents a species of ring around the upper part 
provisional dressing for fractures.
195
of the limb, and nothing is more easy than to unite their ends be-
hind, and fasten them between the two shoulders.   With the same
ease, we could, if we had a very long handkerchief, arrange it first
in the manner of a scarf, as worn by Avomen, making its two halves
pass from before backAvard under the arm-pits, then fixing them af-
terwards to the middle of the scarf between the shoulders.

      Article VI.—Bandages for the Thorax and Abdomen.

  The cravat could also serve to surround the chest or belly, and
take the place of the body bandage.  But, as it is almost always as
easy to procure a napkin as a cravat, I am of opinion that the body
bandage  will, for the most part,  render the substitute M. Mayor
speaks of, useless.
  The  handkerchief has the advantage of being capable of con-
taining the portions of the  dressing for all the regions of the thorax
or abdomen.
  To the chest  we fasten  it below,  in the manner of a cincture;
Ave then raise up its point, to Avhich  having attached a riband,  we
conduct it, in the manner of suspenders, above the shoulder, attach-
ing it to the cincture of the handkerchief.  This forms a triangular
bandage, which may be applied to the right or left, in front or  be-
hind, according to the indication, and in such manner as not to be
disturbed either by the neck or shoulders.
   If we  were treating the abdomen, and especially its lower part,
M^e should arrange matters so, that the base of the bandage should
be turned upward, and that its point, furnished with a riband, could
servo the purpose of a sub-crural bandage below.
   We obtain a scapulary by means of a cravat, one portion of which 
196           NEAV elements of operative  surgery.
embraces the loAver part of the neck, and the other the anterior or
posterior part of a thoracic cincture, (Fig. 123.)
  I have mentioned above how the handkerchief, or cravat, might

                             (Fig. 123.)
replace the suspensory of the scrotum.  I will add, that the dressings
of the anus and perineum may be very Avell made with the aid of
a cravat, which is fastened behind and before to another cravat.

            Article VII.—Bandages  for the Pelvis.

  For diseases of the hip, or breech, it is sufficient to fasten a cra-
vat around the pelvis, then to attach the base of a triangle-folded
handkerchief about the  upper part (la racine) of the thigh.  The
point of this  handkerchief, raised and fixed to the pelvic cincture
(Fig. 124,) enables us to cover all the portions of the dressing Avhich
we wish to support, either in front of  the groin, opposite the great
trochanter, or  on the breech.  If Ave are treating ulcers, wounds
(plaies,) or injuries, (blessures,) of the region of the sacrum, the tri-
angle, fixed by its base around  the  pelvis, and brought  back by its
point between the thighs, (Fig. 125,)  and up  to the pubis, would
fulfil every indication.

           Article VIII.—Bandages  for Amputations.

  After amputations of the limbs, we have often  occasion for
bandages  that are purely containing, and  of dressings that will 
PROVISIONAL DRESSING FOR FRACTURES.
197
prevent any motion of the stump.  The handkerchief, folded as a
triangle, may sen^e for this double indication.
  If it is an amputation of the arm, for example, we pass a cravat
(Fig. 124.)                           (Fig. 125.)
from the armpit of the  sound side, to the supra-clavicular region
of the diseased side, where it is fastened.  The base of the hand-
kerchief, afterwards applied below the wound, is to be fixed by a
knot on the sound shoulder, while we raise up and attach its point
to the cravat on the affected side.
  For the amputation of the thigh, the handkerchief, arranged in
the manner described for the abdomen, and properly adjusted, Avould
very well answer for the principal indication.
  For  an amputation upon the body of the limbs,  (dans la conti-
nuite des membres]) at the middle of the thigh, for example, we should
embrace the stump, at some inches above the wound, with the tri-
angular handkerchief.  The other portions of the dressing being
applied, there would be nothing to do, but to raise from behind for-
ward, and from beloAv upward, the point of the handkerchief, (Fig.
126,) in order to attach it to the circle formed by the base  of the
bandage.
  Adjusted in  this manner, the bandage for amputations is ex-
tremely simple.  As it requires only to detach and lower the point
of it to uncover the wound, the dressings may be renewed without
causing the least movement to the stump.
  What I have just said of amputation  of the thigh, is applicable
to amputations of the  leg  and foot, the arm and forearm.  I will
only add, that the handkerchief thus arranged,  is only to be pre-
ferred when used  as a  purely containing bandage,  or for treating
stumps that are exceedingly painful, or keeping in their place sim-
ple gateaux of lint, or different kinds of  cataplasms.  Everywhere
else, in fact, the bandage exposes to less risk of strangulation, and
allows of more regularity in the distribution of the dressing. 
J 98
NEW ELEMENTS OF OPERATIVE SURGERY.


               (Fig. 126.)
(Fig. 127.)
          Article IX.—Scarfs.

  The different kinds  of scarfs, Avhether
of the leg, (Fig. 127,) or for the forearm.
(Fig.  128,) may be replaced by a  cravat
 
PROVISIONAL DRESSING FOR  FRACTURES,
199
and a handkerchief, in form of a triangle.  Embracing in this man-
ner the  nape, tfie cravat ought to  be tied upon the side or front
part of the chest.  It thus represents a ring, to which are fastened
the two extremities of the triangle that embraces the elbow or the
knee.
  It is also easy to  understand how cataplasms, sinapisms, and
blisters, may be  supported upon different regions of the limbs  by
means of handkerchiefs and cravats.   It is the mode instinctively
followed by the world generally, and which M. Mayor has taken as
the point of departure for  his  whole system  of bandaging, (deli-
gation.)

                Article X.—Uniting Bandages.

  What I have said  of the handkerchief, as a uniting bandage in
hare-lip, or wounds of the  upper lip, shows also that we  could,
in a  case  of  necessity,  convert the  handkerchief or the cravat
into  a  uniting  bandage, both for longitudinal  and  transverse
wounds.

            Article XI.—Bandages for Fractures.

  It is evident,  also,  that by the aid of handkerchiefs, folded in
triangles, oblongs, cravats, or cords, we may make almost all the
dressings required for fractures.  It  is thus that three or four hand-
kerchiefs, (Fig. 129,)  in the form of  cravats, may take the place of

                            (Fig. 129.)
a bandage with eighteen heads, the bandage with bandelettes,
[vide supra,] or that of Scultetus.   In multiplying them still more,
we would obtain a part of the results prooured by the roller band-
age ; and we can  easily perceive  in what manner, when placed
around splints and bundles of straw, (de* paillassons,) they might
advantageously replace the different sorts of cords.  However, this 
200           NEAV ELEMENTS OF OPERATIVE  SURGERY.

part of the  popular  mode  of  dressing by M. Mayor, (Fig. 130,)
would lose much of its value if the mode of dressiifg which I have
adopted in the treatment of fractures came into general use.

                            (Fig. 130.)
  In conclusion, then, the square pieces of linen, the handkerchiefs,
and cravats, folded in different Avays, may, in cases  of necessity,
replace bandages, ties, and compresses, as the surgeon of Lausanne
maintains; but they will never do but as substitutes; for in employing
them, we go back to the surgery of former times, and no  one can
deny that compresses  or bandages, properly applied, allow much
better than handkerchiefs of being adapted to the indications that
different wounds present.  On this point,  then, I feel constrained
to say, that M. Mayor has deceived himself about the importance
of his system of bandaging.
                       CHAPTER X.

                   HERNIA BANDAGES.

  Hernia requires particular bandages, known under the name of
trusses, (brayers.)  These bandages having become the patrimony
of certain surgeons or manufacturers, I am not allowed to treat of
them at length: I will remark only, that the ordinary truss is formed
of an elastic cincture, a sort  of steel spring, well padded, (rembour- 
HERNIA BANDAGES.
201
ree]) Avhich terminates on  one side in a leather piece, and on the
other by a pelote, sometimes circular, and at other times oblong,
and occasionally triangular.   To apply this bandage, we pass it
around the pelvis, then carefully adjust its pelote in the fold of the
groin, on the opening of the crural canal,  or above the pubis, so as
to cover the  track of the  inguinal canal, according to the nature
of the hernia, taking care, however, to avoid the scrotum and sper-
matic cord.  The  leather  is then brought  forward and fastened
upon the external surface of the pelote, by means of small hooks.
The bandage then represents a cincture passing  between the crests
of the  ilium and the great  trochanters.   A subcrural bandage,
brought from  the  posterior  part of this  cincture to the external
surface of the  pelote, gives to the apparatus all the proper degree
of solidity.
   If it is  an umbilical hernia, we proceed  in the same manner, ex-
cept that  the cincture passes upon  the sides between the false ribs
and the bones of the pelvis.  Moreover, whether the pelote of such
bandages  is filled with astringent substances, like those of M.  Ja-
lade-Lafont, or is  elastic and full of  air,  like those of M. Cresson,
or simply padded with elastic materials,  as in the ordinary truss,
we must  always expect irritation, fatiguing compression, excoria-
tions, and displacements, difficult to be avoided.
  The best that I am acquainted Avith to  the present time, are the
bandages of M. Fournier.  For inguinal hernia, the trusses of this
surgeon, which, as has been  recommended by MM. A. Cooper and
A. Thompson, and which I have also demonstrated to be necessary,
press upon the whole track of the inguinal canal, in place of  sim-
ply closing its anterior opening, have an especial efficacy.  Keeping
the tMO principal walls of  the passage  in contact,  they retain
the viscera in the  belly; by the somewhat  forcible pressure they
exercise, they present, moreover, a chance of the radical cure of
the hernia.  I have seen some of those made  by M. Fournier for
umbilical  hernia, which had an extremely  large plate, (plaque,)
furnished behind with a long thick crest, projecting more than an
inch.  Applied upon the hernial aperture,  this crest  reverses   the
two portions inwardly, and soon destroys the tendency of the organs
to protrude into it.  It has always happened  that patients Avho had
derived no advantage from other kinds of bandages have  always
found themselves perfectly  well accommodated Math that of Avhich
I speak.   The umbilical bandages, also, generally have need of a
wide cincture.  To keep them steady, they also require sub-crural
bandages  and a scapulary. 
202
NEW ELEMENTS OF OPERATIVE SURGERY.
                        CHAPTER XL

                VARIOUS KINDS OF DRESSINGS.

   Besides the  pieces of linen, bandages, and different objects Ave
 haA-e hitherto  mentioned, Ave sometimes use medicinal substances,
 under the character of dressing.  Among the topical applications,
 the management of which it is the usual practice to assign to the
 pupils of the hospital, are to be found cerates, cataplasms, pomades,
 unguents, balsams, salves, different liquids, fomentations, the douche,
 (les douches,) fumigations, liniments, &c.

              Article  I.—Dressing avith  Cerate.

  Of the different topical applications Avhich the ancients used in
the treatment  of surgical diseases, scarcely any remain in practice
except cerate and some  of the unguents.
  The cerate most in use is a composition of oil and white wax, if
we desire to have  that of Galen, and of yelloAv wax, if we Avish
to have the ordinary cerate.  With this  cerate Ave make Gou-
lard's ointment, by the addition of the extract of lead ;  an anodyne
cerate, by the  admixture of  laudanum;  the sulphur ointment, by
uniting with it sulphur and a small quantity of the essence of
lemon; mercurial ointment, by mixing Avith it the Neapolitan oint-
ment ; and the ointment of belladonna,  by associating with  it a
small quantity of the extract of this plant.
  Cerate is used in Ararious M'ays.  It is almost the  only ointmenl
that should be used in simple dressings.
  When  Mre have  under treatment  ulcers, wounds, or any kind of
 solutions of continuity whatever, we mean by simple dressing, the
 methodical application of the folloAving articles:  1st. A perforated
 piece of linen, (linge crible,), or fringed bandelette, (bandelette de-
 coupee,) or a gateau of lint  besmeared Avith cerate, is first placed
 upon the diseased part, or upon its circumference, according to
 the  rules established  above,  (see linen  spread with  cerate ;) 2d.
 One or several compresses are then applied over the lint;  3d. Then
 one of the bandages above described, for the purpose  of  securing
 the first articles in a proper manner.
   The plumasseaux ought not to  be spread over but Avith a very
 thin covering  of cerate, and only when, as rarely happens at the
 present time, we are to apply them naked to the skin.  The perfo-
 rated linen  itself ought not to have any of this cerate, except to
 prevent  its adhering  to the edges  of the wound.  It is the same
 with the fringed bandelettes.  The  cerate, in fact, is for no other
 purpose  than  to render easy the removal of the inner pieces  of the
 coverings at each dressing.
  _ The simple  cerate may be used on plain pieces  of linen, or by
 simple friction, Avhen we wish to soften the skin, to cover excoriated 
VARIOUS  KINDS OF DRESSINGS.
203
surfaces with it, or those regions that we  are fearful of inflating,
or parts  enveloped with scabs, which  require to be  softened,  or
those places upon the body that we wish to shave.   Fresh butter
and oil could, in Tact, in such cases, be  substituted for it.  But we
must not fall into the error which pupils too often commit, that is,  in
applying the linen spread with cerate over the lint, unless specially
directed, or that of covering the  perforated linen  with gateaux
spread Avith a thick layer of cerate, since the object in such cases
is to clothe with a greasy substance that piece of linen or dressing
only Avhich is to be in immediate  contact Avith  the wound or its
circumference.
  The dressings  with the  Goulard, opiate,  mercurial, sulphur,  or
belladonna ointment, are made after the same rules, when Ave are
treating wounds, Math this single difference, that the  plumasseau
placed next to the parts, is then preferable to the perforated linen.
But  these different ointments are most frequently employed as fric-
tions. It is thus we treat certain affections of the skin, tumors, and
inflamed regions.

             Article II.—Dressings with Pomades.

  The pomades used at present are but  few  in number.  As topical
applications, they differ so little from unguents and certain balsams,
that they are scarcely to be distinguished.  We employ them in the
treatment of wounds  in the same  manner as cerate.  But as it is
for frictions they are most usually prescribed, the pupil ought  to
knoAv that they are not always applied in the same manner, nor in
the same quantity.  The anti-ophthalmic pomades, for example, are
employed in two very different modes. Some, whose object is direct-
ly to subdue certain kinds of ophthalmia,, are  applied to the ciliary or
glandular part of the free edge of the eyelids, or even  to the surface
of the eye, according to the kind of ophthalmia, but never upon the
skin in the neighborhood.   It is in  this  manner that we apply,  of
the size of a small bean, (lentille]) the pomades  of Janin, Desault,
Lyon, Regent, Dupuytren, white precipitate, nitrate  of silver, &c.
The  important  point  here  is, that  the  pomade should reach the
diseased surfaces, and not be retained by the scales and scabs, nor
by the hairs on the edge of each eyelid.
  If, on the contrary, we were using resolving or specific pomades,
the mercurial, opiate, or»belladonna, for  example, we should take a
quantity of the size of a pea or small nut, (noisette]) and rub it in—
not upon the edge of the eyelids, but upon the skin of these parts,
or, better still, upon the forehead or temple of the diseased side.
  The pomade of Autenreith, which is composed of one to two gros*
of tartar emetic to an ounce of lard, is used only in friction upon
the epigastrium, or some other region, morning and  evening, until
it has produced an eruption which  has  much resemblance to that
of the small pox.
  [* A gros in French weight is four grammes, and a gramme is eighteen grains English
weight, so that a gros is seventy-two grains English weight.__T.\ 
204
NEW  ELEMENTS  OF OPERATIVE SURGERY.
   The pomades of iodide of lead, hydriodate of potash, hydriodate
of mercury, Avhite precipitate,  and calomel, almost all  of which
contain half a  gros to a  gros  of the substances in question to an
ounce of lard,  are also employed in frictions, principally in the
treatment of certain eruptions and a great variety of tumors.
   The mercurial pomade, Avhich Ave sometimes spread upon the per-
forated linen, fringed  bandelette, or plumasseaux  of lint, is often,
hoAvever, much more frequently employed in frictions, or as an unc-
tion.   When, however, Ave desire its action to be purely indirect,
we must prescribe it in the quantity of a scruple to two  gros each
time, repeat the application once a day, or even  once  only in two
days, and spread it over a large extent of surface, rubbing the part
for the space of from ten to tAventy minutes.  If the mercurial oint-
ment, on the contrary, is employed as a topical application, it is not
necessary to rub for so long a time ; but it is advisable then to wse
larger quantities.  It is thus in peritonitis I have   applied  tAvo to
three gros of it to the belly every two hours; and in acute inflam-
mations of the  cutaneous  surface, or subjacent cellular tissue, Ave
use, in the  same manner, as much as two ounces in twenty-four
hours.  It is necessary that the patients subjected to the employ7-
ment of this pomade, should be protected from exposure to cold,
and that they should not carry on their persons pieces of jeAvellery,
either, of silver,  gold, or  any  other  metal, in contact  Avith the
skin.
   To free the skin of these different pomades, simple washings are
not sufficient; first, we have to dissolve the pomade with oil, or
with a weak solution  of soap  and water.  We must also bear in
mind that  the  mercurial  pomade has a strong  tendency to the
mouth, and easily causes  salivation ; that pieces of linen which
have been touched by it easily turn black in ley, and that these
spoil, in  the same manner, all  other linen with Munich they have
been placed in contact; and that Ave ought, therefore, to throAV into
the fire, after having used  them, eArery thing which may haAe been
impregnated with this ointment.
   The pomade  of iodide of lead, which I have called chrysochrome
(color of gold,) from  its beautiful  yellow hue, and to  conceal its
nature from certain timid  patients, is exposed also, in a certain de-
gree, to the same inconveniences; so that, under this point of view
pomades with mercurial preparations, or preparations of lead, exact
more caution than others.
   The balsam of Arceus, or digestive ointment, whether  simple or
mixed with an equal part of cerate, is applied  only  to Avounds.
For that purpose, we  spread a  layer of it, of greater or less thick-
ness, upon  a plumasseau  of lint.  It is the  same with the storax
ointment.
   The white rhasis, or camphorated  ointment, is employed like the
simple cerate, or the sulphur ointment.
   The basilican ointment  should be employed like the balsam of
Arceus.  It has the disadvantage, like this last, of adhering strongly
to the parts, and of sticking unpleasantly to every thing it touches 
VARIOUS KINDS  OF  DRESSINGS.
205
  The canette, or red ointment, should be employed like the cerate,
or the white rhasis, if it  has in reality any greater efficacy than
those in general use in hospitals.

             Article III.—Dressings with  Plasters.

  In  regard to plasters, we  rarely now use in surgery any other
than  the simple plaster, called plaster of diachylon, (sparadrap,) or
the Vigo plaster, the blister plaster being  reserved for  particular
cases. We hear no more of the plaster of Andre de Lacroix, of the
mother plaster and ointment,  (empldtre ou onguent de la mere,) of the
diapalme plaster, and so many others which were formerly in use.
Also, when we Avish to use these plasters  as  topical applications,
we take a certain quantity of them, which we  soften by the heat of
the hands or tepid water, and spread the same with the  thumbs,
rendered pliant with oil  or water, upon a piece of fine  linen or
leather, so as to form a plaster a little larger than the part which
is to be covered with it.  Among those plasters, there are some
which, like  the mother plaster, the diapalme, and the  diachylon,
may  be separated and  removed daily without  much difficulty.
Others, on the contrary, like the pitch and the Vigo plasters, adhere
so strongly to  the tissues, that they easily remain  in place  from
eight to fifteen days.   We also often envelop buboes, the testicle,
and certain tumors, with a Vigo or hemlock plaster, so as to renew
the dressing only every eight or ten days.   By sprinkling the pitch
plaster with tartar emetic before applying it to the skin, we obtain, at
the expiration of four to eight days, nearly the same result as with
the pomade of Autenrieth.
  Plasters, under  the  name  of diachylon plaster, (sparadrap,) are
employed to dress  cauterizations, certain  ulcers and blisters, and
for forming adhesive straps,  (bandelettes.)  In  the first case, we cut
out, e\rery morning, pieces of different shapes, which are applied
upon the diseased part after it has been properly cleaned. In the
second, the strips are cut into different forms and lengths, according
to the kind of dressing they are to compose.
  The adhesive plasters  (bandelettes  emplastiques) which  are used
in dressings should be pliant, but firm and moderately adhesive.  It
is advisable to take off the free edges of each roll, as we do those
of the seams of the linen, of which we wish to make compresses
or bandages..  To cut them rapidly and accurately, we seize Math the
left hand the free or unrolled head of the roll of plaster,  while an
 assistant holds the roll itself apart,  at  a  suitable distance.  The
 scissors, passed quickly and on the line of the thread (en droit fil—
 Fig. 131) from the surgeon towards the  assistant,  will, by their
 mere pressure, and without the necessity of approximating the
 blades, divide  the plaster into as many  strips as we wish.  These
 strips, (bandelettes,) which for the most  part  do  not require  to be
 heated, are employed in the character of a uniting or compressing
 bandage, (Fig. 132.) 
206
NEW  ELEMENTS OF OPERATIVE SURGERj"

              (Fig. J 31.)
                     § I.—Adhesive Strips.

  To apply strips of adhesive plaster properly, it is necessary, after
the lips of the wound are sufficiently approximated, to carry and
attach one of their extremities to an opposite point, in order that the
remaining portion  may be placed directly across the wound • also
Ave must give them great length, and not slacken the  ends before
they have become  closely adherent to the skin.  Though it is the
custom to commence with that which is to cross and unite the mid-
dle of the wound, there are, however, cases Avhere we begin rather
with that Avhich is to be placed below or above  it.
  To remove the uniting strips, we begin by detaching their ex
tremities; we afterwards separate them up to the edges of the
Avound, from which part they are to be removed last, and by a per-
pendicular traction, for fear of disturbing the union, which as vet
has but little solidity, (Fig. 133.)  This precaution would become
useless if they had been  employed  to  hold the lint,  compresses
or other portion of the dressing in the character of' a containing
bandage. 
VARIOUS KINDS  OF  DRESSINGS.
207
(Fig. 133.)
§ II.—English Court-Plaster, (taffetas.)
  In treating small and  superficial wounds, and when we wish to
dispense with all dressing, M'e prefer the English taffeta to the ad-
hesive strips, (bandelettes.)   This taffeta, which is  a kind  of tissue
spread with gum, and capable of being preserved for a long time,
is in the first place cut into convenient strips.  After having moist-
ened  one of its surfaces with saliva, it is sufficient  to apply and
press it for some moments on the skin, and as it Mrere astride and
in front of the  cuts, to enable it to attach itself immediately, and
become quite firm.   To take  it off afterwards, it is requisite to
moisten it again, until it is all softened. [See supra on Caoutchouc
bandages, ~&c.]
 § III.—Strips of Adhesive Plaster employed as a Topical or Com-
                      pressing  Bandage.
  A new mode  of dressing has entered into surgical practice during
the  last thirty years.  It  consists in enveloping  the parts that we
wish to act upon (modifier) by means of superincumbent  strips  of
adhesive plaster. This dressing, first proposed in England by Bayn-
ton for ulcers of the legs, is  made in the  following manner.  We
have  strips of diachylon  sufficiently long  to make one and a  half
turns around the part we wish to envelop.  These strips, which
ought to have a width of from eight to ten lines, and to be  cut  from
pliant, tenacious plaster of sufficient firmness, and  little disposed to
break or scale off, are applied according to certain rules, Mrhich it
is useful not to lose sight of.   If we are treating an ulcer, we  com-
mence by having it well cleansed; the first strip is then applied, by
its  middle portion, upon any point whatever of the circumference
of  the  limb, at an inch or two below the ulcer.   We then bring
back the tAvo halves to a point diametrically opposite, Avhere  they
are crossed, and then prolonged to their terminal extremity, and
always perpendicularly to the surface they are to cover. A second, 
208           NEW  ELEMENTS  OF OPERATIVE SURGERY.

third, fourth, fifth, sixth, seventh, or even a greater number still, are
thus applied successively, so  as to cover or lap over each other to
tAvo-thirds their width, and to form altogether a sort of bracelet,
gaiter, (Fig. 134,) buskin, or roller bandage, Avhich extends, both
              above and below, several fingers' width beyond the
   (Fig. 134.)     limits of the diseased part.
                 It is important that these strips  should not pro-
              duce strangulation, and that they should be confined
              to moderate pressure upon the parts. Instead of being
              placed naked upon the ulcers, it is  often advisable
              to cover the latter with some thin layers of lint, or
              compresses, and afterwards to use also a roller ban-
              dage, to extend  from one extremity of the limb to
              the other.  We  renew this dressing  every day, or
              every other day, or e\*en  at much longer intervals,
              according to the nature or abundance of the suppu-
              ration.  The most general rule is,  to renew them
              eArery three or four days  only.  To remove them,
              they are cut at the point opposite to the AA^ound by
              means of blunt-pointed scissors, one of the blades
              of which is insinuated flatwise, and from below up-
              ward, between the adhesive bandage and the skin.
              If the scissors were brought  from  below down-
              ward, their point would encounter the edge of each
              strip, and might  thus render the operation  longer.
  These strips are in no way intended to approximate the lips or
sides of the ulcers; they act  at the same time as a cleansing and
compressing bandage; the ulcers  beneath are cicatrized by the
conversion  of their  cellulo-vascular surface  into new tissue, and
into cuticular pellicle, much more than  by the approximation of
their edges.  After having removed them, we cleanse off by means
of a dry linen the purulent or other matters remaining on the limb.
If the skin should appear glossy, elastic, and pale ;  if the edges of
the wound seem  firm and of vermilion hue, and exhibit no trace of
erythema or excoriation, the bandage will succeed ;  and it must be
applied again.  In the contrary case, that is, Avhen erythema, exco-
riations, separations (soulevements) of the  epidermis,  itching, and an
ichorous exudation,  are seen under the strips, Ave should lay them
aside at least for some days, and in the mean while substitute for
them either simple dressings, or dressings with some kind of topical
application.  But we  must not allow ourselves to be alarmed with
the dark color which the suppuration then puts on ;  for it is the ef-
fect of the  combination of certain ingredients in the plaster Avith
some of the matters which escape from the diseased surface.  We
diminish the acridity of these exuding matters, and the tendency
of the surfaces to become inflamed, by more frequently renewing
the strips, and by washing, before Ave reapply them, all the surfaces
of the wound with some emollient liquid, or a  solution of lead-
water.
  This kind of dressing, which  Baynton  rarely applied, except to
 
VARIOUS KINDS OF DRESSINGS.
2(d
varicose ulcers of the legs, is fully as efficacious, at least, in a great
number of other  lesions.  Thus I have  frequently employed it in
chronic pains of the joints, (arthropathies  chroniques.)  In that case,
I surround the knee,  elbow, wrist, or even instep, with them, as if I
was treating an  ulcer, and then apply over them the  proper pad-
dings, and a moderately  compressing bandage.  I employ them in
the same way in almost all kinds of wounds or ulcers that we can-
not, or do not Avish to, cicatrize by approximation of their edges. It
is, for example, for ulcers denominated syphilitic, which are so  fre-
quently developed upon the limbs, the best dressing I am acquainted
Avith, after those ulcers have been previously changed in character
by  cauterization Avith the nitrate of mercury, and that the patient
has also undergone a suitable mercurial treatment.  I have seen an
infinite number of patients thus cured in fifteen or twenty days of
numerous ulcers which had resisted all sorts of remedies for many
years.
  Every kind of simple  wound, also, which  continues for some
Aveeks,  and which, in our opinion, requires flat dressings, is gen-
erally cured better under a bracelet of adhesive strips than by  any
other dressing.
  There are, also, no phagedenic ulcers,  even those of a cancerous
aspect, Avhich do not  often yield to these plasters with promptitude,
when the ulcers  have been  previously  cauterized with chemical
substances of a certain degree  of activity.
  [Nothing, according to the judgment  of Dr. Mott, can be more
proper  or true than these eulogiums and directions in regard to
the justly celebrated mode of dressing by strips of adhesive plaster
of diachylon, which, in the United States, have nearly superseded
all  other kinds of bandages whatever.  The opinion of all practi-
tioners of any experience in this country  is in full accordance Avith
these recommendations.   At the Seamen's Retreat Hospital I have
obtained rapid cures by these dressings, Avhen nothing else had the
least effect, especially of those extensive phagedenic, deep-seated,
chancre-like ulcerations Avhich are so apt  to succeed to syphilitic bu-
boes ; and the cure is more certain in fresh young subjects than in old
or broken down, worn out mercurio-syphilitic constitutions.  These
ragged-edged perforations, that go often from two to three inches'
depth into the groin, are also  far more  conveniently reached and
controlled, and their borders infinitely better approximated, by these
strips than by any other mode.   They should cross over each other
from the belly down  along through the hollow of the  groin back-
Avard to the breech, and some of them doAvn the thigh, forming al-
together a stellated dressing, the centre  of which is directly over
the ulcer and  at the  point where the radii converge.  They succeed
Avhen nothing else will.   Also in  old chronic mercurio-syphilitic
ulcers  on the limbs, if not too large ; but in these latter, when  ex-
tensive, and also in those terrific and destructive carcinomatous ul-
cers Avhich make such havoc in their rapid and deep-seated devas-
tations upon, the face, nose, eyes, and now and then on the massive
fleshy  tissues of the upper part of the  thigh and glutei  muscles.
  vol. i.                      27 
210           NEW ELEMENTS OF OPERATIVE SURGERY.
Avhere I  have seen them near a foot in length and near half a foot
deep, where they had nearly quite destroyed the under part of one
gluteus and parts of the  muscles of the posterior part of the thigh
beloAAr. a strong and constant  application of chloride of lime,  or
linen cloths Avet with it and often renewed during the day, together
Avith tonic treatment internally. I have found to effect a cure that
might almost by some be thought marvellous.  Dr. Vache, at  the
hospital at Bellevuc, IV. Y., and where among the poor these fright-
ful  cases, especially upon the face and in  females, are not rare,
effected perfect  cures by similar constant pledgets of strong solu-
tion of sulphate of copper, and a drink of the decoction of the root
of our indigenous yellow dock.   EAren  some, in whom it  may be
said the Avhole side of the face had been carried away, extirpating
with it the eye and half the  nose and mouth, Avere entirely cured.
In all cases of ulcers Avhere  the  adhesive straps can be used, and
the cicatrizations do not  progress rapidly, Ave should use at each
removal of the dressings a Avasli of strong chloride of lime mixed
freely with rain-Avater till it has the appearance of diluted milk, as
water dissolves too little to depend on the solution.   This is cheap
for  hospitals, and, perhaps, has, in this state of mixture of its grains
of powder Avith the Avater, and which grains  afterAvards settle upon
the surface of the ulcer, and  thus  continue  their slight  escharotic
action, more  efficacy than the more elegant, and clear, and costly
solution of chloride of soda in use in private practice.  Good food,
and especially the compound sirup of sarsaparilla as a constant
drink, must not  be neglected in the general treatment.   Dr. Mott
remarks, that the great benefit of adhesive plasters to old ulcers  of
the legs is, that they give tone to the limb by  their mechanical com-
pression, repress exuberant granulations, and thereby promote cica-
trization, and especially diminish  the size of the cicatrix, Avhich is
not effected by the ordinary modes of treating.—T.]
  Burns.  Wounds produced by bodies preternaturally  charged
with caloric, in fact burns, do also admirably well with these strips.
For a burn of the first degree, an application of strips supported by a
bandage slightly compressing, and which may be renewed from the
fourth to the  eighth  day, is  quite sufficient.   If the burn is of the
second degree, that is, Aviih phlyctenae and without phlegmonous tu-
mefaction, I cause the separated cuticle  to be removed, and  cleanse
off  the exuded matters.   The strips are  then applied, and the cure
generally takes place at the end of the second dressing, sometimes
of the first, almost always of the third ; so that, if it has not been
effected by the fourth, this dressing must be abandoned.  If there
is engorgement and tendency to erysipelas, I  commence by combat-
ing these symptoms, by means of emollient cataplasms or bleedings
and then apply the strips.  If the burn is in the third degree thatIV
with alteration or destruction of the surface of the cutis, we proceed
as in the preceding case, and the cure is not the less certain • onlv
it exacts from ten to twenty days.  When the burn is yet deeper
when it involves the entire thickness  of the  dermoid tissue the
strips not being  enabled  to  prevent  the necessary destruction  of 
VARIOUS KINDS OF DRESSINGS.
211
the parts by the elimination of the eschar, are of no use until after
the remoAral of this latter, until, in fact, after the cleansing of the
ulcer.  In other respects, their application to burns  is subject to
the same rules as for the treatment of ulcers.
  I have applied adhesive strips, also, in the treatment of phlegmon,
of inflamed varicose tumors, and certain ganglionous tumors, (tu-
meurs ganglionnaires])  and I am satisfied that we may derive real
advantages from them in these cases.
   Scrofulous ulcers, whether  of the neck or limbs, treated at first
by nitrate of mercury, (nitrate acide de  mercure]) to destroy their
burrowings and loose edges,  are  generally cured better  by the
use of these strips of adhesive plaster, than by any  other dressings.
In fact, I have used this kind of dressing with remarkable success
for different* Avounds, or ulcers  of the  chest and mammary region,
Avhose cicatrization was tardy.
   In speaking of bandages for the scrotum, I have mentioned what
benefit we may expect to derive from adhesive plasters as  a com-
pressing application to the testicle.
            Article IV.—Dressing  with Cataplasms.

   We give the name of cataplasms to the different sorts of paste,
pulp, or pap,  (bouillie,) with Avhich diseased parts are sometimes
covered.  Cataplasms bear the name  of-emollients when they are
made of flaxseed meal, the soft part of bread, or of the  fecula or
leaves of mucilaginous plants boiled in plain water, milk, or water
of marsh-malloAvs.  They are called astringents if there enters into
their composition the powder or decoction of some kind of bark, as
that of the oak, Peruvian bark, or gallnut, or the roots of bistorte,
tormentilla, &c.  They are called excitants Avhen Ave  combine Avith
them ammonia, alcohol, an acid, or some antiscorbutic substance.
Maturating cataplasms contain, more especially, leaves of the sor-
rel, boiled onions,  basilican ointment, or honey.
   In gangrene, or hospital gangrene, (pourriture de  Vhbpital]) we
sometimes add to emollient cataplasms the slices or  juice of lemons.
By boiling Avhite soap  and barley flour in Avater, Ave obtain a lique-
fying cataplasm.  The pulp of certain roots, the carrot, for example,
becomes a resolvent cataplasm when boiled in water.  Grated, and
in the crude state, it forms at  the same time a refrigerant and dis-
 solvent cataplasm, in the same way as the pulp of potato  applied
 cold is a calming and resolving cataplasm for a burn.  Irritating cat-
 aplasms are chiefly made with mustard flour: I shall recur to them
 in speaking of sinapisms.   We obtain narcotic cataplasms by add-
 ing the decoction of poppies, nightshade, (morelle,) hemlock, (eigne,)
 henbane, (jusquiame,) belladonna, or some other  preparation of
 these plants, to ordinary cataplasms.  [A very valuable application
 of this kind,  in our country, says Dr. Mott, is the  fresh leaves of
 the stramonium mingled in a common bread and milk poultice, or
 of themselves after being dipped in hot water.—T.]   But we may
 use these plants  themselves, after having  saturated  and softened
 them by boiling Avater, and then placing  them between two pieces 
212           NEAV  ELEMENTS  OF OPERATIVE SURGERY.
of linen upon the diseased part.  It is in this wa.j I often  employ
the pellitory (la parietaire) upon the hypogastrium, in certain cases
of retention of urine.   In this manner, also, Mr. North informs me
he has often employed the leaves of the tobacco, to assuage pains
and certain inflammations complicated Avith spasm.
  In respect  to emollient cataplasms, unquestionably the most im-
portant of  all, I am convinced that none can be compared to those
of flaxseed meal; so  that the  crumb  of bread, barley meal,  and
different feculas, ought not to be used but when that cannot be  pro-
cured. Boiled and reduced to paste, the flaxseed meal possesses an
uifctuous, viscid, and soothing quality, which is not found in the others.
This cataplasm, also, must not  be either so liquid as to spread out
into pap, nor so thick that it does not moisten the fingers.   In gen-
eral it is advisable to renew it often, especially in hot seasons, as it
rapidly ferments, and then soon acquires irritating properties. Cat-
aplasms are  employed in tAvo  different ways—bare,  or between
two pieces of linen.  [Dr. Mott always applies poultices bare, and
he  considers the practice of enclosing them between  linen ineffi-
cient.— T.]

                 § I.—Cataplasms applied bare.

  To  apply a cataplasm bare, we place a suitable quantity of the
ingredient  upon a compress,  or a square or oblong piece of' linen;
after which we  raise the edges of the linen upon the naked  surface
of the paste, MThich latter is then spread out uniformly  by bringing
back each edge of the linen towards its fold.  We thus obtain a layer
of cataplasm encased, as it Avere, in a compress, (Fig. 135.)  It is the
uncovered portion of this form of poultice that we place upon the
diseased part.  If it is intended for Avounds, ulcers, or uneven  sur-
                   faces, whose suppurations we wish to  modify,
      (Fig-135°        (modifier,) it is advisable to cover it Math a thin
                   layer or with some flakes of lint, Avhich will
                   prevent  the cataplasm from making deposites.
                   In such cases, of course it Avould be ridiculous
                   to place upon the surface of Avounds the per-
                   forated linen, plumasseaux, or other dressings,
                   spread Avith  cerate.  All such applications, be-
                   ing designed to  prevent the linen from adhe-
                   ring to  the wound, become perfectly useless
                   under a cataplasm.
  We may make an emollient cataplasm, thus prepared, resolving
by spreading upon  its surface, immediately before applying it, 'a
spoonful of extract of lead.   In covering it Avith a spoonful of lau-
danum, Ave convert it into a narcotic cataplasm, and in the same
way make  a  sinapism of it by sprinkling it Avith mustard flour.
  Once in place, the cataplasm  should be kept there by means of a
large  compress, which extends on every side beyond its edges and
preATents  its  running upon the  neighboring linen.  This compress
crossed and  fastened by pins, is often sufficient when the patient
can remain quiet.   Otherwise we occasionally surround the com«
 
VARIOUS KINDS OF DRESSINGS.
213
press itself, with the bandage of Scultetus, the roller bandage, or
some of those already described.

           § II.—Cataplasms between two pieces of Linen.

  When placed bare on the parts, the cataplasm has the disadvan-
tage of escaping, or running out in a state of pap, beyond the lim-
its to which Ave would wish to restrict  it, making a dressing of a
very  unpleasant and  uncleanly kind.   On this account, many
surgeons are 'in the  habit  of  enclosing it between two pieces  of
linen ; that is, they spread upon the surface of the paste laid upon
the first compress another similar piece of linen, which is to  be
placed next to the diseased part.  This is a modification upon which
it is well to have correct notions.  The cataplasm does not act only
as many persons suppose,  merely like  compresses  saturated with
tepid water.   Applied bare (or naked) on the skin, or on Avounds, it
places itself in contact with every  indentation, furrow, or uneven-
ness on the cutaneous  surface.  Its marrowy and pultaceous  con-
sistence enables it to adapt itself infinitely better than any kind of
linen to the inequalities of the parts ; so that, all other things being
equal, the  naked cataplasm is much better than that  placed be-
tween two pieces of linen. NeA^ertheless, there  are some regions,
like those of the eyes,  lips, and face in general, Mrhich scarcely per-
mit the employment of the naked cataplasm. As, on the other hand,
there are a great number of  patients who would be  exceedingly
annoyed to see their linen or bed soiled by a cataplasm,  and
others on Avhose tractableness we cannot rely, we ought, in private
practice at least, to know how to enclose a cataplasm between two
pieces of linen.  We proceed then in the following manner :  The
cataplasm  is first arranged like the preceding ; we then cover the
surface with a  square  piece of lawn, tulle, or         ,Fi 136.
gauze, (Fig. 138,) or very open  muslin.  These
tissues,  representing a net-work Math  large
spaces, suffice to restrain  the oozings of the
paste Avithout in any manner interfering Avith
its action upon the diseased surfaces.   If Mre
have  neither tulle,  lawn, gauze, nor muslin,
Ave should  at least  make use  of linen that is
old, or as thin as possible.
            § III.—Remarks on the use of Cataplasms.

  Temperature.  Cataplasms should be applied hot; that is, at a
temperature of from 25 to 30 degrees of Reaumur, [that is, about
90 to 100 of Fahrenheit.]   Below this temperature they are chilly
and  cold,  and become easily  converted  into  revulsives,  (reper-
cussifs,) or resolvents, (resolutifs.)   Above it, they are excitants, or
even rubefacients.
  Re-application. Simple  cataplasms should  be  renewed  every
tAvelve hours at least, and applied in layers sufficiently thick to re-
main moist during this lapse of time.  Kept on for longer periods,
 
211            NEW ELEMENTS OF OPERATIA E SURGERY.
they might dry and irritate the parts in the manner of hard irregu-
lar bodies.  In applying a cataplasm, it is Avell to recollect, that&by
its Aveight it tends to run and spread upon descending surfaces ; and
that it is better, therefore, to apply it from the projecting points to
the deep-seated parts, or from  the  anterior region to the posterior
region of the diseased surface, than in the contrary direction."
  Removal. To remove them, it is generally quite sufficient to seize
them by their longest  border, and then  gently and quickly to turn
them back by making them roll, as  it Avere,  upon an axis to the
opposite border.  If the folds of linen on the poultice should be ad-
herent in any place, we  moisten them Avith tepid Avater before de-
taching them.  When the cataplasm is too soft, or adheres to the
cutaneous  tissue rather than to the compress, we liberate the skin
from it by  drawing upon it gently with the border of the plaster
which is first detached, or by the aid of a spatula.  When AAre havre
no fear of  Avetting  or softening the parts too  much, or Avhen there
is to be any advantage gained by cleansing them carefully, Ave do
not reapply the cataplasm  until after having bathed  them, or left
them to soak some minutes in hot Avater.
  Irritating action.  Emollient  cataplasms  frequently occasion  a
grayish colored puffiness (poursoufflemcnt  grisatre)  of the  ulcerated
surfaces; but that does not, in  general,  prevent the  cicatrization
from going on: it is even remarkable, that an infinite number of
wounds and ulcers  cicatrize much better and more rapidly under
the use of cataplasms of flaxseed meal, than  by any other kind of
treatment.
  [On  this subject of poulticing wounds, and  especially ulcers, Ave
beg leave to refer to a note we have made in the  author's prelimi-
nary appendix of additional new matter at the commencement of
this volume.   We must  venture to  reiterate here  our  dissent from
so respected an  authority as Velpeau,  and our entire distrust of
these relaxant applications in all Avounds or ulcers where  the prim-
itive  acute  inflammation  has been subdued by proper actiA'e
remedies, and has passed into that familiarly  known atonic condi-
tion of the parts, in which, from immemorial time, and consecrated
by  universal  usage,  the  stimulative or corroborative course in
topical as av511 as internal medicaments,  has been adopted  and
substituted.  In  the  worn-out  constitutions of hospital  patients
more particularly, do we  see the pernicious results of obstinately
protracted emollient poulticing, not  only in  retarding, but in vitia-
ting the efforts of nature to produce healthy florid granulations.   It
does, certainly, for the moment, assuage the mere nervous irritation
and pains; but in so much exactly as it is the  reverse,  for example
of the improved and more rational and effective mddern  modes of

  * [This sentence seems,at first rather ohscure.  It is thus—" Qu'il Vaut mieux en o   £
quence le poser des parties saillantes vers les parties profondes, ou de la reVion anteri
Vfcrs la region posterieure du point malade, que dans le sens oppos."__that is as we u d
stand it, the poultice  should be of such variant thickness that it should have a thicker
layer of paste where it comes in contact with the deep-seated surfaces of the cavitv and
vice versa, should be proportionably thinner where it rests upon the projecting or pre minent
parts of the wound.— _T.] 
VARIOUS KINDS OF DRESSINGS.
215
compressing adhesive plasters, does  it increase the difficulties, bv
augmenting the  sensibility and tenderness of the parts, and thus
cause  debility and retrograde action.  Poultices  can, under such
circumstances, be only temporarily  and occasionally applied upon
accidental accessions of severe pain, interrupting the opposite and
true mode of treatment.  Gangrene is one of the frequent  conse-
quences of protracted poulticing, an  eA7ent  not uncommon in its
application to blisters, burns, &c.  Dr. Mott is fully of opinion that
continued poulticing of wounds, after the inflammatory symptoms
are  reduced, greatly diminishes the vitality and tone  of the part,
retards or vitiates the granulations,  and cannot be sustained in
practice.—T.]
   When  these cataplasms have been a long  time on,  and ferment
and become rancid, they irritate the skin and the wound, readily
.produce erysipelas, or at least very frequently cause a sort of vesic-
ular eruption, Avhich, though they oblige us to suspend this topical
application, are no just cause for alarm.
   Cataplasms of plants  should generally be  placed betAveen  two
pieces  of linen;  those  of potatoes,  carrots,  lilies, (lis,) onions, ap-
ples, &,c., require, on the contrary, to be applied bare.
   Cataplasms made with honey, yolks of eggs, and wine, should be
applied in the same manner as those of flaxseed meal.   Moreover,
almost all special cataplasms should be renewed  more  frequently
than the  emollient.  For this reason we ought to change, three,
four, or five times a day, the opiate  cataplasms, those  of the pulp
of fruits or of roots, the herbaceous, and almost all those  of a medi-
cated description.

     Article V.—Dressings Saturated with Various Liquids.

   Surgical diseases are sometimes dressed with applications satu-
rated Avith liquids : it is  thus, in order to rouse, (animer,) excite, and
give tone  to ulcerated surfaces, Ave impregnate Avith aromatic wine,
decoction of bark, solution of sal-ammoniac, &c, the lint or pieces
of linen Avith which we wish to cover them.   So, also, we saturate
with lead-water, brandy, camphorated spirits, or  pure water, cer-
tain bandages by Avhich Ave AAdsh to  aid resolution.  In such cases,
we sometimes impregnate the different portions of those bandages
before applying, as is generally done, for example, in fractures; in
other cases, on the contrary, the bandage is applied first, and after-
wards saturated, when in its place.
   But  there is a  mode  of  saturation in  extensive use at present,
and Avhich I ought to notice in this place : I mean, dressing with
Avet compresses as the only  application.  It is a method  Avhich has
been adopted, for a long period, by various  surgeons  in Germany
and England, and Avhich I myself have often made use  of during
the last ten years.   In place of covering wounds with linen spread
with cerate, or applying gateaux of lint, compresses, and  bandages,
we simply place over them  a folded  compress, which Ave take care
to keep constantly wet, and to change every twenty-four hours. 
216           NEW ELEMENTS of OPERATIVE SURGERY.

  We dress in this way Avith advantage those Avounds which avc are
fearful of becoming inflamed ; also, the greater part of incipient su-
perficial or sub-cutaneous inflammations.  By saturating with cold
water the compressing bandages, also, about inflammatory engorge-
ments, Ave have a powerful resolvent remedy.   I have used it with
signal success in the treatment of certain fractures, phlegmonous
erysipelas, burns, and of various Avounds from contused or cutting
instruments, the operation of cataract,  many  amputations,  and a
crowd of other operations: but if it is true that cold water, employed
in this manner during the hot season, is an excellent topical appli-
cation, it is  also true, that in cold weather it is  much better  to
have recourse to tepid  Avater; so also  is  it true, that  the Avater,
whether cold or tepid,  almost  ah\'ays wets some region that we
would  haATe Avished to protect;  that it  exposes  to chills, colds,
rheumatisms, inflammations of the chest, and a great number of
affections, often  more serious  than the disease itself.  It is also
proper to say, that, applied  indifferently to all kinds  of  wounds, it
may produce as much evil  on the one hand as good on the other.
By  retarding the circulation, it favors gangrene of the contused or
divided tissues ; and by deranging the phenomena of inflammation,
it frequently vitiates (denature) the suppuration, and rarely admits
of immediate adhesion of the lips of the Avound.  It is, in fine, a
kind of  dressing useful  to be preserved, but not meriting all the
eulogiums that have been lavished upon it since Schmucker, and
which it has very recently received among ourselves.

                   Article VI.—Irrigations.

  To render  the  application of cold wet  dressings more uniform
and efficacious,  irrigations have been proposed. The dressing then
consists only of some pieces of linen spread over the diseased part,
and of gentle currents  of Avater falling incessantly upon the linen,
or between the  linen and the Avound.  We use, for that purpose, a
vessel, or some sort of reservoir, such as  a basin, pail, or small
cask, Avhich is  suspended either to the  bed, or some piece of fur-
niture or fixture in the neighborhood, above the plane which sup-
ports the body.  A spigot, ending  in  a certain  number of tubes
either of gum elastic or tin, is fixed near the bottom of the Aressel •
the tube or tubes are prolonged to a level Avith the diseased part, so
as to alloAV the water contained in the reservoir (Fig. 137) to fall upon
it drop by drop, or in a minute stream.  If the diseased part is very
circumscribed,  a single.tube suffices.   In the  contrary case, Ave
increase the number more or less, so as not to leave between them
more than three to four inches, in order that  the liquid may fall
without interruption on the principal inflamed  points.
  To obtain from this  treatment  every possible adATanta«-e  it  is
necessary that  the irrigation should be constantly kept up • that
is to say, that it should not be interrupted and renewed at intervals*
that it should be made sometimes drop by drop, and at other times
in jets, according to the degree of cold we wish to produce ; that 
VARIOUS  KINDS OF DRESSINGS.
217
the temperature  of the  liquid should be sometimes under, some-
times above that of the atmosphere, according as we Avish to subdue

                             (Fig. 137.)
or merely to moderate the inflammation.  It is, therefore, an appa-
ratus that Ave  must watch with  care, and not permit the reservoir
to become entirely empty, and Avhich requires, also, a sufficient de-
gree of docility on the part of the patient.
   The  continued irrigations brought into vogue among us by Josse,
of Amiens, (Melanges de Chir. Pratique, etc., 1835,) often since em-
ployed under the direction of MM. Berard, (Arch. Gen. de Med., 2e
serie, t. VII., p. 5, et 317,) Breschet, (Roberty, These, No. 323, Paris,
1836,)  Cloquet, and others, at Paris, (Gaz. Med. de Paris, 1832, p.
576 ; Bullet, de Therap., 1834; Jour, des Conn. Med. et Chir., t. I. et
II.; These de Paris, 1835-1836,) have also been often made trial of
by myself.  Josse  regards them  as the sovereign cure for fractures,
complicated luxations, simple and phlegmonous erysipelas, phlegmon,
contused M'ounds,  and for all sorts of general wounds that may be
complicated Avith  serious inflammation.  M. Berard, junior, and  M.
Berard, sen.,have extended these applications to many diseases of the
articulations, and especially to certain kinds of white sAvellings, (lu-
  vol.  i.                        28 
218           NEW ELEMENTS OF OPERATIVE  SURGERV.

meurs blanches.) For my OAvn part, I have but little confidence in theii
efficacv. I have seen from the beginning, and I have often so stated
in my lectures, that to make them really effective, the incessant irri-
gations exacted a care and attention Avhich it is almost impossible to
procure in the large hospitals ; that without this they might endan-
ger alternations of action and reaction, and of heat and cold, which
might greatly aggravate the disease ;  and that, by profusely Avet-
ting the bed and the clothes of the patient, they might become the
actual cause  of rheumatism,  or  some  serious affection of  the
chest.  I have remarked, also, that  they readily promoted a morti-
fication of  the  parts, Avhen the Avound Avas accompanied wdth ex-
tensive separations, (decollements,) or that it occupied some part of
the fingers  or the  hand, or the extremities in general.   I have ob-
served, in fact, that while they prevent or diminish the redness of
the skin, and the  tumefaction  of  the deeper  tissues,  they often
masked inflammation, rather than  prevented or destroyed it; that,
therefore, they do not prevent the purulent discharges, (fusees pu-
rulcntes]) and that there finally resulted from all this a thin suppura-
tion of a bad aspect, a general condition of things of a more serious
nature, and a disposition in the Avound less favorable to cicatrization
than by the other kinds of dressing.  In conclusion, continued irriga
tions have not seemed to me to be useful, except in inflammations of
the skin, or those that were sub-cutaneous, and before the establish-
ment of suppuration ; after this first period they are  attended wdth
more inconveniences than advantages.  The dressings wdth simple
saturations of water (les simples imbibitions) may, therefore, be sub-
stituted for them, Avithout danger, Avhere the disease  does not seem
to allow of the employment of strong  mercurial unctions, the com
pressing bandage, or large temporary blisters.  I think I may predict,
from Avhat I haA^e observed, that continued irrigations will not Ion a1
remain  in practice, except as an  occasional treament, and for a
small  number of special cases.
  In short, it is a system of treatment Avhose origin goes back to an
early period.   I have seen in many treatises on  popular medicine,
I have learned in my youth from common  people, and I have myself
noted, that streams of common water constitute  a treatment for
certain  inflammations, and especially for ulcers of the legs.   It is
thus that, for an affection of this kind, I Avent, when fifteen years
of age, to receive upon my leg, for the space of near six Aveeks, and
from two to four hours a day, the water which turned the wheel
of a mill; and it is thus that the peasants  of my native a dilate were
in the habit of holding their limbs under  the rapid streams of run-
ning water.
  [The practice of saturating  light dressings  of linen Avith con-
tinued imbibition of cool water, is, nevertheless,  on the same prin-
ciple as cold  ablutions to the whole  surface in the  highly ardent
and violent fevers  of hot climates, of eminent  practical  efficacy
also, in such  latitudes, in all local  inflammations, bruises, sprains
&c, after the reduction of the more  acute symptoms by bleedin^
&c. In the continued elevated temperature of intertropical regions, 
VARIOUS  KINDS OF DRESSINGS.
219
and the consequent rapid tendency to putrefaction, we have a pow-
erful counteracting antiseptic remedy in this application, preferable,
under all circumstances of constitution, disease, climate, or season,
to the  shock and  revulsions Avhich may be  caused by continued
irrigations, wdiieh  cannot be regulated.  In addition to cold water
dressings, the additional impregnation, Avith diluted alcohol, (aguar-
diente of the country,)  soon becomes necessary and most  efficient,
the moment  the second stage is. arrived.  So  also the  chloride
lotions.  In cold climates and seasons, the cold wet dressings are
generally to be avoided under any form.—T.]

             Article VII.—Application of Hot Air.

   M. J. Guyot, a very ingenious young physician, of extensive sci-
entific attainments, proposed some years ago a mode of dressing
altogether  opposite to  the  preceding.  M. Jules Guyot, in fact,
Avishes that  wounds, or solutions of continuity in general, should
remain dry, and under a temperature of 25 to 40  degrees Reaumur,
(i.e. 88° to 122° Fahrenheit.)   For that purpose, he encloses the
wound or  diseased part in a sort of  box, which is hermetically
sealed, and the air of Avhich is kept at the proper degree of tempe-
rature by means of a tube and a lamp.  To fulfil the intentions of
M. Guyot,  the temperature of this species of stove, in which the
wound is confined, must always be nearly the same, and generally
a little more elevated  than the natural temperature of  the  body.
Some trials of this dressing have been made in my department in
the hospital of La  Charite ; but they have neither been sufficiently
numerous nor varied to alloAV of my making an exact appreciation
of their value.  I fear only, from what I haATe seen, that the effica-
cy of such a treatment may not be in proportion to the irritation it
occasions, the attention  it exacts, and the expense it would involve.

            Article VIII.—Application of Liniments.

  Dressing with liniments is so simple, that we almost alM-ays leave
it to the patients  themselves, or the persons charged with taking
care of them.  We mean by this term, a liquid topical application,
Avhich  has oil for  its vehicle, and certain active medicated sub-
stances for its curative ingredients.  It is in this manner we  make
liniments of olive oil, oil of sweet almonds, (amande douce]) &c., to
which  Ave sometimes add camphor, or ammonia, or preparations of
opium, phosphorus, soap, ether, extract  of belladonna,  henbane,
&c. &c.   Certain  compounds, in which there enters no oil, have
also taken the name of liniments.   It is on this account that the
mixture  of the ointment of malloAvs, (althea) of camphor, and of
laudanum  of Sydenham, and the solution of a certain quantity of
camphor or  ammonia in yolk of eggs, are prescribed under the
title of liniment, though oil may be excluded from it.
   Liniments are applied as unctions or frictions, twice or thrice a
day.   We saturate with  them a piece of flannel or woollen  stuff,
which serves for rubbing the part gently, and which it is often use- 
220
NEW  ELEMENTS  OF OPERATIVE SURGERY.
 ful to leave upon it in the interval from one application to another.
 Sometimes we merely spread them on  the  diseased part with the
 fingers, such liniments, for example, as do not  contain oil.  We
 afterwards apply over the part a soft piece of linen, or a piece of
 flannel, or blotting-paper.

           Article IX.—Employment of Embrocations.

   Embrocations differ but slightly from  liniments.  They consist of
 applications of different kinds of  oils  impregnated  Avith certain
 medicinal substances, and which  are  rubbed upon the skin, and
 retained there  by means of pieces of  linen or some other stuff.
 Thus, the application of a piece of flannel, saturated Avith cam-.
 phorated*  oil  of chamomile or  any other oil,  and  placed on  the
 abdomen, bears the name of embrocation.   It is the same Avith oily
 unctions that are  applied to the face, breasts, or any other  region
 of the body, where we  desire to renew them often.   In fact, em-
 brocations which  are scarcely other than liniments on a  large
 scale, might, strictly  speaking, be  made to include,  also,  certain
 applications of alcohol or ether, employed upon the surface of the
 body.

                  Article X.—Fomentations.

  When we Avish to heat a part, or to keep it in a moderate, uni-
 form  degree of temperature, by means of substances charged Avith
 caloric, we make  use of fomentations.  [The smoothing-iron, tin
 boxes filled with  hot Avater, or  a brick  previously heated  and
 wrapped in linen  cloths, and then placed near the limb, serve also
 for convenient  modes of fomentation.—T.~\  The same applies to
 bottles of hot water, flannels,  napkins,  and every other piece of
 linen  that we heat and afterAvards  apply upon the trunk or limbs.
 It  is,  therefore, a  kind of dressing that we assign  to the  nurses
 or to  the  patients themselves.  Nevertheless,  there are also Avet
 fomentations, that  consist of pieces of linen or other stuff saturated
 with  simple or medicated liquid,  and which are sometime-s used
 instead of poultices.   These liquids, which are sometimes of plain
 water, and at other times of emollient, tonic, astringent, resolvin°* ir-
 ritating, narcotic, or other decoction or infusion, are employed tepid
 or even a  little  hot, and serve as applications, which differ so little
from  ordinary wet dressings as to  make it unnecessary to  dwell
longer upon them here.

                     Article  XI.—Lotions.

  Lotions form distinct applications in themselves, or constitute a
part of several kinds of dressings. It  is in this Avay Ave emplov
liquids upon the surface.  We thus bathe (lotionner) or wash seve-
ral times a day, the surface of  diseased eyes, with collyria of lau-
 danum, belladonna, lead, &c.  In the same Avay, we wash most
wounds and injuries, and eATen  inflamed  surfaces, either with tepid 
VARIOUS  KINDS OF DRESSINGS.
221
water, lead-water, or some medicated liquid, every time we uncover
them, before renewing the dressing.  It is important, in applying
lotions, not to be too particular in removing the plastic matters,
which are apt to become adherent upon the bottom or towards the
circumference of the wound, and to be careful only in cleansing its
surfaces from irritating matters that may be attached to it.

                    Article XII.—Gargles.

   Those liquids, simple or medicated, AAdiich we  use to wash out
the pharynx, and also the mouth, are prescribed under the name of
gargles.  A gargle is generally composed of from four to six ounces
of liquid, and the patient should make use of it from four to six or eight
times a day,, in order to consume, in the space of twenty-four hours.
the quantity of liquid which  I have just mentioned.  The  patient
first fills his mouth with it; then, by throAving the head backward,
he forces the liquid to pass into the pharynx, while, by a series of
moderate and alternate efforts, (par saccade]) he drives out the air
which a  long inspiration  had accumulated in the lungs.  This
expiration, preventing the liquid from descending, forces it forward
by slight  movements, producing a certain sound, which character-
izes this particular kind  of lotion to parts.   Gargling is combined,
often, Avith Avhat might be called  a  snuffing  up, (reniflement,) or
washing out of the nostrils.  Liquids employed as lotions or gar-
gles, may be snuffed up, and thus  carried through the  nasal  pas-
sages to the  pharynx, and voided by the mouth; in the same Avay
as^vhen introduced by the mouth  into the  pharynx, they  may be
forced up and ejected outwardly through the nostrils.

             Article XIII.—Collutories, (Collutoires.)

   Collutories  are applications of  a  liquid, or  sirup-like  consist-
ence, principally intended  for diseases of the  mouth, or pharynx;
that  is, medicinal substances  that are applied by means of a pencil
of lint, lin'en,  or sponge,  to  the  different  ulcerated  or inflamed
regions of the mucous membrane lining the bucco-pharyngeal pas-
sages.  The substances use$ for gargling, snuffing up, and for col-
 lutories, are almost always employed cold; they are, in  fact, lotions,
 fomentations, or washes  of the nasal, pharyngeal,  and  buccal
 cavities.

                   Article XIV.—Fumigations.

   The employment of fumigations is made in a great variety of
 ways, both as to the nature of the substances used, and the  manner
 of applying them to the parts.  Sometimes the fumigation  is com-
 posed only of the vapor of water, or this impregnated with sulphur
 or any other medicinal  substance.  At other times, however, the
 fumigation takes, more particularly, the name of A'apor bath.  We
 have thus fumigations of various kinds—aqueous, sulphurous, mer
 curial, &c. &c. 
222
NEW  ELEMENTS OF OPERATIVE SURGERY".
  Fumigations to the nose are composed of water, milk, or the de-
coction of different plants.   To effect this, it is only necessary to
cover the vessel Avhich holds the  ingredients that are boiling, by
means of a large pasteboard horn, (cornet de carton]) and to keep
the point or apex of this horn in the opening of the nostrils, taking
care to change it alternately from one  nostril  to the  other.  By
placing the beak of the horn in the  mouth, opposite one of the eyes,
or any other given point upon the face, in the place of directing it
towards the nose, we  have a fumigation for the  mouth, pharynx,
eye, forehead, cheek bone, &c.  If it is unnecessary to direct the
vapor precisely upon one point of the face more than another, we
have no occasion for the horn ; the patient has only to coATer him-
self Avith a sheet or any large piece of linen that may enclose him
and the heated liquid as it A\rere both in one chamber.   He inclines
his  face toAvards the A*essel from Avhence the vapor is exhaling, and
in this manner receives the fumigation.
  If the fumigation is to be made Avith liquids, decoctions, infusions,
&c, Ave may either remove the vessel from the fire, and inhale its
A^apor while cooling, or keep  it at a sufficiently elevated tempera-
ture, either upon  a chafing-dish or a furnace.  If we  are fearful
about the respiration in covering the head as  I have just indicated,
the fumigation may be made  in the open air, prolonging it  to a
somewhat longer period.  Certain  kinds of fumigations, as those
that are composed of vinegar, camphor,  benzoin,  cinnabar, dried
plants, or powders in general, as belladonna, henbane, tobacco, &c,
are made by sprinkling some  of those substances upon a chafing-
dish of burning charcoal, or upon a strongly heated piece of metal,
a fire-shovel, (pelle a feu) for example.  Cinnabar, often employed
formerly in venereal affections of  the  scrotum or anus, Avas  first
placed upon  coals, and  its smoke  then conducted upon  the  dis-
eased part, by means of a pasteboard funnel, (entonnoir en carton.)
Vinegar thrown upon the fire, or a  hot shovel, escapes in the form
of vapor, which it is easy to direct in the same way.
'Fi 138)  ^e obtam fumigations of the dried leaves of plants by
v  lg'    smoking them in the manner of tobacco.   We have thus at
       the present time, prescriptions of cigars of belladonna, hen-
       bane, digitalis, &c, in  various diseases of the chest.

                   Article  XV.—Injections.

        The term injection is applied to the washing of certain
       deep-seated regions.  It comprises all  liquids which Ave are
       obliged to force Avith a syringe  into the interior of certain
       canals, or the bottom of certain cavities.   Strictly speakino-
       the term injection is synonymous with a liquid throAvn bv'a
       syringe.
        Injections for the  ear are  made Avith a small syrinx ter-
       minated in an olive-shaped  form, (Fig. 138.)  Those t^f the
lachrymal ducts require Anel's syringe, of which we shall speak
under the article fistula lachrymalis, (Atlas, pi. VIII., fio-s. 9 and 10 ) 
VARIOUS KINDS  OF  DRESSINGS.
223
  To inject betAveen the lids and eye, it is better to use a <Fis-*»0
small syphon syringe, slightly conical in shape, like  the
urethral syringe,  (Fig. 139.)   For the mouth and nose, if
we v/ish to inject  copiously, we have need,  sometimes, of
a syringe of larger size,   the same remark applies  to  ab-
scesses, and  fistulous  passages in all the regions  of  the
body.  If the cavity to be Avashed is very large, we have
recourse to an enema syringe.
  Injections of the urethra are made Avith syringes to contain
about an ounce of liquid, (Fig. 140 ;) the syphon portion is
introduced completely into the canal, Avhich  latter  is held
so that it  closely embraces the  instrument, while Avith
the other hand the piston is forced upon the liquid, (Fig.
140.)  It  is  important  that the  finger making the com-
pression should not go beyond the point of the syringe, and
that the injection thus forced in should be retained a minute  or
two in its place, or, if it  is not of a very active nature, that it be

                            (Fig. 140.)
repeated tAvo or three times at each sitting.  The tendency of these
injections is rarely to penetrate into the bladder.  Supposing, how-
ever, that there may be something to apprehend in this respect, we
should prevent it by supporting the perinaeum upon the angle of a
ehair, or a hard pelote, during the whole period of the operation, or
by causing  some one to  make pressure  on this region with the
finger.
  Injections into the bladder could  readily be made with the  same
syringe, which should be  filled several times; but it is decidedly 
224           NEW  ELEMENTS OF OPERATIVE SURGERY
(Fig. 141.)'
preferable to use one of greater dimensions.   We. begin, then, by
introducing a catheter, (sonde) to which we afterwards adapt  the
syphon of °the syringe.  Nevertheless, this syringe, applied as for
injections of the urethra, or simply prolonged by a canula of gum-
                 elastic to beyond the fossa navicularis, Avill suc-
                 ceed nearly as well.
                   Injections of the  Vagina.   Diseases of the va-
                • gina and uterus often require the use of injections.
                 The syringe used in such cases contains from four
                 to six ounces, and  is known under the name of
                 the toilette syringe, (seringue de toilette—Fig. 141.)
                 This instrument is a straight syphon, like the hy-
                 drocele syringe, if  the injection is to be made by
                 any other person than the patient.   On the con-
                 trary, this syphon must be bent in the form of an
                 arc, or almost at a  right angle, if the female her-
                 self is to be charged with the operation.  This
                 syphon, which may be terminated by an  olive-
                 shaped extremity,  perforated in its top in  the
                 manner of a Avatering-pot, is sometimes made of
                 peM^er, at other times of gum-elastic. Injections
                 of the vagina should be made three or four times
                 a day.   To obtain the object we  haAe in view
                 in using  them, the female should lie upon  her
                 back, with the epigastrium  somewhat  lowered,
                 the  nates raised by a cushion, and the legs and
                 thighs half flexed.   In this position she makes a
                 first, and sometimes a second injection, in order
                 to wash the  parts.   She holds the next injection
                 for some minutes, to prolong  a little the contact
                 of the liquid with the diseased parts.
  If it should become necessary to make  injections into the womb,
which is not in general ATery difficult, Ave should begin by introducing
a catheter, using the forefinger of one hand for our guide, as far
as the neck, and into the  interior of this organ; in other respects,
Ave proceed as has been stated for injections of the bladder.

                    Article XVI.—Enemata.

  The art  of giving enemata is  usually  confided to nurses and
invalids ; often, also, the patients administer them to themselves.  It
is, however, an operation of much delicacy, and one Mdiich may be-
come dangerous, if not guarded by proper precautions.  It is neces-
sary, therefore, that the student or surgeon should knoAv at least
hoAv to point out its rules and direct its performance.  The syringe
Ave use to  give a clyster, is generally of the capacity of a pint;
if we fill it entirely,'the  enema is complete.   It is in this way it
should be given when we  desire to  encourage the stools.  If, on
the contrary, Mre AAdsh to deposite in the rectum emollient or medi-
cated liquids, in  the character of topical applications, or internal
 
VARIOUS KINDS OF DRESSINGS.
225
baths, we fill it only one half.  When we wish certain  liquids or
substances to be absorbed, it is  not proper to inject more  than a
quarter of the syringe.   These quarter portions of an enema, im-
pregnated with narcotic substances, camphor, cinchona, cubebs, or
balsam of copaiva, form a bulk of sufficiently small volume not to
distend the intestine, but to permit the  patient to retain and absorb
it as if he had taken it by the mouth.  The syphon of the syringe, in
such cases, is, as in the injection syringes, ordinarily conical, or it is
cylindrical and straight Avhere the clyster is to be given by another
person. When we wish to make the injection go far up, we adapt to

                            (Fig. 142.)
it a tube of gum-elastic, and the syphon should be curved like the
vagina syringes if we wish the injection to be given by the patients
themselves.  Then the  patient passes the instrument from before
backward, between his thighs, so as to make its beak enter the anus ;
pressing afterwards on the piston, he gently forces the liquid forward
Avith  as much facility  as a  nurse placed behind with a  straight
syringe would do it.
  The instruments termed  clysoirs and clyso-pompes, invented in oui
times as substitutes for syringes, are a kind of forcing-pump, (pompes
foulantes—Fig. 142,) provided with a reservoir, and with flexible
  vol. i.                      29 
226
NEW ELEMENTS OF OPERATIVE SURGERY.
tubes, (conduits—Fig. 143,) also Avith a beak or a syphon that allows
the patient to give himself any kind of injection into the rectum, and
to introduce with facility the different kinds of enemata or clysters.

                            (Fig. 113.)
  To give an enema properly, it is necessary that the pipe of the
syringe or clyso-pompe should, for the extent of about an inch, be
directed a little forward, as if to pass from the perinaeum towards
the umbilicus, in order that it may thus follow the course of the
anus; having reached this depth, which is a little more in man, and
a little less in Avoman, we first slightly, and afterwards to a greater
extent, incline the point of the  syringe backward, as the rectum
follows  the curvature  of  the sacrum, and, above the  sphincter,
is strongly bent in this direction.   In conforming oursehres to these
rules, Ave may penetrate without  inconvenience, to two or three
inches of depth;  but, unless we have a flexible pipe, it Avould be
imprudent to go much further.
  If the syringe has not gone above the line of the sphincters, its point
almost always buts (arc-boute) against the bas-fond of the bladder or
the posterior wall of the vagina, and the liquid comes out in proportion
to the distance the instrument has gone in, or it stops, and does not en-
ter at all.  The same resistance is met with higher up, if the pipe has
not been properly inclined backward, or if it is caught in any Avav in
the folds of the intestine.   It  is then that a serious accident  mav
happen.  If, in fact, in order  to  overcome this unlooked for resist-
ance, we push upon the syringe, there may result from it an abra-
sion, chafing, (eraillure) or even a perforation of the vagina of the
posterior part of  the intestine, or the perinaeum.  These kinds of
lacerations  seem to  be possible, also, by the  action even  of the 
VARIOUS KINDS OF DRESSINGS.
227
liquid itself, forcibly driven into the syringe which has been thus
obstructed  or imprisoned, (enchevetrce)  AVe must not, therefore,
suppose that a danger of this  kind is merely hypothetical; there
have already happened eight instances within my own knowledge,
four of which occurred  in the  hospitals  of Paris, and four in the  .
city.   The  patients in  these cases experience,  suddenly, a  vio-
lent pain, sometimes immediately  followed by syncope, and soon
after by nervous symptoms more or  less alarming ; there afterwards
take place vomitings, and all the symptoms of a Adolent peritonitis,
or extensive inflammation of the pelvic  cellular tissue.  If, under
these last mentioned circumstances, the patients survive, a gan-
grenous suppuration soon takes place about the rectum, showing
itself near  the margin of the anus or perinaeum, and  rendering it
necessary to make numerous incisions that  again place in jeopardy
the life of the patient.  It is in this Avay that six of the cases I have
just enumerated perished, among Avhom Avas a young lady who had
herself administered  the enema with a  clyster pipe.  Of the tM*o
cases that survived, one has an enormous ca\dty in  the interior of
the pelvis,  Avhich has neA'er  yet entirely ceased to suppurate; the
latter, a lady, aged about forty years, and mother of  a distinguished
in-door pupil  of  the hospitals of  Paris,  did not  recoA^er  until
after  haAdng  undergone very serious difficulties, and submitted to
nearly a year's course of treatment.  [Dr.  Mott has seen one case
only,  in all his practice, and that was in New York.  The entire
mucous coat of the rectum sloughed off.—T.~\

                   Article  XATII.—Douches.
  The douche is a kind of injection Avhich  sometimes  has also the
character of an enema: we mean by this Avord the  projection of a
liquid, or gas, upon the body of an individual at a certain distance
from the reservoir.  There are ascending and descending douches.
AVe give the name of descending douches to those which are made
from an elevated place, and that of ascending to those that are made
from below upAvards, upon the anus, for example, Math the view of
OA'ercoming certain obstinate constipations, or into the vagina, to act
upon  the neck of the  womb.   In the douche, the liquid sometimes
falls in drops, sometimes in  a minute stream, (par filet)  at other
times in a jet, or like a shower of rain, or in  rays as through  a
Avatering-pot.  In  short, these different kinds of douches are made
from  a point more or less elevated or Avith  a greater or less degree
of propulsion.  To make the descending  douches  ascending, Ave
have  only to  prolong the tube or canal, Avhich is  connected Avith
the reservoir, and curve  it from beloAV upward in a  bathing  tub,
or  some other vessel, at some  distance under the  perinaeum ; the
cock  being open, then allows the  water to yield  to the  pressure
Avhich acts upon it, and to be thrown upon  the diseased part.
   The vapor douches, chiefly employed in diseases of the skin, are
either dry or wet.  The dry douches are made Math heated atmo-
spheric air, but they are but little used.  The wet douches, Avhich
are made with the vapor of pure Avater,  sulphurous, aromatic,  and 
228
NEW  ELEMENTS OF OPERATIVE SURGERY.
   other vapors, are applied by means of a long pipe, which may be
   made to act in any direction upon different parts of the body.  So,
   also is it easy to  direct vapor douches  upon the eye, ear, nose,
   mouth, or any other region of the body.  AVe may have an exact
•   idea of the manner of applying the douche, by  recalling to mind
   what firemen do in extinguishing fires, or gardeners in sprinkling
   public places or gardens.
     Douches resemble, it is true, to a certain extent, irrigations  and
   injections ;  but  they differ from them in this, that their object  is
   to excite  the parts by the repeated shocks of the  liquid, so that the
   liquids should be propelled from a greater height, or with greater
   force, as they are intended to produce a shock rather than a change
   of temperature, or mere Avashing of the parts; Avhile the effect of
   irrigations is to moisten or cool the parts.

                      Article XVIII.—Baths.
     By baths, we generally understand the substances into the midst
   of which we plunge the whole body, or some part  of it, so as to
   act  upon its surface or temperature.   A\Te have thus  hot, cool,  and
   cold baths; baths of Avater, vapor, sand, or ashes.   A  bath is called
   general, when we  plunge the Avhole  body into it up to  the neck.
   The duration of these baths continues  from half an hour  to  an
   hour, or an hour and a half.
     In foot-baths, the limbs ought to be plunged into the liquid to a
   levol at least with the ankles or the calves.  Such are called pedi-
   luvia, and consist  sometimes of hot water only, which is occasion-
   ally made stimulating by adding thereto a handful of mustard flour,
   or salt, Avith a glass of vinegar, and they are to be continued from
   ten  to twenty minutes.  [A far more effective bath of this  kind, and
   of infinite value in practice as a powerful counter-irritant,  is the
   addition to  the pediluvium of half a pound or a pound of cayenne
   pepper.—T.]
     The hand-baths, (manuluves) are prepared precisely in the  same
   way.
     The  ordinary temperature  of a bath is from  26 to 29 decrees
   of Reaumur, (i. e., 90° to 98° Fahrenheit;) some persons bear it
   very well to 30 degrees, (100° F.,) and even to  31 degrees,  (102°
   F.,) while others find it sufficiently hot at 26 degrees, (90° F.)   In
   general, a bath becomes exciting, and even rubefacient, (rubefiant,)
   beyond 30 degrees, (100° F.,) as it has the character of a  cool bath
   from 18 to  25 (72  to 88° F.) degrees, and a cold bath under 15 de-
   grees, (66° F.)
     Liquid, like vapor baths, are distinguished into simple and medi-
   cated.   The first consist of pure water, the  others of water con-
   taining  gelatine,  if we  Avish to  render  them nutritive, or  some
   aromatic ingredient, or  sulphur,  mercury, the  alkalies, &c.   It is
   important  in giving a bath, that  the  patient  should  not be in too
   small an apartment, that he should not have eaten for the last two
   hours, and that, from  the beginning to the end, he be not exposed
   to the slightest current of air.  It is also necessary, if the chamber 
VARIOUS KINDS OF DRESSINGS.
229
be small, that the air penetrate freely into it;  without that, the
rarefaction of the atmosphere by the aqueous vapor would soon
fatigue the respiration, and might occasion syncope.  It is well to
be enabled to have it in our poAver, from time to time, to introduce
into the bathing tub, Mdiile the patient is in it, hot or cold Avater,
that the liquid may be kept at the same temperature from the com-
mencement to the end of the bath.
  Dry baths, such as those that may be made with sand, ashes, and
bran, and which were formerly used in the  treatment of dropsies,
and to restore the circulation to parts threatened with gangrene,
are scarcely any longer employed  at present.  The  only trace of
them which remains among us, is  the satchels, (sachets) or sort of
cushions, analogous to fracture cushions, which, after being  filled
with hot bran, ashes, or sand, some practitioners still place around
limbs in which the principal arteries  have  been tied.   Though it
may have been right to reject baths of dung and other substances,
whose use has become repugnant because of their filth, it is not so,
perhaps, to have laid aside dry baths in dropsy, and infiltrations
which do not depend upon the manifest lesion of  any viscus.
  In fact, Mre procure by these dry baths, still better than by insola-
lation, an absorption of the serous  fluids, (des liquides blancs) and a
desiccation of parts that are engorged, which we  can obtain by no
other medication, internal or external.

        Article XIX.—Precautions  required in Dressing.

  AVhen we are about to apply a dressing to any wound whatever,
it is useful  to ask ourselves what are the rules that ought to be fol-
lowed to make it as advantageous  as possible. To say that the sur-
geon ought to place himself in a convenient position, that the part
should be properly cleansed, that the pieces  of the dressing should
be laid on  gently, applied with delicacy, and in a manner to sooth
rather than to fatigue  the  patient, and that the  wound should be
placed in a suitable situation after the  dressing, is to teach nothing
to the pupil, for these are  the  suggestions of natural good  sense,
that have no need of being particularized.   But the surgeon ought
to know to what point he should protect Avounds from the action of
air, cold, or heat; to what extent they may be cleansed of the blood
or other matters that  may cover  them; how we are  to proceed
with the first dressing, and with those that folloAV; the advantages
or inconveniences of frequent or procrastinated dressings, of those
that may be removed,  or of those that are to be immoveable.

                       . I.—Action of Air.

   Many surgeons in former times  were under the persuasion that
wounds  should  be  exposed as little as possible to  the action of
the external air; they therefore  recommended the  patient  to be
surrounded with bed-curtains ;  to have prepared beforehand all the
pieces and articles which there might be  any occasion  for; and
when the  Avound presented a large  surface, to cover successively 
230
NEW  ELEMENTS OF OPERATIVE SURGERY.
the different parts of it  with the neAV dressing, in  proportion as
the old one Avas removed; some Avent so far  as to  recommend
holding different kinds of chafing-dishes, or other means of propa-
gating heat, around the patient, to protect him from the possi-
bilitv°of becoming in any Avay chilled, and to remove all appre-
hension of change of temperature during the Avhole course of the
dressing.  The action of the air appeared to them dangerous,  both
because of the irritating properties Avhich they imputed to this fluid,
and of the emanations of Avhich it might be the vehicle.  It is not
Avithout surprise that I have seen these ancient errors revived in
our oavii days, and sanctioned by the name of Dupuytren.  Atmo-
spheric air is so far from being injurious by its momentary contact
with traumatic surfaces,  that many surgeons still ask the question,
if Avounds do not heal  much better in the open air  than by the
most methodically adjusted dressings.   It is at  least certain  that
animals get well very rapidly of their wounds, though they remain
from the  beginning  to  the  end in contact Avith the atmosphere.
The precautions, then, that are  recommended  on this head,  are
utterly useless.  To uncover any wound or ulcer, to cleanse  any
injury whatever, to free it of the  portions of the dressing that en-
veloped it, cannot, in the whole, require  more than a quarter or half
an hour.  But the atmosphere is incapable, in this space of time, of
producing, in its character of gas, the least serious accident.  Con-
sequently, in these matters Ave should confine ourselves to aAoiding
currents of  air, and sudden  reductions  of temperature, (les refroi-
dissemens brusques) and throw a piece  of linen over the uncovered
wound, if from any cause AvhateA7er Ave  should be prevented from
immediately finishing the dressing.
   The despatch recommended by authors could be  of no utility,
except there should be prevailing in the Avards or apartments where
the patient Avas, some contagious  or miasmatic disease, susceptible
of being communicated  through  the suppurating surfaces.  It is,
hoA\'ever, not the less true, that, to perform a dressing well, a sur-
geon should take care to have prepared and arranged beforehand,
in proper order, all the  articles Avhich he supposes he shall haAre
 iccasion to  make use of.

        § II.—Treatment of the Wound at the First Dressing.

   The first dressing of Avounds presents different varieties, accord-
ing as it  is to unite by first intention, or that Ave dress to obtain
secondary cicatrization.
   Union by the First Intention.  In the  first case it is indispensable
that the blood should be effectually arrested, and all the clots care-
fully removed ; that  no blood Avhatever any longer exudes from the
surface of the Avound.   To arrive even with more certainty at this
result, Parish in America, and also a great number of surgeons in
England and Germany, and Dupuytren in France, haAre established
a precept not to dress recent wounds, but after the lapse of some
hours; but this method, which is advantageous in certain instances 
VARIOUS KINDS OF DRESSINGS.               231
is fraught Avith so many inconveniences in others, that it cannot be
adopted without much qualification.     •*
  As Ave are obliged to use adhesive plasters to obtain immediate
union, it is necessary, after having removed the blood by means of
Avashing, to sponge and carefully wipe the edges of the wound, and
the AArhole cutaneous surface in the neighborhood, with  a'napkin or
some dry pieces of linen.  We then attend to the ligatures, Avhich,
after one of their threads is cut near the knot, must be brought for
ward and collected near the lower angle of the wound,  or placed
separately in a right line upon the point nearest to the knot.  After
having turned them back, Ave fasten them upon the skin  by means
of  a  piece  of adhesive plaster placed crosswise.   This is much
better than enclosing them in a small piece of linen by themselves,
or by a ligature  compress, or  fastening them permanently under
the turns of a containing bandage.   In this  kind of dressing we
proceed thus :  first, the adhesive  straps ; secondly, the perforated
linen ; afterwards, the lint;  then the compresses ; and finally, the
bandage.  [Dr. Mott approves very highly of leaving many wounds
exposed for some time, even for the space of an hour  or more, espe-
cially Avhere there is an oozing of blood, or apprehension of much
hemorrhage.  It  is therefore better, also, in such cases, to leave
such Avounds  undressed for  many hours,  and when we  do dress
them, to dress them  loose and with lint, and  allow them to  sup-
purate, and not hope  for first intention.  Much is thus  saved, by
aAroiding consecutive hemorrhage, removal of  dressings, &c.—T.]
   Union by the Second Intention.  When we are not to unite imme-
diately, there is no  need of cleansing  and of  completely washing
out the wound, or of so carefully drying the skin in the  neighbor-
hood.  In the place of retaining  also  one of the halves of each
ligature, A\^e  may cut both at the distance of some  lines from the
knot.   This being done, Ave apply upon the whole Avounded surface
small balls of lint, naked  if Ave AAdsh, to guard against any bloody
exudation, but upon a plain or perforated  piece of linen spread
Avith cerate, if the case is one of an opposite nature.   When the
Avound is  not very deep, Ave substitute for the balls  of lint one or
more  plumasseaux.   In any case, it must be remembered that the
balls themselves  are to be  coATered AAdth plumasseaux.  and that,
setting out from  this point, the dressing  does not differ from the
preceding.  The application of the adhesive plasters  and  the band-
ages at the  first dressing,  should be made in such manner as not
to interfere with the  tumefaction, which must inevitably take place
in the course of the first tAvo or three days.

              § III.—Removal of the First Dressing.

   The removal of the first  dressing, generally creates much appre-
hension in the patient.   The fears  of patients  on this head, are
explained by recalling to mind, that even up to the commencement
of the present century, almost all Avounds, stuffed Avith lint or
sponge and dressed naked, Avere uncovered on the day after the first 
232
NEW  ELEAIENTS OF OPERATIVE SURGERY.
dressing, or upon the day following.  Then, in truth, the first dress-
ing was  rendered excessively painful.   Now, it is  not perceptibly
more painful than the  others.  Not taking  place  until after  the
lapse of three or four days, it has been anticipated by the suppura-
tion, and by the saturation of the under portions of the dressing.
The perforated linen, which  rests bare upon the wound, being
spread Avith cerate, is raised and separated without the necessity
of the least degree of painful traction ;  if there are balls of lint  and
sponge, Ave  do  not detach them  until they have been insulated by
the pus.  This method, already extolled by Magati, is, at the present
time, that of all good practitioners.  It has, nevertheless, been  the
object  of some recent  attacks, and rejected  as injurious by a sur-
geon of the hospitals of Paris, who, returning to the routine of the
ancients  and that of nurses, recommends  that after great opera-
tions the dressing should be reneAved  upon the second  day.   He
has, without doubt, inadvertently imagined, that by this course he
could guard against the purulent discharges, (les fusees purulentes)
erysipelas, and other inflammations, Avhereas it Avould be the best
means of favoring them, for it is only after the third or fourth day
generally, that such accidents show themselves.
  This period of three or four days, however,  necessarily has many
exceptions.  For example, if the part Mras  in too great  pain, and
if the wound seemed to cause too violent a reaction, Ave should
uncover it in the first twenty-four hours, or at least before the end
of the  third day, taking care, however, unless there  should be
some special indications to the contrary, to remoAre only the por-
tions of the dressing that Avere either too hard or improperly placed,
and to leaATe untouched the deepest seated portions.  In other cases,
in cold seasons, for example, or in treating regions or tissues Avhere
suppuration goes on tardily, and where we wish to obtain a free
and immediate  union, (une reunion franchement immediate) we may
Avait even to five or six days.  At the  end  of this  time, Ave must,
in general,  saturate  all the dressing Avith tepid Avater; but  the
bandages, compresses, and sometimes even  the lint  itself, are then
sometimes so strongly glued together,  or indurated by the blood,
that the water softens them Avith difficulty.  In this case, Ave must
soak them at least for half an hour beforehand, or detach them piece
by piece, until M'e reach the edges of  the  perforated linen.  This
being clothed with cerate, alloAvs of being  separated and removed
with all the pieces it supports, without draAving any upon the Avound.

                  § IV.—Hours for Dressing.

  The hour selected for dressing is generally in the morning; this
arises from  a practice  dictated  by the occupations of every one
and from the time that has elapsed since  the period at Avhich  we
Avere enabled to make the last dressing to the wound.  AVhen there
is but one dressing in the twenty-four hours, this practice has  the
advantage of giving more tranquillity to the patient for the remain-
der of the day; but it has the inconvenience of leaving him less at 
VARIOUS KINDS OF DRESSINGS.
233
his ease for the night.  Moreover, we see patients who desire to be
dressed both  night and morning.  I would not say, here, that the
dressing  of the morning should be made after sunrise, and that
of the  evening after  sunset;  for there would result from this, that
in the  month of December, for example, the two dressings would
take place at the interval of five  or six hours, Mrhile in July they
might  be separated by twelve  or fifteen hours.  The best  course
in this matter is, to dress the patients towards eight or nine o'clock
in the  morning, and from seven to eight in the evening.
   These  frequent dressings belong to almost all those of the second-
ary character; they are useful  when Ave are treating wounds that
suppurate  abundantly, or are  employing certain topical applica-
tions—cataplasms, ointments, and liniments, for example. In other
cases they are  calculated only to irritate the wound, and to retard
the process of cicatrization.
   [No healthy wound, Dr. Mott thinks, should be dressed over once
in twenty-four  hours.  They should be let  to suppurate  freely.
They do much better in their own  pus, and they are injured by too
frequent dressing.   A compound fracture  is a good illustration of
this  sound practical precept.—T.]

       § V.—Dressings at Long  Intervals, (Pansements  rares.)

   Formerly,  many surgeons dressed all  wounds once, twice, three,
or four times a day.   Now,  we call  those frequent and ordinary
dressings, which are  repeated  at least  once in twenty-four hours,
and  delayed dressings, [i. e., at long intervals,]  those which do not
take place every day.   These  last are divided  into two  orders.
They merit, in fact, the name of immoveable  when they are only
renewed every tAvo, three, four, or  five days, in such  manner as to
make it necessary to change them a certain number of times during
the course of the cure.
   Permanent dressings should be understood of those  which, when
once applied, remain in place until the wound is cured.   This kind
of dressing, which the Egyptians, Greeks, Arabs, and Spaniards ap-
pear to have often employed, and Avhich M. Blaquiere  revived in
1815, has been definitively adopted by the elder Larrey.  In fact,
Marechal,  on his part, has made  a fortunate application of it at
the Necker hospital, in the treatment of wounds, and the observa-
tions published by M. Sazie, are of a nature to awaken attention
upon this point. I have already described  in what manner we may
best carry out this dressing for fractures. As to wounds, we proceed
in the  same manner as for a  simple dressing, but with the precau-
tion not to touch the  bandage, if no accident supervenes, until at
the end of ten or twenty days, the  epoch at which the union of the
parts ought  to have  been effected.   M. Larrey,  who renders the
dressing perfectly immoveable  in this case, as in the  treatment of
fractures, applies it as well to wounds that are to suppurate, as to
those Avhich  he Avishes to unite by the first intention.   Protecting
the  parts from contact Avith  the air,  applying to them  a uniform
  vol.  i.                        30 
 234           NEW  ELEMENTS OF OPERATIVE SURGERY.

 pressure, and enabling them to escape all traction or inflection, (tout
 tiraillement, toute inflexion) the bandage, imbued  with  the  Avhite
 of egg, or  starch, or Avith dextrine, gives  the pus  an opportunity
 of spreading and concreting at a distance from the  wound, Avithout
 preventing, says M. Larrey, the regular progress of the cicatri-
 zation.
  For my own part, I do not think, in the instance of wounds, that
 the immoveable or permanent dressings haAre all  the advantages
 that M. Larrey attributes to them.   It has  always  appeared to me
 right to renew, from time to time, the  dressings  of Avounds in a
 state of suppuration ; nor can I think Mre can question the advan-
 tage of renewing the dressings in ordinary wounds, provided there
 be no reason  to  suppose that there will be  a  complete  aggluti-
 nation.
  The immoveable dressing, then, is not in fact  preferable to ordi-
 nary dressings,  but for Avounds complicated with fracture, or those
 in Avhich it is  important  to  prevent the slightest  movement,  or
 where Ave  have reason to hope for an absolute   and immediate
 union.
  [Leaving the Dressings on.   AVe would receive this last remark
 of the author with some qualifications, especially as to immediate
 union.  In all those fractures of the body near the great centres  of
 circulation  and sensation, Dr. Mott has always impressed upon his
 pupils the importance, M'herever it  can  safely be done, of leaving
 on the first dressings, for wounds complicated with fracture or not, for
 many days, or even for weeks, or as long a time, in fact, as possible.
 More especially has he insisted, and does still insist  upon this prac-
tice as a surgical axiom, in all fractures of the  cranium, however
vast or complicated, as success of the most marked kind has ever
resulted  to him from this course, even where  several  inches  in
 extent of scull and considerable portions of brain have come away,
directly  from the injury, or in the  course of trephining.   Even  in
 cases, also,  Avhere a portion of the longitudinal sinus has been torn
 away or lacerated, he adopts the same  course, as  in these rather
 rare instances no other addition is made to the dressing than the
 insertion of a single  pledget of lint into the Avounded sinus, which
 arrests  the hemorrhage definitively, especially in  the application
 of the adhesive straps, Avith  a moderate pressure, over the  com-
 presses, upon the incisions.  A recent remarkable case of this kind
 occurred here to Dr.  Mott, in which the  sinus Avas Avounded in the
 vicinity of  the  occiput, and tAvo circular perforations had to  be
 made Avith the trephine in the direction  of the sagittal suture the
under table of the parietal bone being splintered off so as to  press
upon the dura mater.  The dressings were left on, full  a fortnight
 and consisted only of the pledget above mentioned, light compresses
 over the approximated edges of the Avound, and a few adhesive
plasters crossAvise on the scalp, the Avhole making only a moderate
pressure.  The plan of Dr. M. is,  to leave the dressings on  until
they are self-separated  by  the lubricating effect  of the subjacent
bland-pus that constantly besmears  and protects, and rapidlv pro- 
BLEEDING, OR SANGUINEOUS  EMISSIONS.
235
motes the already far-advanced or nearly-completed granulations.
At this time, the under portions of the dressing are so imbued with
the partially decomposing exudations that have soaked into them,
that they become offensive,  and must  be remoyed.   The danger
of removing the dressings to  the brain at an earlier period, is, that
of exciting inflammation in  this organ ; and Avhen the brain has
become once accommodated to the pressure of the dressing, it is
better to defer the second dressing till the critical period is passed
over Avhich is generally within a fortnight.   Serious consequences
have arisen from interfering with the dressings at an earlier pe-
riod.—T.~]
TITLE III.
ELEMENTARY  OPERATIONS.
  I shall include, under the name of Elementary Operations, all
those which  enter into the province of minor  surgery, (la petite
chirurgie.)   I shall consequently explain, in this place, Avhat relates
to the different modes of bleeding, cauterization,  drains, (exutoires)
rubefacients, (rubefactions) vaccination, &c.
                        CHAPTER I.

            BLEEDING, OR SANGUINEOUS EMISSIONS.

  Bleeding is understood of every operation, Avhich  consists in ab-
stracting blood from the human body, with the view of relieving
or curing it.  This operation is divided into many kinds, according
as it is practised on venous trunks, arteries, or the capillary system.
It takes the name of bleeding,  properly so called, when the extrac-
tion of the blood is made from one vessel only. In this case, also, A\re
give it the name of general bleeding.  If we perform it by means
of leeches, scarifications,  or the opening of several small veins,
it receives more especially the name of local bleeding.  General
bleeding is known under the title of phlebotomy, or simply blood-
letting, when it  is performed on the veins; if an artery is opened,
it is designated by the name of arteriotomy. 
236           NEW  ELEMENTS  OF OPERATIVE SURGERY.
     Article  I.—Phlebotomy, or Bleeding properly so called,

  The employment of blood-letting goes back to a period so remote
in the history of nations, that Ave knoAv nothing precise of its origin.
The negroes of Guinea, the Hindoos, the Chinese, the Scythians, the
inhabitants of the Oceanic isles, (de VOceanie.) made use of it before
medicine Mras reduced to the form of a science; every thing proves,
then, that the history of the hippopotamus, spoken of by Polydore
Virgil, should be considered as a simple fable. We may, also, con-
ceive hoAV the loss of blood caused by Avounds,  might haA~e given
man, at the origin of the world, the idea  of taking blood from him
artificially on the occasion of certain maladies. However that may
be, phlebotomy is an operation .which may be performed, and Avhich
the Greek and Roman physicians performed, in fact, on most of the
superficial veins of the body.   To- believe Oribasus, Antylus had
already laid down rules for bleeding  in the forehead, angle of the
eyes, mastoid region, tongue, hand, bend of the arm, ankles, and
ham. We may add, that at the present time, bleeding in the dorsal
veins of the penis, those of the scrotum, neck, limbs, and certain
tumors, also deserves particular notice.

                     § I.—Bleeding at the Arm.
(Fig. 144.)

  Physicians Avho had  imagined that  blood-letting
might be simply evacuant or depletive when applied in-
differently to this or that vein, derivative, on the contra-
ry, Avhen performed between the diseased organ and
the heart, and revulsive when as far as possible from
the region  to  be  relieved, ascribed a great import-
ance to the veins upon Avhich the operation should be
practised;  at that time  their choice Lay between
bleeding  at the arm, neck, or  foot.   Noav, howeA-er
since  those distinctions of the  schools haA^e  lost
all  their  Aralue, blood-letting by the arm  is almost
the only  kind employed.  Even on  the supposition
that we have  gone too  far  in this  matter, and that
phlebotomy in other regions has relapsed into un-
merited oblivion, it is nevertheless always true, that
the theoretic reasons which  governed the practice of
the ancient physicians are evidently too futile to re-
quire to be discussed at the present day.

    A. Veins  at the Fold of the Arm—(Fig.  144.)

  In the  arm Ave perform bleeding upon all the veins
of  a certain  size which  become  prominent  under
the skin.  Thus, the cephalic vein of the thumb the
salvatella or  dorsal Areins of the hand, the different
veins upon the body of the forearm, and the cephalic 
BLEEDING, OR SANGUINEOUS EMISSIONS.
237
vein in the deltoid groove, Avhen it appears too difficult to reach
it in the bend  of the arm, may be had  recourse to.   In this last
region, the veins are so distributed as most usually to present five in
number.
  I.  Outside and upon the outer  prominence of muscles is found
the cephalic, which receives, in passing from the anterior surface of
the supinator longus, on the side of the biceps, the median cephalic
and the  anterior radial.  This vein, accompanied (longee) by the
external cutaneous or musculo-cutaneous nerve, from which  it is
separated in the arm by the aponeurosis to near  the external
condyle, (epicondyle)  is situated between the superfical fascia and
the aponeurosis properly so called ; lower down it is also accompa-
nied (cotoyee) or surrounded by nerves that Arary exceedingly as to
their number.   If it is true, as is asserted, that a surgeon of our epoch
says he has never seen nerves in the neighborhood of the cephalic
vein, it is because he could not have dissected it but upon one or
two subjects,  in whom, by some  anomaly doubtless, they  were
wanting.
   II. The basilic, situated on the inner muscular prominence, passes
over the inner condyle (epitrochlee) to gain the groove of the biceps.
The cutaneous nerve enclosed  in the same sheath is almost always
situated upon  its inner side above the bulge of the muscle.
   III.  The median is seen at the lower part of the region, or near
 the apex of the triangular space which separates the two muscular
masses at the bend of the arm.  This vein, which  comes from the
anterior or palmar region of the fore-arm,  and  which is either
inclined to the external or internal side, soon divides  into  three
branches, one  of which  enters deep between the muscles through
the aponeurotic aperture, to become united with the deep-seated
veins, and the  two others, which separate in the manner of the two
branches of a  Y, to join the basilic and cephalic.
   IV.  Median-Cephalic. The external or cephalic branch of the
median vein follows the outer inter-muscular groove,  is surrounded
 with nervous  filaments, and at one or tMro inches above its origin
 opens into the cephalic vein, properly so called.
   V.  The internal branch or median-basilic crosses very obliquely
 the brachial artery, from which it is only separated by the aponeu-
 rosis, then crosses  the  tendon of the biceps, reaching the basilic a
 little above the articulation.   In short, this vein approaches much
 nearer to the artery M'hile in the hollow of the fore-arm than  a lit-
 tle above, because of the fibrous bandelette of the biceps, which has
 the effect to  separate  the vein from the artery  in this last-named
 place much more than in the former.
    All these veins, though subject to numerous anomalies, sufficient-
 ly resemble in their general grouping the form of a capital M.
    Situated between the sub-cutaneous  superficial fascia and the
 sub-cutaneous deep  fascia, they are more or less easy to be dis-
 tinguished, according as the embonpoint of the arm is more or less
 considerable.   This  arrangement  is the cause, on the other hand,
 why the relative position  of the artery or nerves with the veins  is 
23S           NEAV ELEMENTS OF OPERATIVE SURGERY.

not sensibly  changed by the infiltrations or obesity of Avhich the
bend of the arm may be the seat.
  It results from these anatomical considerations, that bleeding upon
the fore-arm is  more easy in the median basilic vein, but  at the
same  time more hazardous, than in the median cephalic;  that,
strictly speaking, phlebotomy may be performed upon all the veins
at the bend of the arm; that, if the  Areins are more projecting and
more distinct in thin than in fat persons, they have also the incon-
venience of rolling more easily under  the skin, and of being  less
fixed ; that, if in fat persons the vein is therefore difficult to  be dis-
tinguished, the compensation for this is, that it is more steady and
someAvhat more  separated from the parts to be avoided; that  they
are all  surrounded with nervous  filaments, and that, therefore, it
would be absurd, in this respect, to prefer one to another.

                       B. Preparations.

  To perform bleeding at the arm, we must procure lancets ;  pre-
pare a light, tepid water, cold Avater, vinegar, or some other A'olatile
liquid; two bands, (bandes,) one about  a yard in length, called the
bleeding ligature, the other nearly three  yards  long, designed  as a
bandage on the limb after the operation ; a small square compress,
folded six or eight times ;  some compresses or pieces of linen to
wipe with; a sheet folded, or a napkin, to protect the clothes of the
patient; finally, a vessel to receive the blood, forceps, scissors, and
a probe  in case of need.
  I. Lancets.  Without being  able to say at Avhat epoch the  lancet
was invented, or who was its inventor,  we at least know that, up
to the time of the dawn of civilization, phlebotomy Avas performed
with other instruments.  The lancet of the present day is composed
of a blade and its handle, (chasse.)  The frame or handle is made
of two slips of shell, pearl, or horn, fixed  upon the heel of .the  blade,
Avhich they embrace by a rivet that goes through all the three pie-
ces.  These two pieces of the handle, which may be made to  turn
and move upon one another, and upon either one of which Ave may
also turn  or  arrest the blade, afford every facility for opening and
cleansing the instrument.
   The lancet, properly so called, terminates in a point which has
given to it the different names by which it is known.  If this point
is Avide, and,  as it  were, blunted by the  rapid approximation of its
tMro edges, it constitutes the barley-eared lancet, (lancette a <*rain
d'orge—Fig.  145.)   When a little more pointed, it makes the oat-
eared lancet, (lancette a grain (Favoine—Fig. 146.)  When still more
pointed, it becomes the pyramidal or serpent-tongued lancet, (lancette
pyramidale ou a langue de serpent—Fig.  147.)  In fine, if the heel of
the lancet goes back considerably behind the  edge of the handle
Avhen opened at a right angle, it takes the title of the Spanish lan-
cet.  The abscess lancet, which Avas formerly used, and which some
persons still  employ for arteriotomy, did not differ from ordinary
lancets  but by its dimensions, Avhich  are nearly twice their size. A 
                BLEEDING, OR SANGUINEOUS EMISSIONS.           239

case called the lancet-case, (lancetier—Fig. 148,) contains the four
or six lancets we have most frequent occasion for.

  (Fig. 145.)           (Fig. 146.)           (Fig. 147.)              (Fig. 148.)
  II. Hour for bleeding. AVhen Ave perform phlebotomy for an acute
affection, we bleed indifferently at almost any hour of the day.  If,
on the contrary, it is for mild diseases, or that the bleedings are
precautionary, in fine, such as are not urgent to be performed at
the moment they haAre been ordered, the morning is generally pre-
ferred.  MoreoArer, it  is proper that the patient should not have
eaten at least for three hours, and that he does not  eat afterwards
for an hour or two.  There is for bleeding,  as  Mre  see, a time of
election and a time of necessity, which the surgeon should not con-
found.
  III. Position of the Patient. We may bleed patients standing, (de-
bout) sitting, or lying.  We do not bleed them  standing, hoAvever,
except Avith the vieAV of more rapidly producing syncope, this posi-
tion being  at the  same time the least conArenient for the surgeon
and the most fatiguing for the patient.  The sitting  posture on a
chair, an arm-chair, or stool, is that  which is  generally adopted
Avhen the patient is not obliged to keep his bed.  In this position
there is every facility for the assistants and  the surgeon ; the pa-
tient has no need evren of removing his dress ; but there results from
it a manifest tendency to syncope, and additional embarrassment
Avhen any accident obliges us to lay the patient on his back.   Ev-
ery person, therefore, whom  Ave Avish to bleed, should be  placed,
by preference, in his bed, either seated or in a horizontal position.
  AVhatever in other respects may be the position that may haAre
been chosen, it is necessary to spread  a napkin  between the upper
part of the arm and the parts of the clothing or of the bed Avhich
might be soiled by the blood.  We afterM'ards roll up the  sleeves
of the patient to near the arm-pit,  so as completely  to uncoAer the
veins which Ave haAe just been speaking of.  If the  limb  should be
found strangulated by the portion of dress thus  rolled up, it is ne-
cessary to rip it, or take it off.
  IV. The ligature,  called the bleeding bandage, is  a   (Fig. ho.)
strip of red flannel an inch wide, and a yard or a yard
and a half long, (Fig. 149.)  Being pliant and suffi-
ciently firm, it  ansAvers very Avell  the  end Ave have in
view; but without admitting that it may in  reality
alarm the patient, that it seriously exposes to the transmission of cer-
tain contagious affections, it is just to  say, that one end of an ordi-
W^^HB>
 
240          NEAV ELEMENTS OF OPERATIVE  SURGERY.

nary bandage may perfectly well take the place of it, and that it
then becomes entirely superfluous.  AArhether, however, we make
use of the  bleeding bandage,  a riband, or the ordinary linen ban-
dage, Ave must proceed in the same  manner in applying it.   We
place the hand of the patient upon the side of the chest of the sur-
geon, Avho fixes it in this spot Avith the upper part of his oAvn arm.
This bandage, then applied by its middle part upon the forepart of
the biceps, at an inch or two above the vein we Avish to open, should
make two turns on the loAver part of  the  arm, and should be tied
by a single bow-knot,  the loop (ansc) of Avhich should rest above.
This band, the purpose of Avhich is to retain the blood in the super-
ficial Aeins, ought not, howeATer, to be so tightened as to  prevent
the arterial circulation and arrest the pulsations at the Avrist. It is
sometimes  placed higher up, sometimes lower down, even to half
an inch from the point Avhere the lancet is to be inserted, accord-
ing as it appears to distend the veins better in one region than an-
other.   AVe  fasten it  only by a single boAV-knot, the two heads of
which hang down and outside the arm, in order to loosen it Avith
more facility, if that should become necessary in the course of the
operation.  When it is arranged, we  bend the patient's arm, and
then place it for a feAV moments in front of his chest.

                       C.  The Operation.

  The surgeon then arranges his instruments. He chooses  the lan-
cet of the shape of the barley ear, if the Aein is superficial  or volu-
minous, or he is apprehensive that he shall  not properly hit the
moment of elevating  the lancet, (ou s'il craint de ne pas  executer
convenablement le temps d'elevation de la saignee.)  On the contrary,
he uses the oat-eared  shape lancet, when the veins  are less appa-
rent  or deeper, and Avhen he has been  much practised in bleeding.
The  serpent-tongued is scarcely ever  now employed, and Ave no
longer use in France the Spanish lancet. Opened at a right angle,
or at one that is a little obtuse upon its handle, the .lancet is imme-
diately carried up to and placed betM^een his lips by the extremity
of its handle, so that its point is turned towards the arm  that Ave
are about to bleed.  Returning to the  patient, the surgeon  extends
his fore-arm, examines its vessels, makes some friction from below
upward along the course of the veins, assures himself by the aid of
the finger of the position of the artery, and of the tension of the ban-
delette of the biceps, and endeaArors to find if there exists or does not
exist  any vascular anomaly in front of the elboAv.  He then fixes
the hand of the  patient between his chest and the upper part of his
arm, in the hollow of his  axilla, that he may embrace the patient's
elbow Avith his hand on this side, placed downwards in a supine
direction, so as conveniently to stretch the integuments in the bend
of the arm.  He may also, by holding his hand in a state  of half-
pronation, fix the vein with his thumb while his fingers are spread
over  upon the elbow.   It is with his left  hand  that he  thus
supports the right arm, whilst it would be with his right hand that 
BLEEDING, OR SANGUINEOUS EMISSIONS.
241
ne would fix the left arm,  so  that we use our right hand to bleed
the right arm and our left hand to bleed the left arm.  On the sup-
position that the surgeon is not  ambidexter for this operation, and
that he would be obliged to use his right  hand for both  sides, he
should place himself outside, with his back towards the head of the
patient Avhen he  is to bleed in  the left arm.  Then carrying in-
wardly the right hand that holds the lancet, to bring it from the
chest towards the bend of the arm, A\diil_ the left hand extends and
fixes the fore-arm, he Avould succeed nearly as well as by the other
method.
  I. The Operative  Process, (manuel operatoire)  The arm being
fixed, and the vein to be opened properly chosen, the surgeon takes
the lancet, which he held in his mouth, and embraces  it at its heel
betAveen his thumb  and his first two fingers half-flexed. Obtaining,
then, by means of his two other  fingers, a point d'appui on the in-
ner part of the elbow, he then, by forcibly flexing his fingers, draws
back the heel of the lancet towards the palm of his hand ; then, by
a movement of extension, he quickly carries its  point  into the ves-
sel by an angle more or less acute and a puncturing motion, (Fig.
150.)  The absence of resistance, the appearance of a small drop

                            (Fig. 150.)
of blood, and a sensation impossible to describe, soon prove to him
that the  anterior wall of the vein is passed.  Then elevating his
wrist, he pushes the anterior edge of the lancet towards the oppo-
site side and withdraws it in an upward curvilinear [or oscillatory]
motion, (mouvement d'elevation et de bascule.)   These tAvo motions,
also, are  so quick, and so completely involved in each other Avhen
the bleeding is well performed, that it is difficult to distinguish them
  vol. i.                       31  * 
242
NEW  ELEMENTS OF OPERATIVE SURGERY.
with the eye.  Perhaps, hoAvever. it would be more convenient
to seize the lancet as Ave would a pen, and plunge it in perpendic-
ularly.
   The puncturing movement, which some persons haATe  recom-
mended to  be made horizontally, Avith the vieAV of avoiding the ar-
tery more completely, and Avhich others direct to be made almost
perpendicularly, Avould render the upward movement, to a certain
extent, useless.  AVhen Ave use the barley-eared lancet, the opening
of the vein  corresponds almost inevitably to the middle of the  incis-
ion in the  integuments.  AVith the oat-eared,  or serpent-tongued
lancet, Ave  should, on the contrary, have too oblique a Avound,  if the
upward movement was not united to that of the puncture.
  The  lancet being Avithdrawn, the blood immediately leaps out.
But if Ave  look to performing the operation Avith all possible  neat-
ness, Ave immediately apply the  thumb upon  the vein below the
puncture, while Avith the other hand Ave shut the blade upon one of
the pieces of its handle, and pass it into a A'essel filled with cold Ava-
ter. Up to this time, the face of the patient should haAe been turned
to the opposite direction, or covered A\dth a bandage.   The assist-
ant approaches, provided  with a vessel to receive the blood, and
presents himself in front of the puncture.  The surgeon noAv, after
having brought the  fore-arm forward, ceases to compress the  A*ein,
and releases, so to speak, the blood, Avhich then jets out  in an arc
to a certain distance.  If every thing goes on well, he holds the fore-
arm with his right hand, and the lower part of the upper arm with
his left hand, Avhile the patient holds, presses, or turns in his hand,
either a roll of linen, a box, or lancet-case.  By this position,  the
surgeon is enabled to preserve the parallelism between the Avound
of the A^ein  and the wound of the integuments, by increasing or di-
minishing the pronation of the hand of the patient, and by draAving
the skin  to the radial or  ulnar side, according to the indication.
He may also, by  untying  the knot of the  bandage with the left
hand, increase the compression, if the venous circulation does not
seem to be sufficiently excited, or diminish it, if the blood encoun-
ters too much obstruction in the course of the artery.
   [Bleeding in the Arm. Dr. Mott is in the practice of drawing the
attention of the operator to the importance of tying the arm some-
what higher up than is generally adopted, so that the bandage shall
press upon  the swell of the biceps and give an opportunity for the
median veins to be fully distended.  By this means, Ave procure a
more perfect distension of the branches Avhere the puncture is  to be
made.   He also is in the habit of forcing the point of the lancet
(which should neither be too acute nor broad, but of a medium an-
gle on  a long curve) into the vein by a firm,  sIoav, graduated
pressure, rather than by a  sudden sweeping plunge, or puncture as
hastily practised by some, who may thus divide the vein through
and through, if not also an abnormal arterial branch concealed be-
low, and thus cause great if not dangerous mischief by extravasation
into the tissues, a false, circumscribed, or diffused aneurism, &c., re-
quiring often amputation.   There is no necessity, Avhatever, of bur- 
BLEEDING, OR SANGUINEOUS EMISSIONS.
243
ry, if the lancet is sharp and the vein firmly fixed by the thumb of
the left hand, be the integuments ever  so thick or tough.  Also
this cautious method is eminently important  in fat persons, where
the Arein is deep-seated in the  adipose tissues, and Avhere Ave must
often grope our way by the touch or feeling only. Here, too, in such
persons, there is this  compensating  advantage, that  the cutis is
usually thin and delicate,  and easily punctured.  The left hand of
the surgeon should, by long  practice  in early life in the dissecting
room, be made as familiar, if possible, with the handling of instru-
ments  as the right, for it is,  in the opinion of Dr. M., the true  and
safest, and certainly the most  professional mode, to use the left in
bleeding the left arm of the patient.  The hand of the patient should
be held, before and after the operation, edgeAvise; that is, the thumb
fronting upward and the fingers grasping around the upright spoke,
for example, of  the  back of a chair Avhich  is firmly fixed.  The
grasping fingers  may be kept in motion, squeezing, as it Avere, the
round  piece of Avood they embrace.  The arm  should be held slightly
flexed, because it is easiest for the patient, and therefore least likely
to be changed, and it is also the best position for securing a full flow
of blood.—T.\
   II. Quantity of blood to be drawn.  We draw in this way from
three ounces to three or four  pounds of blood, and it is  rare that
Ave wish to take less or more.  An ordinary bleeding is about ten
ounces.  The surgeon, moreover, is to direct  whether there is to be
abstracted a greater or less quantity.
   III.  Palettes.   The ATessel which is  to  receive the blood may be
a plate, saucer, Avash-basin, dish, &c.; but to ascertain with more
certainty  the quantity  taken, vessels have  been contrived which
bear the  name  of palettes or poelettes.  As these vessels, which
contained three ounces in the time of Dionis, have generally noAV
a capacity of four, errors on that account  might occur  in prac-
tice, if Ave did not take the precaution to prescribe  bleeding by
ounces rather than by palettes.
                                There  are  found in hospitals  a
        __(Fig-151)            kind of porringers, containing about
                             twenty ounces, Avhich are divided by
                             four or five circular grooves, (Fig.
                             151,) indicating so many palettes of
                             four ounces, so that without chang-
                             ing the vessel we may know Avhen
there has been drawn either one, two, three, four, or five palettes
of blood.
   IV.  Closing the Vein.  To  close the  vein, the  surgeon having
untied the ligature, immediately applies the  thumb upon the punc-
ture, or a little below it;  replacing the hand of the patient under
his armpit, as at the commencement  of  the  operation, he causes a
vessel to be brought filled with tepid water; then wipes the parts
soiled with  the blood, first with a  wet, then with a  dry  linen.
This being done, he takes the small square  compress, and quickly
adjusts it  upon   the puncture in place  of his thumb.  [Dr. Mott
 
244
NEAV ELEMENTS OF OPERATIVE SURGERY.
prefers a small pledget of lint next the Avound, and then the com-
press.  The lint is softer and more delicate, and less irritating, and
is more likely to remain adherent if the bandage should become
displaced.  A strip of adhesive  plaster is preferable  to a band-
age.__T]  I have always found  it better, in this  case, to draw
with the  left thumb the upper lip of the Avound a little outward,
Avhile compressing also the vein, at the same time that with the
right hand Ave apply the  compress from below  upAvard,  to force
upAvard the lower lip; relaxing then the first lip, we  see it rede-
scend and place itself in contact Avith the other lip;  from Avhence
it happens that they have  no longer any tendency to separate, and
that immediate reunion is  almost certain.
  Moreover, it is important that the pressure exercised by the left
thumb in such cases should be above the  commencement of the
branch which connects the median veins Avith the deep-seated veins
in the bend of the arm.   AVithout that, the blood Mrould continue
to flow, and might alarm the young surgeon.
  The thumb, placed on the  square piece of linen, maintains  the
compression, Avhile with the  right hand the surgeon surrounds the
region Math a figure of 8, the crosses of which correspond to  the
puncture, and which  is tied  by a knot outside, or fastened by pins
above the outer condyle.  The forearm, which has been gradually
placed in a state of flexion during the  application of the bandage,
is then brought in front of the patient's chest, or a scarf is arranged
to hold it.  It should be kept thus Avithout  moAdng for twrenty-four
hours.  At the end  of this  time, the  small wound is generally
united, and it is only for extra precaution that AAre sometimes leave
on the bandage till the day after.   AVe must not, however, forget
that it is from neglecting to  keep the  elbow properly at rest, that
the  wound  in many persons becomes inflamed, and the source of
serious accidents.
  [Some surgeons are in the habit of  using  special bandages,  ex-
pressly woven for tying up the aim  with.  Such are about  an
inch in width, and are  made elastic by the threads of caoutchouc
interwoA^en Avith them.  They are always  fastened by pins,  and
their  elasticity completely adapting itself Avith  a more uniform
pressure  to slight movements at the elboAv joint, prevents the turns
of the bandage from slipping or becoming displaced, and renders
the injunction of rigid immobility, Avhich is  often unpleasant and
annoying to  the patient, not so imperative.  Dr. J. K. Rogers, of
this city, prefers these bandages.—T.~\
  V.  Cleansing the Lancet Standing by the side of his patient, the
surgeon now coolly wipes his lancet, and shuts it up.  This instru-
ment should never be cleaned in hot water, Avhich might rust it or in-
jure its temper.  This is a duty, also, which should not be confided
to any one.  The lancet being turned upon one of the blades of the
handle, is first Aviped on one of its sides, always from its heel to its
point, and Avith fine linen.  It is  then  turned upon the other blade
of the handle, the latter itself having been previously wiped, that
we may cleanse the other side, and afterM^ards dry also the second 
BLEEDING, OR SANGUINEOUS EMISSIONS.
245
(Fig. 152.)
_________!
blade of the handle as was done Avith the first.  We succeed full
              as well, also, by pressing the  lancet,  completely
              opened, on fine linen betAveen the thumb and finger,
              provided  Ave take care  to suspend the pressure
              whenever the point of the instrument, drawn by the
              other hand, arrives between the fingers.
                After this cleansing, the lancet is  replaced in its
              small case of shell, silver, gold, or silver gilt, knoAvn
              under the  name of the  lancet-case,  (lancetier) and
              which,  as  in this figure,  (Fig. 152,) may be  made
              to end beloAV in a kind of scarificator.   It is true,
              hoAveArer, that most  surgeons at present dispense
              with this article, and carry their lancets in the folds
              of their instrument-case.
                   D. Difficulties in Bleeding.

   Simple and easy as bleeding in the bend of the  arm in appear-
ance is, it is, nevertheless, sometimes  a delicate and Arery embar-
rassing operation.  Its difficulties depend upon many causes.
   I. Intractability of the Patient  Children, and even adults, cannot
remain tranquil from the moment we  bring the lancet near their
Areins,  and suddenly jerk back the arm as soon as they feel them-
selves touched by the instrument.  By long habit and much address
we overcome this  difficulty, by  keeping the eye  and instrument
steadily upon the retraction of the limb, and thus, to a certain ex-
tent, perform the operation Avhile following the movement.  But a
more certain process, and Avhich  I have often  succeeded Math, con-
sists in keeping the elbow firmly fixed upon  the knee, previously-
elevated  by means of a stool, or upon the chair of the patient, while
Ave hold also his hand and forearm in the manner mentioned aboAre.
It  is then almost impossible for him to  change the position  of his
arm, and the surgeon  is  Avholly at liberty, if he  is Avell  assisted,
to open the vein as he wishes.
  II. The Vein  over the Artery.   At other times bleeding  presents
difficulties, because the only A-ein Avhich is apparent is  that which
corresponds to the artery; for example,  the median basilic.  In this
case we  sometimes succeed by pronating the  hand of the patient
in order  to force the "artery a little deeper within the tendon of the
biceps, and separate the A^ein  from it,  the vein in that case being
immediately raised up by the aponeurosis. If this movement should
not produce  a sufficient  separation to inspire  confidence, it Avould
be necessary, in case the vein was large and superficial, to .puncture
it by applying the lancet flatwise and horizontally.  Some persons
have devised Tor this particular case a very sharp-pointed lancet,
Avhich has but  one  cutting edge like that of a  bistoury, and Avhich
is to be inserted very obliquely, taking care to keep its back toAvards
the side  of the artery.  But besides that this requires a special
instrument for the purpose, Ave must be con\dnced, from the least
reflection, that it would not be free from danger.   The only Avay, 
246           NEW  ELEMENTS OF OPERATIVE SURGERY.
then, in such cases, is to look for another vein, or to have recourse
to the address of a professed bleeder.
   III. The veins are  sometimes  so deep that  they cannot be distin-
guished through the skin but Avith  very great difficulty.  AA7hen
that is  oAving to their absolute diminutiveness, Ave must seek for
others.  If, as is so often seen among the Avomen of Turkey,  Asia.
and all Africa, the embonpoint of the patient is the cause of the dif-
ficulty, Ave are generally enabled, proAdded the ligature is properly
tightened, and we carefully press the  different points at the bend
of the arm Avith the pulp of the finger, to distinguish  one of the
median  veins—for example, the median cephalic—under the form
of a tense elastic cord, and Avith a blue line Avhich is Adsible through
the skin.  As in this ease the Aein is  completely surrounded Avith
fat, the  surgeon punctures it Avithout  the fear of  its gliding  from
under the  instrument, and proceeds to plunge in the lancet to a
certain depth, to procure the quantity of bood desired.
  Sometimes, also, the Aeins are but  slightly Adsible in consequence
of the emotion the patient experiences, and the enfeebled state (etat
maladif) he finds himself in.  In this case Ave have recourse to im-
mersion of the limb in hot water, keeping it there for a greater or less
length of time, which, however, has the disadA7antage of reddening
the skin, and masking in some degree the track of the  A'eins.  In
other cases we use gentle and repeated frictions on the forearm, or
make the patient move his fingers, or Ave leaATe the ligature on for
a quarter or half an hour.  If  all this  does  not succeed,  and the
indication of bleeding is  imperative, Ave search for another A*ein.
  IV. The blood dont flow or flows badly. Another difficulty in bleed-
ing is, that the vein being opened, there is  some obstacle to the
floAV of the blood.  This  depends  sometimes upon the  ligature
being either too tight or too loosely applied.  The cause of the diffi-
culty in such cases* sufficiently points out its  remedy.  Sometimes,
also, it is the dress Avhich  strangles  the limb in the manner of a
Second ligature above the first.   All that is  required in  that  case
to remove the difficulty, is to loosen or  divide (dcbrider) the portion
of dress in question.   A flake of fat  sometimes protrudes  into the
incision in the integuments ; it  is to be thrust back Avith the head
of a probe, or cut off by the scissors.
   V.  Sometimes, also, the incision is in reality too  small; the sur-
geon ought then, Avithout hesitating, to enlarge it forthwith.  AVith
the oat-eared lancet, we sometimes  make  an opening in the vein
larger than at the skin;  in this case  Ave must immediately replace
the point of the instrument into the puncture, and divide the tegu-
ments by finishing the upAvard movement of the operation of bleed-
ing.  On the supposition, also, that the vein  Avhich is opened may
be too small, we must immediately proceed to another bleeding  it
is possible, also, that there may not be a perfect coaptation (paral-
lelisme)  between  the opening of the  skin and that of the vein • Ave
then successively draAv the opening in the integuments in different
directions, until  it meets that  in the vessel.  If this  conjunction
should appear impossible, we puncture the vein in another place. 
BLEEDING, OR  SANGUINEOUS  EMISSIONS.
247
  YL  If the flow of blood  should be impeded by the debility of the
patient, we should have recourse  to frictions upon the track of the
veins,  slight  strokes (secousses) or slaps (chocs) upon the front part
of the forearm, or make the patient flex  his fingers.   In certain
cases the blood does not run because the patient is on the point of
fainting, or is  seized Avith  some cerebral affection, or other condi-
tion, Avhich arrests or considerably retards the venous circulation.
Here Ave have no other resource than to wait for the  restoration
of the functions of the heart.
  VII. Patients who  have  been  frequently bled,  sometimes have
the principal veins in the  bend  of the  arm riddled (criblees) with
cicatrices.  This condition of the  parts not only often conceals the
vessel, but also is attended  Avith the disadvantage of flattening it,
diverting it from its natural course,  and even sometimes of oblite-
rating it.  It Mrould be idle  to suppose that the same process Mrould
answer in all cases to surmount the difficulties resulting from this
peculiarity.  If the vein is really obliterated, which is generally
indicated by its abrupt disappearance above the cicatrices, we must
puncture farther doAvn.  When the  calibre of the vein is preserved,
there is no difficulty in bleeding above.   We may then  also  easily
puncture below, or with more advantage upon the cicatrices  them-
selves, because,  from their being less  moA'eable, the A~ein,  when
once recognised by the finger, is for the most part easily divided.
   [Another serious   and  unforeseen   difficulty  might  be  found
in the  cicatrix.  Thus, Dr. Mott mentions a  remarkable  case,
Avherein a prolonged  and  painful neuralgia at  the bend of the
arm, from bleeding, in a lady, Avas  not relieA'ed until a small fila-
ment  of nerve, that  had been caught  as  it were, or wedged into
the firm texture of the cicatrix Avhile the latter was consolidating,
Mras actually dissected out of its imprisonment.  Where, therefore,
a cicatrix or many of  them exist, and  unconnected Avith any neu-
ralgic pain in the part, there would, a fortiori, be still greater safety
in making the aperture in that point, so far as concerned the  possi-
bility of causing the accident Ave  have  named.—T.]

                   E.  Accidents from Bleeding.

  Though trifling in appearance, the operation of bleeding is  not
the less exposed to numerous accidents, such  as, dry bleeding, (la
saignee blanche) thrombus  and ecchymosis, syncope, inflammation
of the  neighboring tissues,  lesion of the lymphatics, puncture of
the fibrous or nervous tissues, and phlebitis.
  I. Missing the Vein.   AVe say that a surgeon has made a saignee
blanche* [literally, white bleeding,] when the puncture he has made
in the  arm is not followed by a flow of blood.   This accident may
arise from our having wished to puncture a vessel that was too
deep or too rolling, (trop roulant) or badly supported, or  from the
  * [We think a saignee secke, or dry bleeding, would be more expressive, if sarcasm is
intended upon the blunder or faux pas.— 7'.] 
21S
NEW  ELEMEN1S  OF  OPERATIVE SURGERY.
 skin itself being flabby, or the bend  of the arm badly .lighted, or
 from the patient having made an unexpected movement, or, in fine,
 from some one of the difficulties which I have  before enumerated.
 Sometimes, however, the blood does  not run, though the vein has
 been opened.  I have already remarked above, that  syncope, a
 vivid emotion, or a  lesion of the  brain, were ordinarily the cause
 of this last mentioned accident.  AVhen the saignee blanche is OAving
 to the Arein not having been touched, we must, provided Ave can
 distinguish the vessel at the bottom of the puncture, immediately
 have recourse again to the lancet, and  open it; in the contrary
 case, and should this prove difficult, it is  better to puncture the
 same vein, or another vein, upon a different point.
  II. Thrombus.  If there should  occur effusion of  blood betAveen
 the teguments and vein to such extent, before the bleeding is over,
 as to cause a sluggish tumor to be formed, in  shape of a bump,
 (bosselwe) of Avhich the small wound represents  the apex, it  is
 called a thrombus.   This accident is  OAving to  the parallelism be-
 tween the Arein and tegument having been disturbed; in some cases
 it prevents us from taking the quantity of blood we  desire.   If the
 surgeon notices it in time, he brings the two punctures together as
 exactly as possible ;  if that should not be sufficient, and the blood
 should stop running too soon, Mre  should  havre to choose betAAreen
 dilating the wound Avith a lancet, and a  neAV puncture, either on
 the same  arm or the other; but, unless Ave should be perfectly
 sure of succeeding by the  first course, it would be more advisable
to adopt the other.   After the bleeding, whether it has  been per-
fectly effected or not, the thrombus acts like any other effusion of
blood in the cellular tissue ; that is, it insensibly disappears by ab-
sorption, and  need  never cause any uneasiness. AVe promote its
resolution by covering it AAdth a graduated compress saturated Avith
a resolving liquid, as, for example, a solution of common salt, lead-
water, or brandy.
  III. Ecchymosis means  a  livid or  bluish spot Avhich appears
around the wound,  and  sometimes to some distance above and
below it, upon the  second or third day after the bleeding.  This
has no other  inconvenience than that of  leaA ing, for the space of
from six to twelve days, the appearance of a bruise in the bend of
the  arm; it is an accident Avhich does not require any treatment.
  IV. Syncope.   Many patients -are seized with  faintness, (lipothi/-
mie) or fall into a complete syncope, before having lost the quantitv
of blood Ave wish to  take from them.  Timidity, or  some idiosyn-
crasy and peculiarity of constitution, are often the cause  of this
accident.
  Syncope is  promoted by a  large opening of the vein, and by the
erect position of the patient;  it occurs, also, from the individual
haAdng eaten but a  short time before, or from his havin°- been
seriously put  out of humor by some unforeseen circumstances.   As
soon as it  happens, Ave  must place the thumb on the puncture  laAT
the  patient in a horizontal position, and throAv cold water or vine-
gar and water upon his face; if after some  minutes he comes to 
BLEEDING, OR SANGUINEOUS EMISSIONS.
249
himself, and we  have not yet taken a sufficient quantity of blood,
Ave release the vein in order to continue the bleeding; in the con-
trary case, we remove the ligature to proceed to the dressing of the
Mround, and the employment of the different remedies used in syncope.
  V. Lesion of the Lymphatic Vessels.  Some surgeons pretend that
after bleeding there may take place an  exudation  of lymph from
the puncture ; that in fact the puncture itself may remain fistulous.
This, in my opinion, is, if I am not deceived, an imaginary accident,
to whose  account probably has been placed some other kind of
wound; but it is not the less true, that bleeding is  sometimes the
cause of disease in the lymphatics, and of angioleucitis, character-
ized by certain red lines Avhich extend from  the puncture  towards
the axilla or the hand, and by the  painfulness  (endolorissement) of
the supra-articular and axillary ganglions, and which takes place at
the expiration of some days, as a consequence of bleeding, as well
as from any other wound.
   ArI.  Puncture  of the  Nerves.  The ancient authors  attribute nu-
merous accidents from bleeding, to wounding the nerves in the bend
of the arm.  It  might in fact be possible, in performing this opera-
tion, to puncture the branches of the musculo-cutaneous,the internal
cutaneous, or possibly even the median nerve; but the inflamma-
tions, the  gangrene, and death even, said  to have followed this kind
of lesion,  must obviously be ascribed to something else:  Avhat has
been written upon puncture of the nerves,  has rather been predi-
cated  upon preconceived opinions  than  upon well-recorded facts.
At present it is so rare to see accidents after bleeding which cannot
be explained Avithout calling to our aid the puncture of the nerves,
that no one scarcely any longer speaks of these kinds of wounds.
Nevertheless, if, after a  puncture  of the lancet at the bend of the
arm, there should supervene violent pains,  conAoilsions, or tetanic
symptoms, as has been asserted, and without our being enabled to
refer them to some  particular inflammation, Ave should cover the
limb Avith compresses saturated with decoction of marsh-mallows,
or with emollients sprinkled Avith tincture  of opium, or wet them
two or three times a day with some narcotic liniment, at the same
time that we should  give  internally calming and  anti-spasmodic
drinks : the section of the nerve would not be allowable until after
the trial of these remedies.
   [Dr. Mott  has met with a  number of cases of  neuralgia from
puncture of the  nerves in bleeding  at the bend  of the  arm.   In the
case of his, related a feAV pages above, the neuralgia not only super-
vened immediately after bleeding, but was afterwrards  increased
by the traction upon a filament of the nerve  imprisoned in the inci-
sion Avhen cicatrization took place.—T.]
   VII. Puncture of the Tendons. Formerly they attributed to punc-
ture of the tendon  of the  biceps, or of the aponeurosis, almost all
the accidents Avhich occasionally follow bleeding ; but besides that
this puncture is  difficult in ordinary cases, we know at the present
time that  it could not produce the dangerous consequences that are
imputed to it.   Who, in fact, does not perceive that  the puncture
   vol. i.                      32 
250
NEW ELEMENTS OF OPERATIVE SURGERY.
of a tendon or aponeurosis, or that the puncture, or even section
of some of the nervous filaments in the neighborhood of the veins
of the arm, could not of themselves cause the least degree of danger.
[This remark of the author, as is seen by the grave neuralgic symp-
toms Avhich are mentioned aboAre, as occurring in the practice of
Dr. Mott, from implicating a filament of nerve in  the bend of the
arm, and requiring the exsection of the filament, must  be taken
Avith some  allowance.—T]  All that we may say on this head, in
favor of the opinion of the ancients, is that a punctured nerve, apo-
neurosis, or tendon, may give rise to inflammation in the lamellated
cellular tissue, which is reflected upon or surrounds them, and thus
become the source of serious inflammation.
  VIII. Inflammation of the Wound. If the lips of the puncture havrt
been properly brought together, if the limb has remained unmoved.
and the compression has not been too great, the Mround from bleed-
ing is almost always united at  the expiration of twenty-four hours.
[We have repeatedly seen it in healthy, robust subjects, and once
eA*en in a delicately formed female of 80  years,  perfectly  united
m the space of four hours, so as to  alloAA^ the bandage to be remoATed
a ith safety.  In one case recently, it  Avas effected in three hours
ifter taking a pint and a half of blood.—71.]  On the contrary, the
aeglect of  these precautions, and the employment of a soiled lan-
cet, expose the Mround to the risk of inflammation and suppuration.
  AVhile the edges of the puncture only are red, SAVollen, and pain-
ful, there is no danger, and the  application of simple dressings or
emollient cataplasms, and afterAvards, at the end of tAvo or three
days, a diachylon plaster, suffice for the cure.
  If, on the contrary, this condition of things  is accompanied with
engorgement of the subjacent tissues and a  certain degree of tume-
faction, it may,perhaps, be the commencement of aformidable disease.
  IX. Erysipelas.  Bleeding, like every other species  of AAround,
sometimes  causes simple erysipelas, Avhich is recognised by its or-
dinary appearances upon the skin.  Unfortunately, the  erysipelas
it  most frequently  occasions is of the  phlegmonous kind.  This
rarely occurs before the expiration of two, three, or four days, and
its usual cause  is a simple inflammation of the edges of the Avound.
The patient then complains of pain, heat, and swelling in the bend
of the  arm ; the tumefaction, as  in every other phlegmonous ery-
sipelas, occupying  chiefly  the sub-cutaneous tissue, and extending
itself to a greater or less distance upon the arm or fore-arm.  The
treatment of this erysipelas should be energetic and prompt. If the
affection is yet in the condition of a small phlegmon, emollient cat-
aplasms and the expulsion of the pus by pressure might, in the be-
ginning, suffice. At a more advanced period, it Avould be necessary
while continuing these means, to recur immediately, if there existed
a  purulent  collection,  to  methodic  compression,  associated Avith
resolvent fomentations, or even to the application of a number of
leeches.  The employment of numerous incisions would be prefera-
ble only Avhere there existed purulent collections with a separation
of the teguments.   On the supposition that neither compression nor 
               BLEEDING, OR  SANGUINEOUS EMISSIONS.           251

leeches Avere desirable, we might make trial of strong mercurial
unctions.
  X. Phlebitis. In place of puncture of the nerves or tendons, mod-
ern surgeons have introduced inflammation of the veins.  It is cer
tain that  bleeding  may, and often does, in fact, occasion purulent
inflammation of the internal membrane of the punctured vein, and
that, therefore, it may produce all the consequences of phlebitis and
purulent infection—a species of poisoning that rarely fails to prove
fatal to the patient; but I had said, in the year 1825, (Anat des Re-
gions, torn. i.,'art. Pli du Bras) that there had  been attributed to
phlebitis  consequences which do  not belong to it; that is to say,
that persons had characterized Avith the  name  of phlebitis almost
every case of phlegmonous erysipelas, or  of angioleucitis, produced
in consequence of bleeding.  It is important, then, that the surgeon
should endeavor to avoid this confusion, and that he should learn
to distinguish the three diseases which I have just named.  He wall
not err in noting that angioleucitis, before becoming very severe, al-
ready occupies a very considerable space ;  that phlegmonous erysip-
elas is accompanied AAdth extensive, diffused, and, ordinarily, uniform
tumefaction, making the bend of the arm its centre, or prolonging
itself,  in the direction of the axilla, along the groove of the biceps,
in the form of a long caky induration,  (plaque longue) more or less
painful, accompanied with symptoms only of general inflammation ;
Avhile phlebitis is characterized by a dull pain, the sensation of a hard
and knotty cord, and the existence of red patches, (plaques rouges)
irregularly distributed along the course of the veins, and, finally, at
the end of some days, by tremors and symptoms of putrid feA^er.
  In short, Ave must  recollect  that, in such cases, as in all others,
phlebitis may be external, that is, occupy only the exterior envelopes
of the A'ein;  internal, haAdng for  its seat the internal  coat of the
vessel; or complicated, Avhen formed by the  union of the tAvo pre-
ceding varieties.
  It is external phlebitis, more especially, which has been confound-
ed with phlebitis properly so called, though it belongs rather to phleg-
monous erysipelas ; and it is especially internal phlebitis which is
dangerous, because of the pus Avhich it may infuse into the blood.
  The causes of phlebitis are sometimes impossible to determine ;
it is true, that a dull-edged or dirty lancet, or a  repetition of punc-
tures, and which tear  rather than cut; also,  that a bad dressing
and improper movements of the  patient in the  first twenty-four
hours—in fine, that every thing which is  capable of disturbing the
union  by first intention of the lips of a Mround, are sufficient to ex-
plain its cause in a great number of cases; but it is also true, that
bleeding, performed  in the  best manner possible, and a puncture
Avith the  cleanest and best prepared lancets, do not always exempt
us from this terrific disease.
   No  remedy has  yet been  found for phlebitis, when it is internal
and has  already become extended.  In the beginning,  and while it
is yet circumscribed, we should have recourse to the  same treat-
ment as for phlegmonous erysipelas ; that is, either to the free ap- 
252
NEW  ELEMENTS OF OPERATIVE SURGERY.
 plication of leeches and emollient cataplasms, a properly adjusted
 compression, strong mercurial  frictions, or temporary (volant) blis-
 ters, sufficiently large to extend beyond the limits of the inflamma-
 tion.—(See Introduction, supra.)
   XI.  Wounds of the Artery.  Another accident, Avhich may happen
 in performing venesection, is the puncture of the artery.   This oc-
 curs either  from some sudden movement of the  patient, or from
 some anomaly in the  A'essels, or because the  humeral artery is too
 closely united to the  vein which it had been thought advisable to
 open, or, in fine, from the  aAvkAvardness of the surgeon.   As soon
 as the artery is opened, the blood issues out with force, and in suc-
 cessive jets, (per saltum)  and immediately assumes, in the basin, a
 red color, and a lively and frothy appearance.  As, however, there are
 individuals whose blood, as they themselves  describe it, is full of
 life, (vif) and in whom a simple puncture of a vein is succeeded by
 that leaping motion, and a flow of blood of a highly red color, we
 must not rely exclusively on the appearances mentioned.
  We may ascertain Avith  certainty if the artery has been wounded,
 by compressing  the vein immediately below  the puncture Avith a
 certain degree of force.  If the blood  is  arrested by this pressure,
 there is nothing to fear, the Arein only is opened.   If, howeA'er, its
jet thereby becomes stronger, it is an additional reason for belieA*-
 ing that there is a Avound  of the artery ; it could, hoAvever,  happen
 that a communicating branch between the deep-seated and super-
 ficial veins might deceive  us.
  All doubts Mall be removed by shifting the  pressure to the inside
 of the arm and above the elboAV. By this mode, in fact, if the artery
 is wounded,  the  blood will be stopped, change its  character, and
 cease to leap out in curved jets;  Avhile  in the contrary case, the
 stream Avill  pursue its  ordinary course.   Moreover,  as  it might
 happen, also,  that  an abnormal division of the brachial artery-
 might be found at some other points than those of its ordinary track,
 it Avould be  necessary, before  pronouncing definitively, to make
 pressure in this manner successively upon the inside and the outside,
 and on the middle part of  the front and lower part of the arm ;  or
 better still to make the first compression in the-hollow of the axilla
 against (contre) the inner  side of the  humerus.  It  is for Avant of
 taking all these precautions that some  surgeons, alarmed by  some
 of the symptoms above described, have thought they had punctured
 an artery, when the A*ein  only had been opened.  It is in this Avay
 I haAre seen  some practitioners lose their self-possession, and aban-
 don their patient, because they  had observed that the blood leaped
 out in jets, though  they had punctured the basilic Axdn below the
 artery; and others become alarmed in  the same Avay, because, not
 reflecting that they had made pressure below the deep-seated me-
 dian vein, they attributed  to a wound  of the  artery the continua-
 tion of the floAv of venous blood.
  Should, however, this accident happen, the surgeon ou^ht so to
 conduct himself, if he can, as to maintain his self-possession suf-
 ficiently not to betray his fears to the patient.  We must say to 
BLEEDING, OR SANGUINEOUS EMISSIONS.
253
the patient that his blood is highly vitalized or inflamed—that
this is a reason Avhy much should be taken from him ; in tranquil-
lizing him, we must place him in such a position as to permit the
blood to run until it has nearly caused syncope, if the constitution
or health of the individual do not present objections.  To arrest the
blood in such cases, we must make upon the  puncture a circum-
scribed and much stronger pressure than for ordinary venesection •
we therefore form, by means of small graduated compresses, a sort of
pyramid, whose apex should rest on the wounded region, and which
should be fastened by means of a figure of 8 bandage, and afterwards
by a roller extending from the wrist to the armpit.   Formerly this
compression was effected by neatly enclosing in  a piece of paper or
linen, a solid plate, or a sou, for example, Avhich Avas then slipped
betAveen the folds of the  graduated compress.  We justify these
precautions in the eyes of the patient, by telling him that if his arm
were less securely bound, the heat and activity of his  blood, and the
Advacity of his constitution, might expose him to the danger of hav-
ing the wound reopened.  We afterAvards frame reasons  to induct
him to support this dressing from eight to fifteen days,  and even t<
haAe it reapplied if there should be danger of its becoming displaced
   In case the hemorrhage does  not reappear, we may possibly in
this  case  effect a  cure of the  wound in  the vessel.  No one,
however,  at the present  time,  admits that  this Avound can  be
cicatrized without obliteration of the  calibre of the  artery.  It is
nevertheless  true, that in two  cases  that were admitted into the
hospital of La Charite, in 1836, in consequence of puncture of the
brachial artery at the bend of the arm, the cure Avas accomplished
Mdthout the pulse ever having  ceased to beat  in any point of the
Avhole extent of the  forearm.  I may add, that  similar facts have
been noted by a surgeon of London, Avho in one  case had an oppor-
tunity of proving, by dissection upon the dead body, both the actual
cure of the former wound, and  the preservation  of the calibre of
the Aressel.   It is neAertheless true, that, after the remoAral of the
bandage, and even in spite of the bandage, and  in the very first
days, there Avill be found  either a primary false  aneurism, or one
by infiltration, or a circumscribed false aneurism, or a varicose ane-
urism, (un aneurisme  variqueux)  and that from that moment there
is no longer any other resource than the ligature of the artery.  (See
Ligature of Arteries.)  We must, however, take care that Ave are
not deceived by  false appearances.  I have seen after  venesection
an infiltration of blood, which, though so large that it occupied the
entire thickness of the bend of the arm, Avas cured without any bad
consequences following, by the  employment of compression and
resolvents,  (resolutifs,) though  every  one supposed  it a  primary
false aneurism.  On the other hand, I have seen the  pulsations  of
the artery produce a thrombus so uniform, soft, and regularly ele-
vated as to  lead to  the belief  of a circumscribed aneurism.   In
another case there was a  purulent collection, accompanied with a
slight degree of pain, which deceived the  surgeon  in the same
manner.   [In extensive practice, especially in  the vitiated consti-
• 
254
NEAV ELEMENTS OF OPERATIVE  SURGERY.
tutions of hospital patients, Ave must not, as the author justly re-
marks, be surprised to find, after the utmost care as to the edge and
cleanliness of the lancet, and  dexterity in the manipulation of it,
that more or less inflammation—rarely, hoAvever, phlebitis or the
forms of erysipelas—Avill ensue.   The inflammation, ordinarily, is
that of the pure  phlegmonous  character from any incised Avound,
but it  is  frequently followed by more  or less suppuration in  the
superficial parts  immediately surrounding  the wound, which must
be treated, as in other cases, by poultices, and afterwards  incision
into the purulent  sac.—T.~\
  I am of opinion therefore that we should, in  every case, treat
this  accident by  resolvents  and methodical  compression,  as if it
Mere really in our power to effect a radical cure, and that Ave must
not resort to the ligature until after having made trial of the other
means  from eight to  fifteen days, unless,  however, there should
supervene some complication of a serious character.
  Bleeding in the Hand.  The veins Me have recourse to, under
such circumstances, are  those on the dorsum of the hand or of  the
forearm.  The  rule is, to puncture that which is the most promi-
nent ; but as the veins which  return  from the index finger and
thumb to form the cephalic, and those  which come from the index
and middle fingers, and from the little and ring fingers, to form the
salvatella, give rise to two trunks  of considerable size, it is com-
monly upon the  cephalic of the thumb, or  upon the  salvatella,
that we perform venesection in  the hand.  In this case it is better,
but not indispensable, to remove the ligature from  the arm, and
place it above the Avrist.  In fact, the puncture of the cephalic
vein of the thumb, or of the  salvatella, is wholly without  danger,
if we take care not to touch the subjacent tendons.  AAe should
more frequently have recourse to this mode of venesection if the
veins in question always presented  a sufficient degree of volume,
were equally apparent in all individuals, and that we alM^ays had
it in our power to abstract from them the quantity of blood desired.
Unfortunately, hoAvever, this is  not always the case, and it is pre-
cisely in persons in Avhom the veins at the bend of the arm  are but
little prominent, that those in the hand  also are smallest.
  Bleeding in the  Cephalic at the Shoulder.   It is in consequence of
this difficulty that it has been proposed, at the present day, to make
an incision of an  inch in length on the forepart of the shoulder in
order to reach the cephalic  between  the  deltoid and pectorali*-
major, at  the bottom of the deltoid grooAe.  But  besides the obiec-
tion, that  in this  case the vein  is  accompanied by the descending
branch  of the  acromial artery, it is situated so deep that it Avould
be more easy, and much less dangerous, to arrive at it by an inci-
sion of  the same  kind in the  external groove of the  biceps at the
distance of three or four fingers width  above the external condyle.

                   § II.—Bleeding in the Neck.

  Aenesection at the neck, employed in the sixth century by Alex-
ander Trallianus, and aftenvards  extolled  by Paul of _Egina and 
BLEEDING, OR SANGUINEOUS EMISSIONS.
255
the Arabs, Avas so much in vogue in the sixteenth  century  that
Thomas Bartholinus professes to have had recourse to it a hundred
times Avith success.  Nevertheless, it is  rare that it is resorted to
at present. AVithout pretending to decide in this place if it be true
that it may have more influence upon  diseases of the head than
bleeding by the arm, I Avill nevertheless  give a careful description
of it.

           A.  The Veins that may be opened in the Neck.

   The Aeins of the neck that are  selected for this operation are the
external and anterior jugulars.
   Situated betAveen the platysma myoides and the cervical  apo-
neurosis, the external jugular descends  obliquely from the parotid
region, into the supra-clavicular depression, crossing,  in a Aery ob-
lique direction, the outer side of the sterno-mastoid muscle ; many
branches of  the  cervical plexus surround it  in  its superior half.
Below, where it  is farther remoAed from nervous  filaments, it
receives many veins from  the shoulder  before it terminates in the
sub-clavian or internal jugular vein.
   The anterior jugular vein, which is often wanting, and Avhich
only attains  to a considerable size in persons  in whom the upper
half of the external jugular is but little developed, descends from
under the chin and lower jaw, or from the face, where it is united
with the facial, obliquely downwards and outwards, to terminate
in the internal jugular vein, a little below the thyroid cartilage.
   The anterior jugular might be punctured, without difficulty or
danger, instead of the external jugular; but as it does not always
furnish the quantity of blood Ave Avish to extract, and  as we almost
always haAe it in our  power to use the external jugular itself, it is
scarcely ever thought of Avhen wishing to draAv blood from the neck.

                        B. Preparations.

   When we propose to perform  venesection upon the jugular, we
must procure  a handkerchief or narrow cravat, tAvo small bands, a
square compress,  some cards,  or  a  grooAe  of metal, and the other
articles of which I have spoken in treating of bleeding at the arm.
Wc may also, as  in this last, place the patient in a chair, but it is
far better to operate upon him in bed.
   I. Compression.  AVe commence by making  pressure under the
point to be punctured.  This pressure may be  effected in different
Mrays. The machines invented for this purpose  are entirely useless.
The most simple  mode is, to place a graduated compress of some
thickness upon the loAver part of the vessel in the supra-clavicular
depression, and to cover it  by the middle of the cravat, or a narroAv
band, whose  extremities are  attached by means of a knot under
the axilla of the opposite side,  (Fig.  153 a) or held  tight in this
direction by  an assistant.   We obtain  the same result by  causing
pressure to be made upon the vein by the thumb of another person,
or by compressing it ourself below the point we wish to puncture, 
256           NEW ELEMENTS OF OPERATIVE SURGERY.

while the skin is made tense above by means of the index and middle
fingers.  M- Magistel, who has published a very good treatise upon
bleeding, sometimes effects this compression by means of a  porte-
cachet "supplied with a pelote ; but  it is evident that the finger of

                            (Fig. 153.)
the operator, or a cravat, or the extremity of a band, or a riband,
passed from the supra-clavicular region to the holloAv of the oppo-
site  axilla, perfectly  accomplish the object in view, while they
interfere as little  as possible with the operation itself.  If the vein
should not be sufficiently swollen, Ave should cause the patient to
move his jaws as in mastication.

                    C. Puncture of the Vein.

  There are, in fact, many reasons for opening the external iugular
in its loAver half,  rather than in the neighborhood of the parotid re-
gion.  First, it is generally smaller above than below; ao-ain, it is
at that part of it near the os hyoides Avhere it is most surround-
ed Avith nerves ; nevertheless, we should not puncture it at the ex- 
BLEEDING, OR SANGUINEOUS EMISSIONS.
257
treme lower part, as it might  then be  difficult to make pressure
beloAV, and the branches of the cervical plexus here again surround
it at this point.  We make  choice, moreover, of the right or left
side, as in the arm, according to the convenience of the surgeon or
patient, or according to the  size or prominence  it presents upon
one  side  rather than upon  the  other.   [A convenient point is
where the vein is  passing over the sterno-cleido-mastoid muscle,
first, because the  vein  can be  rendered more prominent  in  this
point; secondly, because you can here command the hemorrhage
better.—T]
  The patient, having the head and face a little inclined to the op-
posite side,  being properly  supported by  alezes,  and with  the
shoulder a little depressed, the  surgeon, placed on the side of the
bed, stretches the integuments and the vein with the left hand, takes
the lancet in his right, and punctures the vessel with the same pre-
cautions as in bleeding by the arm, except that he makes a wound
a third larger.  Some authors recommend  not to  cross the vein
from one side  to  the  other, for fear,  say  they, of producing a
thrombus in the deep-seated  cellular tissue,  and causing there in-
flammation,  purulent collections, abscesses, &c. ; but these fears
are, it appears to me, without any plausible foundation, and  I do
not believe that there would be any cause for alarm, though we
had found that the point of the lancet had penetrated even to the
aponeurosis of the neck.
  The question also has been discussed, as to the direction that
should be given to the wound.  If made obliquely, from below up-
wards, and from Avithin outwards, this wound  Avould divide, nearly at
a right angle, some of the fibres of the platysma-myoides ; in which
case the puncture  easily remains open, and the blood  flows freely.
Made in an opposite direction, the cut of the lancet M'ould pass be-
tMeen two  bundles  (faisceaux) of the same muscle, and would
make a Meund whose edges would have, as  it is said, a great  ten-
dency to become approximated.  Without denying that there may
be truth in the substance of these remarks, I  ought, nevertheless, to
say, that having sometimes opened the external jugular in one di-
rection, and sometimes in the other, I have never seen that there
was any great difference in the result.   However, I would not ad-
vise the preliminary incision and use of the bistoury, as spoken of
by M. Magistel.

                      D. Flow of Blood.

  As soon as the  vein is opened, and while  the pressure is contin-
ued, the surgeon deposites his lancet in clean water, and receives
the blood directly into a basin, if it issues out in an arc ;  or if, as is
most frequently the case, the blood dribbles out slowly, (coule en
bavant) he places under the puncture the extremity of a card, curved
in the form of a  gutter, to  conduct the fluid into a basin, or  any
other vessel. If, after having begun to run, the blood should appear
to stop, we should cause the patient to have recourse to the move-
  vol. i.                       33 
258
NEW ELEMENTS OF OPERATIVE SURGERY.
ment of mastication, or, at least, we should endeavor to remove the
difficulties which have thus retarded the flow of the blood.
  The  desired quantity of blood being once obtained, Ave remove
the pressure and then  apply the thumb on the puncture, in order to
give time to wash and Mdpe the parts soiled by the blood.  Without
recurring to adhesive plasters, which endanger erysipelas, or to the
suture, which Avould be more painful  than the bleeding itself, Me
apply, instead  of  the  thumb, a small graduated compress, as in
bleeding at the arm.   [Nevertheless, there can be no objection to
adhesive plasters, decidedly the most  to be relied on here, and al-
most in all cases, for dressing of Avounds, to keep the compresses
firmly and securely attached.  Infinitely preferable, we should deem
them, to a folded cravat or kerchief.—T.]
  The best containing bandage in such cases is a cravat, the mid-
dle of which is placed  on the sound side of the neck, crossed on the
graduated compress, and its extremities attached under the opposite
axilla.   On the next day, or the day after, the bandage may be re-
moved.  We must  take care not to make any pressure upon the
air passages.
  E. The accidents to which Ave are exposed in  puncturing the ex-
ternal jugular vein,  are, as in  that of  the arm, the  missing of the
Aein, (la saignee  blanche)  thrombus, puncture of the nenes and
lymphatics, and different kinds of inflammation.  Nevertheless, we
have here neither tendon nor  large artery to disturb  us, but  it is
one of those veins by opening into M'hich many persons think at-
mospheric  air may be introduced into the heart and kill the patient.
It  is for that reason it  is recommended not to remove the pressure
from it until at the moment when Ave apply the graduated compress
to  the puncture, and also that  Ave  should apply this compress from
below upward, before raising the thumb.
  Phlebitis and phlegmonous erysipelas would be attended  here
with yet more dangers than in the arm, because of the neighbor-
hood of the chest and heart.

                   § III.—Bleeding in the Foot.

   Like that of the jugular, bleeding in the foot, so frequently in use
even in the  last century, is noAv scarcely ever employed, notwith-
standing the exertions made by Leroy and Fretau in its faAror. It is
rarely any  longer resorted to but for some congestive  affections of
the head or uterus.  It is, moreover, designated by an incorrect
name, for the puncture is almost always made on the veins of the
leg, and not on those of the foot.

                          A.  Veins.

   We might, in truth, open, in almost  any part  of it,  the great Ae-
nous arcade, which runs  from the roots of the toes to the internal
malleolus, after the manner, in some degree, of the cephalic from
the thumb, and toAvards the external malleolus after the manner ol
the salvatella; but, if we performed venesection upon this, it would 
BLEEDING, OR SANGUINEOUS EMISSIONS.
259
in general, yield but too little blood.  As in the hand, so in the foot,
we do not bleed there, except where we have no other resource.
  The internal  saphena, situated betAveen the integuments and the
tibia or aponeurosis of the leg, is accompanied, also, from its origin
to the knee, by the nerve of the same  name.  It is  iare that Ave
find it behind the malleolus, but almost ahvays situated at its com-
mencement, on the inner or anterior surface of this eminence.
  The  external  saphena, ordinarily of less size than the internal,
and  generally more irregular, is situated at first nearly between
the tendo-Achillis and the  fibula, ascending from thence towards
the ham,  Avhere it  receives, from the upper and posterior half
of the thigh, a long anastomosing branch before  it terminates in
the popliteal vein.  It is likewise accompanied by its nerve of the
same name.

                         B. Operation.

  To bleed in the saphenas, we require a ligature and most of the
oi her articles already mentioned, but we  require, moreover, a suit-
able vessel and hot Avater for a  foot-bath.  This Aenesection  is
more easy in the- evening than in the morning, or in persons that
have taken some exercise than in  those Avho haAe not left their
beds during the day.
  The patient  may be  seated  in a chair or an arm-chair, or upon
the edge of the bed; this last  position is the  most convenient for
all.  AVe  commence by placing the limb we wish to bleed in the
hot AATater up to the beginning  of the calf, in  order to  produce a
congestion in  that  part, and to render the Aeins more prominent.
The surgeon then  arranges his dressings; at  the  end of some
minutes he  removes the limb  from  the bath, examines the veins,
and applies the ligature.  Between the calf and the knee, or above
the knee,  this ligature  produces less effect  than at three or four
inches above the malleoli.
  After having properly compressed  the parts by a double turn of
the bandage, we fasten  this ligature by a knot, outside if it is the
internal saphena vein, and inside if we wish to  open the external
saphena.  We  immediately replace  the  foot in hot water; after
Munich the  surgeon  seats himself in fron* upon a stool, provides
himself Avith an aleze folded four or eight times,  places his  lancet
in his mouth, withdraws the foot of the patient and fixes it upon
his knee, carefully Mdpes it, as  well as  the lower part of the leg,
causes the knee to be held by an assistant, fixes the  vein with the
thumb of the left hand at the point where it appears most easy to
open it, and punctures it (Fig. 154) with the right hand if he ope-
rates on the right leg, as has been said in speaking of the other
modes of bleeding, taking care to make  the opening rather large
than too small.
  AA7hether this vein be opened transversely, obliquely, or length-
wise, it nevertheless gives rise, occasionally, to a jet of blood in the
form of an arc at first, while at other times the blood from the very 
260
NEW ELEMENTS OF OPERATIVE  SURGERY.
beginning runs with difficulty.  If it runs in a jet, we receive it
in a vessel, as in bleeding at the arm ;  but if, what is infinitely
more common, it  escapes  dribblingly, (en bavant) we immediately
replace the foot in hot water, so that the  puncture may be found
at a short distance below the surface of the liquid.
  That the bleeding may not be arrested too quickly, we rub the
part from time to time with the finger, or with linen, with the view

                            (Fig. 154.)
■^^MUkiik
of preventing the formation of clots within the lips of the punc-
ture.  We cause the patient, moreoAer, to move his toes.
  In short, we cannot  in this  manner ascertain but very imper-
fectly, and that by means of the greater or less discoloration of the
Mrater or of the linen  that we place in  it, the quantity of blood
abstracted. "
  When we wish to stop it, we remove  the  ligature, bring back
the foot to the  knee, place the thumb on the puncture, wipe  the
limb with care, remove the foot-bath, apply a  small square com-
press, then fasten it by means of a figure of 8 bandage, which
surrounds the tarsus or the instep by its  anterior loop, and  the
lower part of the leg by its upper loop ; the figure of 8 being ter-
minated by one or two turns and a double knot or pin on the side
opposite to the wound.  It is this bandage which Ave designate
under the name of stirrup, (etrier)
  C. Accidents from bleeding  in the foot are almost all referable
to a wound of the saphena nerves.  AVe  cannot, in  fact, wound
the arteries but in consequence of anomalies difficult to foresee
  The size of the internal saphenus  nerve, and its intimate rela-
tions with the vein, are such that it  is almost impossible to avoid
it.  Though many accidents imputed  by Sabatier and others to the 
               BLEEDING, OR SANGUINEOUS EMISSIONS.            261

wounding of this nerve, may be referred to inflammation  of the
lymphatics, or of the sub-cutaneous cellular tissue, if not to that
of the vein, it is difficult, hoMever, not to admit that puncture of
the nerves of the  leg has been sometimes followed by accidents
of a serious character.  The  symptoms, as in the  arm  and neck,
would be pain, convulsions, &c.  For these, also, we must use simi-
lar remedies.  Erysipelas, and all other kinds of inflammation, are
infinitely more easy to control when  they  are the result of this
kind of venesection than of the others.  But an accident which is
peculiar to it, is the puncture  of the periosteum and the breaking
of the lancet.  I do not, however, think that the first of these acci-
dents merits all the importance Avhich has been ascribed  to it.  As
to the second, it may  doubtless happen, but it is rare.  We  should
remedy it immediately, by enlarging the wound, and proceeding to
search for the point of the instrument with  a forceps.  Left in the
tissues, this small foreign body could cause at most only  a phlegm-
onous inflammation there,  and afterwards a small abscess, which
would ultimately cause its separation from the parts.

     § IV.—State of the Blood drawn from the Veins in Bleeding.

   When patients are bled in the arm, the blood being received and
preserved in a vessel, may be'examined at leisure, for the space of
twenty-four hours.  At the moment it escapes from the vein, we
often hear the patient, or the persons who  surround him, cry out,
that it  is thick, clear, lively, (vif) or altered, according as the jet is
more or less rapid; but Mdthout denying that its greater  or less de-
gree of coagulability, or plasticity, (plasticite) may insensibly nar-
row the aperture of the vein and retard the jet from it, the surgeon
ought not, however, to accord any degree of importance to these
common expressions.   When the blood is deposited in the vessel, it
takes on a variable aspect, according to the nature of the patient's
disease, and  also according to the manner in which it has flown.
Thus, the blood of an individual perfectly healthy will remain red
and vermilion, while that of a pleuritic patient, or one affected with
rheumatism, will present a coat of yellowish  fibrine two to three
lines thick ;  and that of an individual laboring under typhoid fever
will remain fluid, (diffluent) greenish, or of a variegated black color.
We must recollect, besides, that, in the same diseases, this aspect
will not be the same when the blood is draAvn by a small orifice as
when it issues through a large one, or when it dribbles out as when
it escapes by a continued jet, or when it is received into a flat, wide
vessel as Mrhen it falls into a narrow and deep palette. [Neverthe-
less, most important  deductions in practice are, in our opinion, to
be made from these appearances of the blood drawn, which are in-
dependent of any contingencies of the shape of the vessel used, &c.
These are, its dark or bright  color, and its inspissation or attenua-
tion—in other words, its thick, glutinous,  fibrinous  character,  in
plethoric, robust habits and entonic inflammations, causing  almost
its immediate and entire  coagulation and  consolidation, in a few 
 262          NEW ELEMENTS OF OPERATIVE SURGERY.

 minutes, throughout its whole substance; or its limpidity, or fluid,
 thin, and watery appearance in dropsy and adynamic fevers ;  its
 coal-black color, tarry consistence, and highly carbonated condition,
 where respiration and decarbonization are defective, as in phlegm-
 atic temperaments  and sedentary persons that feed Avell; also, its
 bright, frothy, sparkling, vermilion, arterial  color and natural con-
 sistence in the sanguine temperament, and when the lungs are large
 and* expanded, and much exercise is taken.—T.~\

           § V.—Bleeding in certain particular regions.

  Besides the veins of the arm, neck, and foot, the ancients bled,
 also, in those of  a great number of other regions—the occipital or
 auricular, the frontal, the angular of  the  orbit, the nasal, the sub-
 lingual, and the  dorsal of the penis,  for example ; but  now, and
 since  the discovery  of  the  general circulation of the blood, we
 never scarcely use this mode of venesection,  so much lauded by the
 Greek  physicians, and  especially by  Marcus Aurelius Severinus.
 Perhaps, in truth, it has been rejected in too summary a manner.
 For my part, I am not  convinced that bleeding in the veins in the
forehead, or in the vena preparata, and in the veins of the mastoid
region, has not some advantages  in  inflammations of the scalp,
 (cuir chevelu;) nor that  that of the angular vein, M'hich is contin-
uous with the ophthalmic in the orbit, is devoid of efficacy ; nor that
the bleeding of the ranine veins in diseases of the tongue, those of
the scrotum, penis, knee, and, in general, of the veins nearest to the
diseased part, ought  not, in many cases, to be preferred.  M. Jan-
son, in the present  day, has extolled these  modes of venesection,
and I have often employed them wdth  very favorable results.
  In conclusion, Me  perform bleeding of the vena preparata, or of
 the forehead, by compressing the vein  with the thumb  between the
'wo eyebrows, while we puncture it on the point where it is most
conspicuous.   The vein of the large angle of the eye, communicating
 ivith those of the orbit and face, would have  to be compressed near
 'he caruncula lachrymalis, and on the root  of the orbitar process
 if we Mashed to  arrest  the  course of the blood there.  When Me
open the  ranine veins, we must puncture them rather  in the direc-
 tion of the lower Mrall of the  mouth than of the proper tissue of the
tongue, if we Meuld avoid with certainty the arteries of the same
name.  The dorsal veins of the penis,  which  are ordinarily of suffi-
cient size, should be compressed posteriorly near the symphisis pu-
bis ; those of the scrotum, and those which  run upon the surface
either of the joints or certain tumors, having  no fixed course should
be distended and punctured after the manner of simple  varicose
veins.
  In all  these varieties of  a enesection we  must, if  we wish to
draw a certain quantity of blood, expect  to be obliged to puncture
several veins successively, or the same vein  in many places.   It is
for this reason, doubtless, that almost all practitioners at present
substitute leeches in the place of this operation. 
BLEEDING, OR SANGUINEOUS EMISSIONS.            263
                   Article II.—Arteriotomy.

  It appears that bleeding by incision  of the arteries was in  use
at the time of Hippocrates,  Celsus, Galen,  and Aretams; and a
great many surgeons continued still to  practise  it in  the  fifteenth,
sixteenth, seventeenth, and even eighteenth centuries.  At the pres-
ent day it is almost entirely abandoned ; and I much fear, in spite of
the reasons urged in its favor  by MM. Larrey and Magistel, (Traite
Pratique des Emissions Sanguines, Paris, 1838, p. 44 et  suiv.) that
arteriotomy will remain in the oblivion into which it has in reality
fallen.  No one, for example,  will venture to return to bleeding by
the radial artery, nor to that of the arteries of the tongue.   Arteri-
otomy, even in the mastoid region itself, will not be reinstated in
favor, and that of the temporal region is the  only one that has  any
chance of being preserved.
  The temporal  artery, in truth, is of  sufficient size to furnish a
suitable quantity of blood.  Situated superficially between the skin
and aponeurosis, supported by bones rather than by soft parts,  and
separated  from every important organ, it may  be opened without
difficulty, and afterwards compressed with the certainty almost of
effeoting  its  obliteration.  The objection, however, is  the  danger
of an aneurism succeeding to the puncture, as has often happened,
and of experiencing difficulty in arresting the blood, or of finding
the bleeding stop of itself before having furnished the desired deple-
tion,  and also  the chance of obtaining as  good a result by the
simple opening pf a vein.   If,  however,  it should be thought neces-
sary to recur to the opening  of the temporal artery, we  must not
open  the  trunk of this artery immediately  above the zygomatic
arch in front of the tragus or  helix, but one of its branches on the
side of the forehead, about fifteen lines anterior to the meatus audi-
torius.  There, in fact, the artery is nearly outside of the temporal
muscle; it is prominent under the skin, its  pulsations are easily
felt, and it rests almost immediately upon the bone ; if  its anterior
branch should seem of sufficient size, the operation in fact may be
performed much farther in front, and on a line with the external
orbitar process.   In every case  we require  a strong lancet, or a
bistoury, a long narrow band,  a graduated compress, and the other
articles necessary in bleeding  at the neck.
  The patient, lying down or  seated, ought  to have his head held
to the opposite side; with the left hand the surgeon fixes the artery,
while with the right, armed Avith the instrument, he divides it; in
order to render the vessel  more conspicuous, the patient, if he is
not in a state of unconsciousness, should be  recommended to press
his jaws tight together.  The  lancet is  inserted transversely or ob-
liquely, as in venesection.  If,  however,  the bistoury is used instead
of the lancet, it is equally important  to make it penetrate from
the integuments to the artery,  (Fig.  153 b) and also from  the
deep-seated parts to  the  exterior,  as when we  puncture, the  im-
portant point here being to cut the vessel  completely through in 
264           NEW ELEMENTS OF OPERATIVE SURGERY.

the place of performing a simple puncture.   As soon as the artery
is opened, the blood ordinarily leaps out with force ;  it is received
either directly into a vessel, or by the aid of a card or gutter of tin;
if it stops too soon, avc Avash the puncture with tepid water, in order
to detach the clots from it.  AVhen the bleeding is terminated, the
artery is compressed above and  below with the thumb and index
finger of the left hand; the parts are Avashed and wiped ; the small
square compress is applied, and then compression is made, either
with the packer's knot, (le noeud d'emballeur) which patients gene-
rally support badly, or, what is better, by means  of some turns of
the bandage, properly applied.  I do not think that  the suture or
torsion should be used here in the beginning.  The accidents from
opening the temporal  artery are  reduced, in fine, to the possible
formation of an aneurism, or to the puncture of some nerA'ous fila-
ments.   [A small globular, superficial, purple-colored aneurism,
Avith a thin cuticular pellicle for its sac, and of the size of a pea or
hazelnut, may form, it  is true, immediately after the cicatrix is
completed ; but  it is generally perfectly cured,  and the artery in
this part effectually obliterated, by Avell-directed compression, per-
sisted in for several weeks, or even months, in spite  of occasional
rupture of the sac and  hemorrhage, which may alarm the young
surgeon.  I have not, in any of those cases, found it  necessary to
recur to a ligature.—T.]


                 Article III.—Local  Bleeding.

  We  generally give  the name  of local or capillary bleeding to
that of the small vessels, Avhen performed  as near as possible to
the diseased region.  It is a name, however, but little suitable to it,
for bleedings at the anus for diseases of the abdomen, those at the
epigastrium, and at the parietes of the thorax, for affections of the
stomach and lungs, those at the neck for diseases of the encephalon,
are full as much general bleedings as those by the arm.
  The name of capillary bleeding is not much of an improvement
in expressing the idea of the practitioner, for there are local bleed-
ings performed on small veins (veinules) that are too large to retain
the name of capillary.  It must  be conceded, then, that the term
local  bleeding, whatever be its object, should be applied to the
opening of vessels too small to give egress to a  large quantity of
blood.   This bleeding is effected by means of leeches, the lancet
bird-peck punctures, (des mouchetures) or scarifications.

                         § I.—Leeches.

  A. The leech is an animal of the family of hirudo, and employed
in medicine from almost immemorial time.  The best are the  leech
termed medicinal, of a  greenish hue, and marked with six  narrow
iron-colored bands,  and the officinal leech, whose color is browner
and Avhose longitudinal bands are of a rusty tint. 
BLEEDING, OR SANGUINEOUS EMISSIONS.
265
  B. lo  apply  leeches, the  part must be previously washed, and
sometimes even besmeared with sweetened water, milk, or blood.
When  the leeches are hungry and sprightly, all these precautions
are unnecessary.  On the contrary, if they do  not incline to bite,
we may  heat them or dry them by rolling them between folds of
dry linen, so as to excite them gently.  Also, Ave apply them some-
times singly, or in mass.  In the first case, each one is seized by the
fingers, either naked or between linen, so as not to lose hold of them
until they are well attached.   Some persons, as M. Magistel and
others, seize them near their posterior extremity with a forceps and
force them thus to fasten themselves on any part we choose.   The
pupil should know that the leech, by its vermicular movement and
unctuous coat,  slips through  the fingers with remarkable facility.
In the second  case, we make  use of glasses or the hand, holding
the leeches  in  a piece of linen. The  small liquor glasses [wine-
glasses]  are preferred for circumscribed  regions, or Avhen we do
not wish to  apply but  a small  number of leeches.  The tumbler,
(le verre  de cabaret) on the  contrary, is used, if we haA e a large
surface, and wish to apply from ten to fifteen leeches.   These ani-
mals, placed in the glass, and having no other exit, are obliged to fall
back upon the living tissues, (Fig. 155,) and rarely fail to attach

                             (Fig. 155.)
themselves in a very short time.  Sometimes, however, they remain,
as if asleep, near the bottom of the glass, and do not detach them-
selves from it unless Ave apply some cold substance.  Even though
the leeches bite well under the  glass which covers them, there re-
sults, nevertheless,  the inconvenience of the punctures being too
  vol. i.                       34 
266
NEW ELEMENTS OF OPERATIVE SURGERY.
nearly approximated together, if we use a small glass, or, if it is a
large glass, of having them frequently collect, as in a circle, around
its circumference.   But we use, generally, the hand, provided Avith
a piece of linen, instead of the glass of Avhich I have just spoken.
The leeches  are then gathered into a compress, in order to ap-
ply them immediately to the  integuments,  in  such  manner as
to keep the linen moderately pressed around all  that part  of the
skin Avhich the leeches occupy, (Fig. 156.)  If this precaution were
not taken,  the leeches Avould  soon escape,  and vveuld be  lost by
creeping about in all directions. The small cuvette of silver wire, in
form  of an egg-stand, which some  persons  have  devised  for this
purpose,  is a  useless contrivance.  The fingers,  the forceps, the
glass, and the  hollow of the hand,  provdded with linen, are accessi-
ble to all and always  sufficient.  [When these usual modes, how-
ever, fail, as they too often do, a glass tube,  with a  narrow aper-
ture,  through  which the  leech can merely protrude his  mouth,
(that is,  his pointed extremity,) Avhile a bulge in this part of the

                            (Fig. 156.)
tube admits of full distension of his body, w ill be found useful, es-
pecially in applying  leeches in narrow passages, as to the tonsils,
tongue, gums, nares, ear, anus, vagina, &c, &c.  In all cases, a
sovereign remedy to  excite them is, to dip the glass, before using it,
or placing the leeches in it, into ice-water, and they are soon glad
to get as far as possible from it, and huddle together upon the Avarm
skin.   Another still  more efficient mode, especially in  applying
leeches to loose, flabby tissues, (as to the scrotum in orchitis, &c.,)
Avhere it is difficult to keep them on by any means, is, to use a, cup-
ping-glass, or, better still, the receiver of an air-pump,  and after
exhausting it till considerable congestion is produced, put  on the
leeches, and  a gentle stroke or two more of the  pump, compelling
the leeches to look  to the blood for the  supply of oxygen  to
their spiracles, will  make them seize greedily hold of the minute
Aessels.  A mode to induce them to  bite, recommended recent-
ly, is that  of placing them in beer or ale before applying them. 
               BLEEDING, OR SANGUINEOUS EMISSIONS.           267

  It is also unnecessary to apply leeches one by one, but upon cer-
tain regions, or upon some cavity lined Math mucous membrane, for
example.   AA e know Avhen the leech is attached by his distension
and the suction movement of his  pump, as well as by the pain he
causes.  The time he requires to fill himself varies from half an
hour to an hour and a half.   They increase to three, four, or five
times their bulk.   If the leeches do not fall off of themselves, we
may easily loosen their hold by sprinkling them Avith salt, tobacco,
or,  better still, Avith ashes.   To  remove them by force,  or by pres-
sure on the skin, would endanger tearing their mouths and leaving
in the tissues some particles of their cupping apparatus, (ventouse.)
Persons who have recommended cutting off the posterior extremity
of the leech, to make the blood run more abundantly, forget that this
operation causes the animal to fall off immediately.   Running  a
thread through his tail, in order to  haAe better command of his
moAements, Avould incur the risk of preventing him from biting, and
perhaps soon cause his death.
  Each leech draws from two to four gros* of blood.  There flows as
much, also, sometimes from the puncture ; but I do not know what
credit to attach to the assertion that the leech abstracts two and  a
half times his weight of blood.

                     C.  To stop the Bleeding.

  In all cases when  the leech has come off, we  are in the practice
usually of letting the puncture Aoav for half an hour; if, at the ex-
piration of this time, there  is nothing to apprehend, Ave coAer the
part Avdth a  large emollient poultice, which thus absorbs the re-
mainder of the blood ; if Ave do not wash the bleeding to be copious,
or if it continues beyond the time required, there are various means
of checking it.  The first of these consists in covering each puncture
with small pieces of agaric, or in sprinkling them with colophane,
ashes, or spider's web.  Styptics, such as vinegar, eau de Rabel, creo-
sote, or a very hot compress, might  do equally well, aided  by a cer-
tain degree of pressure.
  Sometimes  the  hemorrhage  resists these  first measures, so
as  to  endanger the life  of the patient,  especially  in  infants.
In that case Ave may recur to cauterization Avith the head of  a
probe, or Avith the  bird-beaked  cautery, (cautere en bee  d'oiseau.)
The crayon of nitrate  of  silver has always answered Avith me,
in uniting compression with it.  This  crayon, cut  in the form
of  a  cone, should be applied by its  apex into the puncture, and
held there one or tAvo minutes.   As the blood immediately tends to
spread the caustic, it is advisable to substitute quickly, in place of
the lapis  infernalis, a small  hard  ball of lint, and small pieces of
agaric, or very narrow graduated compresses, and to press on these
objects Avith the thumb until the blood ceases to Aoav.  We are yet
more certain to succeed by compressing the contour of the puncture
[* See the measure of a gros above.] 
268
NEW  ELEMENTS OF OPERATIVE SURGERY.
with a ring, while we cauterize as above.  It would not be practi-
cable to apply the suture, or to seize the tAvo sides of the wound and
strangle them between the branches of a forceps, but in a small num-
ber of cases, and they are means still less to be relied on than those
I have just mentioned.   I cannot say that a cupping-glass, applied
upon a part that the leeches have quitted, Avill aAert all the hemor-
rhage, by filling all the punctures with clots, as M. Ridolfo believes.
For myself, I do not believe  this kind of hemorrhage  can  resist
compression, cauterization by nitrate of silver, the employment of
the small ring, or the red hot iron methodically applied..  [The
most efficacious and certain mode of putting a total stop to the
exudation of the blood,  which is  often alarming in infants, for
example, in  leeching  the  neck for croup,  &c, Avhere  pressure
cannot be  made Avithout strangling  the air-passages,  is  to pass
a  fine needleful  of delicate but strong Avhite  silk thread, with
a fine sewing-needle, through the  lips of the  puncture once or
twice, as in  taking up a stitch,  and then fastening the ligature
with  a firm  knot.  It is done in a moment, and the bleeding is
instantly stopped, creating much surprise  to the alarmed friends
and bystanders.  This delicate  and easy operation may be perform-
ed upon all the punctures that continue obstinately to bleed, though
that is not generally the case with more than  tMe or three at  most.
I am indebted for this ingenious  and important suggestion to Dr.
Richard K. Hoffman of this city.  In reference to M. Ridolfo's re-
commendation of the cupping-glass to check the blood,  it will be
seen, in  our  previous note,  that the effect is and must  be, by its
suction, directly  the reverse.  Torsion might sometimes answer,
were it not for irritating too much  the already inflamed puncture.
It  is to be remarked, says Dr. Mott, that in infants it is sometimes
next to impossible  to apply the stitches  as above mentioned, but
that a more  easy and quite  as effectual a mode is, to insert a deli-
cate needle  across the perforation, and then to fasten it there and
draw the aperture together by the figure of 8 twisted suture.—T.]


                 D. Preservation of the Leeches.

   When the leeches have fallen off, it may perhaps be  advisable
to preserve them, to be used at another time.   There  are many
methods employed to effect this, but the best is  to throAv them on
the hearth, and  to  allow them to creep there  on the hot ashes.
That is much better than sprinkling them with tobacco or salt, and
especially than disgorging them by force, by pressing them Avith the
fingers from  one  extremity to the other.  When they are entirely
empty they  are  cleaned and washed, and placed in vessels half
filled Avith water, which are changed every three, four, five, or six
days.  To preserve them  in large quantity, it  suffices  to throAv
them into large basins, and not to take them out  but at the expira-
tion of some months.  [It is stated that  the  American leech may
 be depended upon for doing its duty, if  it be kept previously in
distilled water.—T.]                                      " 
BLEEDING, OR SANGUINEOUS  EMISSIONS.
269
  Punctures from leeches do not generally require any care; if they
are not irritated, nor their scabs torn off, a period of two to four
days is sufficient for the cure.  They are, however, sometimes the
cause of erysipelas, angioleucitis, and small abscesses.

      E. Regions of the Body where Leeching may be Applied.

  With the exception of the track of the arteries, or of the large sub-
cutaneous veins, as in the limbs and neck, we may apply leeches
to every part of the body; Ave  must  also add, that we may, by
avoiding the vessels themselves, apply them without  any inconve-
nience to the limbs.  Thus, we place  them upon the large angle of
the eye, the temple, and the mastoid processes, for ophthalmias and
cerebral affections; to  the anus, pudenda, and groins, for diseases
of the abdomen and genital organs; to the epigastrium,  for  affec-
tions of the stomach; on the entire abdomen, for inflammations of
that cavity; and generally to every part where the blood appears
to have accumulated. At the angle of the eye we apply them by a
small glass, or place them on one by  one.   On the skin of the eye-
lids they occasion often a considerable swelling, which  must not
alarm us ; upon the inner lining of the lower eyelid it is also neces-
sary to  apply them in succession, and in such manner that they do
not puncture too near the ciliary edge of the organ.   In that place
it is  rarely advantageous to employ more than two or three at a
time.  Moreover, they occasion but little pain there, and  fill  them-
selves quickly.   It is when Ave apply  them to the  nares, tonsils,
and gums, that we may require the  forceps to hold them, or we may
make them pass through a cone of glass, or a piece  of card  rolled
up in the shape of a trumpet.  The card is in my opinion the best.
The beak of it, being of sufficient width to allow the mouth of the
                              leech to pass through it, ought not to
           (Fig. 157.)             be so large as to allow the animal
                              to escape entirely from it.  Apply-
                              ing thus the apex of the  card to a
                              convenient spot, the leech  is  di-
                              rected by means of a  ring,  or by
                              the finger,  (Fig. 157,) as by a sort
                              of piston, and we haAe then no fean.
                              that  it can escape.   To  the anus
                              leeches  ordinarily  attach   them-
                              selves  very quickly;  to prevent
                              their getting into the  intestine, it
                              has  been recommended, uselessly,
                              as I  think,  to plug up the anus by
                              means  of  a small  tent of oiled
                              linen.   To apply them to the neck
                              of the womb we make use of the
                              speculum,  and  the  entire  specu-
                              lum  (speculum plein)  is preferable.
The instrument being adjusted, the  leeches are placed  in it, and
 
270
NEW ELEMENTS OF OPERATIVE  SURGERY.
are forced along, or of themselves soon make their way to the os
tineas.

                     F. Leeches Internally.

  If it should happen, as in certain instances it is said to do, that the
leeches have escaped into the rectum, Ave should destroy them there
by means of injections of salt Avater or tobacco infusions.  If they
should have got into the oesophagus, or even the stomach, Me must
in that case also have recourse to salt water.  Tobacco fumes and
vinegar would be  less  efficacious.  In the larynx or trachea,  the
accident  would be more formidable, and we should  be obliged to
have recourse to tracheotomy.  [In conclusion, we consider the glass
tubes with a bulge at one extremity, as described in a note above,
preferable to  a trumpet of pasteboard, wine-glass,  or any  other
contrivance.
  Consequences of Leech Bites.   Among the most formidable  in
appearance, and slightly alluded to by the  author, is  the  abun-
dant serous effusion, or sub-cutaneous oedema, which their suction
poMer, communicated to the capillaries in all loose, flabby textures,
occasions, giving rise to a tumefaction apparently alarming, as (when
applied to the eye) in the whole face, resembling a sudden attack
of erysipelas, closing up the eyelids, and causing much uneasiness,
from the  dryness, tension, and heat of the stretched dermoid tissue.
So in the scrotum  and penis, causing in the latter, sometimes, an
cedematous inflammation, or even phymosis or incarceration of the
glans, more serious than the original disease for the removal of which
they were  employed.  In all  such cases, a mild emollient, cooling
lotion, such as of pulverized slippery-elm  bark  solution strained,
or flax-seed, and  afterwards  a  very weak solution of  lead-Ava-
ter or diluted ether  and alcohol combined, as in true erysipelas,
are all that is required in  addition to saline purgatives and absti-
nence.—T.]

   § II.—Bird-Peck Punctures (Mouchetures) and Scarifications.

  Leeches, while they draAV a certain quantity of blood, produce
an irritation which many physicians regard as of much importance
in local bleedings; and there are many physicians who think that
no other  kind of bleeding  can be  substituted for leeches.   Hoav-
ever  that  may be, the bird-peck  puncture and scarifications,
which also have the effect of irritating the tissues, at the same
time  that they allow a certain quantity of blood  to be  abstract-
ed, have often been prescribed  in place  of leeches : they are,
however, two different operations, which  it is important  not to
confound.

                  A.  The Bird-Peck Puncture.

  The name of mouchetures is given to those simple prickings per- 
BLEEDING, OR SANGUINEOUS EMISSIONS.
271
formed on the integuments, with the view of unloading the parts
of the fluids that may have stagnated, or been infiltrated into those
tissues.   We haAe recourse to it in cases of serous  infiltration,
whether of the limbs,  trunk, scrotum, or penis, in individuals affect-
ed with anasarca, or local cellular dropsy.  We recur to it in some
cases of congestion or sanguineous engorgement of the conjunctiva,
nares, tonsils, tongue, inside of the mouth, and even in the  treat-
ment of certain  kinds of erysipelas.   To perform these punctures,
there is no need of needles, nor any other special instrument; the
ordinary lancet, directed perpendicularly (Fig.  158) upon the tis-
sues, and drawn back  in the same manner,  after having been
quickly plunged into them to the depth' of a line or two, always
suffices.  The punctures performed in this way should be numer-
ous and made with rapidity.   The only inconvenience they present
is that of exposing to the risk of erysipelas, and of thus causing in
debilitated and dropsical patients (individus anemiques  ou  infiltres)
inflammations which  sometimes speedily pass into gangrene.  [The
most convenient and speedy Mray of making these punctures is with
the lancet open, at an acute or right angle, upon its handle, which
latter is held lightly between the thumb and  fore-finger, placed
near the extreme point of the handle, so as to have a better lever.
This is the origin of the term bird-peck puncture.—T]

                            (Fig. 158.)
B. Scarifications.
  I do not mean here the puncturings made directly into the small
Veins which are often seen on the surface of diseased regions, or on
certain tumors: this is  a kind of local phlebotomy.  The scarifica-
tions, which are actual incisions, and not simple punctures, consti-
tute one of the most ancient modes of bleeding.  They were in use
at the time of Galen and Oribasus, for we remark in these authors
that Antylus, for performing them,  Mras  in the habit of  using a
scarificator with many blades.  From those remote times scarifica
tions have never been  entirely abandoned.  If, to effect fhem, we
no  longer  use  a  sharp-edged shell, flints, or stalks of wood, there
are still employed particular kinds of scarificators for the conjunc- 
272
NEW ELEMENTS OF OPERATIVE SURGERY.
tiva, interior of the nares, or urethra, or for the cutaneous surface.
The German scarificator, (Fig. 159,) the English  scarificator, that
which the manufacturer Charriere (Fig. 160)  has  modified, or that
of M. Larrey, (Fig. 161,) are the only ones which  deserve to be re-
(Fig. 159.)                                             (Fig. 160.)
tained.   Moreover, the lancet,  bistoury, or razor, or the  fleam
(filamme) of veterinarians, suffice for all cases.
  Scarifications are sometimes intended as a substitute for bleeding
or leeching; at other times  to subdue certain  inflammations.   In
the  first case they are made, indifferently almost,  with the lancet,
bistoury, or razor, instruments that should be held like an arc, or in
the  fifth position, and which  ought not to penetrate over half a line
in depth, and should be drawn rapidly across the skin from  space
to space, (Fig. 162.)   In the second  case, we scarcely use  other
than the bistoury.  In that case, it is generally advisable to  pene-
trate to the sub-cutaneous layer ; for these are  true incisions, from
one to two inches in length, which we make at a distance of twelve

                            (Fig. 162.)
to fifteen lines apart, upon regions affected with phlegmonous ery-
sipelas, or infiltrations tending to gangrene.   In  these  cases the
convex bistoury should almost always be preferred.  If we incline
to employ the razor  for scarifications, it is advisable to use that
M-hich ends in a rounded extremity.  When we employ the scarifi
cator, it is first necessary to make its blades recede into the box by
turning the spring of the instrument.   This being applied upon the
skin, we press upon the button which makes the spring act, and the 
BLEEDING, OR SANGUINEOUS  EMISSIONS.           273
blades immediately cut  into the skin by moving in the arc of a
quarter-section of a circle.  In this way the twenty scarifications
are made at once, and the operation is over in an instant.  But we
penetrate always to the  same depth, whatever may be the region
which requires to be scarified, and we obtain in this manner punc-
tures  rather than  true  scarifications.  With the razor, lancet, or
bistoury, on the other hand, we make incisions as superficial, long,
or deep, and as few or many, as Me may desire.   With some prac-
tice, we may execute them almost as rapidly as with the scarifica-
tor ; and young surgeons, moreover, find in  this exercise an excel-
lent means of familiarizing themselves to the handling of the bis-
toury.
   The use  of the scarificator, then, should be reserved for patients
who are exceedingly timid, and for intractable persons, or such as
cannot be reasoned with.
   The scarifications do not require any particular treatment after-
wards.   They are small Meunds which cicatrize  immediately, and
which, moreover, could not require any other attentions than those
given to wounds in general.

                    § III.—Cupping-Glasses.

   After the leeches have dropped off, or when we have performed
puncturings or scarifications, we sometimes wish to prolong the
flow of blood by applying a cupping-glass to the  wounded part.
   We understand by cupping-glasses, a sort  of bell-shaped  vessel
in which a vacuum is created, and which  is then immediately ap-
plied upon  the skin  Avith the view of producing a congestion, tume-
faction, and elevation of a portion of this tegument.
  Cupping-glasses present two principal varieties, as to the object
for which they are intended to be employed; that is to say, there
are dry and scarified cuppings.

                       A. Dry  Cupping.

  The object of dry cupping is solely to irritate certain regions of
the integuments, and to draw the fluids to it by  a greater or less
degree of revulsion.  The cupping-glass
itself was anciently the extremity of the           (Fie-1630
horn of some  animal.  At present they
are of different shapes—some have the
form of small bells surmounted by a but-
ton, (Fig. 163,) or of a simple gourd.  In
a case of necessity we might use an or-
dinary drinking glass—they are,  also, of
various sizes.
   In  some  countries, in Italy and Germany,  for example, dry cup-
ping was used in  the time of Dionis, under the  title  of hygienic
means, as the  massage and electricity are at the present time  in
  vol. 1.                       35
 
274
NEW  ELEMENTS  OF  OPERATIVE SURGERY.
France ;  but with us there never have  been any grand vaulted
halls  nor stoves, whither we  could  repair and  have ourselves
cupped at pleasure, as in Germany.
  To  apply dry cupping, we must first rarefy the air, or create a
vacuum  in  the vessel in  some way or other.  AVe effect this  by
various  modes;  the Germans  confine  themselves  to  dipping the
glass into very hot water, from whence it is drawn out quickly, to
be applied immediately upon the  skin.  A  more simple mode con-
sists in keeping the  flame of a spirit lamp for some seconds within
the cupping-glass, and then transferring this last to  the integu-
ments as quickly as possible.   This is the mode of MM. Backler,
Rohmer,  and Buchel, who, in importing dry cupping from Germany,
have  endeavored to infuse a taste for it in Paris.  This is an easy,
expeditious method, requiring but  little address to perform it  with
ease.   It is found more convenient, hoAvever, to rarefy the air in
the glass by burning in it either tow, lint,  cotton, or  paper, espe-
cially paper manufactured from silk, or Me  may simply burn alco-
hol.   I do not speak of the small candle, the sulphur matches, or
night-lamp, that some introduce into the  cupping-glass upon a bit
of card, because they are bad contriArances.  It is desirable that the
wool or paper used should be slightly impregnated wdth alcohol 01
ether.  In other respects these substances should be very dry, light,
and thin, (rarefiees)  After having placed them at the bottom of the
vessel, Me  apply the fire to them; or, better yet, if paper is used,
AAe make it into a peloton of net-Avork, (a laciniures multiples) and
very porous, which we  light while Ave hold it in the forceps, and
then immediately place it in the  cupping-glass.   The important
point  is to apply this upon the skin before  the ignited body is en-
tirely extinguished.   It must, how ever, be  on the  point  of being
consumed, otherwise it might burn the patient in falling upon his
skin.
   The skin  is immediately expanded and swells while it reddens
under the  cupping-glass.   We leave  the  glass  on  one  or  two
minutes.   To remove it, we depress the integuments  upon some
point around its circumference by means of the thumb, while with
the other hand we endeavor to make the glass incline to the op-
posite direction.  The  slightest opening  effected  in this manner,
alloM's the air to enter, and the cupping-glass to be detached.  We
afterwards reapply it upon other parts of the skin, as  many times
as we judge proper, or we have a number of them, which we
place on immediately, before  detaching the first.   AAe thus apply
cupping-glasses to  the breasts, to arrest certain  uterine hemor-
rhages, to the  anus, to reproduce hemorrhoids, and  on different
parts of  the body, under the character of a  revulsive.

                     B.  Scarified Cuppings.

   When we employ cupping-glasses  to draw  blood, we apply
them after the  separation of leeches, to prevent the bites of these
worms (anndides) from closing, or upon the punctures or scarifica- 
BLEEDING, OR SANGUINEOUS EMISSIONS.           275
turns, to promote their bleeding.  In the two first cases it suffices
to recall what I have said of dry cuppings and of the application
of leeches, to understand the whole operation. As to scarified cup-
pings, properly so called, they are employed most usually in the fol-
lowing  manner: the  first step  consists in rarefying the skin as
above ; the glass being removed, we rapidly scarify with the lancet,
bistoury, razor, or scarificator, the congested  portion of the skin, so
that the small wounds are sometimes simply parallel, or dispersed
in quincunxes, (quinconces) or crossed like window frames or made
so as to include small rhombs, (losanges) or sometimes in imitation
of certain fancy figures, &c.
   The  cupping-glass, prepared as in the first case, is reapplied as
quickly as possible, and so on wdth the others.  The blood oozes
out immediately from all the Avounds, and escapes into the glass in
greater or less quantity, according as the vacuum has been more
or less complete.  When we have taken the necessary quantity of
blood, or the  cupping-glasses produce  no more, we detach  and
empty them; we remove the blood from the skin, then, if Me judge
proper, reapply them av ithout additional scarifications, taking care,
nevertheless, not to replace  the  edges of the  glass too often in the
same groove of the skin, for  fear of producing a cauterization.  We
might, in this  manner, abstract a large  quantity of  blood from the
same place, but it  is better to  increase the number of cupping-
glasses.

                  C.  Air-Pump Cupping-Glass.

  This instrument is composed  of the ordinary cupping-glass,  and
the body of an air-pump, (pompe aspirante) which is adapted to it
or removed at pleasure, (Fig. 164.)   We  avoid thus the necessity
of rarefying the air of the cupping-glass  by  heat;  it is sufficient,
in order to create the vacuum, to apply the glass to the skin and to
set the pump in motion ; by opening a cock  on its  side we  allow
the air to  re-enter into the glass, and thus detach it whenever Me
wish.  When  the  scarifications are finished and the instrument
reapplied, we may draw a large quantity of blood ; Me then remoAe
the glass and clean the parts, then recommence in the same man-
ner, till Ave have produced the effect desired.
  Other persons, Sarlandiere among  others, have  transformed  the
air-pump cupping apparatus into an instrument called bdellometre,
(Fig. 165.)  It is a pump cupping-glass,  armed with a scarificator
of five or six blades;  so that the instrument  once applied, alloAVS
of the vacuum being made, the skin to be  scarified,  and the bleed-
ing completed without changing any thing.

                D. Cupping-Glass of M.  Toirac.

  To conclude, there are others, M. Toirac in particular, who, to
make a more effectual substitute for leeches, have  devised  small
(spindle-formed glasses with narroAv apertures, or ordinary cupping- 
276
NEW  ELEMENTS OF OPERATIVE SURGERY.
glasses, which by means of a long tube of flexible tissue, or gum-
elastic, communicate with the body of a pump, so that we may apply
them at a great distance, and at the bottom of any cavity whatever.
Thus modified, (Fig. 166,) the air-pump cupping-glass would better
(Fig. 164.)                                         (Fig. 166.)
deserve the title of an artificial leech, than the instrument to which
the English have applied this name.
  Of all the modes of applying  the scarified cuppings, or cupping
in general, there are really none to reject but the bdellometre, since,
in one respect, it does not exactly answer the intention of the sur-
geon, and, on the other hand, is too much complicated.
  Local bleedings should not be confounded with general bleeding ;
in addition to  the fact that they do not abstract blood rapidly, (some
persons having gone so far as to advise to apply leeches only one by
one, that they may thus succeed each other for the space of twenty,
thirty, and forty-eight  hours,) they also have the effect of  creating
a special irritation upon the integuments. It must not, however, be
forgotten, that by phlebotomy we abstract from  the patient venous
blood only, blood consequently which has lost a  portion  of its nour-
ishing principles, and which has become charged with a large pro
portion of excrementitious  matter,  (detritus •)   whilst by  leeches,
puncturings,  and scarifications, we draw also  arterial as well as
venous blood. It has  even been thought, erroneously, however, as
I believe, that of  equal quantities of blood abstracted, local bleed-
ing debilitates more than general. 
CUTANEOUS IRRITATIONS.
277
                        CHAPTER II.

                CUTANEOUS  IRRITATIONS.

  We create upon the skin irritations that are either temporary or
permanent, under the title of frictions, rubefacients, Aesication, and
suppuration.

                     Article I.—Frictions.

  Some practitioners employ, though rarely at the present time, fric-
tions continued for a long time, sometimes on certain articulations,
which it is desirable to render more supple, sometimes along the en-
tire course of the vertebral column, with the view of exciting mus-
eular action, or of  counteracting certain deep-seated affections.
There  are employed for this purpose the  coarser descriptions of
brushes,  or portions of rough linen, which are briskly  rubbed, and
with some degree of force, upon the parts we desire to irritate.
  The principal precaution to take in such cases is, not to rub to
the degree of congesting or reddening the skin, nor to proceed so
far as to abrade it,  (a Vexulcerer) or make it bleed.


                    Article II.—Massage.*

  The massage, which is much used in Russia, Germany, and many
other countries, under the character of a hygienic resource, and for
which they have constructed in those countries establishments like
ours  in  France for bathing, consists in  pressure,  traction, and all
sorts of movements that  another person may impress upon the dif-
ferent regions of the body.  The individuals who devote themselves
to this employment, press, pinch, (compriment) and rub with their
hands the middle portion of the limbs; they twist, draw, bend, and
extend the fingers  one after the other; they act in the same man-
ner upon the  articulations of the wrist, elbow, shoulder, foot, leg,
and thigh, and do this with the view of rendering  the muscles and
ligaments, in fact, the whole fibro-muscular system, more supple.
As the massage may be made effectually useful, especially if there
be associated with  it a hot temperature and vapor baths, as in a
great number  of  chronic affections, particularly in  those pains
  * [This may be translated by the word " shampooing," an ancient process in the East,
from which that of massage is undoubtedly derived.—T.] 
278
NEW  ELEMENTS  OF  OPERATIVE SURGERY.
  termed  rheumatic, it deserves  to  be retained, and its application
  should be under the direction of a surgeon.

                     Article III.—Rubefaction.


    AAe redden the skin by creating there an artificial and unnatural
  redness, analogous to that of an incipient erythema.   The means
  employed for this purpose  are  hot water and all substances im-
  pregnated with caloric, provided they are held at a certain dis-
  tance from the body, or are not long enough in  contact with it
  to produce phlyctaena?.  Mustard flour, however, is almost the only
  thing now used for this purpose.  AAe must take care to have it
  pure and fresh, and not mixed with other farinaceous matters, and
  that it is made  into cataplasms. Under this form it takes the name
  of sinapism.
    Up to within a recent period, sinapisms were made with vinegar
  and mustard flour, under the idea  that the vinegar rendered them
  more active ; at present Ave are in the practice of another method.
  The progress of chemistry having shoAvn that the volatile oil of mus-
  tard was decomposed by the vinegar, and  that hot water retarded
  its disengagement, induced M. Trousseau to prepare sinapisms with
• cold water.  I have  generally used them in this way since 1834,
  and it is certain, that in this form they act as well, at least, as with
  vinegar.  I have made a comparative trial of  the two kinds, by
  putting the vinegar sinapism, for example, on one side of a patient,
  and the water sinapism on the other; but experience  has shown
  that the sinapism made with water is the most active.
    Nothing, moreover, is more simple  than  the  application  of the
  sinapism.  The mustard flour is mixed with the  water precisely as
  has been said in speaking of naked cataplasms ;  the paste is after-
  wards spread upon a thick piece of linen, the  edges of  which are
  flattened down in order to make the  cataplasm more perfect.  Ap-
  plied sometimes to the plantar,  or to the dorsal surface of the foot,
  the legs, or some other region of the body, even to the breasts, with
  the view of recalling menstruation, or between the  shoulders to
  check hemorrhage, the sinapism ought to  remain in its place from
  one to three hours, according to the degree of irritation Me wish to
  produce, or according to the sensibility of the individual. If we re-
  moAed it too quickly, it would produce no effect; in leaving it on
  too long, it might cause vesication.
     It is Avell to  add, that with patients in a state of unconsciousness,
   as women in  convulsions or spasms, (eclampsie)  and in cases of
   dangerous fever, apoplexies, &c, they may appear at first to have
   had no action, though they have, in  fact, produced on the skin a
   considerable degree of irritation.  It is to be remarked, that persons
   Avho have  remained three, four, and five  days without exhibiting
   any appearances upon the place which the sinapism occupied, have,
   nevertheless, at the moment Avhen the senses resumed their natural
   functions, been affected not only with rubefaction, but also vesica- 
CUTANEOUS IRRITATIONS.
279
tion, and in some cases even Avith eschars.  I saAV this particularly
in a lady attacked Avith puerperal convulsions, and M'hom I attend-
ed in consultation with M. Larrey.  [To  render the mustard sina-
pism still more active and expeditious, it  is often  advantageous to
sprinkle it  over with cayenne pepper.—T.]
  AVhen the sinapism is removed, Ave should cleanse the part with
tepid water, if it should not be requisite to produce an intense de-
gree of rubefaction.  If there should already be too much pain and
redness, we must cover the part with cerate, or some other emol-
lient substance ;  in the contrary case, we may confine ourselves to
cleansing and wiping it Avith linen.
   In the place of" genuine  sinapisms, Ave  sometimes make use of
mustard cataplasms, or baths.  There are  cataplasms of flaxseed
meal, the exposed surface of which is sprinkled with mustard flour
before applying them on the skin.  As  these  cataplasms are inca-
pable of causing Aesication, and are prescribed only as gentle ex-
citants, they should remain  on all night, or all day, and they exact,
moreover,  no special precaution.

                    Article IV.—Vesication.

   The practice of vesication has been  most extensively employed
in  all times.   It consists  in  producing  upon the surface  of the
skin blisters filled Avith a  Avhite or serous fluid.  We effect  this
object with a great variety of substances.   Most of  the acrid
plants,  almost all the ranuneulas, also  the  euphorbias, and the
spurge-laurel,  furnish a material for  obtaining this result.  It is
for this purpose that bruised spurge, (esule) thistle, (tithymale)
euphorbia, and ranuncula,  or  the juice of these plants, and the
clematite  and oil of  anacardium, have  often • been  employed.
At the  present time, however, in order to produce vesication, we
scarcely ever use any thing else than ammonia, boiling water, sub-
stances dipped in boiling water,  or different preparations of can-
tharides.
   Ammonia, when applied to the skin,  causes vesication almost
immediately.   AVe rarely use it, unless it  be  indispensable  to
act with great expedition.  We  then  wet a piece of linen, or a
tent of lint or  sponge Avith it, and, holding it in the forceps, pass
it over the teguments, or keep it there unmoved for the space of a
minute.
   The Pomade of Gondret, composed of liquid ammonia and lard,
produces most frequently a  simple rubefaction, and not a true vesi-
cation.  We rub it in with the finger, morning and evening, upon
the region Ave wish to irritate, as on the skin of the  eyelids, forehead,
and sinciput, for example, in some cases  of amaurosis, until the
epispastic  effect, or a considerable degree of rubefaction,  is  ob-
tained.
   Boiling  water also produces vesication very rapidly; but as it
is difficult to measure its effects, it has been proposed to employ it
under another form.   Carlisle, an English surgeon, obtained blis- 
280
NEW ELEMENTS OF OPERATIVE SURGERY.
 ters by placing a wet linen,  folded twice  or  four times, upon the
 point to be irritated ; and by then  applying to the linen the num-
 mulary cautery (cautere nummulaire) heated to a reddish brown:
 it is a mode too imperfect to  be retained.
   The hammer, used by M. Mayor, is evidently preferable.  With this
 instrument, which is found everywhere, and the flat and somewhat
 broad head of Avhich is dipped in boiling water, Me procure the
 same effect as by the process of Carlisle.  None of these things,
 however, can take the place  of  the  blister,  properly so called.
 With the preparations of cantharides we are better enabled to give
 to the vesication the form and  extent we desire.  Moreover, the
 vesication caused by cantharides is not the only effect that we may
 expect from them.
   Blisters  with  Cantharides.    Among the  insects comprised in
 the family of meloe, there are  tMe species, the  mylabra of chic-
 ory and the  cantharides,  which are specially endowed with vesi-
 cating properties.  The researches of M. Bretonneau have, it is
 true, shown that the mylabras might, in cases of necessity, replace
 cantharides ;  but this latter is too well known, and too easily pro-
 cured, to allow of our attempting to substitute other insects in its
 place.
   Under the  character  of blister we use various preparations of
 cantharides.  Cantharadine, applied to the skin by means of paper
 or oiled linen, causes vesication with certainty and great rapidity.
 It is a mode introduced into practice by M. Bretonneau, and one
 with which I  have  myself been equally well satisfied.  Others have
proposed vesicating paper, from which we have only to cut out the
slip, to  be applied  to  the  surface of the teguments; but the
 method  the most common, and which  procures the most certain
results, is the  following: we spread the blistering ointment upon a
piece of fine skin or sparadrap, or, better still, on a piece of linen.
After the plaster has been properly formed, we  sprinkle  it  over
with finely powdered cantharides.  We then give a margin to the
 edges by a small quantity of the gum  diachylon, or fold over the
 edges of the  linen upon its border.   The skin having been previ-
ously cleansed, and afterwards rubbed with vinegar, then immedi-
 ately receives the  blister, which is then  fastened with  strips of
 adhesive plaster  and compresses, or with a compress  and proper
containing bandage.
  In lieu of blistering ointment, we  may, in a case of necessity,
make use of leaven, (levain)  or  any paste Avhatever, which may
in the same  manner, be sprinkled with cantharides.   The  same
result could  also be obtained, if Me simply placed the blistering
powder, wet Avith vinegar, upon a piece of diachylon plaster.  This
powder, soaked with oil, and placed on linen, could equally avell be
substituted for the  plaster; but the  plaster being more convenient
in more common use, and of more certain  effect, will conlinue to
have the preference.
  With  either of these preparations, our object is to produce two
results:  1. A  more or less active irritation upon the skin • and 2 A 
                     CUTANEOUS IRRITATIONS.                  281
                                                          *
more or less abundant evacuation of serous fluid.   For the first
purpose, the blisters  are employed as revulsives; in the second,
they ought to be  regarded as evacuants.   However, whether they
be prescribed for  one  or the other of these objects, they are not the
less  divisible into  two  kinds, temporary,  (ve'sicatoires volants) or
permanent blisters.  Blisters are limited to  revulsives but in a few
cases, when, for example, they are  not  used to the  extent of
causing vesication, (des phlyctenes;)  then  their effect  is reduced
to a simple rubefaction.   Whenever  they raise the  cuticle  an
exudation  of fluid takes  place,  and  they belong  to  the class
of evacuants.  It is  from not having  contemplated their  action
in this point of view, that  the  schools of solidists and  anato-
mists have reduced  blisters  to the  character of simple external
irritants.   For myself, I am convinced that blisters may,  in  re-
gard to the lymph,  be  compared to leeches;  and as respects
the  blood,  to cupping :  so much  so, that I would willingly  es-
tablish in   therapeutics serous or lymphatic,  as  well as sangui-
neous  emissions ; lymphatizing,  (lymphees) as well as bleeding,
(saignees.)

                     § I.—Temporary Blisters.

   Most practitioners  understand by a temporary blister, (vesicatoire
volant) one that is not left sufficiently long  upon the skin to elevate
the cuticle, or one that is shifted from one region to another.  Others
say  that the temporary blister should be kept on till the epidermis
is separated, and that,  having cut the bladder on   its  dependent
part, we should take care  not to remove  the cuticle, and should
dress the surface with dry linen.   I admit that we may consider a
temporary  blister under this point of view, but I generally employ
them in another way.  With me the  temporary blister differs from
the permanent only in this,  that we do not  excite suppuration from
it after the removal  of the plaster.   Thus, vesication being  pro-
duced,  I empty  the bladder by simple punctures with the lancet
or a pin ; I also often remove the whole of the separated cuticle.
But  in place of beet (poiree) leaves, or an exciting ointment, I cover
the surface with blotting-paper, (papier brouillard) or simple linen,
besmeared with cerate.   Used in  this manner, the temporary blis-
ter appears to me to  constitute a  mode altogether peculiar, which
I have frequently used in  the last ten years  for the purpose of
lymphatic emissions.  The  temporary blisters, also, which I use for
this object, differ altogether in size from that of ordinary blisters;
to point out their  dimensions in  one word, it  is sufficient to  say,
that the plaster should extend from half an inch to an inch beyond
the  limits of the swollen or inflamed part.  Under this form tem-
porary blisters may be applied Math advantage over  the entire cra-
nium, in concussions (commotions) of the brain;  upon  the  whole
circumference of the neck, in certain cases of angina;  upon  one-
half of the thorax in pleurisy, or  pericarditis; on the entire epi
gastrium, in a great number of affections of the stomach; on a
  vol. i.                       36 
282          NEW ELEMENTS OF OPERATIVE  SURC.ERY.

large portion of  the  abdomen, in a  crowd of acute or chronic
affections of the hypogastrium; on the entire of the great articulations
in arthropathies of the soft parts ; on a limb affected with phleg-
monous erysipelas, angioleucitis, or phlebitis ; on  the  greater part
of the inflammations  of the  lymphatic glands ;  and on a great
number of phlegmonous inflammations.   [The great difficulty in
these vesicatoires volants, as  they are called,  is, that after  even
the smallest sized phlyctaenae,  or clusters of  minute vesications
only,  are once produced—and they may be in  two  hours  in a
young, and in three or four in an adult person—it  is next  to impos-
sible to prevent the irritation in most cases  from  going on to sup-
puration.—T.]

                   §  II.—Permanent Blisters.

  Blisters that are to remain on, are also evacuants, but  no longer
in the manner of the temporary blisters Avhich I have just spoken
of.   Designed to keep up on some part of  the skin a slight degree
of suppuration, they also have the advantage of  abstracting  from
the blood any deleterious ingredient; but they do  not produce such
abundant evacuations that they can  be compared to sanguineous
emissions.  Moreover, they are applied almost ahvays at a consid-
erable distance from the disease, and only in the character of revul-
sives.  However  this  may be, those two kinds  of blisters require
the same kind of  processes in their application.   It is only in  rela-
tion to the  subsequent dressings that they differ.  When once ap-
plied, as has been said above, the plaster, taffeta, paper, or  epi-
spastic linen, is secured by means of the containing bandage best
adapted to the form of the region to be covered  ; the blisters are
afterwards dressed in the two following ways.

                    A.  Temporary Blisters.

  Upon the supposition that we Mdsh to preserve the epidermis, we
must,  after having  punctured and  emptied  the  bladder,  place
over the part a piece of linen, or dry paper, and secure it by a roller
or circular bandage.  As  the exudation continues from the irritated
surface for some days, the portions of the dressing imbibe it, become
hardened, and are sometimes difficult to detach ; it is, consequently,
better to besmear the  paper or linen with  a thin covering of emol-
lient ointment or  cerate.   In cases where we might apprehend too
much exudation, the perforated and cerated linen  might be substi-
tuted for blotting paper.   AAe place the  gateaux of lint and the
compresses over this, and then support the whole by means of a
bandage, as in any other simple dressing.  If we wish to remove
the cuticle, and the sometimes very thick layer  of plastic lymph
which is found undePit, we separate it at first on  one of the points
ftf the circumference of the phlyctaenaj, and  afterwards detach the
remainder of it, either by tearing it away, or cutting it off with the 
CUTANEOUS IRRITATIONS.
283
scissors.   The skin, being put in contact with the atmosphere by
this operation, is  greatly irritated, and ordinarily becomes the seat
of very acute pain.  It is, therefore, advisable, when we look more
to the evacuant than the revulsive effect of the blister, or when we
have to deal with nervous and timid subjects, to substitute a large
emollient poultice at every other dressing.  The cuticle is detached
without  pain  at  the removal of the first or second poultice, and
without its being necessary to cut or tear it.
  After this first dressing, the temporary blister should be covered
every morning Avith paper or linen spread with cerate, and not with
leaves of succulent  plants, (plante grasse)   Treated thus, it dries,
ordinarily, in from three to six days.  We must, however, recollect,
that its circumference, or a margin (liseref) of unseparated cuticle,
constantly remains ; that this margin, I repeat, often remains irri-
tated, and tends to suppurate in the manner of a tourniolle.  We
put a limit to  this slight  difficulty, which might  serve as the point
of departure for an erysipelas, by taking care cautiously to detach
from the margins of the blister the smallest  particles of separated
cuticle.

               B. The blister, which is to remain on,

always requires that the cuticle should be removed, that we should
dress them  for a day or two  with simple greasy substances, a beet
leaf besmeared with butter,  for example, and afterwards  proceed
in good season to the use of stimulating ointments.
  These ointments, known under the names of epispastic ointment,
ointment of garou, and savin, are  used  to spread upon the linen
which we directly apply to the denuded integuments.  Sometimes
we use a beet leaf, or that of the cabbage, or ivy, or a piece of taf-
feta spread with gum, or blotting paper, or simple linen.  With
taffeta  and the leaves  of succulent  plants we  generally obtain a
more abundant and bland suppuration.  But the paper and linen are
more convenient  for use.
  Permanent blisters should  ordinarily be of the breadth of a five-
franc piece.  As  they are to  be kept  on for  a  certain number  of
months, it is important to circumscribe them with precision, and to
prevent as much  as possible  their  spreading and  slipping.   We ef-
fect this object by a very simple precaution : a piece of linen, pierced
with a circular hole and spread with cerate,  is  first placed so as to
leave uncovered  that extent  of skin only where we desire to estab-
lish suppuration; the plaster spread with stimulating ointment is
then applied over this aperture ; there remains nothing more than
to place over the whole a compress folded double, and the neces-
sary containing bandage.
   Unless there should be acute  pains, or too abundant a, suppura-
tion, the blister, in mild seasons, should only be dressed once in
every twenty-four hours.  Uncovering  it morning and evening, as
most patients wish, would only tend, by irritating the surface, to
vitiate the secretion of pus. 
284
NEW  ELEMENTS OF OPERATIVE  SURGERY.
  Blisters to the legs, thighs, or head, are supported and dressed in
the same manner as those to the trunk, by means of the ordinary
containing bandages.   It is the same with blisters to the nape of
the neck and the mastoid region.  It  is the blister to the arm only
that requires a  particular bandage.  In this  region  the first ban-
dage we use is a roller; but Ave must be particular to begin it at
the loAvest part near the elbow, and to extend it to the border of the
axilla, taking care not to make  it  so  tight as to interfere Avith the
circulation below, but to give  it  sufficient firmness, however, to
keep the other portions of the dressing protected from all displace-
ment.
  We must here add,  that there is found in commerce, and  at the
bandage-makers, different kinds of bracelets and pieces, which ena-
ble the patients themselves to perform this dressing  with the  great-
est  degree of ease. Finally, the permanent evacuant (exutoire) blis-
ters should generally be placed on the inside the calf, towards the
middle of the inner side of the thighs,  on the outer and middle part
of the arm, and on the middle of the  posterior region of the  neck,
seeing that they are more easy to keep on and to dress in those re-
gions than anywhere else, at the same time that they are, in those
parts, in the neighborhood, also, of a good deal of cellular tissue and
numerous lymphatic vessels.
  NotAvithstanding the employment of blistering ointments, it often
happens that the blister tends to  dry up.   Independently of the con-
stitution of the patient, this result may happen from the ointment
not being sufficiently irritating, or, in  fact, from its being too  much
so.   In the first place, we must  change it, or increase its strength,
while, in the other, it  is to be weakened by diluting  it with lard.
Above all, it is here important to quiet the irritation, and to remove,
by the aid of emollient poultices, or taffeta-plaster spread av ith ce-
rate, the white layer deposited on the blistered surface.  AVe sub-
due the excess of irritation, the erythemas,  and the tendency to
erysipelas, in the neighborhood of every blister, by  lotions of lead-
water, compresses soaked in elder (sureau) Avater, or by poultices
of flaxseed.  Moreover, we must recollect that the temporary blis-
ter, and even that which has suppurated but from fifteen to tAventy
days, produces very little change upon the mucous net-Avork of the
skin, and leaves scarcely any trace  after its  cicatrization ; Avhilst,
in the course of a considerable length of time, blisters may produce
fungosities and ulcerations which it is not always easy to  cure, or
which, at least, after their cure, leave indelible marks upon the in-
teguments.

                Article V.—Drains, (Exutoires)

  The word exutoire is applied to a suppuration artificially kept up
on  a circumscribed space upon the surface of the body; under this
character the permanent blister is a drain. The same may be said
of  issues, or cauteries, and the seton. 
CUTANEOUS irritations.                  285
                          § I.—Issues.

  Cauteries, or issues, (fonticules) are small superficial ulcers, es-
tablished with the view of preventing, moderating, or curing cer-
tain diseases.   Like  the blister, and drains in general, the issue
is, at the same time, revulsive and evacuant. Like the blister, also.
we employ it in two  different ways : 1. On certain tumors, in the
neighborhood of certain articular swellings, on the sides of the spine
in some cases of diseases of the spinal marroAv or vertebrae, and on
different points of the thorax for various affections of the chest. In
these respects, issues may, to  a certain degree, be compared to
the temporary blister, since we apply them as near as possible to
the disease, and, in general, suppress them  soon, preferring rather
to shift them upon different points, than to keep them always on
the same.
   2.  In the character of derivatives,  or revulsives,  issues have
some analogy Avith the permanent blister, since Me ordinarily place
them on regions remote from the disease, and we sometimes keep
them in the same place for many years, and in some patients during
even their Mdiole lives.   On the sides of the perinaeum, along the
spine, and on the articulations, upon different kinds of tumors, and
the contour of the parietes of the thorax, cauteries, or issues, should
be dressed by means  of bandages  adapted to the form of each of
those regions.
   The permanent  issue, being  scarcely  ever applied but  to  the
cranium,  and upon the  nape, arm, thigh, or leg, requires, on this
account,  to be regulated by some  general rules.
   Thus, for the head,  we generally apply it upon the anterior fon-
tanelle.
   In the nape, I prefer placing it in the sub-occipital fossa, that is,
in the kind of depression bordered on each side by the splenii mus-
cles, above by the occipital bone, below by the spinous process of
the axis, and corresponding to the posterior occipito-atloidean liga-
ment, than to place it, as is generally directed, near the middle of
the posterior region of the  neck.  In the place that  I indicate, the
issue is nourished  by a considerable  quantity of  cellular tissue,
continuous, in  some degree, with  the external surface of the dura
mater, and in  the near neighborhood of important  vessels and
nerves.   It  is, therefore, a  region  very  favorable to the action of
drains, when we desire to act upon affections  of the brain or eyes.
   In the arm, the cautery should be applied in the depression bound-
ed above  by the insertion of the deltoid, in front by the biceps and
brachialis-anticus muscle,  and behind by the triceps muscle, inas-
much as the cellular  tissue at this point is sufficiently abundant to
supply a good suppuration, and that the muscles cannot effect any
disturbance or change in the artificial ulceration.
   The cautery to the thigh should be placed at three  or four fingers
breadth above the  inner condyle of the femur, in the hollow which
separates the vastus internus from the adductor magnus, or inter
nal border of the ham. 
286
NEW ELEMENTS OF OPERATIVE SURGERY.
   In the leg, it must be placed under the garter, (jarretiere)  three
fingers' Avidth below the inner condyle of the tibia, and in the hol-
low bounded behind by the gastrocnemius internus, above by the
tendons of the pes anserinus,* and in front by the inner edge of the
tibia.
   In fine, cauteries should be applied opposite to muscular intersti-
ces, and on points that are the most abundantly supplied with fatty
cellular tissue.
   Whatever may be the locality  where the issue is established,
we should, nevertheless, recollect that surgery possesses many meth-
ods by which this operation is effected.   The three methods still in
use at present, are incision, blistering, and caustic.
   Issues  by Incision.  The most ready  means Ave possess for es-
tablishing an issue, consists in making a small incision into the in-
teguments, and keeping it from closing by placing a foreign body
in it.  For that  purpose, the surgeon makes a fold of the  skin by
means of the thumb and fore-finger of the left hand;  he then di-
vides this fold, by puncture or incision, to the extent of from four to
six lines, and in such manner as to traverse the  Mrhole thickness of
the cutis.  Or we may limit ourselves to  stretching the integuments
with one hand, whilst we divide them by a puncture with the other,
holding the bistoury in the manner  of a  writing pen.  The convex
bistoury, held like an arc, or in any other manner, would not offer
the same advantages.  The  incision haAdng been made,  we place
in it a small  and \ery hard ball of lint of a pea shape, in order to
change it into an ulcer; a perforated piece of linen, a layer ( gateau)
of lint, and  compress, and  then a  suitable bandage, complete the
operation.  The dressing should not be removed but at the end of
three or four days, that is, at the period when the suppuration ap-
pears to have become  established;  we then insert an  issue-pea
(pois a cautere) in the place  of the  ball of lint, and the same dres-
sing is afterwards renewed daily.
  Issues by Blistering.  When a blister, which  we desire should
be kept open, constantly tends to dry up,  it sometimes happens that
the patient or surgeon may wish to change it into an issue.  In such
cases, we  should cover the whole surface of the blister with a piece
of linen spread with cerate, and provided with a small hole in its
centre ; after having arranged  this linen in its  place, the opening
is filled up with a pea, which should rest bare on the suppurating
surface ; Ave then apply to this pea a compress several times folded,
and a suitable bandage ; thus pressed, the pea gradually excavates
a hole in the skin, and ultimately excites a suppuration there, more
or less abundant,  while the linen, spread with cerate, and renewed
every morning, rapidly dries up the remainder of the suppurating
surface.
  This kind of cautery is decidedly bad.   The skin, not being divi-
ded, and only depressed,  tends continually to rise upward, so that,

,K* tPa-re doi?> or Pea an8erinu8> »s a phrase applied to the  tendons of the  Bartorius,
uie gracilis, and the semi-tendinosus, near their insertions into the upper part of the inner
Burface of the tibia.—T.] 
CUTANEOUS IRRITATIONS,
287
without a sufficiently strong pressure, carefully watched, the issue
would disappear from one day to the next.  It should not be pre-
ferred, therefore, except  in patients who  are exceedingly timid or
unreasonable.
  In timid persons, who  have an extreme dread of every kind of
pain, we establish sometimes a small blister, by means of ammo-
nia, boiling water, or cantharides, in order that we may proceed, at
the end of some days, or almost immediately, in the manner I have
just pointed out.  But we have the  same objections to make to this
kind of issue as to that which precedes it.
  Issue with Caustic. The caustic most generally used for making is-
sues is potash prepared by alcohol. We begin by placing on the skin
a piece of sparadrap or diachylon plaster, of the diameter of from
twelve  to fifteen lines, and pierced in  its centre with an aperture of
one to two lines in width.   It is this aperture which must corre-
spond exactly to the point upon the skin that we Mdsh to ulcerate ;
we then place in this opening a small particle of very dry potash,
of the size of a large pin's head, or a grain of hemp-seed; a second
piece of diachylon plaster, as large again as the first, is applied over
this; the whole  is  covered with a compress three or four times
folded,  and then we apply a suitable containing bandage.   Some
time after the potash liquefies, by combining with the tissues ; a pain
somewhat acute is then soon experienced by the patient,  but it
rarely continues over four to eight hours.   At the end of six hours
the caustic has generally produced its effect; what then remains
of it is changed and almost entirely neutralized. We might, therefore,
without danger, defer removing the dressing until at the expiration
of tMenty-four hours.  In the fear, however, that the potash, now
become liquid, might spread itself to a  greater distance than is
proper,  we are in the practice of removing it from the skin  at the
end of from  six to eight hours.   This unaAeidable liquefaction of
the caustic, in fact, requires that we  should calculate upon  it, and
apply to the  skin  a particle of potash only one  half or one fourth
the size of the eschar that we wish to produce.  Thus, for an issue
of from four to six lines, we use a piece of potash of the diameter
of from one to two lines.
  Employed  in this way, the caustic produces an eschar which in-
cludes  the entire  thickness of the skin,  and requires from ten to
twenty  days to become  detached.  When the eliminatory inflam-
mation  has expelled it, we place a pea in the ulcer and the issue is
established.  If we  wish to proceed more expeditiously, we may,
on the very first days, make a crucial incision upon  the eschar, (le
pointescarrifie) raise the four angles of the division, and adjust the
pea immediately.   If, as sometimes happens, the eschar should con-
tinue to dry up gradually, and to  favor cicatrization in the tissue be-
neath, it will be necessary to dress it with some irritating ointment,
as, for example, basilican or epispastic ointment.   In the  contrary
case, that is, Avhen it is surrounded with a florid (sanguine) inflam-
mation, Ave  must have recourse to emollients in general, and par-
ticularly to  flaxseed poultices.   If every thing goes on regularly, 
288          NEW ELEMENTS OF OPERATIVE SURGERY.

and we neither AAdsh to hasten nor retard the separation of the es-
char, Ave may limit ourselves to dressing it every  morning with
linen spread Avith cerate.
  Once established, the issue may be kept running by the ordinary
pea, that of the  iris root, (pois d'iris)  or of wax, or the different
kinds of medicinal peas.
  Those Avho are interested in  the manufacture have,  naturally,
maintained that such or such a description of pea offers more ad-
vantages than any others ;  but practice demonstrates that it is a
matter of very little moment whether Ave use this or that kind.  If
the issue is to have more than four to six lines of diameter, as is seen
in issues employed as counter-irritants,  it is often advisable to place
in it, at the same time, tMe, three, or four peas. [The common gar-
den pea Dr. Mott considers as good as  any thing.—T.]
  The derivative issue is, however, kept open very well by the
presence of only one of these peas.  The issue peas, perforated and
attached by a thread, have the advantage of being more easily re-
tained in the ulcer, and of allowing of their remoATal without diffi-
culty.  They are, also, so much the more preferable, because  vege-
table peas, increasing in size under the action of the humidity of the
parts, sometimes become confined within the ulcer; and wax peas,
or the different  sorts of medicinal peas, permit themselves to be
partially covered over, during the interval between the  dressings,
by the contraction of the small purulent cavity.
  The dressing of issues is also  a very simple affair; after having
washed and cleansed the ulcer, Ave place the pea  in it, taking care
to raise up its thread and fasten  it outside by a small slip of adhe-
sive plaster, (diachylon.)  We then place OAer this  either  an ivy,
cabbage, or beet leaf, which has been previously wilted at the fire,
(ramollie par la chaleur) and had the ridges upon it  removed, or a
small plaster of  diachylon, or  taffetas, (taffetas gomme;) linen,
spread with cerate, would not sufficiently promote the suppuration,
and plasters of the  mother ointment  (onguent de la mere) have the
disadvantage of soiling the skin too much. A compress, many times
folded, is placed over the whole, and the  rest of the  dressing  is, in
every respect,  similar to that for a blister.  An  issue in the sub-
occipital fossa, concealed by a  plaster, and then by  the  hair, may
be very neatly adjusted Avith the aid of the upper edge of the cra-
vat ; but it is better to support it by means of a plaster, or a band,
the two extremities of  which are attached to the  front part of the
head, or brought back  upon the nape, and  then around the  neck.
For the arm, the issue bandage is exactly similar to that  for a blis-
ter.  For the thigh, or  leg, Ave use only a simple circular  bandage;
we may add, that the issue, also, should not be dressed but once in
twenty-four hours, unless there  is too  abundant a suppuration, or
some special indications.

                    § II.—Seton, (Fig. 167.)

  In surgery, the word  seton signifies three things : 1. A linen band
which we pass through certain cavities, where we wish to promote 
                     CUTANEOUS IRRITATIONS.                 2f'9

suppuration, or retain the principal openings ; 2. A drain, formed
by a Kind of sub-cutaneous fistula, which is kept up artificially by
the presence of a skein (meche) of linen, (linge) or cotton ; 3. The
operation which is performed to establish this drain.

                             (Fig. 167.)
  As  a drain, the  seton has  some analogy with the issue.  In the
place  of effecting a purulent exudation upon the surface of the skin,
it exerts its action  on the sub-cutaneous cellular tissue.  So also is
it more powerful and effective than the blister, properly so called,
and even than the  simple issue in deep-seated affections.
  The seton  may be applied upon all the regions of the body—on
the head, face, or neck ; on the chest, for diseases of this cavity ; on
the hypochondrium, in affections of the liver ; above  the  pubis, in
some  affections of the bladder ; to the perinaeum, for diseases of the
prostate ; on the joints, affected Math white swellings ; everywhere,
in fact, where it may be useful to establish an irritation and a de-
rivative suppuration.  Nevertheless, Me rarely employ a seton as a
drain, except on the back part of the neck.  Thus, also, many au-
thors  speak only of the seton to the nape.
  To perform this  operation upon the nape, we must have—1. A
straight bistoury, an abscess lancet, or the instrument known under
the name of the seton needle; 2. An eyed probe,  (stylet-aiguille)
threaded with a narrow strip of band, or a skein of  cotton; 3. A
perforated piece of linen, besmeared with cerate, a gateau of lint,
a long compress, and a band  of two to three yards in  length; 4. A
napkin, (aleze) hot water, and sponge.
  vol. i.                       37 
9/jfJ           NEW ELEMENTS OF OPERATIVE SURGERY.

  The patient, being  seated  on a chair, or lying down upon his
side, inclines  his  head forward.  The napkin is  placed on  his
shoulders, in order to attach its two upper angles to the forepart of
the chest.  The surgeon then makes a longitudinal fold in the mid-
dle of the nape, gives one of the extremities of this fold  to an as-
sistant, holds the other fast himself with the fore-finger and thumb
of his left hand, whilst with the right hand, holding the cutting in-
strument, he quickly passes through its base.  If he uses the straight
bistoury, he may, if necessary, direct its cutting edge, in that case,
downAvards or upwards, from left to right, or from right to left;
but I find  it  more convenient to hold it like a writing pen, and to
carry it from right to left, with the back turned either upMrards or
downwards.  In this manner, the bistoury, having traversed the tis-
sues horizontally in the  line of its upper or lower border, easily al-
lows of the first incision being enlarged, either in advancing or in
coming out again, (en ressortant) if we take care to elevate its han-
dle a little as  soon as  its point has transfixed the cutaneous fold.
Before withdrawing it, we cause the probe, threaded with  its skein,
to slide in upon one of the sides of its blade ;  Ave  may also pass
this  probe  from the handle towards the  point, or from the point
towards  the  handle of the bistoury.  As soon as its button has
passed beyond the double incision, we  remove the  cutting instru-
ment, in order to take  the probe, which Ave draAv with one hand,
while with the other we support and direct the skein.
  The large or abscess lancet, which was formerly much employed,
and which is scarcely any longer used at present,  has the advan-
tage of making a wound in entering and one in passing out of per-
fectly equal dimensions, and perhaps, also, of causing a little  less
pain ; but, by means of a gentle oscillating movement, (leger mouvc-
ment de  bascule)  the bistoury easily gives the same result as the
lancet; and as it allows of our making an incision sometimes nar-
row  and  at other times wide, according to the desire of the  surgeon,
and as, in taking care, when we withdraw^ it, to press with its back
against the tissues, it causes no more suffering after the incision is
made, it  is very natural that the abscess lancet should have been
generally laid aside.
  The seton needle, a kind of abscess lancet, a little curved on its
flat part, very thick, and also with a transverse eye near its heel,
in order to receive the skein, has the adArantage of easily piercing
through the parts, and, at  the same time, of drawing along after it
the skein or band Avhich is to remain in the wound.
  The only objection that can be urged against this needle, the in-
vention of Boyer, is that of not being indispensable, and of not giv-
ing to the  incisions, as the bistoury does, sometimes a greater an
sometimes a less diameter.  [The seton needle is used and prefei
red by Dr. Mott, who, when he  has none at hand, has recourse
an ordinary lancet and eyed probe.—71]
  Meanwhile, the skein, once passed through, should be  detachei
from its  conductor.  As it had  had its shorter extremity doubled
upon its longer one, and  been besmeared with butter or cerate it 
CUTANEOUS IRRITATIONS.                  291
suffices to undouble it to have an opportunity of detaching, also, the
needie and probe from  it.  The wounds and all the parts soiled
with blood are now Aviped; then the perforated linen is adjusted ;
we fold the short nead of the skein over this and a little to the upper
side;  to this succeeds the layer  (plumasseau) of lint and the com-
press.  This being done, Ave must roll up, (pelotonner) or fold upon
'tself a sufficient number of times, the long portion of the seton skein,
in order to raise it, in the form of a paequet, upon the exterior fold
of the compress, to the  point where it would be least liable to be-
come soiled.   The band serves to fasten the whole by means of
some circulars. In the neck, as everywhere else, we ought to pierce
only.through  the skin  and the  sub-cutaneous fascia.   If the en-
veloping aponeuroses were comprised in the incision, it would run
the risk  of wounding  the muscles, arteries, and  nerves,  or, at
least, of producing deep-seated suppurations.   The two wounds
of the seton  should be  separated at least an inch apart, and even
an inch and a half when we have no fear of exciting too abundant
a suppuration.  It is, moreover, easy, in measuring the fold of the
skin, to know very nearly what  will be the  length of the  perfora-
tion, since the skin of this fold, Avhen once left to resume its place,
wall be one half wider.  In the place of a  narrow  linen band,
we employ, in some cases,  a roll of cotton thread ;  Me have thus a
less  irritating skein,  one  generally easier to move, and much ex-
tolled by Dupuytren.  But for that reason alone, that this skein is
less irritating, (plus douce) it is far from being suitable in all cases.
At any rate, Ave should  be wrong in conceding to the one any very
superior  efficacy over the other.  We do  not generally dress the
seton for the first time till at the end of three or four days; that  is
to say, at the period when the  suppuration shall have  been estab-
lished, the same as Avith Avounds in any other operation.
  Subsequent dressings.  The bandage being removed, we take care
to separate the two portions of the seton both from the compress and
from the  layer of lint, and from the perforated linen, which are de-
tached with care ; Ave remove or cleanse off, with a sponge dipped
in hot water, the matters or incrustations in the neighborhood ; we
moisten, in the same manner, the middle portion of the skein, (le
cote du plein de la meche) if it is hardened by its contact Math the
blood or pus.   AVe besmear this  portion of the skein, to the extent
of four to five  inches, with cerate or some other ointment; Ave then
seize  its  free  extremity and draw it to the other side, in order to
bring the fresh  and newly anointed  part  into  the  Meund.  The
soiled end of the skein is immediately removed by a cut of the scis-
sors, and the  surgeon has nothing farther  than to proceed to the
dressing, as in the first  instance.  These dressings are afterwards
renewed every day, or even more frequently, the same as in treat-
ing an issue or a blister.  The skein first applied will answer for a
longer or shorter time, according as  it has greater or less  length.
When it is nearly exhausted, it is unnecessary to recur to instru-
ments to introduce a new one.   All we have to do is to attach the
latter through a slit in the old one, which thus answers the purpose 
292
NEW ELEMENTS OF OPERATIVE SURGERY.
of a probe or needle for the new one.   Nevertheless, avc might
&titch their ends together with a needle.  The skein (meche) 01
cotton Avould require that the filaments of the extremity of the ola
one should be intertManed with those of  the extremity of the  new
one, and that they should be fastened together by  some circular
turns of thread.  It is unnecessary  to add, that this union should be
freely anointed with cerate and smoothed down regularly Math the
fingers in both cases, before forcing the new skein to follow the old
one through the opening.  If, however, either by accident or inad-
vertence, we should have entirely  withdrawn the exhausted skein,
the probe Avould easily suffice for  introducing the new one.   It is
to be remarked, that this last method causes, in reality, much less
pain than the others, and that, if it is not employed, it is because
of the fear which patients  have of it, from the idea they attach in
their minds to every thing which bears the  name  of an instru-
ment.
  When the seton is applied to children, or intractable persons, Ave
guard ourselves against any displacement of the skein, by taking
care to tie the two ends into a knot to  make a large circle of it,
which should be folded and collected together into a paequet upon
the most elevated part of the bandage.

                 § III.—Accidents  from Drains.

  Blisters, issues, and setons, are liable to various accidents. They
often cause, for example, simple erysipelas, and this accident be-
longs more particularly to blisters than to the other drains.  Often,
also, these artificial ulcerations produce either angioleucitis, prop-
erly so called, and all its  consequences, or engorgement and inflam-
mation of the lymphatic ganglions  in the  neighborhood.  It is  also
possible, and this is to be remarked more  particularly of the seton,
that  drains might produce phlegmonous engorgements, and even
true  abscesses.  We may indeed suppose that  they may become a
point of departure for purulent infections, either by phlebitis or re-
sorption; but this last accident must necessarily be very rare.  One
of the most common results is  the affection of the lymphatic  sys-
tem.  If all practitioners  Avere aware how many patients there are
who have kernels in the  neck and under the jaws, and are after-
wards labelled with the title of scrofulous subjects, merely in con-
sequence of drains they have Avorn, for a longer or shorter time
previous, either on the nape or cranium,  Ave should  see fewer of
those emunctories established permanently in patients who cannot,
in reality, derive any advantage from them.  In fact, the different
diseases of which I have just spoken are liable to the same dangers.
and  require the same kind of treatment, when  caused by drains as
when originating from any other source.  On the supposition thai
the accident has yet but just commenced,  or presents itself under a
mild form, it  is possible that we may arrest it  by means of simple
emollient compresses, or mild topical applications, even though the
drain be continued.  In the contrary case, unless there shall be 
CUTANEOUS IRRITATIONS.
293
urgent necessity of keeping up-the artificial ulceration, we  should
remove from it every foreign substance and source of irritation.
  Drains also cause irritation when they are not attended to with
all the care which is required to keep them clean.   In such cases,
by means of better-arranged dressings, they soon resume their nat-
ural course.  When a drain is covered with fungous growths, or
cellular granulations too prominent, we repress their surface by
powdered alum, or nitrate of silver.  If the blister tends to spread
too much, or more on one side than another, we can easily circum-
scribe it by leaving a single aperture only open in the cerated linen,
or blotting paper, intended to cover all the rest of the surface.
  The issue, which also  sometimes tends to eat in, or to become
displaced by progressive ulcerations, either owing to the weight of
the peas, or in consequence of pressure improperly applied, cannot
be restrained in its natural limits but by pressure in a contrary di-
rection, and by a carefully adjusted dressing.  We prevent the track
of the seton from cutting itself through, and its incisions from be-
coming extended in a Aertical direction, by taking  care to fold the
skein, at every dressing, in such manner that, by placing  it rather
towards the occiput than in the direction of  the  shoulders, it shall
exercise no traction upon the wound.   If the seton, from lack of
irritation, should no  longer incline to suppurate, we may re-excite
it by substituting for the cerate, with which the skein is besmeared,
either basilican, balsam of Arcaeus, or any other drawing (epispastic)
ointment; so, also, if it should happen to excite the parts too much,
we should cover it morning and evening, for some days, with emol-
lient cataplasms.

                  § IV.—Suppression of Drains.

  Patients who Avear a drain for a long  time are generally fearful
of drying them up.  Regarding this artificial ulceration as an emunc-
tory intended to draw off the noxious humors of the body, they gen-
erally imagine that, if suppressed, the matters which had issued
from them would ultimately produce some serious affection.  Phy-
sicians are divided on this question into two classes. Some, indeed,
treat the  fears of  common people, relative  to the suppression of
drains, as chimerical, and class among the tales of old women every
thing that our ancestors have said on this subject.  Others concede
that there may be sometimes danger in too  suddenly arresting an
old  drain,  but they explain it on the  principle of  the influence of
habit, by saying that the sudden disappearance of such an irritation
may well cause disturbance in some of the functions.   It is a sub-
 ject which has been, in my opinion, treated of too lightly.  Modern
researches  on the condition of the humors and the  state of the
blood in  certain patients, authorize us  in believing that an issue,
seton, or blister, might, in truth, abstract  from the natural fluids
some elements or principles that it would not be Avell to leave there;
that these emunctories  might, in fact, have, to a certain extent, the
property of purifying the humors, as Avas believed in ages past. From 
294
NEW ELEMENTS OF OPERATIVE SURGERY.
whence, therefore, it is reasonable that, when we wish to suppress a
drain that has existed for some time, Me should do it only by de-
grees, or, in fact, temporarily substitute another for it, and reinforce
our hygienic precautions, by  administering internally some tisan
and  depurative drinks, such  as the  decoction  of  dock, burdock,
chicory, and the juice of herbs, together with purgatives.
                        CHAPTER III.

                     CAUTERIZATION.

  In surgery, we give the name of cauterization to an operation
wnich has the effect to destroy the vitality and organization of the
tissues to a certain depth.   We obtain this result by two kinds of
agents : 1.  By certain chemical substances which, on that account,
take the name of potential  cauteries;  2. By inert bodies charged
with caloric, and which are  known in this state under the title of
actual cauteries.

                Article I.—Potential Cauteries.

  We use  potential cauteries, or chemical  caustics, to change the-
surface of certain wounds  and ulcers, to destroy tumors, or estab-
lish artificial ulcers or issues.  It is thus we daily put into use the
nitrate of silver and nitrate of mercury, caustic potash, butter of
antimony, Adenna powder, the  paste of Frere Come, or that of zinc,
and many of the concentrated acids.  All these substances cause,
for their first effect, the formation of an eschar ; but, as they do not
all  act in  the  same manner,  nor with the same energy, there are
some of them that are much used, and others that are scarcely ever
employed.

            §> I.—Nitrate of Silver, or Lapis Infernalis.

  The caustic most used is, unquestionably, the nitrate of silver.  I
do not speak of  its employment here under the form of solution or
ointment, but solely as nitrate of silver liquefied or crystallized. It
is in this solid state that it is used to touch strictures in the urethra,
the interior of the nasal canal, the pustules of small pox, the vesicles
of zona, and other cutaneous eruptions ; the swardy (couenneuscs) in-
flammations in  the interior of the  mouth and pharynx, erysipelas,
cysts  that we Mash to inflame, the interior of certain abscesses, the
track of  certain fistulas, and the surface of wounds and ulcers in
general.   AVhen the lapis infernalis is  to be  applied to an ulcer,
Avith the view of repressing  its cellulo-vascular surface, the surgeon
should use it gently by rubbing a little upon all the exuberant veg 
CAUTERIZATION.
295
etations, with the precaution, hoAvever, of leaving untouched about
a line s breadth of the outer pellicle which generally occupies the
periphery of the wound.  The ulcerous surface whitens thus in a
few moments, and is converted into a thin inorganic lamella, which
Is detached and falls off in the space of twenty-four or forty-eight
hours, and allows of our repeating the same operation at the expi-
ration of this time, if all the prominences upon the wound have not
been sufficiently reduced.
  In abscesses, cysts, and fistulas, we  apply the nitrate of silver
crayon to the interior of the  cavity, so  as to touch Avith a certain
degree of force  the Avhole extent of its Avails.  In the mouth and
pharynx we proceed as in wounds; it is the same in certain cases
of fungous or purulent  ophthalmias, with certain degenerations in
the neck of the uterus, certain varieties of eczema, erysipelas, &c.
If, on the other hand, it is proposed to cauterize ulcers of the cornea,
or cutaneous vesicles or pustules, it is important to  have a straight
crayon, sometimes slender, or cut into a shelving edge, or tapered
into a point, and to appply it rather quickly upon the point to be
touched and to withdraw it as soon as possible.   Around the nails,
where we often find the tourniolle, or that purulent condition  known
under the name of  onglade, the crayon  of nitrate of silver,  shaped
in a wedge form, should be inserted as  deeply as possible between
the cutaneous fold  and the horny plate.   We  proceed in the same
manner in cauterizing the inner side of the gum when there should
take place between it and the teeth any diphtheritic (diphtheritique)
inflammation, or actual ulcerations.
  The pupil ought not to forget that the nitrate of silver blackens
the skin;  that  the  skin, thus spotted, retains from six to ten days
the appearance»of being stained with ink ; that it is the same with
linen we use for wiping it; and that if, after having used it, Ave do
not take care to dry it well, it will liquefy and be decomposed in
the case.   It is, in  fact, owing  to this very property that  nitrate
of silver has of causing black spots upon linen and the skin, that it
is  sometimes used  to mark  the  places where we wish to use the
bistoury, and to note the changes which are effected in the  size or
length of certain parts.
  In conclusion, the nitrate of silver,  M'hich rather modifies the
surface of the  tissues  than  really cauterizes them, and which is
incapable  at most  of producing a deep eschar, has the advantage
of being exceedingly convenient for handling, and  of favoring the
cleansing  and desiccation of surfaces at the same time  that it
represses or destroys (mortifie) them.

       § II.—Nitrate of Mercury, (Nitrate Acide de Mercure)

   The most valuable caustic after the nitrate of silver, is unques-
tionably the nitrate  of mercury, with excess of acid.  I have  myself
used it for a great many years, with  marked advantages,  in  an
infinity of diseases, in all kinds of ulceration resulting from syphilis,
for example, in many varieties  of scrofulous  ulcers  in scorbutic 
296          NEW  ELEMENTS OF OPERATIVE  SURGERY.

ulcers, ulcerations of the neck of the w omb, and for all growths,
(plaques) whether ulcerous or incrusted, or with vegetations of the
integuments, which threaten to take on, or have already assumed, a
cancerous aspect.  This caustic, being liquid, is enclosed in a vial,
Avhich must be stopped with emery, since it rapidly acts upon cork,
or any other vegetable substance.  AVe dip into this liquid  a  small
pencil of lint, fine linen, or sponge, firmly attached to the extremity
of a rod of Meod or Avhalebone, then gently touch with it the sur-
face to be cleansed, taking care to protect the neighboring tissues
by means of linen, lint, or a piece of diachylon plaster.   If we
have  under treatment ulcerations whose surface alone has  need
of being modified, we  only touch the parts lightly with the pencil
moistened Avith the nitrate.   We proceed in the  same manner, also,
at the bottom of fistulas, and of openings  and  different kinds of
burroAvings of parts, (decollement)  It is  only in cases  of  cutane-
ous exuberance, and of parts that are actually to be destroyed, that
we should bear on Avith a certain degree of force.  AVe might also
here replace the  pencil or sponge by a glass tube, which is easily
charged with a drop of caustic, and Avhich would conduct  it  with-
out difficulty to the diseased part.
  Moreover, if we wish to make use of the same pencil again, we
must  stir it briskly in water immediately after using it, in  order
to clean  it and separate from it every remaining particle of the
acid.  The eschar that the nitrate of mercury makes does not gen-
erally disappear  so  soon on wounds, but sooner on the skin, than
that from the nitrate of silver.  The applications, also, of the former
should only take  place every four or five days, while Ave may repeat
those  of the latter every second day.   After cauterization with the
nitrate of silver,  we dress either with the perforated linen and lint,
or with cataplasms, as in  simple cases.  The  nitrate of mercury
allovvs us to proceed in the same way Avhen the cauterization  is
superficial  and of little extent; but in the contrary case it  may be
necessary to  cover  the part either with compresses or emollient
cataplasms, at least during the first  tAvelve to  twenty-four hours.
Like the nitrate  of silver, the nitrate of  mercury employed in this
manner, it is said, does not appear to be  susceptible of absorption.
This  last fact, however, is  not  placed entirely  beyond dispute.  I
have  seen some accidents, which seem unquestionably to prove
that the nitrate of mercury, to a certain extent, passes  sometimes
from the cauterized surface into the mass of the circulation.  I have
seen,  for example, two or three Avomen Avho had undergone only a
gentle application of this caustic upon the neck of the uterus, and
who, on the day after, or the  day after that, were seized Avith a pro-
fuse mercurial salivation. I have observed the same thing in another
woman, in whom I had very slightly cauterized a simple cutaneous
ulceration a  little above the right knee.  I have even seen  acci-
dents much more serious supervene after the employment of nitrate
acid of mercury, but I would not venture to affirm that they  were
really the effect of this caustic, rather than of some of those coinci-
dences that so often surprise us in practice.  It is enough, however, 
CAUTERIZATION.
297
to show that Ave should not use this nitrate but with caution, and
that Ave should closely watch its effects.

                     § III.—Other Caustics.

  A.  Butter of antimony,  nitric, sulphuric, and hydrochloric acids,
and ammonia,  are attended Avith such  difficulties in their employ-
ment, that Ave generally substitute for them the potash, or some one
of the compositions of which I am about to speak.  Having shown
the mode of applying caustic potash to the skin  when treating of
cauteries and  issues, I do not think it necessary to recur to it here.
If we desired to make use of butter  of antimony, or the  concen-
trated acids, as  is still sometimes done to circumscribe malignant
(charbonneuses) affections, the malignant pustule, or hospital gan-
grene, we  should  moisten a pencil of linen or lint with them, or
conduct them  through a glass tube, as  has been described in speak-
ing of the nitrate of mercury.
  B.  The paste of Frere Come, which  is composed of arsenic, old
burnt shoes, and spider's web, like the powder of Rousselot, and all
arsenical compounds, for a long time in vogue, has the advantage
of  cauterizing only within the limits that we trace for it, though it
does so to a sufficient depth, and of allowing, also, the cicatrix to be
formed under the eschar; but it has the inconAenience of being
susceptible  of partial absorption,  and of hazarding, therefore, the
poisoning of the patient.   I  shall return to it in speaking of the
destruction  of tumors.
  C.  Vienna Paste.   There has been in use for some time a paste
composed of five parts  of potash and  six  parts of lime, triturated,
and reduced to a paste by adding thereto a small quantity  of alco-
hol.  This composition, knoAvn under the  name of Vienna caustic,
applied in the manner of  caustic potash, produces its effect in  less
than a quarter of an hour, and appears to cause, perceptibly,  less
pain than the  caustic potash or concentrated acids.   It may, there-
fore, be used for making issues.
  D.  Zinc Paste.  M= Canquoin has  introduced into practice a
paste, which,  when  prepared, presents in some  degree a resem-
blance to the  color, elasticity, and consistence of caoutchouc.  This
paste, Avhich may be preserved for a great length of time, and car-
ried in the pocket like taffeta, [court-plaster—vid. English Taffetas,
supra]] is composed  of chloride of zinc, meal, and a little water.
The inventor  recommends the addition of a small proportion of the
butter of antimony; but I have made some with  the hydrochlorate
of  zinc, flour,  and a  small quantity of water, which appears to be
endowed with all the properties of the paste of M. Canquoin.
   To apply it, it should be cut  into pieces of greater or less  size
and thickness—to produce eschars, from two lines even to an inch
in thickness—destroying  the tissues as if they were separated by
a cutting instrument; with this provision, however, that we should
have previously removed the cuticle from the skin, for without that
the zinc paste has absolutely no  action.   It is. however, a caustic
  vol. i.                       38 
298
NEW ELEMENTS OF OPERATIVE SURGERY.
 which has scarcely any use  but for  cancerous affections, and of
 which I shall speak AArhen treating of the extirpation of tumors.
   [Caustics.  Sir Benjamin Brodie, in some late practical remarks
 on caustics, says, when you wish to keep open the edges of an ori-
 fice to a sinus, &c, lest matter should form within, it is better to
 use caustic potash than nitrate of silver, as he has seen the  latter
 close it.  In the bite of a dog, as in the hand, Avhere you cannot be
 sure of completely excising the complex tissues, melt the alkali in
 a platinum cup, and dip in a  blunt-pointed probe, which latter, be-
 coming thus  incrusted with  the caustic, maybe made Avith cer-
 tainty to penetrate beyond the deepest  part that the saliva of the
 dog has reached.  The alkali is  equally efficient in destroying the
 bottom of a diseased  lymphatic gland that has suppurated.   For
 warts on the penis or pudenda, nitric acid is often better than the
 nitrate of silver, which  is in those cases too weak.  Or the  nitric
 acid, 3j., may be used in combination with  3ij. of muriated tinc-
 ture of iron.  And for these warts  a good escharotic, also, is pow-
 dered savine  and aerugo aeris sprinkled upon them, as it causes
 sloughing.  To avoid destroying  the surrounding  skin, have along
 with you some vinegar when you use the alkali, and bicarbonate
 of potash when you use chloride  of zinc, and so  Avith  other  caus-
 tics.  Little vascular spots in  children's faces, formed from a large-
 sized vessel Avith  several branches, may be  treated thus.  Touch
 the principal vessel with some nitric  acid in a glass pen, or insert
 into a puncture in the vessel a fine point of potassa-fusa, and you
 destroy the vessel, and by a little vinegar outside  prevent the skin
 being injured.  You thus  obliterate the vessel Avithout leaving a
 scar.  He recommends, also, nitric acid to small mulberry-colored
 superficial congenital  nawi  (agglomeration  or meshes of blood-
 vessels) on the skin, but the insertion of red-hot needles, (not named
 by Sir B. Brodie,) Ave  may remark, have superseded every thing
 by their admirable efficiency  in  completely and  harmlessly eradi-
 cating the worst description of these naevi, even in infants of a few
months old.  In  sub-cutaneous  and  purple-colored  naevi, Sir B.
Brodie recommends caustic as far preferable to ligature.  Puncture
them, he says, with a finely-pointed lancet, and introduce a probe
which has  been  dipped into  fused nitrate of silver.   Sloughing
ensues, and then obliteration of the vessels.   If the tumor is Targe,
repeat the  application.  You save the skin by using  a narrow
instrument for dividing it.  Use olive oil in the vicinity,  to prevent
excoriation from the nitrate of silver.  But in these naevi, also, Dr.
Mott has used the red-hot needles with the happiest results.   Sir
B. Brodie recommends, also, for certain purposes, pastes containing
mercurial compounds; but as a general rule, Ave think  all mercu-
rial applications are to be avoided where other caustics will answer
equally Avell or better.—(Adde Medical Times, 1840 ; Medical Ga-
zette, 1841.)   Dr.  Roe, of New York, greatly extols the use of con-
centrated  nitric acid,  as for the formation of a large eschar  upon
tne praecordia in chronic inveterate affections of the digestive  or- 
CAUTERIZATION.
299
               .Article II.—Actual  Cauteries.

  If all substances charged with  caloric,  and Avhicn when ap-
plied to the tissues would  produce an eschar, merited the title of
actual cautery, boiling water, inflammable oils, and the different sub-
stances employed for making moxas, would take this name, as well
as metals heated red-hot in the fire ; but  usage has decided other-
Mdse, and obliges me to reserve the title of actual cautery for instru-
ments  of iron, steel, brass, &c, which, after surcharging them with
more or less caloric, are used for the purpose of destroying the tissues.
  I must, however, speak of the moxa before  examining metallic
cauterization, properly so called.

                          § I.—Moxa.

  Much employed in China  and Egypt  for many ages past, the
moxa rarely entered into the practice of European surgeons  until
at the  close of the last century.  Its form and nature, since then,
have been singularly varied.  That Avhich is most frequently used,
is made  of cotton, strongly pressed in the form  of a cylinder in a
piece of linen or old compress.
  To form it Ave take a piece  of carded cotton, which  is rolled up
and shaped into a  cylinder, and then enveloped in linen, Avhich is
tightly wrapped around it, so as to give to it the consistence of a
peloton of wool. We  fasten the whole by means of a thread, which
is bound around the cylinder from one end to the other, or sewn by
a close stitch along one of its sides.  We divide the cylinder thus
constructed into pieces of  from  eight to ten lines in thickness, the
diameter of which varies from three lines to an inch.
  Instead of enclosing the cotton  in  linen, some persons find it
more convenient to besmear it with a solution of gum.  But the
moxas  made in this manner  are generally too soft.  In order to
render  the cotton more combustible, others impregnate it previously
with a concentrated solution of nitrate of potash.  This last modifica-
tion is  vverthy of being preserved.
  To apply the moxa, we seize it Math a dressing forceps, or with
the  porte-moxa, (Fig. 168, a) a kind of ring with three feet placed
at the end of a long handle, or by adjusting it in an aperture in a
piece of pasteboard ;  it is applied bare by one of its extremities to
the part we wish to cauterize. We then  apply the fire, unless we
should have preferred to ignite its free extremity before applying it.
To keep up the combustion, we are obliged to blow it.  For this pur-
pose Ave do not use the mouth, because of the smoke and sparks which
would  be thrown on the face,  and the fatigue  which would neces-
sarily result from it, but the tube constructed by M. Larrey, (Fig.
168, b) or a simple bellows.   The surgeon,  provided with forceps,
holds the moxa in onehand, and with the otherfixes the mouth of the
bellows,  or the point of the tube, in order to be enabled to regu-
late it conveniently, while an assistant puts  the instrument into 
300
NEW  ELEMENTS OF OPERATIVE SURGERY.
action.  If the current of air should fall constantly upon the same
point of the moxa, the burn Avould be made in an irregular man-
ner.  AVe must proceed, therefore, in such Avay that the beak of the

                            (Fig. 168.)
bellows corresponds successively to all the points on the burning
surface.
  When the fire reaches to about three lines from the skin, it be-
gins to occasion a little pain.   This pain afterwards becomes more
and more acute, until the eschar is formed; that is, until the cylin-
der of cotton is entirely burnt.  At the moment when the fire comes
in contact Math the teguments, there is  heard a snapping noise,
(pUillement) or a species of .crackling, (craquement) altogether pe-
culiar, and caused by the skin becoming crisped and split,  (.se fen-
dille)  It is proper, during this operation, that the  neighborhood
of the parts should be covered by linen, to protect them from the
sparks and  particles of fire scattered about  by the  action of the
bellows.
   The pain  which results from the application  of the moxa. gene-
rally less  acute than the patients expect from it, does not cause 
CAUTERIZATION.
301
them to cry out, until the burning  approximates the layer of the
moxa next to the skin.
  If it be desirable to apply several moxas to the same region, we
proceed Avith the second, and then with the third, in the manner al-
ready described.
  We obtain by this operation  a blackish  colored eschar,  a  little
crisped, and which penetrates to greater or less depth, according
to the thickness of the moxa and the time it has taken to burn. Or-
dinarily, hoAvever, it includes only a part of the thickness of the in-
teguments, and does not reach, but with few exceptions, or by acci-
dent, to the aponeuroses or tendons.  As it is necessary that the
eschar should fall off from the effect of the inflammation, it is cov-
ered, if not during the first days, at least at the  moment when the
separation commences,  either with a plaster of diachylon,  or of
mother ointment, (onguent de la mere) or some other unctuous ma-
terial.  When  it is once detached, the moxa resembles an ulcer,
which it Avould be very easy to convert, and which is, in fact, some-
times converted, into an issue.
   Under the title of simple moxa, we dress this solution of  conti-
nuity like a wound or simple ulcer  ; the  cicatrization is  generally
effected between the fifteenth and  thirtieth days; the eschar falls
from  the eighth to the fifteenth;  Avhich makes from three  to six
weeks for the whole duration of the moxa.
   In  place of proceeding thus, several surgeons have proposed to
ignite a piece of camphor, or phosphorus,  and to let it burn upon
the skin; but, in this Avay, Ave obtain  eschars either too superficial
or too deep, too narrow or too Avide, and the pain is still more  acute
than in the preceding.   [Dr. Mott, however, prefers camphor  Avhen
a powerful effect is not wanted, as  it  is  the cleanest substance of
this class, and the quickest in its action.]  Others, and particularly
M. Jacobson, make use of small cylinders  of linen  previously im-
pregnated with chromate of potash, and Avhich  thus burn  Mdthout
the necessity of blowing.  I  haAe  made use of the moxas of M.
Jacobson, and have had every reason to approve of them.  Never-
theless, the others are so easy to make, that it Avould be difficult to
dispense with them.
   The doMm of the mugwort, (armoise) proposed by Sarlandiere, in
example of the Chinese, has equally failed of coming into  general
use.  The same may be said of the pith of the  turnsol.,   extolled
by Percy, and the moxas that Regnault kept separate from  the skin
by a circular piece (disc) of linen, of greater or less thickness.  The
ordinary moxa is still the only one, at  the present time, which offers
security and all the facilities of application desirable.
   I Avill add, moreover, that the efficacy of moxas, in the opinion
of practitioners, has singularly diminished Avithin the last ten years.
In fact, it is nothing but a burning which  could easily be replaced
by the red-hot iron, or  the  hammer  dipped in boiling water.   In
conclusion, they can only be useful  when we m ish to irritate ac-
tively some  region in the neighborhood of the disease, and upon
points that are exceedingly circumscribed. 
302           NEW ELEMENTS OF OPERATIVE SURGERY.
  We apply the moxa to the temple, to the mastoid process, and
below or around the articulations, upon the course of the bones, and
along the spine.   We may,  also, apply it  anywhere else, taking
care to avoid the course of the nerves, arteries, veins, and tendons,
and all the organs which it would be dangerous to burn.
  [Lime Moxa.—Dr. Osborne, of Dublin, has availed himself of the
high temperature  produced by lime in  the act of slaking, for the
purpose of a moxa.  About an inch depth of the powder is placed
on the skin, inside a porte-moxa, or a strip of card bent so as to form
the section of a hollow cylinder.  Some  Avater is  dropped on and
mixed with it.  In about two minutes, the mixture swells and be-
comes dry, producing a high degree of heat, amounting, according
to some experiments, to 500° F.  Dr. Osborne deems it the best of
all moxas, from its being very capable  of being  made equal in
power to the potential cautery by increasing the bulk  of lime, also
from its convenience, and its emitting no  sparks or smoke.  When
less lime than the quantity above mentioned is used, and w hen left
on but a short time, a thick crust is formed, as after the application
of acetic acid, which crust separates in proportion as the new skin
is perfected underneath.  AVhen the quantity of lime is large, and
kept on wfiile the heat continues, a complete destruction of the skin
ensues, and thus deeper issues may be made, and in shorter time
than by the usual escharotics.   He  ingeniously  determines  its
strength beforehand, by ascertaining to what depth it  Avill coagu-
late the albumen of an egg when applied on the shell.  Dr. Osborne
says its advantages consist in producing a contraction  and change
in the action of the vessels beneath, Avith great excitement  of the
absorbents, enabling them to return to a state  of health after the
failure of other means, as noticed by Larrey, and  as is familiarly
knoAvn in the practice of veterinary surgeons.   In a case of ulcer-
ations in the  upper part of the rectum and in the sigmoid flexure,
wdth purulent and bloody discharges, this  moxa, applied over the
latter externally, effected a complete cure before the ulcer  of the
moxa (about the size of a crown) had filled up.  Similar success
folloAved  in a case of softening of the tubercles, and in another of
purulent  infiltration after pneumonia; also, it was used wdth benefit
in two cases of severe hip-joint disease, in one of which the joint
had become destroyed, and Mras extensively enlarged.   Lime from
the lime-kiln, if fresh, answers Avell for  ordinary purposes.  The
cheapness of this  moxa  is another recommendation.  The ulcer
made, it must be recollected, is ahvays twice  the  diameter of the
lime applied.—Dublin Journal of Med. Science, January, 1842.—T.]

              § II.—Metallic Cauteries,  (Fig. 169.)

  The actual cautery, properly so called, is understood of metallic
rods of various forms, and which are heated to different degrees be-
fore being applied to the skin.  We may make use of rods of gold,
silver, or platina, instead of steel.  M.  Gondret,  indeed, pretends
tnat copper acts four or five times more quickly, and, consequently, 
CAUTERIZATION.
303
causes less pain, than iron or steel; but the infusibility and capaci-
ty for caloric of these last are so well known, and they are so easy
to be obtained, that all surgeons continue to prefer them.
  We have cauteries of a reed shape, (en roseau—a) a sort of cylin-

             «               (Fig. 169.)
«         &         c            e       J   3
drical rods that may be applied to the deepest passages ; the olive-
shaped, (en olive—b) which serve for burning the interior of certain
cavities and cysts, and the bottom of small excavations. The coni-
cal (c) cautery is more particularly designed to penetrate through
a certain quantity of tissues.   The hastile or cultelaire cautery is a
species of shield, (rondache—d) or sapeur's hatchet, designed for
making burnt lines (des raies defeu) upon the integuments.  When
we wish to cauterize flatwise and upon a large  surface, we employ
the nummulary (nummulaire)  cautery, (e)  That which Percy has
described  under the name of the annular cautery is not used; but
Ave  sometimes employ the bird-beaked,  (bee d'oiseau—f)  and the
haricot (g) cautery.
  All these cauteries, which are sometimes straight and sometimes
curved, terminate in a rod which is furnished with a handle at the
time of being used.   The tail of the  cauteries, moreover, is so ar-
ranged, that the  same handle (h) may be applied to all.   For that
purpose, it is only necessary to turn a small screAV, placed on the
side of this handle, to enable us to fasten or withdraw the cautery.
When we desire to apply these instruments, we place them upon
a chafing-dish in the midst of burning charcoals, which  are kept
in a state of active combustion by the bellows ;  the degree of heat 
304
NEW ELEMENTS OF OPERATIVE SURGERY.
we Avish to obtain is determined by the color the metal assumes in
becoming heated.  Thus, the gray is the lowest degree  chosen
and the  dark  red, the cherry red, the yellow red, and the white red.
folloAv in succession.  It is necessary to recollect, that the pain i*
this operation is in an inverse ratio to the degree  of heat em-
ployed.
  The cauterization by the hot iron takes the name of inherent cau-
terization, (cauterisation inherente) when we disorganize  the tissues
by a continued application of the  metal  upon the diseased part;
ten to fifteen seconds ordinarily suffice,  in this case, to obtain an
eschar, if the  cautery is heated  to a  white heat.  On the  supposi-
tion that we Avish to go deeply, it would be better to change the
cautery AAdien it sinks to a dull red heat.  In all cases Ave ought to
act quickly, and not leave the cautery in its place till the cooling
is completed, if we do not Avish  it  to  adhere to the eschar and en-
danger some laceration.  In order to protect the neighboring parts,
Me coAer them, generally,\vith some interposing substances, either
linen,  felt, or  pasteboard, Avhich we  take care to wet with saline
liquids, unless Ave apply the cautery through a canula of metal, or
wood, covered with Avet linen.  The result is, in eAery respect, sim-
ilar to that of a burn in the fourth degree, and exacts the same
precautions for the treatment.
  Cross (transcurrent) Cauterization.   The ancients, who frequently
used transcurrent  cauterization,  employed it, as the veterinary sur-
geons do at present, to trace lines  and different figures upon the
diseased  regions, and  especially about the articulations.  It  is the
hatchet cautery Avhich is used for this  purpose; heated to Avhite-
ness, it should be passed by its cutting edge upon the region to be
cauterized, so as to burn about half the thickness of the skin.  AVe
thus make a certain number of grooves, which should not approach
nearer than half an inch, and may  be made parallel,  though it
is sometimes better to arrange them in  the shape of fern-leaves,
(enfeuilles defougere)  The consequences of this kind of  cauteri-
zation are very similar to those of moxa.
  Objective Cauterization. AVe mean by this last epithet  something
analogous to insolation. In fact, the objective cauterization is made
by means of burning  charcoal, or a metallic body heated  to a red
heat, and which is held at a certain distance from the part.  Eulo-
gized by Fabre in the last century, objective cauterization, Avhich
I have sometimes thought it  advisable to  make trial of, is rarely
any longer advised at present, and appears to me to merit the dis-
use into which it has fallen.
  We see, by these few details, that  the  actual  cautery which is
employed in venomous or poisoned wounds, to arrest certain hemor-
rhages, to prevent hydrophobia, to limit and destroy the  malignant
pustule and carbuncle, (le charbon) cancerous growths, and vari-
ous tumors, requires the reed or olive-shaped, the conical, bird-beaked,
haricot, or nummulary cautery, when we desire inherent cauteriza-
tion ; that  the  hatchet cautery is, in fact,  for cross-cauterization
only,  and that pieces of metal would suit  much better for objective 
VACCINATION.
305
cauterization.   Every thing shows, that if the ancients, especially
Severinus, made a singular abuse of the actual cautery, modern
surgeons have neglected its employment too much, and that they
do not attend sufficiently to the reasons urged by Percy in favor of
this  therapeutic means.  We must, however, acknowledge that
the actual cautery runs the risk of never recovering its ancient
popularity, either  because art  now possesses means which, to a
certain  degree, take the  place  of it, or that it  inspires  a great
degree of dread in most patients, because, before using it, we have
to be very sure that we can demonstrate its efficacy.
   After the employment of the actual cautery, the treatment is the
same as after the application of  moxas.
                        CHAPTER IV.

                      VACCINATION.

  The small-pox, a disease so often formidable, and always loath-
some, has found in the vaccine virus an almost constant preventive.
To maintain to-day that the vaccine does not destroy the principle
of the small-pox, would be absurd ; it would scarcely be less so, to
persist in saying that no vaccinated individual can be attacked
with small-pox.  I have not in this place to consider how far it is
useful to revaccinate those who have  been vaccinated in their
youth; nor can the subject of the necessity or inutility, at the pres-
ent day, of retaking the vaccine fluid at its natural source in the
cow-pock, now occupy my attention ; but vaccination, of itself, is
of a utility too indisputable to permit me to dispense with pointing
out to pupils the manner of performing it.
  There are in vaccination three principal circumstances: the ope-
ration, the development of the vaccine, and its preservation.

                    Article I.—Operation.

  We may vaccinate in many different ways.   Some have  thought
that after having made friction on the part with a piece of linen,
to the point of excoriating the  cuticle, it  would be sufficient, in
order to  attain the end proposed, to apply upon the surface thus
prepared another piece  of linen impregnated  with the  vaccine.
Others, after the example of Osiander,, have advised to  destroy
the cutis by means of a blister.   There were others, also, who
made a  slight incision into the integuments, and insinuated be-
tween the lips of the  small wound a thread imbued with vaccine;
but they have now, everywhere, substituted  for these three  pro-
cesses the simple puncture.
  vol. i.                       39 
306
NEW ELEMENTS OF OPERATIVE SURGERY.
  To effect this, we use  either the vaccine-needle (Fig. 170)  or
an ordinary lancet, whose point is slightly charged Avith the pre-
ventive fluid.  Holding the  instrument in the right hand, after the
manner of  a Avriting pen, or as for bleeding,  the  surgeon inserts it
very obliquely (Fig. 171) between the  epidermis  and the rete mu-


                                     (Fig. 171.)
cosum, to about one line in depth, so as to cause at most only a very
small drop of blood.  Before Avithdrawing the lancet it  is Avell to
move it a little within the puncture, then to wipe its two  sides, one
after the other, upon the surface of the little wound.  We proceed
in this way on four to six different points, and the operation is ter-
minated.  This is done with so much rapidity and  so little pain,
that infants asleep are not awakened by it, and the most intractable
have scarcely time to cry.  The skin should afterwards remain ex-
posed to the air from five to six minutes, in order to give time for
each puncture to  dry.  It is  sufficient, after that, to cover the part
with a piece of fine linen, and to dress the infant as usual.
  The number of vaccine punctures is altogether arbitrary.  We
are in the habit of making six ;  some, however, make but four, and
every thing shows that it would be sufficient, in  truth, if we had
only one good one; but  it is better, in reality, to have  too many
than too few, seeing that  they rarely all take.
  The region of the body has little in reality to do with the success
of the vaccine ;  we could  succeed in vaccinating the foot, leg,
thigh, breech, abdomen, cjiest, head, and neck, quite as well as on
the thoracic members; but Ave prefer the arm, as the most conve-
nient for all the circumstances of the operation.   It is generally on
the middle third of the humerus that the vaccine  is applied, taking
care  to make three punctures on each  side ;  one on  the outer
side of the deltoid, the other opposite the insertion of  this  muscle, 
VACCINATION.
307
(Fig. 172.)
^\
and the third under it, (Fig. 172, a.)   In  this way they are sep-
arated an  inch at least  from one  another,  are  easy to  watch,
and protected from all friction.  Instead
of placing them in this manner, some sur-
geons prefer arranging them in a triangle,
one in front, the other behind, and the third
below on the point of the deltoid,  and this
with  the  vieAV of  keeping their cicatri-
ces afterwards more  easily covered.  In
either mode  it is necessary that the child
should be undressed, and that his limb be
entirely free.  Embracing it below Math
the left hand, the  surgeon stretches the
outer surface of it, while  with the  right
hand he performs the punctures spoken of
above.
  The age which suits best for vaccina-
tion, is that  of the last six months of the
first year, and throughout the whole second
year.  It  is not that in a  more advanced
age children have less to hope from the
vaccine;  but as  in waiting they are ex-
posed to the  occurrence of the  small-pox,
it is very natural that many families prefer
having them  vaccinated as soon as pos-
sible, that is to say,  in the first months
after the birth. Experience seems to have
proved, moreover, that at the second month,
and even in the first Aveeks, this operation
is as effective as at a later period.  It re-
sults from this, that in seasons of  epidem-
ics infants should be vaccinated at a very early period, while if the
small-pox is  nowhere  prevailing, we may MTait till the middle or
end of the first year.
1		
	p ^	
,		
	h	1 \
Article II.—Progress of the Vaccine.
  The wounds of the vaccine  are not ordinarily the seat of much
action, and remain in the state of a simple puncture, (a) or of a
prurigo pimple, (papule de prurigo) to the end of the third day.
This lapse of time is knoAvn under the name of the period of incu-
bation.
  At the moment even of the operation the punctures are surrounded
with a large areola of some  lines, and of a pale rosy color, and
then a little tumefaction, which all disappear at the end of a quar-
ter or half an hour.
  On the fourth day, the small wound seems to rest on a hard base,
and its apex strikingly assumes the  appearance of the bite of an
insect. 
308          NEW ELEMENTS  OF  OPERATIVE SURGERY.

  On the fifth day, the Avhole presents a conical vesicle, whose apex
begins to be depressed.  Quite a severe itching sometimes accom-
panies this first stage.
  On the sixth day, the base  of the vesicle is enlarged and its apex
is depressed.   But it is not until on the seventh day that Ave  see
formed around it a  slight swelling, this latter also  having at its
circumference a narrow inflamed areola.
  On the seventh day, (b) the vaccine pock is still more depressed,
and of a fawn color, and is surrounded with a silver-colored ridge,
(pourrelet) evidently distended by a fluid.
  This ridge (bourrelet—c) increases sensibly on the eighth day, and
is surrounded with a rose-colored zone and with a tumefaction,
which, on the ninth day, is extended from one puncture to another,
if they have not been separated more than an inch apart.
  It is not till on the ninth day (d) that the vesicle is the most de-
veloped, and that its apex begins to assume the  form of a small
dark-colored crust.
  On the tenth day, the vaccine pock, more  flattened, less shining,
and manifestly enlarged, rests upon a general tumefaction exten-
sively developed.  Then the Avhole outer side of the arm is swollen,
as if from clusters  of furuncles, (furoncles rapproches.)  It is ac-
companied with heat, and the patient complains of a severe itch-
ing.  Then, also, the child sometimes becomes fretful (maussade)
and difficult to manage ; he feels restless, and has  a slight fever
and chills, accompanied with paleness of the visage,  and swellings
in the axillary glands.
  On the eleventh day, («?,) the poclf is hard, flattened, and destitute
of fluid;  it assumes a  pearl-gray or dirty yellow color, and  be-
comes covered with a dark-colored eschar.
  The stage of inflammation is thus terminated.  Now comes the
stage of  desiccation.  On the twelfth  day, (/,) Ave observe  a scab,
which  occupies the epidermis, a remnant of turbid liquid, and an
areola, Avhich is paler, harder, and of less extent,  than the day be-
fore.
  On the  day after, and on the  succeeding days, the engorgement
which  surrounds each pock diminishes more and more, and the li-
quid of the pustule becomes puriform.
  Counting from the fifteenth day, the vaccine scab, changing from
a fawn to a dark red color, now assumes a more or less deep-brown
hue, and stands out more and more  from the  surface of the skin.
This scab, sometimes raised  up  by pus, and accompanied  wdth  des-
quamation of the neighboring cuticle, falls from the twenty-fifth to
the thirtieth day, leaving a dotted (pointillee) cicatrix, easily recog-
nised, and which never disappears.

            Article III.—Anomalies  of the Vaccine.

  Vaccination does not  always proceed with as much regularity as
I have just described;  there are cases where the  inflammatory
stage is formed at the end of twenty-four or forty-eight hours, while 
vaccination.
309
in other cases it will not be manifested before the expiration of a
month, and in consequence of a second vaccination.  It  appears,
also, that this stage may last from three weeks to a month, instead
of being restricted between the third and twelfth days.   History
also makes mention of persons so repugnant to the vaccine, that it
has required eight  to  ten  successive  operations before the  virus
would take.  It  is also said, that, in certain cases, the vaccine has
produced only some general symptoms, leaving, however, the sys-
tem protected against the small-pox.
  False Vaccination. In place of a  genuine vaccination,  which is
the only one  that is protective, we sometimes obtain only a spuri-
ous  one.  This  false vaccination takes place in individuals who
have had the small-pox, or who had already been vaccinated.  In
other cases, it arises from  having used a dull-pointed or rusty lan-
cet ; or because the vaccine was bad, too old, or decomposed—in a
word, because the fluid was spurious, or that the operation  has been
badly performed.  In such cases there is generally no stage of in-
cubation, and the suppuration is found  in the vesicle on  the third
or  fourth day.   The  stage  of desquamation,  on the contrary, is
longer, and the  cicatrix has none of that dotted appearance which
makes  it easy to distinguish from every other mark on  the skin.
Sometimes, also, the scab falls on the fifth day, and is reproduced
and detached anew, as with ulcers in general.  [In reference to the
 pointillee, or dotted appearance of the  cicatrix, it  is well to add,
that  its shining, smooth, glossy appearance, and  white or pearly
white color, and its circular or ovate form, and its usually slight and
sometimes greater depression beloAV the general surface of the sur-
rounding skin, and also the  pellicle-like thinness of the new cuti-
cle covering this depression  or cicatrix, so transparent  as  some-
times to  permit the  minute  veins  to be seen beneath it, are all
characteristic marks  of the genuine  vaccine, not to  be  over-
looked.— T.]

    Article IV.—Preservation and Transmission of the Vaccine.

  Previous to the sixth day, it Meuld be next to impossible  to ob-
tain from the vaccine vesicle the least particle of liquid,  and thus
to make use of it for vaccinating another child.  The seventh, eighth,
 and ninth day, the end of the sixth, and the beginning of the  tenth,
 only, allow us to obtain any that will prove efficacious.  Later than
 this, the scabs being pulverulent or moistened, the pus which they
 contain, would  rather produce a false  than  true vaccination.  I
 should  also add, that, from experiments  made at Tours from 1816
 to  1820, on a great number of patients, the preservative  property
 of the  vaccine  is at its maximum  of intensity at the end of the
 sixth to the commencement of the  eighth  day.   We extract and
 pieserve this liquid in various ways.

                § I.— Vaccination from Arm to Arm.

   If the child to be vaccinated is near that which is to furnish the 
310
NEW  ELEMENTS OF OPERATIVE SURGERY
 vaccine,  Ave  make a  few  punctures on  the swollen border (le
 bourrelet  peripherique)  of the  pustule;  Avith the point of the lan-
 cet, or a  needle, Ave take  a  small drop of this liquid to transfer it
 immediately, as has been  said, to the arm of the other child. Af-
 ter  having made  tAvo  punctures with the first drop, Ave  return to
 take a second, then a third;  Ave  might even, for greater certaintv
 supply the lancet  anew at each puncture.


                              §11.

   If it should become  necessary to transport  the vaccine to some
 distance, we should open the  border of the pock, as in the preceding
 case, and then  charge  with the fluid the  points of several lancets,
 which should be immediately shut up in their handles, from Avhich
 latter they are kept separate by means of a small piece of  paper.
 We thus  arrive at the child to  be vaccinated without any fear that
 the  vaccine  may  have  become decomposed, provided it is applied
 before the end of the first or  second day.

                              §  III.

   But it is often required to preserve  the vaccine for a much longer
 time, or to transmit it to great distances ; many means have been
 devised for this purpose.  One of the oldest,  and which Avas em-
 ployed by Jenner,  consisted of tAvo  small square plates of crystal
 glass, (g) one of Avhich  Avas  holloAved out in the middle  into a
 slight depression,  (cupule.)  It  is in this cavity that the vaccine is
 deposited, after which the plates  are  placed together, and the bor-
 ders then luted w ith glue or sealing-wax.  This process has the in-
 convenience  of requiring much more vaccine than it is sometimes
 possible to obtain.  In other  respects, it is exceedingly convenient
 and useful.   Many persons  have substituted  the employment of
 simple plates of glass, (h,)  the  middle part of which is applied to
 the vaccine pustule to receive its liquid, and then the two luted to-
 gether, as with the others.  In  adopting this mode, it is impossible
 to aveid losing a very considerable quantity of the liquid, or to pre-
 vent its desiccation.
   The threads that Avere  formerly used, as Avell as the pieces of
 linen, to imbibe the vaccine fluid, are  no longer employed, since the
 incision and friction have been abandoned.

                   § IV.—Bretonneau's Method.

   The most  valuable  mode  known  at present, is that which we
 owe to M. Bretonneau.   This  physician has proposed glass tubes,
 of from fifteen to  eighteen lines in length.  Spindle-shaped, (fiusi-
formes—i) capillary, and drawn out at the lamp of the enameller,
 they are applied like a  writing-pen by their point, inclined at the
 same time more or less downward, to  each drop of liquid ; they 
VACCINATION.
311
thus become filled by capillary attraction.  Presented afterAvards
successively to the flame  of a candle, the extremities of the tube
are melted, shut and converted into a small bulb, (boule) which for
greater security may be enveloped in wax.  The tubes  thus pre-
pared  and put aside in the hollow of a quill or some other case,
after the manner of needles, preserve the vaccine in a liquid state,
and in all its energy, to an indefinite period.
  To avoid breaking when they are to be  transmitted to a great
distance, Ave place  them  in cases or  small boxes filled with bran,
saAvdust, or charcoal.  It  is Avithin my knoAvledge,  that vaccine
sent in this manner to America, has produced at the expiration of
three years as many vesicles as punctures.
  More recently, M. Fiard has had tubes constructed, one of the
extremities of Avhich resembles  the  bulb of a thermometer, (j)
Held in the palm of the hand this bulb becomes heated, creates to
a certain degree a vacuum, and as it cools compels the vaccine to
be  forced into it.  But the tube of M. Fiard is too large, and seems
too difficult to fill, or would require, at least, too great a quantity
of  vaccine, to suppose  that they could be substituted for those of
M. Bretonneau, which latter are  now in general use.
  In Avhatever manner, however, the vaccine has been collected,
we must make use of it as if it had been taken from  arm to arm.
If it has  been preserved  in the mode of Jenner, we unglue the
plates of the crystal, move them upon each other, in order to sepa-
rate them, and dip  the  point of  the instrument into a drop of the
liquid.  If we have used  the plates of glass, it is necessary, after
having separated them, to moisten a little, by means of the finger,
Met with tepid water or  saliva, the  dried vaccine matter, before
charging the lancet AAdth it.  By the method of M. Bretonneau, we
begin by breaking the tAvo small heads of the  tube ;  we then adjust
the largest of the two  extremities into the glass tube of a blow-pipe,
which latter should be two or three times longer than the vaccine
tube, or we insert it merely into a stalk of straw.  Raised to the
mouth, the extremity of the blow-pipe, thus arranged, serves to force
the vaccine  upon the point of the lancet,  (Fig. 173,) which is held
in  one hand,  Avhile  the other  directs the tube, and prevents  it
from moAdng.   In this manner a  tube Avhich contains  less than a
drop of A'accine, may suffice for six and sometimes eAen a  dozen
punctures.
  Though the taking aAvay the  fluid from all  the  Aesicles of the
child may have no effect  in  destroying the efficacy of the opera-
tion upon it, it is, however, as AAell to leave  at least  one of them
untouched.  It must be  also confessed, that this abstraction renders
the progress and changes  of the vaccine evidently much more irri-
tating, without being of any advantage to the person  Mrho submits
to it.  The  quantity of the vaccine fluid, also,  is in relation wdth
the development of the pock from which we take it,  and not with
the constitution or health  of the child that furnishes it.
  [M.ules of Preserving ; also, the Test of Purity.   Dr. Mott thinks
the best Avay of preserving and transmitting the virus is upon small 
812           NEW ELEMENTS  OF  OPERATIVE SURGERY.
(Fig. 173)
flattened ivory points, about an inch or an inch and a half in length,
charged with the virus, and placed in small vials carefully sealed
with wax.  It is the neatest and most convenient.   Points of quills
are the common mode in this country.  The dried scab, shut up in
sealed vials, is a most excellent mode of transmission. When used it
is powdered, and, moistened with saliva or water into a little paste,
is a most efficacious mode, and may for a long time retain its virtues.
Again, scarifications, and those crossed, and all of them restricted to
a small space, is, in Dr. Mott's judgment, a much better mode of
communicating than puncture or any other plan, unless when it is
from arm  to arm, where puncture is preferable.   Next to Jenner,
Brice, of England, comes in for much praise, as having introduced
a great improvement in vaccination, and Mrhich improvement is
the only true test of  the constitutional effect of the vaccine  dis-
ease.  It is this: on the fourth or fifth day, on puncturing the mar-
gin of the  pock, there will be obtained on the point of the lancet a
particle of lymph, which, upon being inserted upon the same or
the other arm, or any part of the body, will  take effect, and go on
and reach  maturity pari passu with the pock from which it is pro-
cured, thus proving the  constitutional effect of the vaocination 
PERFORATION  OF  THE EAR.
313
In this curious pathological phenomenon, the stage to Avhich the
primary vesicle has advanced, imparts a proportionate maturity to
the one which is reproduced by it, and they proceed on together,
the original and its type and test.—T.]
                        CHAPTER V.

             PERFORATION  OF THE  EAR.

  The rings  and jewels wbich women usually wear in their ears,
and Avhich many men also formerly wore, cannot be inserted with-
out a small operation, known under the name of the perforation of
the lobe (lobule) of the ear.
  Whether it is performed when young, or not decided upon until
after  puberty, the operation is so simple, that the persons upon
whom it is performed are scarcely sensible of it, if the proper pre-
cautions are observed.   It consists in quickly perforating the lobe
of the ear, in its middle portion,  through and through, at three to
four lines  above its  lower extremity.  We begin with benumbing
the part by rubbing it, Math  a certain degree of force,  between the
thumb and fore-finger.  We now press the base of a  cork against
its posterior surface,  and then effect the perforation with  the other
hand by means of a particular kind of instrument. This instrument
may be a kind of punch, (emporte-piece) or a needle armed with a
canula, that is to say, a very small hydrocele  trochar.   The punch,
perforating the lobe,  separates a small fragment of it, which it car-
ries with it into the cork, (Fig. 174.)  As soon  as it has completely
perforated the part, and that Ave have disengaged it from the cork,
Ave remove from its cavity, by means of a pin, the fragment of tissue
which it has cut, in order to attach to the punch  the  extremity of
a leaden Avire, which is draAvn through the perforation by means of
the puneh, which thus serves the purpose of a larding-pin, (lardoire)
When  Ihe  trochar is preferred, which is in fact more convenient,
we force it in the same manner  to a certain  depth into the cork.
After having withdrawn its  punch  Ave introduce the leaden wire
into its canula, which latter is immediately  Avithdrawn, and the
operation is finished.
  In place of a leaden Avire, whose ends must be united and twisted
to prevent displacement, some persons make use  of a  skein of
thread or cotton, and sometimes, also, of the  ring itself, so as to
make the operation complete at once.  But as these foreign bodies
are to act at first in  the manner  of  a seton, their object being to
force  the wound to convert itself into a fistula or passage, by means
Df the cicatrization on the surface of its cavity, the lead, for those
  vol. i.                      40 
314           NEAV  ELEMENTS OF OPERATIVE SURGERY.

reasons, is in reality the one to be preferred. AVhen the interior of
the perforation has  undergone this cutaneous transformation, that
is, at the end of fifteen, twenty, or thirty days,  sometimes more,
rarely less, we may substitute the ring itself for the temporary con-
trivance of Avhich I  have just spoken.
  This small operation, relating to a homogeneous tissue, which
includes  neither vessels, large  nerves, nor muscles, nor tendons,
does not endanger  any serious wound ;  thus, therefore, is it daily
performed by jewellers, and even by common people.  It is well to
know,  however, that, like any other puncture,  it may cause an
erysipelas, or  even  a phlegmonous inflammation, in the lobe of

                            (Fig. 174.1
the ear.  I have frequently seen small abscesses form  around the
aperture, and it not unfrequently happens that  the puncture ulce-
rates and cuts its way out by means of the seton.  In this respect
the punch, effecting a loss of substance, offers some advantage over
the trochar.  It is because of the tendency of the wire to cut the
parts, that  it is better to puncture a little higher up, rather than
lower down.  In order to avoid all inflammation and suppuration,
it is better to move the temporary ring, generally every day, taking
care to besmear it with  a little ointment or fatty substance.  It is
proper to knoAV, also, that if by chance the seton  should cut through
from the perforation before the definitive formation of the  fistula,
the hole would shut up very quickly, and that it  would then be
necessary to recommence upon  another point, or  to repass a new
seton  through  the first wound  by means of a blunt  probe.   On
the supposition that inflammation  or purulent collections  should
manifest themselves about the foreign body, it would  be better to
withdraw it, to reapply it at a later period, than to persist in keep-
ing it in its olace. 
OPERATIONS  ON THE TEETH.
315
                        CHAPTER  VI.

      OPERATIONS THAT ARE PERFORMED ON THE TEETH.


  Like all other parts of the human body, the teeth require ATarious
special operations, which consist—
  1. In favoring their egress ;
  2. In giving them a proper direction ;
  3. In maintaining them in a state of proper cleanliness;
  4. In filing them to arrest the progress of caries ;
  5. In filling them ;
  6. In cauterizing them;
  7. In effecting their extraction.
  For this chapter I have not wished to rely upon my own propel
experience ; I have desired my friend, Dr.  Toirac, one of the most
skilful and capable dentists of the capital, to prepare it  for me.
The reader, therefore, must expect to find here the doctrines and
precepts of this distinguished practitioner, rather than mine.

Article I.—Incision of the Gum to favor the Egress of the Teeth.

  If the  acute  pains and convulsions, which the infant sometimes
experiences in pushing forth its  first teeth, depend upon the resist-
ance of the gum, the incision of this part is indicated.  This opera-
tion, Avhich is effected Avith a  lancet  or  bistoury, does not  succeed
well, except it is performed sufficiently deep, and so that the divis-
ion  (debridement) is complete.  The incision for the incisor and ca«
nine teeth should be simple, and for the molar, crucial.
  The last or wisdom tooth, in the lower jaAv, may also  require the
use of a cutting instrument: this is when it appears to be arrested,
in part, by a thick border (bourrelet) of gum. This border inflames
and ulcerates, and causes sometimes intolerable pains, which ex-
tend to the ears,  to the parotid and sub-maxillary glands, and to
the neck, and, by sympathy, to the  teeth of the upper jaAv.  A
simple deep incision, and, better yet, an excision in form of a V,
with its apex forward, suffices in most of  the cases ; we take the
precaution of introducing under the loosened portion of the gum a
small dossil of cotton or  lint, to retard the too prompt cicatrization
of the weund.  If it should be judged proper to make  a complete
removal  of the flap, (lambeau) a bistoury,  or good pair of  scissors,
and a dissecting forceps, would suffice.   If we should desire to ef-
fect the  same result by  cauterization, the  small  curved cauteries,
heated to whiteness, should be preferred to the potential cauteries,
which are ordinarily insufficient. 
316           NEW ELEMENTS OF OPERATIVE SURGERY.
             Article II.—Straightening the Teeth.

  Nature, which makes every sacrifice for the arrangement of the
first teeth, has often need of the  assistance of art for  that of the
second dentition.   If the dental arches are well developed; if the
arch of the  palate is  wide and rounded; if, at the age of five or
six  years, the milk teeth are separated, leaving certain intervals
between them, it is to be presumed that those which are to suc-
ceed them will be placed regularly upon the alveolar border.  But
if, on the contrary, the curve which the jaws make is narrow and
protrudes forward ; if the milk teeth are small and wedged togeth-
er ; if,  in fine, the  vault of the palate is contracted and elevated
into a cone,  these signs of an unfavorable aspect announce an ir-
regular dentition, which it will be essential to watch.
  As a general rule, it is important not to remove the milk teeth
too soon, that is, before nature has indicated by their looseness the
presence of those that are to succeed them.   This method is injuri-
ous, because the jaws, by contracting themselves, cause the alveo-
lar  border to be diminished, by which means osseous cicatrices are
formed, Avhich render the egress of the second tooth more difficult.
There are, however, cases where the premature  extraction of the
first teeth, as well as the sacrifice of one or two of  the second den-
tition, are necessary ; but it is easy, from what we have just  said,
to foresee the moment for this a long time in advance.
  When the dentition has not been properly directed, or that it has
been impossible to  effect a regular arrangement of  it; when some
are out of the arc  that they ought to form, and some are snags,*
(sur-dents) or cross each other, or are of unequal length, avc must
recur to the  different mechanical  expedients used  for such cases,
and wdiieh consist of threads of silk or metal, plates of different
forms, inclined planes, &c.  The younger the subject is, the more
promptly will the means we employ succeed.
  When  a tooth projects too much, supposing that it is,  in this
case, a large or small incisor, it can be brought into the  circle  by
passing a cord of the proper size on the outer  surface of its neck ;
we  then conduct this cord so that it may pass on the posterior face
of the  neighboring teeth ;  afterwards it is brought  forward  by
passing it betAveen the  canine and first bicuspid,  and finally tied
upon one of them.   If we wish to bring the same tooth forward, in
the case that it should be found too far back, instead of placing the
cord on its  anterior face, we should pass it behind, and we should
in the same  way make our points d'appui upon the  canine teeth, or
upon those more remote.
  If the teeth that  we would wish to bring forward should be found
imprisoned by those of the lower jaw, as sometimes happens to in-
dividuals with prominent chins it is easy to be conceived that the
action  of the threads would be almost nothing, since the movement,
[Sometimes called wolves' teeth.—T.] 
operations on the teeth.
317
which we should have the intention of producing on tne teeth above,
would be neutralized by the obstacles which would be constantly
opposed to it by the teeth below.   It would be necessary, then, to
dispense  with the cords, and  have recourse to the inclined plane.
With the cords and the inclined plane, which are used together or
separately, we  may effect all the results desired for restoring and
adjusting the  position of the  teeth.  [A very efficient and easy
mode, which I  have practised, when one of the large incisors, for
example, of the second dentition  in the upper jaw, has emerged
only one half from the gum, and, as often happens in such cases,
takes an abrupt direction backwards, or within the mouth, is this :
Cut out a portion of the. gum in front, of the shape of a narrow per-
pendicular  A inverted, of the  length, say, of the part of the tooth
that has emerged, and the two branches of which  should,  at their
base, be at the distance from each other of about one half or two
thirds the breadth of the tooth.  This excision is  very conveniently
made on the superior  half of the  anterior surface  of the tooth
which  is yet covered by the  gum,  and  causes  little or no pain,
while the effect of  it is perfect in unbridling the tooth, and, in a
few weeks, enabling  it to resume, by the pressure of the gum be-
hind, which now has  no antagonist force, its proper position in the
arc. When the tooth is entirely protruded, no traces are to be seen
of the excision.—T.]
Article III.—Cleaning the Teeth, (Fig. 175.)


                  (Fig. 175.) ■
y
^    I
  When the daily use made of the brush does not prevent the teeth
from becoming covered with tartar, we should have recourse, from
time to time, to the employment of an instrument.  Before com-
mencing the operation, we should have at hand a glass of tepid 
318
NEW  ELEMENTS  OF  OPERATIVE SURGERY.
water, if it is in winter, a Avash-basin for the person operated upon
to spit in, and a napkin to Avipe the instruments.
  The patient being placed on a suitable seat, so that his head is
supported behind, and the operator, having at hand all the instru-
ments which  he considers necessary, places  himself on the right;
then taking the  simple scraper, (grattoir—a) in the manner of a
writing-pen, the  mouth being slightly open, he uncovers the teeth
of the lower jaw, and keeps the lip depressed by means of the fore-
finger, while with the thumb he supports the tooth upon which he
is acting Avith the instrument, the point of which he forces below
the tartar, in order to break it into fragments, which must be dis-
placed from below upwards, in order not to  wound the gum; he
proceeds thus with each tooth, until he finds no more foreign mat-
ters to remove.   The same instrument, by having the point almost
square, is more convenient for scraping the small and large molars,
and is attended with less risk of wounding the cheek, M'hich is kept
aside by the fore-finger.  Then taking the curved scraper, (b) he
effects the removal of the tartar Avhich is found on the opposite
side of the same teeth:  for this purpose, the operator places  him-
self sometimes in front and sometimes behind the patient, accord-
ing to his convenience, taking care to guide his instrument so as not
to wound the gum.  All the tartar discoverable having been re-
           moved, he  introduces between the teeth the extremity
  (Fig. 176.)  0f ^ blade of the instrument, (c) in order to complete
           the cleaning.   In order to be certain that no more re-
           mains, he  makes use of  the  small mirror, (Fig. 176.)
           which is so placed in the mouth as to  enable him to ex-
           amine each tooth successively.
             The teeth of the lower  jaw being entirely cleaned,
           he then proceeds to those of the  upper jaw; this row
           of teeth is, in general, less covered  with tartar  than
           the preceding.  To clean them, the surgeon passes his
           arm around the head of the patient ;  with the  fore-
finger he  raises  the  upper lip, while the middle  finger, placed
on the free border of the tooth he is cleaning, supports it, especially
if it is loose ; as with the incisors and canine teeth beloAV, he must
here use the  scraper a and the scraper b.   The  instrument Fig. c.
serves to scrape the inner side  of all the teeth.
  There are other details that we pass over in silence, and which
good  sense, address, and practice know how to employ when the
occasion requires—such as supplying the mouth, from time to time,
Avith  water, to remove the foreign bodies that  have become de-
tached, or  the blood in persons whose gums are swollen, soft, and
bleeding.
  We sometimes meet on the crown of the teeth with deep spots,
which are very difficult to remove with the instrument; they then
require the use of an acid, more or less diluted (etendu) with water, 
OPERATIONS ON  THE TEETH.
319
which is gently applied with the end of a match, (allumette) an.d
which we must immediately Mdpe off, that it may not extend to the
neighboring teeth ; we iise, also, for this purpose a piece of pum-
ice-stone, shaped in form of a cone ; the extremity of it is dipped
in water before using it. It is very seldom, hoAvever, that Me have
to recur to these means, which are not to be used but with much
circumspection, for fear we should destroy too much of the enamel
portion cf the tooth.


                 Article IV.—Filing the Teeth.

  The file (d)  is chiefly employed to level those teeth which have
too mudn length, to separate them when they are too much crowd-
ed,  to remove the caries that attacks them, and  to free them of ine-
qualities of every description ; internal  diseases and fractures pro-
duce, occasionally, a roughness which would wound the cheek, lips,
or tongue,  if the file were not used to destroy it.
  The small flat files, cut sometimes  on one  side,  sometimes on
both, serve to  separate the teeth.  They are  usually held in the
hand; it is only when we wish to separate the large molars that
we have  recourse  to a file-handle, (porte-lime)  The  round and
half-round files are only used when we wish to file the teeth to a
level with  the  gum, when their crown is nearly destroyed, or we
wish to fit  in an artificial tooth.  The triangular file, which is called
also tire-point, serves to file down  the teeth which rise above each
other.  It  is made to act flatwise on one of its sides, or one of its
angles ; we thus make a groove of greater or  less depth, in order
to obtain a hold for the clench (mors) of a pair "of cutting-pincers,
to remove  by a  single stroke  the portion of the tooth Avhich is in
excess.
  The manner  of handling the file is simple ; it requires, however,
some address and delicacy on the part of the  person that uses it,
especially Avhen it is applied to the teeth in front.  As a general
rule, while we  are removing  the  diseased part, we must manage
the external table of the tooth in such a way as to prevent it from
having a disagreeable appearance.  The incisors and canines are
those that  most frequently require attention to this precept; it is
also necessary that the file should be  placed obliquely from before
behind, so  that  it may cut much  more behind  than in front.  We
must take  care to leave at the neck a small projection, (talon)
which resists the approximation  of the teeth.  This precept might
be neglected, if the space between the teeth which have been sep-
arated should be thought too great.  As to the lateral teeth, it is
sufficient to  separate them more or less, according to the progress
the disease has made.
  Operative Process. Whatever may be  the object we have in view
in filing a tooth, the patient should be  conveniently seated.  The
operator, placed on the right, holds the file betMeen the thumb and
fore-finger of the right hand.  He dips it in hot water, if it is in 
320
NEW ELEMENTS OF OPERATIVE SURGERY.
winter, and passes  the  left arm, as  in cleaning the teeth, around
the neck of the patient; then raising the lip Avith the middle finger
of the same hand,  he files the tooth steadily, (sans sccousse) and
without employing  force.  If  the file  sticks, (s'engage) he stops,
draws it out, and dips it in hot water, in order to remove the matters
it has become covered with.  Teeth, properly filed, should not ap-
pear to hav e been touched; it is proper, also,  in order to complete
the operation, to round off the angles and the sharp edge which the
instrument leaves.  In this manner  we  cause all  the roughnesses
t< disappear, and try to  give to the tooth its original form.


                 Article V.—Filling the Teeth.

  We give this name  to the operation by which we introduce lead
into the cavities which the teeth present, in consequence of caries or
particular alterations  of the enamel.   They formerly used  for this
purpose only sheet-lead in very thin laminae, (enfeuille tres mince;)
since  that, recourse has  been had to tin, Avhich oxydizes less; to
gold, silver, or platina leaf; finally, to the metal of Darcet, render-
ed more fusible by the addition of a sixteenth or twentieth of mer-
cury ; by means of  the actual cautery, we melt this last composi-
tion in the cavity we  wish to obliterate.
  The operation of filling is  one of the  most  simple and  easy.
Nevertheless, it should not be done without taking into consideration
certain conditions, which relate as much to the choice of the metal
to be employed as to some particular cases  where we must abstain
from practising it. Gold, silver, and platina are employed, by prefe-
rence, to  fill  (obturer) the cavities which may present themselves
in the incisor, canine, and all the other teeth, which, by their posi-
tion, are seen between the lips. The  other metals may be reserved
indiscriminately for  the other teeth, [excepting all mercurial alloys,
amalgams, &c, which cannot  be too strongly condemned and pro-
scribed, as producing  the most disastrous consequences, salivation,
destruction of parts, &c.—T.]
  Operative Process.  The patient being  seated, and the head sup-
ported against the back of an arm-chair, it  is necessary, first of all,
to remove carefully, by means  of a rasp, (rugine) or a small probe,
whatever there is of foreign  matter in the dental cavity.   We
gently scrape the Avails of this  cavity; then pass into it,  succes-
sively a number of  times,  small balls of cotton, and continue this
operation till the cleaning is complete ; we satisfy ourselves, also,
that there is no ichorous exudation going on through the canal of
the tooth; for, in checking it  by the  filling, we  should bring on
pains and abscesses, the  pus of which might  extend sometimes to
remote parts, giving rise to fistulas, the cure of which could not be
effected without  taking out the filling, or, perhaps, extracting the
tooth.  If the dental pulp should be exposed, it would be necessary
to endeavor to destroy it by the processes we have pointed out, for, 
OPERATIONS ON  THE TEETH.
321
unless that is done, the operation would be impracticable, or Avould
produce insufferable pain.
  Every thing having been done properly, the operator rolls be-
tween his fingers, without  compressing it, a small ball of the me-
tallic leaf which he wishes to use, and the size of which is nearly
three times larger than the cavity he Avishes to fill; he places it on
the opening,  and forces it gently, at first, in  the centre ; he then
successively brings together the surrounding  parts, until they are
all  introduced.   If the metal should bulge out too  much, or inter-
fere with the shutting of the jaws, Ave should take  care to remove
the excess with a scraper.   Then making use of the blunt extrem-
ity  of a probe, (/,) we should polish the metal and burnish it, so as
to leaAe no roughness.
  When Ave desire to make use of the fusible filling, (du plomb fon-
dant) we proceed, at first, as with the ordinary filling:  we clean,
then scrape, the cavity of the tooth; then, passing cotton seAeral
times into it, to free it from moisture, insert a small piece of fusible
metal, and then  apply to  it the extremity of a probe, (e,) heated
at a fire, or  by  a  lamp or candle.  When we perceive that the
composition is  melted, we  press it with the finger to make it take
the  exact form of the cavity, then level with a scraper the parts
which are found in excess.
  At different epochs, and also in our OAvn times, they have greatly
extolled various kinds of paste, as capable of replacing the different
metals we have mentioned ; but they are far from effecting in an
advantageous manner the results that have been attributed to them;
and  experience unfortunately  daily proves, that those  self-styled
discoveries, up to the present moment, have turned only  to the
profit of charlatanism.

           Article VI.—Cauterization of the Teeth.


  The object of cauterizing the teeth is to destroy the  sensibility
which exists in them.   Hot iron and caustics of different kinds are,
by turns, used for this purpose  The preference should be accorded
to the hot  iron, which  acts with more celerity and certainty, though
it may often prove insufficient.
  The cases in which we  may resort to cauterization are—1. When
Ave  haAe filed a tooth, to relieve the sensation which is  produced
upon the part we have operated upon by water, cold air, and sub-
stances of a greater or less degree of acidity ; 2. When a tooth has
experienced a shock which has broken a portion of it, or when the
teeth have been much worn down by mastication ; 3. When caries
has made sufficient progress to lay the dental pulp bare.
  This operation is performed by small cauteries, made of different
forms and thicknesses, according  to the place Mrhere we wish to
apply them.  The flame  of a candle, or of a small spirit lamp, or-
dinarily suffices  for heating them.  We apply them carefully to
the part we wish to cauterize, taking care, if it is  a tooth  which
  vol. i                    41 
322           NEW ELEMENTS OF OPERATIVE SURGERY.

has been filed, to touch only the  part  laid bare,  (partie eburne'c)
and avoiding any action on the enamelled portion.
  When we  have to destroy the  dental pulp, which is done with
sufficient facility on the teeth that have but one root, as in the in-
cisors and the canine teeth, Ave make use of a small pin, or a needle
heated to a white heat, which is held by a  forceps, or, better still,
by a needle-holder, (porte-pointe;)  [that is,  a handle, into which a
needle, or any thing similar, may be firmly fixed.—T.]   The  point
of this instrument is  quickly introduced into the opening AAdiich
communicates with the pulp, taking care to enlarge it, if the pas-
sage is too small.
  If Ave Avish to  use  potential cauteries, Avhich are applied more
especially to the molar teeth, because of the number of their roots,
we must begin by carefully cleansing off the caries by means of
the scoop and by rinsing the mouth Avith tepid Avater.   AAe then
take a small ball of cotton, slightly moistened, upon which we scrape
a small quantity of lunar caustic, and then introduce  it into  the
dental cavity.  Creosote, chloride of zinc, the nitric and hydrochlo-
ric  acids, the essential oil of cloves, cinnamon, and mint, are also
used upon a  small ball of cotton, which is reneAved once or twice
in tAventy-four hours;  this dressing is to be repeated until the in-
sensibility is  complete, which Avill  then  allow us to proceed to  the
filling, of which Ave have already spoken.
  Destruction of the pulp by bruising it, (par le broiement)  AVe haAe
given this  name to  an operation  by which the dental pulp  is  de-
stroyed without having recourse  to  cauterization ; this operation,
which is attended Avith considerable pain, consists in introducing
into the dental canal a hog's bristle,  or  very small probe, which is
moved about by turning it around between  the  thumb  and index
finger.  It is  a means which succeeds very well, but is more pain-
ful than cauterization.


 Article A'll.—Of Extraction of the Teeth, and the Instruments
                 THAT ARE USED IN THIS OPERATION.

                 There  are few operations in  surgery  for which
               more instruments have been invented than for  ex-
               tracting teeth.  Of all those that have been con-
               trived, there are  a very small  number that have
               been  retained  in practice.  I  will describe  those
               only that enter into this list,  and which are suffi-
               cient for all  the operations.

                      § I.—The Key of Garengeot, (Fig. 177.)

                 Without  entering into  a description of all  the
 C    □   _)  modifications which this key has  undergone since
               its invention, I will remark, that  the most secure
 and commodious form appears to me  to be  the following: The
l£_S 
OPERATIONS ON THE  TEETH.
323
Keybit (panneton) is of a medium length, and it may take its point
d'appui at a convenient distance from the tooth to be extracted.
When it is too long, the alveolar process is readily broken ;  when
it is too short, we may fracture the tooth.  Upon this keybit are
two notches for receiving the bifurcated heel of the  hook, the di-
visions of which adapt themselves to it, and are fastened by means
of the  pin, which has at the end some threads of a screw to prevent
its falling out.  The  advantage of this arrangement  is, to give us
the power of applying the hook close up to the termination of the
keybit, for the extraction of the last molar teeth.  We may easily
change the hook  to  either  side, and make use of different sized
hooks, according as they may be required.   The curve in the stem
(tige) of the turnkey, where it joins the keybit, is also essential, that
Ave may not be incommoded by the teeth in front when we are op-
erating at the bottom of the mouth. The handle, which is removea-
ble, may, by that means, be adapted to other instruments.   Sepa-
rated from the stem, it may also be better adjusted to the pocket-
case.
  Operative Process. After having carefully examined  the tooth we
wish to extract, and adjusted  the hook to the key, and wrapped
around the keybit a small  piece of bandage,  or the corner of a
napkin, we firmly grasp the handle of the  instrument in the right
hand, the  stem passing between  the fore and middle  finger.  The
patient having his  head supported against the back of an arm-chair,
and holding the mouth sufficiently open, enables the surgeon to in-
troduce the stem of the key, which he guides with the  fore-fingei
of the left hand, to  the tooth he wishes to extract;  the same finger
serves  to push aside the cheek or the  tongue, as  the case may be,
and to adjust the keybit in a proper manner upon the  gum;  in ap-
plying the finger afterwards upon the hook, it holds this last  firmly
fixed upon the neck of the tooth, as near as possible to the edge of
the alveolar process.  This being done, we give to the instrument
a twisting  movement, tending to turn the tooth in the direction of
the keybit; this movement should be made  gently and without  any
violence, in order that we may give to the surrounding parts the
opportunity of yielding to the elasticity which is proper  to them,
and that Ave may wound them as little as possible.  As soon as Ave
perceive that the tooth is completely loosened, (luxee) we give to
the instrument  an  upward movement,  and  thus effectually extract
it, or we finish its extraction by seizing it with a straight or curved
forceps, according  as we operate above or  below,  especially if Ave
find  that a small portion of the alveolar process has  been carried
off with the tooth, or the gum is adherent to it to a  considerable
extent.  It is then proper to make use of a curved bistoury, or
scissors, to disengage it  completely.  In all cases, we should en-
deavor to  avoid this inconvenience,by properly separating the gum
from the tooth before the operation.
  In operating with  the key, it  is almost always the practice to
grasp the  tooth from wdthin outwards ; but there  are cases where
it is indispensable to act in an opposite direction. They are—1 
324
NEW ELEMENTS OF OPERATIVE SURGERY.
AVhen the croAvn of the tooth presents a manifest inclination in the
direction towards the tongue : in thus forcing  the tooth to move  in
the arc of the circle that  it naturally describes, we run much less
risk of breaking it;  2. AVhen the crown of the  tooth, undermined
by caries, offers on its inner side no point  d'appui to sustain the
hook; 3.  AArhen the gum, in fine, on the side of the  cheek, is the
seat of an active inflammation, or an abscess.

§ II.—Tlie Straight Tooth Forceps (Davier droit) and Straight Pincers.

  These  two instruments, which are always confounded together,
differ from each other in this, that in the  dav ier  the  clipping
branches are  arched in the direction of their articulation; its upper
branch is longer by a line or two than the other, and goes beyond
it, which gives them a  resemblance to a parrot's bill.   It is neces-
sary to have  acquired a certain degree of tact in the use of it,  or
we  incur  the risk of breaking  the tooth that we wish to  extract,
should the latter offer any considerable degree of resistance.
  The straight pincers,  (Fig. 178,)
has the clipping branches  separated    <Fig-178-)   (Fis-"'^   <Fig-,80->
laterally.  It is used like the davier,
to remove the front teeth when they
are not too much decayed, and Avhen
they offer a hold sufficiently firm to
resist a certain degree of pressure.
The Z shaped pincers  (Fig. 179) of
Dr. Toirac is  one of the most conve-
nient  for reaching the bottom of the
mouth in operating upon  the teeth
of the upper jaw.
  The Operative Process.  The  pa-
tient  being placed  as above, with
his mouth open, we raise the upper
lip Avith the fore-finger of the  left  hand, the thumb being placed
upon  the  border of the teeth ; the instrument being  held in the
right hand, we grasp betAveen the bite of the pincers the tooth Ave
wish  to extract  as  high as possible under the gum; this being
done,  Ave make half rotatory movements, and on loosening the tooth
we  draw it toAvards us  in the direction of the external border of the
alveolar process.

     § HI.—The Curved Davier (Fig. 180) and Curved  Pincers.

  There is the  same difference  between these two instruments  as
between  the  straight  davier  and straight pincers.  The  pincers
should have the preference, and  it is advantageous to have them
°l di{ferent sizes-  They are particularly useful in removing teeth
that have  not much solidity, and the milk teeth, from both  jaws.
  We seize the tooth, without giving to it the twisting movement,
as in using the straight pincers, and endeavor to detach it gently
I 
OPERATIONS ON THE TEETH.
325
forwards, drawing it at the same time towards us, or out of the
socket.

              § IV.—The Elevator, or Carp-Tongue.

  The instrument thus named is composed  of a  stem, Avhich  is
adapted like fhe key to a handle, and the bent extremity of which
is terminated  by  a quadrangular  flattened and truncated pyramid.
This is one of the  most valuable of instruments, and which no other
can  supersede, for the  extraction of the last molars, or wisdom
teeth.
  Operative Process.  The patient being seated, Avith the head firmly
supported upon a resisting body, we grasp the handle of the instru-
ment with the whole,hand, the fore-finger and the thumb being sepa-
rated upon the stem, and holding it- firmly; the operator stations
himself on the right, if it is a tooth on the right side, and on the
left, if the tooth belong to the left side.  He then introduces the point
of the elevator flatwise between the tooth he wishes to extract and
the next molar, which serves as a point d'appui;  then, by an oscil-
lating movement,  drawing towards himself and downAvard, he pries
out the tooth, pushing it upward and at  the same time backward.
It is  proper to  remark, that during the operation it is  advisable  to
place the fore-finger, wrapped in linen, on the  inner side of the
crown of the  tooth we wish to extract, in order to arrest the point
of the instrument, which might slip and wound the  base  of the
tongue at the  moment when the  tooth, forced with too much vio-
lence, should suddenly give way.  It is necessary, also, in order  to
facilitate the operation, to loosen the tooth laterally by means of a
bistoury or gum-lancet, (dechaussoir) and its posterior part with the
myrtle-leaved  curved gum-lancet; this form of instrument  is very
convenient in such cases.

              § Y.—The Dog's-Foot, (Pied de Biche)

  This name  is generally given to  a steel instrument terminating
in one end in  a  pear-shaped  handle, and in the other in a slight
bifurcation in form of a forked foot.   The most convenient (Fig igL)
and effectual dog's-foot for removing all the roots of a tooth,  °^
is the following, (Fig. 181.)   We are indebted for  it to Dr.  (r
Toirac, and it  may be applied to all the points of the mouth.
Consisting of steel moderately tempered, it represents a Z,
the terminating branch of which  should not be over half a
line  in length.
  Operative Process.  The handle of  the dog's-foot being
wrapped in a napkin, we grasp its  stem with the whole hand;
then, supporting its smaller extremity upon the root we wish
to extract, we push it forcibly from below upAvard when we
are operating  on the lower jaw, and from above downward
when on the upper jaw.  The operator places himself upon
the side upon which he  operates.  As  in the preceding case, we
IS 
826
NEW ELEMENTS OF OPERATIVE SURGERY.
must pass the finger, wrapped in linen, upon the side  opposed
to the action  of the instrument, for fear of Avounding the  cheek if
it should too suddenly slip.

   Article VIII.—The Straight  and  Curved Cutting Pincers.

  These instruments  may be, to a certain degree, replaced by the
straight and  curved pincers  of which we have spoken, Avith this
difference, hoAvever, that their cutting branches, when  approxi-
mated, have the form of a ring, in  order that the croAvn of the tooth
that  Ave cut may be embraced by it.  We employ them to remoAe
fragments of teeth that wound the tongue, crowns of teeth  in great
part  destroyed by caries, or Avhen we wish to preserve some roots
of teeth to aid mastication, or to  insert there the pivot of an arti-
ficial tooth.

                Article  IX.—General  Remarks.

  The surgeon, when called upon  to operate upon the mouth  of a
child, ought to have instruments much smaller than  those Avhich
are in common use for adults.
  It  is necessary that he should know, also, that in daily practice we
sometimes meet with teeth and roots that present difficulties in ex-
traction impossible to be  overcome by ordinary instruments; and
that  it is  then better to abstain from  vainly attempting a painful
operation, which may lead to serious consequences, such as contu-
sions, wounds of the gum, fracture of the tooth, or of a portion of the
alveolar arch, nerveus symptoms difficult to subdue, or even to a
general disturbance of the whole system, as  in timid ft males,
especially during the  period  of utero-gestation, lactation, i>r  the
menstrual flux. 
divisions
327
TITLE IV.
GENERAL  OR  COMMON  OPERAT.ONS.
  Those operations that are performed after the same rules,upon cer-
tain regions of the body, have appeared to me to merit the title of
common or general operations; only, as there are those among them
which form, to a certain degree, the point  of departure for others, I
will subdivide this grand class into two families, the one for simple,
the other for complex operations.
  The greatest number of operations are composed of several differ-
ent stages, which are often in themselves so many distinct operations.
Everywhere, in fact, in operative surgery, we find incisions, dilata-
tions, extractions, and reunions,  alone, or in various  ways asso-
ciated.  To dilate and to extract being the province of some opera-
tions in particular, and each time requiring, so to speak,  different
instruments or processes, nevertheless constitute two  indications,
whose examination  in this place would be superfluous  ; but as
there  are few operations that do not commence with  a division and
terminate with a  reunion, it appears  proper to  say a few words at
first of diaeresis and synthesis.
          PART  FIRST.

SIMPLE OR ELEMENTARY OPERATIONS.
                        CHAPTER I.

                        •  DIVISIONS.

                Section I.—Cutting Instruments.

  Leaving  out of consideration the laceration (dechirure) and tear-
ing (I'arrachement) of parts, and ruptures, which are also divisions,
diaeresis has no other agents than the bistoury, scissors, and some
particular instruments. 
328
neav elements of operative surgery.
          Article I.—Manner of holding the Bistoury.

  In itself the bistoury is a complete arsenal to surgery.  If it avc re
absolutely necessary, it could supply the place of all other cutting
instruments; for  that reason, the surgeon should study, before all
other things, to use  it scientifically.   There are three principal
Avays of holding it: 1. As a table or carving knife ; 2. As a pen in
Avriting ; 3. As  a  drill-bow, (archet.)  As each of these three modes
also have several modifications, I shall briefly point them out, giv-
ing to each the  title of position.

§ I.—First  Position—the Bistoury held  as a knife, the edge down-
                            ward.

  In this position, which is the most common, the handle of the
instrument, enclosed in the palm of the hand, and supported by
the ring and little fingers, is  grasped  betAveen the thumb and
middle finger at the point of junction of the handle with the blade,
Avhile the fore-finger rests on the back of the blade.   Thus held, it
offers all the  firmness and security desirable ;  we may thus move
it in any manner, and give to it any particular direction we may
wish.  If it should be necessary to  employ much force, to  cut into
solid tissue, excise large flaps, or Arast and very hard tumors, or  to
pare off certain dense excrescences, nothing would  be easier than
to bring the fore and middle fingers back and in front of the others
upon  the open  border of the handle, and thus to grasp  it Avith the
full hand.

  § II.—Second Position—the Bistoury held as a knife, with the edge
                           upwards.

  In place of being directed towards the tissues, as in the preceding
position, the  edge  of the bistoury  should sometimes  be turned
in an opposite direction.  It is the belly, then, of the handle, and not
its back, which  presses against the palm of the hand, and the thumb
and fore-finger  which grasp its sides, while the middle finger passes
under it as well as the ring and little finger. Thus turned upwards
and in the direction  of  the back of the hand, this position is pre-
ferred for some incisions from within outward that  require more
force than grace in their motions.
                                      «
§ III.—Third Position—the Bistoury held as a pen, the edge downward,
                         the point forward.

  Emerging from the back of the hand, the handle of the  bistoury
In this third position, as in the first, is also held between the thumb
and the first two fingers.  The remaining fingers are left free to find
some point d'appui near the part to be divided. 
divisions.
329
§ IV.—Fourth Position—the Bistoury held like a writing-pen, with the
                        point backward.

  In the fourth position, the middle finger, advancing more or less
upon one of the sides of the blade, turns, in the act of flexion, the
point of the bistoury  towards the operator, or his wrist, in such
manner that its  edge looks towards  the palm of the hand, from
which it is separated by a triangular space of greater or less extent,
and having its base backward ; the greater part of the delicate in-
cisions made  in  dissections require the third  position, the  fourth
being more suitable to puncturing and to incisions from deep-seated
parts to the surface.

§ V.—Fifth Position—the Bistoury held as a pen, the edge upwards.

  To dissect, or to cut from us, and to enlarge certain deep-seated
openings, we are often obliged to change the relations of the edge of
the bistoury, to direct  it in the plane of the dorsal surface  of the
fingers, and to place its back on the palmar surface ; apart from this
circumstance, which obliges the fore-finger to be substituted for the
middle finger, it  is  held with the point  either directed forward or
inclined towards the wrist,  as in the  third or  fourth position,
according  as the  fingers are extended or flexed, and as it may be
desirable to make a continued incision, or merely to divdde attach-
ments.

      § VI.—Sixth Position—the Bistoury held as a drill-bow.

  The sixth position holds, in some measure, the middle place  be-
tween the first and second.  As in one, the handle of the instrument
rests in the interior of the hand, and as in the  other, it is held only
by the  ends of the fingers ; it differs from both, however, in this, that,
in respect  to the  axis of the  arm, the bistoury is situated  upon a
horizontal plane, and the pulp of the  extended fingers supports it
on  one side, while the thumb is applied to the other.  The three
varieties of this position are easily distinguished.   In the first, the
edge of the bistoury is turned downward ; in the second, wdiieh re-
sembles the second position, it  is turned upward; and in the third,
it is directed from right to left, except that, in place of holding its
handle by the flat faces, the fingers and the thumb, being directed
upon the edges of the  handle  grasp it by its back and belly.   The
first of these modifications, allowing us to cut  with great delicacy,
is particularly useful in cases of scarifications in phlegmonous ery-
sipelas, where we have  decided to operate by incisions, and also
for the opening of large sub-cutaneous abscesses.  We rarely have
recourse to the second, but to divide small lamellae while guiding the
bistoury upon the groove of  a director.  The utility of the  third,
also, is confined to a small number of cases,  Avhere, from the fear
of Avounding some subjacent organ, we believe it advisable to di-
   vol. i.                       42 
330
NEW ELEMENTS OF OPERATIVE SURGERY.
vide horizontally, by successive laminae, as in the manner of planing,
(en dedolant) the tissues which  present  themselves, as is done in
front of certain arteries, for example, or in the operation for stran-
gulated hernia.

          Article II.—Manner of holding the Scissors.

  The manner of holding the scissors being familiar to every one.
I have no necessity  of describing it.  I shall confine myself to re-
marking, that, in place of the  fore or middle finger, it is the ring, or
even the little finger, and the  thumb, Avhich are to hold the rings of
the instrument.  The first two fingers being placed forvA'ards, either
upon the handles, or on one of their sides, increase their force and
give more precision to their movements.
  The use of scalpels, (des couteaux) and of particular kinds of bis-
touries, will not be described until Ave come to the operations which
require them.
                     Section II.—Incisions.

  All incisions are referable to tAvo fundamental methods: Some
are made from the skin toAvard deep-seated organs., and are named
from without inwards; the  others, on the contrary, are made from
the deep-seated  organs towards  the exterior,  and are named from
within outwards.  The preference to be given to the first,  or to the
second, depends upon a thousand  circumstances, which will be suc-
cessively explained  in the sequel, and in great part recapitulated
under the head of opening of abscesses.
  AVhatever may be the  method  determined upon, the  incision is
performed—1. Towards the operator, (contre soi) when the bistoury
is brought from the commencement of the incision towards the op-
erator ; 2.  From the operator, (devant soi) when the case is directly
the reAerse ; 3. From left to right, (de gauche a droite) when, m ith
the right hand, Ave direct the  handle or point of the bistoury, either
directly crosswise,  or obliquely backwards and outwards, Avhile
flexing the  fingers, wrist, or forearm, that Avere previously extend-
ed ; 4. From right to left, (droite a gauche) if, under the same  con-
ditions, Ave perform with the left  hand, or even with the right, in
holding the bistoury in a particular manner.
  The direction from left to right, being altogether  natural,  is,
therefore, that which one takes most Mdllingly ; so that the others,
which might indeed be considered as exceptiors, are not, at any
rate, so often indispensable.
  The single or simjile incision is that AAdiich is made in one direc-
tion, and Avhich may be made Avith a single stroke of the bistoury:
almost always straight, and  sometimes curved or semi-lunar, it is
that which, in combining itself under a thousand forms, gives place
to the complex and multiplied incisions, Avhose shape, formerly so
varied, is reduced now to that of a V, an arcade ^, or a half cir-
 cle o, a T, a cross +, an ellipse  CZ> an oval A, a crescent /=5^
 an L, and  a star _£i 
divisions.
331
                   Article I.—Simple Incisions.

                         § I.—Direction.

   Unless there is a special indication, the straight incision should
be parallel—1.  To the great diameter of the part; 2. To the direc-
tion of the arteries, large veins, or principal nerves ;  3.  To the
course of the fleshy fibres and muscular masses, or that of the ten-
dons ;  4. To the natural folds of the integuments;  or, 5. To the
great axis of the tumor.
   Upon the dorsal  or plantar surfaces, or on the sides of the foot,
around the knee, in front, behind, and outside of the thigh, we make
them, in general, correspond with the  axis of the limb, because the
vessels, nerves, muscles, and tendons, take nearly this  direction;
behind the malleoli, Ave make them  a little concave in front, be-
cause  in this place the same parts are obliged to make a slight
curAe to reach the  sole of the foot; on the inner part of the thigh
they Avould be  oblique,  and in the  direction  of the  sartorius, the
saphena vein, or the  femoral artery ;  in the fold of the groin, we
only make them in the direction of this groove when they have not
to penetrate below the sub-cutaneous cellular tissue ; the impor-
tance of the Aessels is paramount here to every thing else.   On the
breech, the muscles serve as guides, as they do also on the sides of
the abdomen, while in front,, and behind this cavity, it is  the axis
of the body; the chest is exactly in the same  case, except  towards
the hollow of the axilla, where it is better to follow the axis of the
trunk than the  fibres of the serratus anticus.  The hand  requires
that Ave should have regard to the wrinkles on its palmar face, and
the bend of the  arm  to the arrangement of its veins, muscles, or
arteries, rather than to the direction of the  limb ;  in the neck, the
incision should be in relation with the muscles, vessels, or axis of
the part;  but it is rarely advisable to make them crosswise, except
in the bottom of the supra-clavicular fossa; on the cranium, they
follow the  radius of the sphere on which they are made, and will
be thus found parallel to the muscles and the principal arteries ; on
the eyelids, they will be in the form  of an arc, because of the mus-
cles, wrinkles, and arteries ; it is the same nearly on the lips; they
Avail be straight on the nose, and oblique, in this or that direction, on
all  the other regions of the face,  according  as  they shall fall on
such or such a wrinkle, or on the course of the vessels or muscles ;
in the ear, in fine, it is the projections of the organ which will de-
termine their direction.   The nature and the locality, superficial or
deep-seated, and the form of the diseased part, can alone cause any
deviation from these rules.
  Stretching the Skin. There are many ways of stretching the skin,
vAdien we wish to make a simple incision—1. With the ulnar bor-
der of the left  hand, the thumb acting in an opposite  direction ;
2. By grasping the part underneath Avith the whole hand ;  3. With
the extremities of the four fingers placed on the  same line, and in 
332
NEAV ELEMENTS OF OPERATIVE SURGERY.
the direction Avhich the bistoury is to take ; 4.  By taking up a fold
of the integuments ;  5. By draw ing the tissues apart by means of
assistants, in order to have both hands free ; 6. By drawing upon
one side, while an assistant draws the integuments in the other di-
rection.
  AVhere  we make tension with the thumb and little finger, it is ne-
cessary that the part  should be held firmly; and the tension is rare-
ly equal on all the points, unless we join with them the action of
the fore-finger, and  even  that of the  two  other  fingers.   The
grasping the organ itself (empoigner Vorgane)  is a mode that is not
applicable but to the limbs and to some tumors that are exceedingly
salient, or very much isolated.
  With the ends of the fingers only the skin is  held  firmly secure,
and the nails furnish a point d'appui for the instrument, but the
tension is incomplete  and acts only on one side.  The taking up of
a fold of the integuments suits but in a very small number of cases,
and is not always practicable.  The hands of the assistants, or of an
assistant,  are  never  as secure as that of  the  operator, and can
scarcely ever be called into requisition, except in incising  around
or upon the  surface  of tumors  or voluminous masses.  The first
mode, then, is the best, and it is for the surgeon to determine under
what circumstances he should have  recourse to the others.   The
important part of  it is, that the tension should be  alike on both
sides.  Otherwise, the Avound  in the  integuments would, after the
operation, be no longer in  correspondence with the division of the
deep-seated parts.

               § II.—Incision from without inwards.

  If we wish to cut from without inwards, the bistoury may be held
in the first, third, or sixth position, according to the degree of force
to be employed, the situation of  the disease, and the extent we in-
tend to give to the wound.  The convex bistoury, which, all other
things being equal, cuts better and causes less pain, has the incon-
venience of leaving, more readily than the others, a queue* (trainee)
at the  extremities of the incision, and of not being adapted to those
more  minute dissections that go below the depth of the cutis, nor
to those which  are made  on  excavated  parts, and which require
that the instrument should act especially on its point. The straight
bistoury, though it is less rapid in its action in the beginning, is in-
comparably more  convenient  afterwards, and  could, if necessary,
be substituted in all cases for the preceding.
  In the first position, the  convex  bistoury is applied, by the most
salient point on its blade, to the middle  of the space stretched by
the thumb and fore-finger, then drawn  from  left to right to the
place Avhere the incision is to terminate, so as to divide the whole
thickness  of the cutis in the first cut, and more deeply still, if there

  * [Meaning the small superficial  cut—a sort of queue or tail—which, from the shape
of the bistoury at its point, it almost unavoidably makes in enterinn. and leavin_- the in-
cision.— T.]                                        be, 
Divisnx.?.
333
exists underneath no important organ to avoid.  In order that it
may leave as little of a queue as possible, we take care to make it
with firmness in the  beginning, and to elevate the wrist in finishing
it.  In holding it in the third position, it Avill cut  more Avith its
point than with  the swell of the blade, and will run less risk of
Avounding the subjacent parts and of  leaving long queues ; but it
will lose some of its facility (legerete)  of movement and other ad-
vantages.  In the sixth position it cuts  after the manner of a razor,
and divides Avith equal ease the most delicate and soft tissues and
those that are the thickest and most tense,  (tendues;) only that it
is not firm, and seems like cutting  in the air.
  The straight bistoury, held in the first position, and applied as in
the preceding case, and making the cut and withdrawn in the same
manner, acts especially upon its point, penetrates to much less
depth, but in a  more  uniform manner, and leaves  scarcely any
queue.  In the third position, it is necessary to  plunge in its point
by puncture  by raising the handle a little, and then gradually de-
pressing its  heel as we draw the  instrument, and to terminate by
elevating the wrist, so that the point may be placed almost  perpen-
dicularly ; in conclusion,  if used in this Avay, the instrument com-
mences by an oscillating movement from above downwards, and
finishes by an oscillatory movement from below upwards.  Being
satisfied by experience  that the queue of the incisions  is a matter
of no great inconvenience, I think it immaterial, in commencing and
terminating them, whether it be by puncture or by drawing with the
straight bistoury. In this position, the little finger, fixed to the right
of the incision, serves as a support  to the rest  of the hand, and gives
every security to  the steps of the operation;  lastly, in the sixth, the
action of  the instrument is, in  every respect, similar to that of the
preceding, and held in the same manner, with this difference, that it
does not penetrate as well nor  as quickly.

             § III.—The incision from within outwards.

  To cut from within outwards, we operate either with or without
a director, or wdth the bistoury or the scissors, and sometimes  on a
part that  has not been operated upon ; at other times through an-
other division.
                             §IV.
  Without a  director, and  when there is no previous opening, the in-
cision  is made either from or towards the operator, and with the
straight bistoury.
  From the operator, (devanl soi) the instrument, held in the second
position, is introduced by puncture ; after which the wrist is quickly-
elevated, that the bistoury may divide  the tissues, from its heel to
its point, and be converted into a lever of the second kind  ; or we
raise the point by depressing the handle, so as to pass through the
skin a second time by puncture, and terminate by bringing the bis-
toury back to us, with the cutting  edge upward, so as to divide thn
tissue  (la  bride) by making it act as a lever of the third kind. 
334
NEAV ELEMENTS OF OPERATIVE SURGERY.
  Towards the operator, (contre soi) we hold it, Avith the ring finger
fixed on the side  of its blade, at  such distance from the point as
may limit its progression.  AVe then introduce it by puncture ; when
it has entered far enough, we quickly elevate it perpendicularly, in
the manner  of a lever  of the second  kind, by drawing its  heel
towards us, as if to convert the fourth position into the third, in  such
manner, in fact, that, by extending the fingers, its point when with-
drawn is found entirely free, and  directed forward like the point
of a pen, in  place  of being turned towards the upper part of the
Avrist, as it was in entering.

                             §V.
  On a director, when there exists a previous opening, AAe guide the
instrument into it, either from or towards us; without  a director,
when the thing appears easy; and in the contrary case, flatwise
upon the fore-finger, or upon a grooved sound  if the finger is too
large ; we  afterwards proceed as above.   The sound is  held in the
left hand, like a swing, or lever of the first kind, to which the index
finger placed below forms the fulcrum, the thumb fixed  on its  han-
dle the power, and the tissue to be divdded, which its point tends to
raise, the resistance; to glide upon it with facility, the bistoury
must  be  guided in the second, fourth, or sixth position, with the
edge upward.   The grooves  Avhich have  no terminating crest,
present no obstacle to the point of the instrument, which may thus
emerge from within outward, traversing through the tissues;  w ith
this crest,  it is necessary, on the contrary,  to  raise the bistoury
up, as  a lever of the second kind.   The narrower the bistoury is,
the better it advances ; the convex  bistoury does not answer in  such
cases, because its extremity is too wide, and that its point, by being
thrown too much backward,  buts (arc-boute) readily against the
grooAe of the director.   HoAvever little convex the back of the bis-
toury may be, it tends, in escaping, to leaAe some lamellae between
its point and  the director.
  After having  arranged the director, we may also proceed in
another manner, viz : endeavor to  feel its point through the  skin,
for example, then, Avith a cut  of the bistoury,  to lay it bare  by a
small transverse incision, as in making a counter-opening ; the point
of the instrument,  placed in the  groove of the director,  is  then
glided along towards the handle of the sound, or from right to  left;
or, what is as well, without taking the trouble to make a previous
incision, the bistoury being held in the fourth position, Ave fix by
puncture the point of the bistoury  on the director near its beak, to
make it glide quickly as Ave bring  it towards us.
  With scissors, it  weuld be necessary to slide  one  branch  of it
along the finger or director, leaving the  other outside, and cutting
from us, and as quickly as possible, all that we wish to divide.

             § VI.—With a Fold of the Integuments.
  In timid and  intractable patients, if the skin  is Aery flexible, or
it is not  desirable to go deeper than that tissue, it is  sometimes 
DIVISIONS.
335
necessary to take up a fold of it before cutting it. This fold, whose
thickness varies, according as we wish to  give  greater or less ex-
tent to the wound, ought to be held on one  side by the assistant,
placed in front, and on the other by the operator.  We then divide
it on its free part, down to its base,  as in incisions from without
inAvard, or in the opposite direction, that is to say, by puncturing it
and cutting through it, from its  adherent  border towards  the free
border, as Math incisions from within outward.  The pressure made
upon the integuments blunts their sensibility, and consequently ren-
ders the pain less acute; moreover, as the  bistoury only perforates
through the parts, in the manner  of an arrow, the operator runs no
risk of failing, or of being  embarrassed by the  movements of the
patient; only that we  are not so sure in  this, as in following the •
other method, of giving the incision the precise extent and neatness
requisite.

      •  § VII.—Raising Layer after Layer, (en  de'dolant)

  The incision in a horizontal direction, or en de'dolant, is that wdiieh
is least frequently had recourse to, and only  when we wish to sep-
arate,  layer after layer, on the  same  point, the  different tissues
which cover an organ which it is important to avoid; the bistoury
is held in the sixth position, the edge sidewise;  the left hand, pro-
vided with a good forceps, raises up each layer of the tissue, while
the right hand divides the detached layer by carrying the bistoury
under  the point of the forceps.   Almost  exclusively reserved for
the operation of hernia, this  kind of excision,  however, is some-
times met Avith in other operations, those, for example, for aneu-
risms.

                Article  II.—Compound Incisions.

  Complex incisions being only a combination of simple incisions,
are necessarily subject to the same rules  of practice, and may be
made from without inward, or from  within  outward, and with or
without a director.

                              §1.

  The V  incision  is composed  of two straight incisions, which,
though setting out from the same point, terminate at so much the
greater distance from each other, in proportion to the greater length
we desire to  give to the  triangular flap which they include.  Its
point,  unless  there are particular  counter-indications,  should be
turned towards the most  depending part, and  we commence the
incision by its base.  The reason for this rule, which at first sight
seems little in accordance with the object in view, is, nevertheless,
easy to comprehend: if the bistoury was  placed in the upper ex-
tremity of the first incision, in order to commence the second, the
instrument, before dividing it, would roll up, displace, and wrinkle 
336           NEW ELEMENTS OF OPERATIVE SURGERY.

its border, Avhich is necessarily badly supported, and would cause
more pain than usual, and make an irregular and contused inci-
sion ; the convex bistoury would, in addition, have the inconveni-
ence of leaving a queue  beyond the external border of the  first
m ound, or of not separating the second from it at its angle but very
imperfectly.  In commencing by the base of the  flap, nothing of
this kind happens.  The skin is not more difficult to extend for the
second incision than for the first.  The bistoury itself, in some de-
gree, stretches it in approaching the apex of  the triangle, which it
isolates and completes Avithout the least difficulty, should the sur-
geon understand the  proper  manner of elevating  the wrist as he
finishes the incision.
  To detach the flap thus  limited, it is  seized by its point Avith the
forceps, for Avhich it is well to substitute the fore-finger and thumb
as soon as that is  practicable.  The right hand, armed Avith the
straight or convex bistoury, held in the third position if we Avish to
cut toAvards us, or by flexion of the fingers; in the fifth, 6*n the
contrary, if we Avish to cut from us, or by extension of the fingers,
dissects it from below upward, or from its apex towards its base,
taking care  to raise with  it as thick a layer of cellular tissue as
possible.   Formerly the incision in V was confined to the trephining
of the temporal bone ; at present it is not necessarily limited to any
part, but is used in the removal of certain tumors, and in the  ope-
ration for some disarticulations.

                             §11.

  The oval-shaped  incision, which will be considered under the
head of amputations, differs from the V incision in being continued
from one branch to the other, as it passes around the base of the
flap, which is thus completely detached; it  is, in fact, constituted
of the V incision and that of the semicircle.

                  § III.—The Crucial  Incision.

  The crucial incision, as its name imports, results from tMro simple
incisions, which cross each other at right angles.   It is only the
second of these incisions which requires to be described.  We com-
mence it on the left side of the division, with the same precautions
as for every other straight incision; but in the place of carrying it
to the  other side without  stopping, we terminate it by raising the
wrist at the moment when we reach the wound, whose left lip only
we must confine ourselves to cutting.  To complete it, the operator
must change his position, unless he prefers  changing the bistoury
to the other hand, and does on the right what he has just finished
doing  on  the left;  in a word, it is an incision of two stages, (en
deux temps) whose  two  halves  meet, and have  their point of
junction in the first wound, Avhich prevents the instrument  from
rolling up and folding under its edge the second lip of the primi-
tive incision, as it would  almost inevitably do in passing from left 
DIVISIONS.
337
 to right, to finish with a single stroke.   The dissection of the four
 triangles which result from this  double section, being only the
 repetition, four times renewed, of that described in speaking of the
 V incision, requires no other details.

                              _  IV.

   The T incision differs from the crucial incision only in one point:
 it is, that, in  place of passing from the two sides, its transverse
 branch rests upon the straight primitive incision.  It is thus reduced
 to two stages,  instead of  comprising three, as the crucial incision
 does.  In other respects, the same steps are to be taken in the di-
 vision of the tissues, in the dissection of the flaps, and even in the
 manner of holding the bistoury, in both cases. One being a simple
 modification of the other, the crucial incision and the T  incision are
 indicated wherever the straight incision is not sufficient to lay open
 the parts which we wish to isolate or remove ; the  relatiAe value
 of either is to be determined by the size of the body to be detached,
 and the crucial incision  is not,  in reality, necessary, unless the T
 incision, with its two flaps, does not give the surgeon all the facility
 and freedom required for going through with the operation.
  The bistoury, carried flatwise between the teguments and such
 tissues as are to be avoided, then turned again to cut from within
 outwards, or conducted upon a grooved sound, would convert  the
 straight, simple incision into a complex one, as effectually as if it
 was directed upon  the integuments from  without inwards.  This
 method, in fact, is sometimes followed or preferred.

                              §V.

  The elliptical incision, which becomes almost indispensable Mrhen-
 ever it is  believed necessary to remove with a  tumor a certain
 portion of  its coverings, is composed of two curvilinear incisions,
 Avdth the concavities looking towards each other.  The marking out
 of its direction with ink is an absurdity which has no other incon-
 venience than  its inutility, except, however, in certain  rare  cases,
 where the least deviation of the bistoury might incur  the risk  of
 serious consequences.  It  is then that the hand of an assistant be-
 comes useful in stretching the skin upon one side, while the surgeon
draws upon the other.  The rule  requires that the most depending
incision should  be made first, that the blood which it causes to flow
may, in no respect, interfere with the execution of the other.  It is
made by cutting towards us from left to right, and in such manner
that an assistant may raise the tumor, Avhile the operator, with his
 left hand, stretches the integuments below.   The  reverse of this is
 practised for the second : here the surgeon himself ordinarily per-
 forms the part  of drawing upon or depressing, Math the  ends  of his
 fingers, the mass to be  excised  or  extracted, while his assistant
 stretches the skin above, taking care that this tension shall act  at
 the same time in the transverse and longitudinal directions, in such
  vol.  i.                       43 
338
NEW ELEMENTS  OF  OPERATIVE SURGERY.
 manner, that the instrument, placed upon the left or upper extrem-
 ity of the lower incision, may effect an incision as neat in its com-
 mencement as in the middle part of its track, and, also, that it may
 not roll up the skin in terminating.  AVe should not forget, moreover,
 that this upper incision, acting upon a depressed part, has need only
 of a slight curvature for the course of the knife, to render it quite
 concave when the parts are left to  themselves.

             § VI.—The  Ci'escent-Shaped Incision.

  Some persons, in these latter times, have supposed that a double-
 curved incision,  with the  convexities concentric, might, in  cer-
 tain cases, be substituted advantageously for the  elliptic  incision.
 The semi-lunar flap which it circumscribes  leaves a w ound with
 loss of substance, the  convex border of which is easy to dissect
 and to reverse upon its base, so as to enable it afterAvards to be
 brought back into the concavity of the  other, and  upon the bot-
 tom of the solution of continuity.   Perhaps, in fact, Ave should em-
 ploy it for the extirpation of those  massive tumors where we have
 it in  our power to preserve almost all of the skin, and Avhere a
 straight incision would not expose  them sufficiently.  It would pro-
 cure the same advantages  as the elliptical incision, without inter-
 fering so much with immediate union.  The dissection of the inner
 lip  of a simple semi-lunar or  arched incision,  when  we  do not
 wish  to make any excision of the  skin, may be considered in the
 same point  of view, relatively to  the V, T, and crucial incisions,
 which latter, in such cases, it weuld frequently render  unneces-
 sary.
  I will add, that, in detaching by dissection the lips of any incision
 whatever from  the  subjacent parts, to the extent  of one or many
inches, according to the nature or situation of the weund, we may
 cover over a very considerable  loss of substance;  and that the
integuments thus detached become  elongated, and thus alloAV of our
bringing into immediate contact the edges of a great number of
 wounds that we would have scarcely supposed susceptible of it.

                    § VII.—The L Incision.

  Employed in  laying  bare some  large  arteries, the  carotid and
 subclavian among others, the L incision  has no need of being de-
 scribed in this place.

        Article III.—Incisions Applicable to Deposites.

  We may say boldly, that the bistoury is pre-eminently the reme-
 dy for abscesses, Avhether they be  hot or cold, diffused or circum-
 scribed, massive or diminuti ve.  The pain is nothing in comparison
 with the dangers that it prevents,  and I cannot easily understand
 how its use has been so often dispensed with, unless  it be that the
 fluctuation which results from phlegmonous inflammations remains 
DIVISIONS.
339
obscure.  A heroic remedy as it is, in sub-cutaneous inflammations
themselves, supposing that it opens no abscess, what harm can re-
sult from  its  application?—a  Avound  altogether  simple,  which
disgorges the tissues and is never an obstacle to the termination of
the principal disease, the progress of which, on the contrary, it al-
most alM'ays favors.  AVhen  Ave have been witness to the havoc
insidiously made by the presence of pus, infiltrated  or effused into
the midst of the organs by the resorption of this fluid, or its bur-
rowing along the cellular tracks and tissues, it  is truly impossible
to hesitate between such dangers and the fear of an unnecessary
incision.
   All kinds of straight incisions are applicable to abscesses, whose
treatment, however, I do noj intend to speak  of here.   The large
lancet, called the abscess lancet, formerly employed for this purpose,
has completely fallen into disuse since the last half century.  The
ordinary lancet, sometimes  still used in  its stead, does not  suffice
but  for a small number of cases, Avhen, for example, the  skin is
very thin and  the  abscess very superficial or small; and even in
these the bistoury would still be constantly preferred to it, were it
not that Me sometimes  meet with persons Avho, though terrified
with the mere name of bistoury, will submit readily to the punc-
ture of a lancet.

         § I.—Opening of Abscesses from within outwards.

   There is no circumscribed abscess  that cannot be opened from
within outwards.   The operation is  rapid and but little painful;
the instrument  enters by puncture ; its point plunges into the inte-
rior of the abscess, and its edge, raised from the heel towards the
point, stretches the cutaneous Avail in proportion as it divides it, in
place of causing its depression.   In this case, the straight bistoury
is the only one  which is proper ;  it is only held in the fifth position
when we Avish  to cut from us at the bottom of certain cavities—
among others,  for certain abscesses in the mouth.  In the  second
position, on  the contrary, it is  in very general  use ; in holding it
thus, Me have all the  power and freedom required; it  easily cuts
from us, and as obliquely as we may desire, and nothing is more
simple, in order to convert it into a leAer of the second kind, than
to  elevate  the  wrist  at  the moment of terminating the incision.
The fourth  position is yet  more convenient : the  point d'appui,
Mdiich  it allows us to have with the last fingers, is an advantage
Avhich the second does not offer in the same degree.  The puncture
is made toMrards us; the hand and the fingers being flexed, it is suffi-
cient, if Ave bring them to their natural direction by draAving upon
the handle of the bistoury, to assimilate it to a lever of the  second
kind, as in the preceding, to cut from the heel towards the  point,
and to divide the entire wall of the abscess, throughout its whole
extent, Avith great force and celerity. It is the position in Avhich there is
least danger from the inconsiderate movements and intractableness
of the patient; andl have for a long time been in the habit of em- 
340
NEW  ELEMENTS OF OPERATIVE  SURIVERY.
ploying no other, except when there is some special counter-indica-
tion.  The puncture haAdng been  made, the rest of the incision is
completed, as  it Avere, spontaneously.   If it  Mere necessary, this
position Avould not hinder us any more than the second from piercing
entirely through  a  hard and superficial abscess, as it  is proper
sometimes to do in furuncles, or carbuncles, and some other promi-
nent abscesses Avith thin Avails, upon the limbs.  The  best bistoury
in such cases, as in the opening of abscesses in  general, when from
within outAvards, is  the bistoury Avith  a straight blade, regularly-
tapering, and with a keen edge ; we hold it more or less  obliquely,
according as the deep Avail of the  abscess is more or less remote
from the surface ; if it should touch, or plunge into the first with its
point,  the  inconvenience,  in  ordinary  cases,  Avould scarcely be
thought Avorthy of arresting the attention; but  the danger would
be so great, when the abscess lies  in front of a large  artery, or an
important viscus, that the very idea of it is frightful. For  prudence'
sake, then, if not from necessity, as soon as from feeling no resist-
ance, or in any other manner, we  are assured  that it has entered
the abscess, we should cause it to pass much more  in  a parallel
line  than  in one perpendicular to the  axis of the limb or the  dis-
eased part, and  not  prolong  the incision but in raising up the in-
strument.
  In this mode of incision, the stretching of the parts  with the  left
hand, while the right hand is directing  the bistoury, though useful,
is not alMrays indispensable.  If the abscess is vast and superficial,
or situated at  a great distance from eAery  delicate part, Ave may
even dispense with  taking any point d'appui for the fingers,  and
look only to the movements of our hand, as if  we were cutting in
the air.  Howe ver familiar one may be  with the habit of handling
instruments, one of the fingers, detached as it were from the others,
and placed on  the corresponding side of the blade, gives us  confi-
dence, puts  us  on our guard against the  danger of plunging  the
point of the instrument to too great a depth, and in most cases is
the only precaution required.

        § II.—Opening of Abscesses from without inward.

  Abscesses en  nappe, or diffused abscesses, those that  are  deep-
seated and those that are formed about the  joints, upon the track
of vessels, and upon the surface of organs which it would be dan-
gerous to  come in contact Math or to penetrate, render it desirable
that in most  cases  the opening  should  be made from without
inward.   The first require large incisions, either with the  straight
bistoury in the first or third position, or with  the convex bistoury
heM in the same manner.  With the straight  bistoury, in the  first
position, we incise by applying  the whole length of the cutting edge
(en plein) on the skin, as for deep scarifications, and we draw it
rapidly while passing from the heel to the point; in the third posi-
tion, its point is first plunged by puncture into the abscess; the in-
cision is afterwards  continued  by depressing its heel  and the  rest 
INCISIONS.
341
of  its  blade ; the bistoury thus again becomes a lever of the sec-
ond kind, but acting from above  downward, in the manner of a
straw-cutter, (coupe-paille)  With the convex bistoury, held in the
first  position, we  cut quickly and deep; it generally suits better
than any other for such occasions, since it is admirably adapted by
its form for the numerous incisions that we are sometimes  obliged
to make, at certain distances from each other, upon different points
of a purulent collection.
  Deep-seated abscesses are naturally divided into two orders:  1.
Those which, being covered over with a thick and dense layer, re-
pose on no region (foyer) which it is important to avoid; 2. Those
whose depth prevents our ascertaining their precise positions, or
which it is not prudent to approach but by degrees.  There is no
objection to operating upon the first by puncture with the straight
bistoury held in the third position, as for those on the  eminences
of the  hand, for example, the palmar face of the fingers, the
outer side of the limbs, the breech, cranium, and posterior region
of the trunk.  The incision by puncture does not do for the sec-
ond :  if we open  them with the  straight bistoury, it is necessary
to carry it  from  without  inward with the  right hand,  which
holds it in the first or third position, and to divide, layer by layer,
all the parts which conceal the abscess, making use of our left fore-
finger, applied from time to time to the bottom of the Avound, in
order that we may ascertain to a certainty the fluctuation or pre-
sumed depth of the abscess.   It is  thus that Me proceed  for ab-
scesses under the aponeuroses, between the crural muscles  and the
femur, in the holloAV of the ham,  about the humerus, in the thick-
ness of the walls  of the  abdomen or chest, and on the forepart of
the neck.
  If we did  not observe the  same caution in the neighborhood
of the articulations, we should run the risk of opening into the
synovial membrane, and of exposing the surfaces  of the bone to
the contact of the  atmosphere, Avhile the incisions, layer by layer,
do not deprive us of the option of reaching there ultimately, when
we may deem it indispensable so to do.  If the abscess is extensive,
and the integuments are sufficiently thin, the convex bistoury makes
a neater incision, and causes less pain.   When its situation is less
clearly defined, we have recourse  to the straight bistoury, which is
better adapted to delicate dissections.
  We should proceed upon  the same principles  in the vicinity of
an artery, aneurism, or hernia, and near the pleura or peritoneum,
because we  are then sure of not going beyond the anterior Avail
of the abscess before encountering the pus, and can stop when Ave
think it advisable, also identify the pulsations of the vessels, and
ascertain with the finger on what tissue we  are acting; Avhile in
the incisions by puncture, and from Mdthin outward, nothing can
protect us against the dangers from the bistoury when we have
once begun.  Who does not know that the  instrument has been
often plunged into an  aneurism,  a large and healthy artery, the 
342
NEW  ELEMENTS OF OPERATIVE SURGERY.
intestine of the hernial sac, &c., even by celebrated practitioners,
from having neglected to attend to these rules ?
  [Surgeons  cannot, says Dr. Mott, be  too careful how they pro-
ceed under the circumstances above specified with so much ability
and precision by the author of this inestimable work.   All prudent
surgeons had better look on before they take a step where the life
of the patient  may possibly be hazarded.  It is a golden rule,
where there  is any doubt, to give the patient the benefit of it by
withholding all unnecessary  interference.  If surgeons  were to
proceed in this way under all such circumstances, Ave  should not
have to lament the mistakes which ignorance  of relative anatomy,
and rashness of conduct, have in all countries too often occasioned,
and by Avhich a severe and just  reproach has been cast on our no-
ble profession.—T]
  One of the principal objections to these incisions from without
inward, is their  pressing upon the abscess in opening it: and that
the abscess is  no sooner opened a few lines, than this  pressure
drives out the pus, depresses the walls, and makes it almost abso-
lutely impossible to continue the incision wdth  the same stroke.
That, however, should be  understood only of  slow  or gradual
incisions.   Those which can be made rapidly Avith  the  entire
edge  (le plein)  of a straight bistoury, or,  better still, with a con-
vex  bistoury, held  in the  first  or sixth position, as in deposites
of a  vast extent situated  immediately under the skin, have not
the same inconvenience, and are, in reality,  the least painful of
all.
   With a Director.   To enlarge the opening of an abscess, the
finger or a grooved sound serves as a conductor to the instrument,
and  the bistoury or the scissors are guided,  as  has been said  in
speaking of incisions  from without inward, by means of a director,
after a previous opening in the skin.

          § III.—Opening Abscesses by Complex Incisions.

   It is thus, also, that the operator should proceed, if, in place of a
simple incision, he should wish to open the abscess by the V, T, or
crucial incision. Such modifications, more often useful than most
practitioners seem willing to admit them to be, are of great benefit
in sub-cutaneous abscesses  with diseased condition of  the  skin.
The first opening being made from the left and upward, for example,
and the sound effecting a separation to the right, a second open-
ing is made in this direction, and the abscess, thus disclosed to Alew,
presents a V incision.  When the cul-de-sac  is upon one side, avc
immediately make  a T incision, and  in those collections in Avhich
 we Avish to lay the bottom entirely bare, the crucial incision is also
 used.  From whence it follows, that, Avith  the exception  of the
 elliptical or semi-lunar incisions, all the different kinds of divisions
 may be called to our aid in the treatment of purulent collections,
 but that the simple  incision is, nevertheless, almost  the only one
 required for them. 
INCISIONS.
343
  Article IV.—Incisions applicable to the Dissection of Tumors
                          and Cysts.

  The contrary of what takes place  for abscesses is observed in
relation to cysts and tumors ; for these the complex incision is most
generally indicated.  When  all the  skin,  however, is to be pre-
served, the simple incision is often quite sufficient. Rolling, or very
moveable tumors, covered with a pliant  and sound skin, do not
always require an incision with  many branches.  The testicle, the
breast, and various degenerated  ganglions, have  often been ex-
tracted through a straight and simple incision,  though they had
acquired considerable development.


                    § I.—Form of the Incision.


  A.  The straight incision, forming a single slit, (boutonniere) should
exceed, by half an  inch or an inch, or even more, in its two ex-
tremities, the limits of the tumor, and should go through the entire
thickness of the adipose tissue.   There are, then, many modes of
continuing the operation: to seize with a forceps, or the first fingers
of the left hand, each lip of the wound, and to  dissect them one
after  the other, and from within outwards, with the right hand,
while  an assistant draAvs the tumor in an opposite direction with
his  fingers, or Avith a hook or an erigne, is one of the modes most
frequently adopted.  Others prefer, Avhen the pliableness (souplesse)
of the parts allows of it, to press with the thumb and first ringers
of one hand through the skin, as deep as possible upon the sides of
the mass to be extirpated, as if to  expel  it through the wound,
while wdth the other hand they  cut perpendicularly the  adhesions
of the cellular tissue, in  proportion as the edges of the incision re-
cede outwardly or retract backwards.  If the tumor is pendent,
Ave  arrive at the same result by  embracing it underneath with the
palmar face of the  entire hand  spread out.  By this last  method
the pain is generally less, and the operation is  at the  same time
quick,  easy, and  secure,  but, unfortunately, it  is not  applicable
everywhere.   Some find it more convenient to hold  the tumor
themselves, and to cause the lips of the incision to be kept apart
by an assistant, while they dissect and isolate it.  It is thus, in fact,
that it is proper to proceed in all cases, as soon as the anterior face
of the  tumor is free. In adopting another course to separate it from
the deep-seated tissues, the surgeon would run the risk of going too
deep, or  of not removing all the diseased parts; in this matter he
can depend only on the evidence of his fingers,  which  have, also,
the inappreciable advantage of being enabled to perceive the ar-
terial pulsations,  if they should present themselves there, and with
the action of the  other hand of regulating their movements without
difficulty, as also the tractions which they exercise. 
344
NEW ELEMENTS OF OPERATIVE  SURGERY.
                       B.  The V Incision.

  It Aveuld be an error to suppose that the elliptical and crescentic
incisions were the  only ones which  allow of our taking away a
portion of the substance of the cutaneous tissue ; the Ar incision has
frequently  fulfilled  the same indications.   In  cutting many V's,
or triangular flaps, connected at their base, and upon the contour
of very large sized tumors, we remove with the disease a stellated
piece of integument, which does  not  afterwards prevent us from
covering the entire wounded surface  with the preserved triangles.
Delpech and M. Clot have had recourse to something similar in the
removal of enormous (elephantiasiques) tumors that they have de-
scribed, and I have proceeded in the same manner for the removal
of bloody (hematiques) masses on the fore part of the knee, and with
tumors of all kinds.

                C. The T and Crucial Incisions,

Which are only used when the skin which we do not wish to trench
upon is not  sufficiently pliable to allow a straight incision, to lay
bare the tumor in a proper manner,  are also indicated in certain
cases in conjunction with the elliptical or with the crescent-shaped
incision; for example, when the base of  a cyst is  extended too
much beyond the flap of integuments which we have just circum-
scribed, or when it appears difficult to dissect  alternately each lip
of the wound, or that we  do  not wish to have the flaps too large.
The T and crucial incisions, in fine, resolve themselves into a trans-
verse incision, on one of the edges of the weund for the T incision,
or on both successively for the crucial incision.

                 § II.—Dissection of the Flaps.

  Whatever  may be their form and extent, these different incisions
give rise to flaps which it is necessary to dissect off from their apex
to their base.-  This is generally the most delicate part of the ope-
ration, and is not performed exactly  after the  same  rules for all
kinds of tumors.

                     A.  Concrete  Tumors.

  In all cases of lipoma, or any other  solid  mass destitute of ma-
lignancy, the edge of the bistoury should be more inclined towards
the tumor or the deep-seated parts than towards the skin, since the
more thickness we give to the flap by the preservation of the  cellu-
lar  or adipose tissue that  lines its inner surface, the more highly
organized {vivace) is  it, and the more disposed to reagglutinate it-
self (se recoller) to  the subjacent tissues.   If the contrary  mode
should be adopted, the instrument would leave nothing but the
mere skin, and might perforate it and  render its preservation  or re- 
INCISIONS.
345
union impossible ; while, though Me should even go too far on the
inner side, we do not see, in truth, Avhat evil would result from it.

                          B. Cancers.

   Carcinomatous tumors require a little more attention; the skin
undoubtedly should not be too much attenuated, but it is important
at the same time not to turn over (renverser) with it any portion of
morbid tissue.

                       C. Cysts, (Kystes)

   The dissection of  encysted tumors, and of sacs  full of liquid or
semi-fluid  matters, which we wish to remove without opening the
cysts, or to extirpate  entire, demand still  greater care ; the walls
of  the  cyst are sometimes  so thin that the least  deviation of
the bistoury inMrards divides them; the sac  is immediately voided ;
the tissues cease  to be capable of distension,  and the operation
which, w ithout this accident, would have been easy and one of the
most simple, becomes one of the most laborious and, in a  great num-
ber of cases, even impossible to complete.   It is  necessary, then,
while Ave endeavor to preserve as much as  possible of cellular tis-
sue when  we are dissecting out a cyst, that Ave  should turn the
edge of the knife a little more towards the integuments  than in the
direction of the tumor, as often as the walls of the sac to be avoided
are so superficial, or appear so thin as to  be easily perforated.
  It is  also proper to remark, that certain  cysts do not demand so
many precautions, and that we may confine  ourselves to slitting up
their  whole anterior wall by a  simple incision, or a T or crucial
incision, as if Ave Avere opening an abscess;  deep-seated and adhe-
rent hydatid tumors, whose interior we wish to cauterize, or whose
entire cavity we would  desire to place in contact  with the air, to
cause them to suppurate, also  come under this  exception.   We
shall see, farther on,  that it may be  the same with encysted tumors
of the cranium, &c.

                     D. Abdominal Cysts,

Collections  of fluids  in the neighborhood of  the  splanchnic  cav-
ities, and the adhesions of Avhich wdth  the  adjoining serous mem-
branes do not appear to be definitively established, (bien assurees)
very often justify a mode of incision much eulogized by some per-
sons in these latter  times.  It  is a simple  incision,  straight or
curved, and layer for layer, with a straight rather than a  convex
bistoury held in the first or in the third position, and directed from
without inwards.  If the cyst is in the  abdomen, we cut gradually
to the peritoneum, which we lay open to the tumor, in the event
of its non-adhesion, but leave untouched, if it appears to be merged
into the wall of the greatly attenuated morbid sac.  The operation
•s there arrested for the moment; a roll of lint is placed  lengthwdse
  vol. i.                      44 
346
NEW ELEMENTS OF OPERATIVE SURGERY.
in the Avound to keep its lips apart, and renewed, for the space of
several days, as often as there shall be need of it.  Protected from
the  pressure of the divided tissues, the cyst has a tendency to pro-
trude into the incision, approaches the  outer  surface, and finally
often bursts by opening spontaneous^, sometimes on the morrow,
more frequently after the lapse of some days.   If it was left free,
this  preliminary incision  would cause an adhesive inflammation,
Avhich would not be long in reuniting the anterior wall to the layers
which cover it, and then we might perform a puncture, or an  in-
cision, without the least danger of causing an effusion into the belly.

                    Section III.—Punctures

  Whenever a surgeon plunges the point of an instrument with a
single stroke through the tissues, he performs a puncture, (ponction)
Punctures from within outwards are almost all made wdth the bis-
toury and suture needles, or Math  instruments having springs ; the
others, that is, those that are made from without inwards, are per-
formed sometimes with a straight bistoury or a lancet, as has been
seen in the preceding articles; sometimes with a needle, or with par-
ticular instruments, the trochar, &c.; with a straight or round needle,
or one furnished with an eye near its heel, like a sewing-needle, as
in certain sutures; with a longer  needle, surmounted by a head, a
handle, or a ring, as in acupuncture ; with a needle having a cutting
point on one or both  its sides, or straight or curved, when Ave Avish
to explore certain  tumors and collections of a doubtful  nature, as
many practitioners have recommended since Hey, and as has been
still more recently done by M. Pacini (Discors. del Dott Pacini, etc.,
1836, broch. in 8vo) in a Avork expressly written upon this subject;
wdth needles with cutting edges, and of the shape of arcs of a circle,
and furnished  with an eye for thread, as, for example, in most su-
tures ;  with different kinds of trochars, when we wish to convey a
canula to the bottom of some reservoir or cyst, to draw off its liquid
only, and not to leave behind a cicatrizing Avound, properly so called.

                    Article I.—Acupuncture.

  By acupuncture is understood  a puncture which  traverses the
tissues Avithout breaking the continuity of their fibres.  The nee-
dle to be used for performing acupuncture should have the form of
a regular cone, and in general be exceedingly fine.  This needle,
being three or four inches in length, and terminating in a small
many-sided  handle,  or by a ring, should  always be surmounted
by  a metallic  eye when Ave wish to change the acupuncture into
electro-puncture.  We insert it while rolling it between the fingers
of  one hand, which hold it like a writing-pen, and press it gently
upon the skin, which latter the other hand is employed  in keeping
stretched.   Some  persons make it enter by making taps upon its
head with a small hammer ; for myself, I prefer, when the rotation
does not suffice, to press perpendicularly upon  its upper extremity
with the fore-finger, while the thumb and other fingers  hold the 
INCISIONS.
347
needle in the manner already described.  Thus conducted, its point,
separating and not dividing the organic fibres, may traverse the
arteries, even the heart itself, and the most important organs, as I
have  myself often made it do, (Journal Hebdom. Univ.,  1831, t. ii.,
p. 57,) without giving rise to any effusion of liquid, and without
leaving the least trace of its  passage.   In pushing it more rapidly
by a simple effort of pressure, as some persons among us do it, there
is in general a little more pain produced, but  prudence forbids that
AAe should  apply it upon these principles along the track of the
great Aessels.
   Electro-puncture  is performed like acupuncture, only that  it is
not always necessary to insert the needle as  deep, and that, being
once  in its place, it should be put in  communication with a gal-
vanic pile, or a Leyden jar, by means of some  description of con-
ductor, Avhatever that may be.

               Article II.—Exploring Punctures.

   2.  The needle preferred for ordinary punctures is more easy to
guide, and should not be as fine as the acupuncture needle. Though
the round needle may have been advised for  opening a  passage to
gas pent  up in a strangulated intestine, it is, nevertheless, to the
spear-shaped needle, (aiguille en fer de lance)  with  a straight or
curved point, that we  always have recourse as an explorative means
in such cases.   A tumor shows itself in a complex region of the
body; we are not sure  that it contains a liquid, or do not know if
this liquid is blood,  pus, or serum, or whether the tumor is an
abscess, cyst, or aneurism.  Puncture with an  appropriate needle
immediately removes all doubts.   If there is  fluid within the mass,
it causes some drops to issue from it, and enables us to determine
its nature ; the  small wound it makes immediately closes, even in
the case of an arterial cyst, and  the  surgeon  then makes up his
mind  Avith a full knowledge of the cause.  Its insertion is regulated
by the same rules as that of  the  bistoury introduced by puncture,
that is to say, that the right hand seizes it sometimes as a writing-
pen, and sometimes as a knife,  by its handle or head, in order to push
it in, Avhile the left hand stretches the parts. As  it is a little wider at
the point than at the stem, the liquid passes  along this last, and
enables us to make up our judgment before withdrawing it; and to
determine also  the  moment of its  entrance into the cavity.  I haAe
no need of adding, that, in order to have only a simple puncture,
we should, in withdrawing it, bring it back with care through the
same track which has opened  a passage for it.
   The spear-shaped  needle, which I  make  use of for exploring
punctures, is nothing else than a straight cataract-needle, like that
which was in use before the time of Scarpa.   With this needle
we distinguish without difficulty the different kinds of deposites of
every solid tumor; but it is not always sufficient to indicate the
nature of the matters  contained  in a cyst.   Unless, in  fact, the
matter is very fluid,  nothing issues  out by the puncture,  and the 
348           NEW ELEMENTS  of  operative surgery.

surgeon may remain in a state of uncertainty.  If there is neither
a large-sized artery nor an aneurism to fear, Me then substitute for
it the point  of a lancet, or of  a  bistoury  Avith a straight  keen
blade.
  In place of holding the lancet as in bleeding, I hold it as a wri-
ting-pen, and insert it  in the  manner of a needle.  The  bistoury
should be inserted in the same manner.   If there still remains any
doubt, Ave may glide in a fine probe upon one of the sides of the
instrument, in order to dilate a little the lips of the wound.   If Ave
should desire to avoid all parallelism between the puncture of the
skin and that of the subjacent tissues, it would answer to penetrate
very obliquely into the tumor, or, after having forcibly drawn its
coverings in one direction only at the moment of puncture, to  alloAV
them to return to their position.

     Article III.—Puncture  with  Trochars, (Trois-Quarts.*)

  The use of the trochar is  especially distinguished from that of
the needle, lancet, or bistoury, by the canula which the instrument
carries  with it, and  Avhich becomes  the conducting-tube of the
fluids we wish to evacuate.   Whether its point be  flattened, like
that of  a lancet, or pyramidal, with three  cutting edges, and the
rest of the shaft smooth, as it generally is, it  requires a certain
force to make it enter; from this  results the necessity of embracing
the trochar with the full grasp of the  hand.   We place its handle
between the thenar and hypothenar eminences,  or  betAveen the
hollow of the palm and the last two fingers flexed.  The thumb and
middle finger, a little more advanced, hold it near its termination,
whilst the fore-finger, extended, holds the instrument  at a greater
or less distance from the point, in order to limit the depth to which
ft is to penetrate.  In  a case of necessity Ave  might, for greater
security, detach the middle finger from it, and select a point d'appui
for this finger upon one side  of  the place that is to  be punctured.
In general I prefer holding the handle with my full  hand, and of
limiting the entrance by the nail of the thumb, which 1 keep fixed
at  a proper  distance from the point.  When  it has  entered, the
thumb and fore-finger of the left hand adjust its canula, the spoon-
beak (bee de cuiller) being directed  downward,  while  the  right
hand draAvs upon the handle,  and removes the  punch.  The  sac is
emptied, and the liquid received in a vessel.  To remove  the tube,
it is sufficient to draw a little briskly upon its head, while the fin-
gers, which till this moment have held it, are applied upon the sides
of the puncture,  in order to hold back the skin, or the walls  of the
cavity, by giving them a point d'appui.
   This instrument, called trocart, or trois-quarts, presents also nu
merous varieties, relative  to  its  calibre, length, or form.  In punc-
  * [The word trochar, though undoubtedly a corruption of the French trois-quarts, has
obtained such universal currency that it would be next to impossible to attempt, witli the
author, the restitution of its primitive orthography.— T.] 
REUNION.
349
tures in  general, it is  sufficient to have two of them; one small,
called the hydrocele trochar, for tumors of moderate size containing
liquids of great tenuity ; the other almost as large  as a goose-quill,
called the paracentesis trochar, for large tumors or liquids of some
degree of consistence.
  The groove which is upon the canula of some trochars, and the
openings with Avhich some authors prefer to have  them perforated
in their loMer third, allow, in the first arrangement, the bistoury to
be introduced upon it, if it should be necessary to incise the sac, and
in the other, the liquids to run into it from all the sides of the cavity
at once; but as they  at the same time permit  certain matters to
infiltrate themselves betAveen  the  canula and the  tissues, Avhich it
distends, it is better to dispense Avith them.
  The employment of  the trochar demands certain precautions.  It
is important, first, that the extremity of the canula  should not reach
entirely to the base of the pyramid of the punch, that it does not form
any elevation or border, and that its other end remains firmly clasped
to the handle at the time of the puncture.  It is afterwards  neces-
sary to bear in  mind,  that  a  button-headed probe is required to
clear it out and remove' from it the flakes or  other solid substances
which might interrupt the flow of the liquid during the operation.
I will add, that  if the  opposite walls of the cyst are not separated
but  by a feAV lines, the instrument, tending inevitably to approxi-
mate them more while entering,  may perforate through them at
one  stroke, and lead to serious accidents.   The error being once
committed, we remedy it by removing the punch from the canula,
and then AvithdraAV that also by a gentle rotatory movement.  At
the  moment when  the deeper Avail of the sac is disengaged from
it, it naturally falls into the cyst, and the liquid immediately runs
out.   AVe then push it back again a little, and nothing is easier
than to adjust it afterAvards as we Avish.  It is necessary, in fact,
to obtain preAdously as exact  an idea as possible  of the thickness
of the Avails of the cavity.  I shall return to all these subjects in
speaking of operations, and particularly of hydrocele.
                        CHAPTER II.

                           REUNION.

  The reunion of divided parts is  obtained by the position of the
patient, or of the wound, and by means of bandages and plasters,
and especially by the suture.

                      Article  I.—Sutures.

  The approximation of the lips of  a wound by means of threads
or metallic pins, (tiges me'talliques) being the only one among the 
350
NEW ELEMENTS OF OPERATIVE  SURGERY.
means of union that is entitled to the appellation of a bloodv ope-
ration, is the only one Avhich I shall at present examine.  The suture,
evidently borrowed from  the  art of the tailor, formerly enjoyed a
reputation which, to judge by  the practice of most operators at the
present day, could scarcely be credited.  Since the time of Pibrac,
who has censured it so much, and who, in a memoir in other respects
but little  conclusive, wished, to  a certain  extent, to reject it from
the domain  of surgery, the suture has been constantly losing its
former importance in  the eyes  of practitioners; so  that it is no
longer in fact recommended in classical works but for a small num-
ber of cases.  The partisans for and against it have  both exceeded
the limits of truth.  If the suture does not  merit the  praises Avhich
were formerly bestowed upon it, it merits still less, perhaps, the
disuse into Avhich it has in our days fallen.   The only Mell-founded
objections that can be urged against it, are that of augmenting the
pain, and prolonging the operation ; but it is only necessary to have
been Avitness to what takes place in hare-lip, staphyloraphy, rhino-
plasty, genoplasty, cheiloplasty,  and enteroraphy, to be convinced
that these inconveniences have been much exaggerated.  In those
kinds of unions, neither the pain nor the inflammation are the ob-
jections ;  and  the  practitioner would be too fortunate if he had
no other  difficulties to overcome or combat.  As  to the greater
duration of  the operation, Avho would Aenture  to make a serious
objection  on  that  account, if  the  suture had the advantages that
were attributed to it before the time of Pibrac and Louis ?
  To speak emphatically, it is requisite that we  should remark, that
the suture is not in reality dangerous4 as the ancient Academy of Sur-
gery pretended, but only that  it is useless in an infinity of circum-
stances, and scarcely ever  indispensable.  It is only  indicated  in
wounds in which Ave  desire immediate union;  there are, also,  in
these kinds of lesion a great  number of cases in Avhich  it might
be dispensed with, Mdthout inconvenience,  as there are also others
where it is totally impracticable.   Preferable to all kinds of band-
ages or plasters, where we Avish  to keep in coaptation large flaps,
moveable or badly supported integuments, membranous or Aery
delicate organs, it would give but little assistance in wounds Avith
firm lips (levres fixes) abundantly supplied with cellular tissue, and
which penetrate to the thick muscles of the limbs or trunk, and the
edges of which follow only the movements  of the subjacent parts.
  With the suture no pressure is necessary ; we may dress lightly,
(mollement)  and afterwards dispense with any traction upon the
teguments in the neighborhood ;  the coaptation, which runs no risk
of being  displaced, is effected through the whole thickness of the
bleeding borders.  With adhesive straps, or bandages, we produce
more or less irritation upon the skin ; the contact is rarely perfect;
and should the cutaneous  tissue be someAvhat flabby and detached,
the lips of the Meund constantly tend to roll up inAvards, and do not
touch but upon that part of their line which is nearest approximated
to the epidermis; the least effort, the least imprudence causes them
to be displaced, and all the regions of the body do not permit of 
REUNION.
351
their application ; Ave do not see, in fact, hoAV, in case of strangula-
tion, it would be at all more  difficult to  relax  or divide  a stitch
of the suture than an adhesive strap or piece of linen.  AVithout,
therefore, conceding as  much favor to this remedy as Delpech, M.
G ensoul, and the greater part of our surgeons in the principal towns
in the south of France do, whose views M. Serre (Traite de la Re-
union Immediate, etc., Paris,  1830) has so correctly embodied, I
think, with this last author, that it deserves to be reinstated  to a cer-
tain degree of consideration in surgery.
   Of all the sutures that have been described, science has  scarcely
retained any other than  the interrupted (entrecoupee) suture, or that
wdth separate stitches; the whip-seamed, (a surjet) or glover's, (du
pelletier;) the  zig-zag,  or  suture  with alternate side-stitches, (a
points passes;) the noose,  [or loop,]  (a anse)  or Le Dran's ; the
twisted, (entortillee ;)  and the quilled  (emplumee ou enchevillee) su-
ture.

                   § I.—The Interrupted Suture.

   To apply the suture wdth separate stitches, Ave procure  as much
thread, simple, doubled,  tripled, or quadrupled, and well waxed, as
we intend to use in the  different stitches ; also, a certain  number
of needles.
   The needles that  Avere still in use in the last century, and which
were curved and flattened in their anterior half only, and  straight,
round, or a little depressed laterally, and pierced in the same direc-
tion Avith a long eye behind, are entirely abandoned at present; for
these, we now  everywhere prefer  needles  that are curved into a
regular arc of  a circle, of the same width and thickness from one
end to  the other to within a feAv lines of their point, and having a
square opening made in the posterior part transversely through their
thickness.  These last, generally adopted since  the time of Boyer,
(Mem.  de la Soc. Med. D'Emul., t. iii, p. 79,) are, notwithstanding,
very inconvenient.  The  arc which they form renders their passage
through the tissues difficult; and, being almost  as thin at  the heel
as at the point they are apt to break.  I  am more  disposed to make
use of spear-shaped (enfer de lance) needles, with cylindrical stem
and lateral eye, (chas lateral)  and which, like the ancient  needles,
are but slightly, or not at all, curved in their posterior half.   The
others  are indispensable only  for sutures that we are obliged to
make at the bottom of certain cavities or excavations, and the ad-
vantages that Boyer attributes to them have not appeared  to me to
be confirmed by experience. A needle, attached to each extremity
of the thread, is required only when we wish to pass both  of  them
through the  internal or  cellular surface of  the wound ; otherwise,
one is  sufficient for each stitch. Other things being equal,  it is bet-
ter to  perforate one  of  the edges  of  the wound from without in-
wards,  and the other from Avithin  outwards ; the operation, con-
ducted in this manner, is more prompt and less painful; the instru-
ment draAvs less upon the skin from without inwards than in the 
652
NEW  ELEMENTS OF OPERATIVE SURGERY.
opposite direction, and is  not  attended with the inconvenience of
changing  the  needle or hand  in passing from one lip to the other.
AAe should begin upon the straight or upper lip of the wound. The
surgeon pinches this lip by placing his left thumb  (the hand being
turned in pronation) on its  inner side, and the fore-finger of the
same hand upon its outer  part; then he raises the  lip and reverses
it  slightly  outwards.   Havdng seized the  needle, armed with its
thread, with his right hand, placing his thumb  in its concavity, and
the fore-finger and middle finger, and eAen  sometimes the ring fin
ger, upon  its convexity, where the needle is rather large, in order
to convert it into a lever of the third kind, he inserts the point of it
into the skin at two, three, or four lines from the division, pushes it
in with a circular movement, and brings it out of the wound where
the left thumb guides its progress and direction.  After having re-
laxed his hold on the heel, as soon as it is sufficiently7 advanced, the
operator seizes its point, by placing his thumb upon its convexity,
and  continues to draw upon  it, bringing the  thread with  it by a
movement of supination;  he then takes it as he did at  first, and
proceeds immediately to the  second step of the operation, which
differs from the first only  in this, that the needle should perforate
the second lip of the wound by beginning upon its deep-seated bor-
der, (sa face profonde) [within the wound.—T.,~\ and that, instead
of the fore-finger, we  place  the thumb upon the skin, in order to
hold it firm.
  The other stitches are but  the repetition of the first; and Avhen
many are to be inserted, we usually begin  with that on the right,
or the lowest one.
  The rule which  directs the first  stitch to  be placed upon the
middle of the wound, is not applicable but to a very small number
of cases.  It is suitable only after the removal of  certain tumors,
and for wounds with flabby flaps,  (lambeaux  filasques) or  simple
wounds with very moveable  teguments ; otherAvise, it is almost al-
ways better to begin on one of the extremities, or one of the angles
of the division.   The more the stitches are approximated, the more
they favor  immediate union, and the less distant are we obliged to
make them from the line of the wound; it is also important, in
most anaplasties, to leaAe only twe or three lines between them.
As a general rule, the more they are approximated the better  the op-
eration succeeds.  It is the same, also, Avith all other kinds of sutures.
  If  any reasons should incline us to use the ancient method, and
place a needle on each end of the thread, the upper or straight
border of the wound, being raised up as before, should be perforated
the first, from its adherent [or  internal] surface to its free [i. e., its
outer] surface, while the right hand should be turned in supination,
in order to place the thumb on  the concavity of the needle, which is
pressed by a movement of pronation ; the perforation of  the other
border should be made with the second needle, exactly as in the firs.
method.
  When Me have to act upon tissues that are exceedingly resisting,
Ave avoid  Meunding the fingers, and acquire a greater degree o: 
REUNION.
353
force, by covering the whole heel of the needle with a thick pSce of
linen.  In such a case, it is advisable, also, in order to obtain a point
d'appui, to place the two points of a forceps, slightly opened, under
each  side of the bleeding surface, where the  point of the  needle
is about to penetrate.
  Instead of using separate threads, we may also, as I have often
done, and have seen M. Dieflenbach do, insert all the stitches of a
suture with the same thread.  The first stitch is immediately tied
into a knot, and the thread cut near the knot.   We proceed in the
same manner, and without stopping to insert the other stitches, un-
less it should be necessary to change the needle. The preparations
for the operation, and the operation itself, are both thereby some-
what expedited.
  Another mode, which I have found very successful upon the eye-
lids and anus, and especially upon the vagina, consists in inserting
with  the  same needle,  and with one thread only,  all the stitches,
and without tying or cutting any of them.  For that purpose Ave
have  a very long thread, and at each insertion of the needle leave
outside a loop  (anse) of several inches in length;  afterAvards, by
dividing all the loops, the surgeon obtains as, many distinct liga-
tures, Avhich he has only to tie separately.
  De La Faye, who used this  kind of suture, first  placed the lips
of the wound in contact, or caused them to be  held so by an assist-
ant, so that he might perforate them with one and the same plunge
of the needle.
  These, however, are only slight and  unimportant varieties of a
process, which  each one may modify according to  his own views,
or the special indications he Avishes to fulfil.
  To terminate, the operator cleanses the parts, seizes each liga-
ture by its two extremities, adjusts the coaptation, and ties  the
different threads, one after the other, upon the  least dependent side
of the wound, where he fastens them by a bow-knot.  In placing
them even upon the track of the Avound, we have, neAertheless, the
advantage of exerting a more uniform degree  of tension and com-
pression upon each side.  I generally adopt this, and find it does
well.  The placing of a little lint between them and the wound,
so that they may not press naked upon the skin, as some persons
have  recommended, is a practice which would only be justified by
the necessity of loosening the  suture the next or second day after
its  application.  In all other cases they should remain in their place
without any thing intervening.  A layer (gateau) of lint, or a per-
forated piece of linen, spread with  cerate, and then dry lint, and
compresses, and a few turns of bandage over them, serve to support
them, Avhen covering the parts with  simple compresses, wet Avith
cold water, or even  leaving the suture open to the free air, might
not seem to be sufficient. It is well, also, in some cases, to aid their
action by adhesive straps of diachylon.
   If  nothing of particular moment  should supervene, Me do not
take  away the threads until the third, fourth, or even the fifth day;
if the tissues, placed in contact, should be thick and very dense, it
  vol. i.                       45 
JkJ4
NEW  ELEMENTS OF OPERATIVE SURGERY.
mighOeven be advantageous not to remove the suture until at the
end of six, ten, or tvvelve days ;  and it can only be by inadvertence
that some have advised to leave it on for a month, for ulceration is
far from requiring as  long  a time as that for cutting through the
parts.  To remove them, Ave divide them Math the scissors at the
loAver extremity of the loop; the right hand afterwards seizes the
knot, or upper extremity, either with the fingers or  with a forceps,
and gently removes  them one  after the other, while with some of
the fingers of the left hand, or  with another open forceps, Ave sup-
port the skin and corresponding lip of the wound.

             § II.—The Loop Suture, (Suture a Anse.)

  Le Dran proposed, especially for enteroraphy, after having intro-
duced  the threads with  the  straight needle,  as in  the interrupted
suture, to unite all their extremities in one group, and to leave them
collected in this manner outside without tying them.  His object
was, to have it in his power to separate them at a later period, and
to withdraw them one  after the other, Avithout being obliged to di-
vide any thing. Thq  evil of this process of  Le Dran consists in the
puckering (plissement)  of the sutured part, a  puckering which re-
sults from the tendency to approximation of the stitches  (anses) of
the suture, caused by the tail-shaped cord which  groups  them out-
side the wound.  The plan, in consequence, has not been retained,
except in cases wdiere  a single  thread suffices, or when, after hav-
ing inserted  several, we  may retain them separately outside, as is
still done for certain  intestinal sutures. I will recur to this again.

    § III.—The Continuous Whip (a surjet) [or  Glover's'] Suture.

  The glover's (du pelletier)  suture, so called, is that which is gen-
erally employed after the opening of dead bodies and in veterinary
surgery.  Not less frequently employed in human surgery formerly,
it is at present, and improperly, as it  seems to me, almost entirely
excluded from it.  Wounds of considerable length, or that  involve
hollow organs, are not  less conveniently adapted to it in the living
than in the dead; and  the strangulation,  which it is accused of  so
easily producing, is so  much the  less a reason for rejecting it, that
it does not fbllow this any more frequently than it does the others.
  The whip suture, moreover, is so well known in the glover's and
tailor's art, that its name alone  is sufficient  to describe it; we begin
it like the interrupted suture, except that a straight needle is more
suitable than a crooked one, and that, in place of perforating the
lips of the division one after another, we  endeavor to bring them
face to face, and to include them in the same fold, in order to pierce
them at one puncture,  (du meme trait)  The assistant then stretches
and keeps extended the two extremities of this fold;  the  surgeon
pinches it above with the thumb and fore-finger of the  left hand
turned in pronation,  carries the needle to the  straight or upper lip,
a little above and at a suitable distance from the wound, pierces 
REUNION.
355
the fold, draws the thread through, and causes the assistant to hold
its extremity, or ties a knot in it to hold it, brings back the needle
obliquely crosswise over the wound to the same part of the skin, at
three, four, or five lines from the first puncture, and continues on in
this  manner, so that the last stitch passes a little beyond the other
extremity of the fold, and that the whole suture represents a certain
number of spiral turns ; if it  does not appear to  be  sufficiently
tightened, Ave draw upon the two ends before fastening them; in
the contrary case, we widen (etaler) a little the fold of  the wound.
In order that  it should be well done, it is  necessary that the  two
lips  of the wound, without  being strangulated, should  touch each
other throughout their whole  surface, and that  the  fold should be
perfectly effaced.  We finally terminate the suture by making each
of its extremities pass, as in a running knot, around the spiral turn
next to it. When we wish to remove it, we cut, with the aid of the
scissors, each oblique bridle that it  forms, then draw out all its
stitches  separately; or we  confine ourselves  to untying its upper
extremity, in order to disengage  successively  the different turns of
the spiral, and draw the thread out entire by its loAver end.
   When Ave cannot include the two sides of the wound in the same
puncture of the needle, each stitch of the glover's suture should be
made precisely as in the interrupted suture, from Avhich, in reality,
it differs, as is seen, but very little.

§ IV.—The  Zigzag Suture, that is, with alternate Side-Stitches, or as
         in Basting, (Suture d Points Passes ou en Faufil)

   This suture, the suggestion of Avhich is  attributed to Bertrandi,
and  which De Courcelles had already spoken of, (Man. des Oper.
les Plus Ordin. de  la Chir., 1756,) is in a  continuous thread,  like
the preceding, and also commences and terminates like that; but,
in place of passing spirally in front of the Avound, to go from one
side  to the other, the thread perforates its fold each time, first from
right to left, then from left  to right, and so on to the end, so as, in
reality,  to form zigzags, which  leave the anterior edges of the
wound free and uncovered.  Consequently, the  needle perforates
the tissues by  beginning on the right border;  drawn back through
the left border, it perforates them anew, but  in an opposite direc-
tion and a little above, to come out  again upon the right border ; it
is returned through this last at some lines above ; drawn out again
upon the other, it is reinserted a  little farther on,  as at first; in
such manner that it creeps along, as it were, (marche en serpentant)
and  not  in spirals, (amlages) like the glover's suture.  Some sur-
geons attach  to it the advantage of not  tearing  out  or cutting
through as easily,  because of the lateral stitches which  it every-
where makes  between two punctures, and of not strangulating like
the  other by passing over the wound.   M. Champion also thinks
that  it  fav ors, more than the  glover's  suture, the adhesion of the
wound with the neighboring parts, as, for example, of a divided in-
testine with the peritoneum of the abdominal walls.  In admitting 
 356           NEW ELEMENTS OF OPERATIVE  SURGERA

 that this may be so, Ave must allow, at least, on the other hand, that
 it has the inconvenience of drawing unequally upon the two halv es
 of the division, and of not supporting its anterior surface.   Though
slightly improved by Lombard, (Plaies Recentes An. VIII. p. 19,) and
imitated by Beclard, who proposed that we should make use of two
threads of different colors, and by M. Champion, who, with the same
object, had confined himself to making a knot at  the two extremi-
ties of one of these threads, the  zigzag (a points passes)  suture is
scarcely ever  used, and may nearly always  be replaced  without
any danger by the  interrupted or by the glover's suture.

         § V.—The Twisted Suture, (Suture Entortillee.)

  One of the sutures the most frequently employed, is that which is
 made by means of threads (cordonnets) passed in various ways
 (diversement) around metallic pins, (tiges metalliques) which are left
 remaining  in  the thickness of the tissues.  Needles  of iron, steel,
 gold, silver, lead,  copper,  brass, &c,  straight, curved, thick, fine,
 long, short, round,  and flat, have been employed for this purpose ;
 but  it has  resulted in this, that ordinary pins, Avhich are  found
 everywhere, and which, in truth, answer the  purpose full as well
 as metal of the most precious  kind, or that  which has been  the
 most laboriously wrought, have now been almost universally substi-
 tuted for them.  They are prepared by sharpening and flattening
 their points in any way we  choose, as upon  some vessel of free-
 stone, or a  fixed piece of stone, and in covering  them with cerate
or tallow.  If they are fine, or if the parts  they are to perforate
have but little density, even these  slight  preparations are not re-
quired.  If the  wound occupies a moveable part, the lips or eyelids,
for example, and is vertical, the pin that is to be applied first is
that  which is  nearest to the free border of the organ ; the others
follow afterwards in succession.  When the two extremities of the
wound hold firm,  (se  tiennent) or we wish  to  fasten cutaneous
flaps, the placing of the needles is no longer subjected to the same
rules.  The operator then begins  at  the middle, point,  sides, or
base of the parts he wishes to bring into coaptation, according to
the difficulties he supposes he has to overcome.   Under this point
of view, he must be left to his owoi particular judgment. The right
lip of the wound being held by the fingers  of the left hand, as in
the interrupted suture, or with the  forceps, erigne, or any other ap-
propriate instrument, he inserts the needle or pin from without in-
wards, makes it appear at the interior of the wound, and continues
to force it  towards the other lip,  which he  seizes in its turn  and
perforates from within outwards, so that the  needle comes out on
the skin at the same distance ; the needle is then immediately  em-
braced by a turn of thread, which  passes under its head and point,
 at the same time that it crosses the forepart  of the wound and tends
 to force its two halves against each other ; an assistant holds  fast
 the tMe ends of the thread and keeps them  a  little tense, while the
 surgeon proceeds to the application of the other pins.  As soon as 
REUNION.                        357
they are all placed, we occupy ourselves with arranging them and
surrounding them with threads.  The middle part of a long liga-
ture is placed on the last pin, then passed and crossed many times
in figure of 8 on its two extremities, conducted by a figure of X to
the next needle, and crossed in the  same manner on the head and
point of that, before going to the third to return upon the second
and first by additional figures of X. We terminate with a knot, or
by rolling its two ends into a cord, Avhich is turned back under the
head of the metallic pin.  In order that the needles  may not Avound
the teguments, a small piece of lint or adhesive plaster is placed
under each one of their extremities ; there is nothing then to do but
to cover them with a suitable dressing, if it should be judged ne-
cessary to use any.
   Their removal is made at the same  periods as those of any other
suture.   We begin by removing the pin which supports the least
traction, in order not to take away the others until the day after,
or the day after that, should the reunion not be, found sufficiently
firm.  Should we haAe any apprehensions on this subject, it is bet-
ter to take away the needles only at first, and to leave on for a day
or two the paequet of thread, which, adhering to the parts and be-
coming more or less hard, does the office of adhesive plasters ; there
is no objection, moreover, to our substituting some strips of adhe-
sive plaster for two or three days in the place of each needle that
has been removed.  It is necessary, also, that the straight lip of the
wound should be carefully supported by the fingers  of the left hand,
or, better still, by the extremities of a dissecting forceps, while with
the other hand, or with  another forceps, we draw  on the  head of
the pins in a straight line, turning them around upon their own
axis by small moAements of rotation.  The  punctures  that  they
leave in the place exude and suppurate for a day or two, and cica-
trize like every other wound of the same nature.

               § VI.—Quilled (Enchevillee) Suture.

   The infibulation which is still practised by some of the orientals,
and which for a long time has been in no other way employed in Eu-
rope except to protect the female  of  some animals, the horse, for
example, from the furious passions of the males, is  a kind of quilled
suture, in fact a grillage ;  but in the place of metallic rods, used on
the mare for the particular purpose for which they are intended,
this suture in the human  species  is  made Math threads, and tAvo
small lateral stems,  which should be more solid.  It  is  applied
like the interrupted,  suture, but with double  threads,  leaving a
loop at their free ends.  When they are all adjusted, we insert in
a parallel direction with the wound,  and into each of the loops, a
stem (tige) of wood, a piece of hollow quill, or the end of a sound
or of a gum-elastic bougie, a roll of adhesive plaster, a small me-
tallic rod, or any cylindrical body Avhatever of suitable length and
thickness; the loops at the other extremity of the threads are then
opened, that a  similar  stem may be inserted in them, and  upon 
358           NEW ELEMENTS OF OPERATIVE SURGERY.

which they are successively tied into a knot, after having effected
the coaptation of the borders Avhich are to be united, Mdthout making
too great a constrictive forte, but in such  manner, nevertheless, as
not to leaA e a void between the two sides of the wound.
  The quilled suture,  though rarely indispensable, has, neverthe-
less, the advantage of making an equal pressure upon all the points
which the  threads tend to approximate, of being more solid than
any other,  of not  tearing out  the  parts  as  easily, and of being
specially adapted to straight, long, and deep wounds of the walls
of the abdomen and those of the limbs.  Ravaton, who used it also
in transverse wounds, fastened  it upon plasters cut  and rolled into
cylinders.  These small rolls have the advantage of moulding them-
selves easily  and without  any effort to all the irregularities  of the
wound.  In order to have the loops as small as possible, Ravaton
proposes, moreover, that all the threads should perforate each of
the cylinders, instead of surrounding them entire.   Thus modified,
the quilled  suture is applicable  to all wounds of  any considerable
length, or those whose  union cannot be maintained Avithout the aid
of a certain degree of resisting power. It is used frequently in place
of numerously multiplied stitches, and is the only one that tends to
approximate  the parts from the bottom toAvards the  surface.  This
last advantage is attended with  an inconvenience which it is proper
to recollect, namely, a perceptible  gaping open, often, of the cuta-
neous edges  of the wound.  This, however, is remedied either by
means of adhesive plasters, or by passing afterwards under the cylin-
ders a certain number of threads, Mdiich are each tied in a knot as
in the interrupted suture.   The only objection, then, that  can be
urged against this suture, is that of exacting a little  more care and
time than the continuous suture, and of never, in fact, being in any
case imperatively required.  It  will be spoken of again, under the
head of Suture to the Perinaeum.

              § VII.—General  Remarks on Sutures.

  In  every kind  of suture Mdiatever,  Ave must avoid multiply-
ing their stitches, or separating them too far apart.  The inter-
val to be left between them,  should vary also according  to the
greater or less degree of resistance  to be overcome, and according
as the wound is  more  or less distended, or the walls to be held up
more  or  less  flabby or difficult to be supported.  Stitches  at the
distance  of half an inch apart ordinarily suffice for  the  quilled
suture, and for some cases of the twisted suture;  in other cases,
on the contrary, they are required to be at the distance of three
lines  or more apart, while  an  inch is  sufficient  in some circum-
stances ; but  this is only to be learned from particular examples,
which cannot properly be given in this place.   If  the lips of the
wound do not gape between the  stitches, and if these latter are
sufficiently tightened to put the  living surfaces into contact, but not
so much  so as to interfere Avith the inflammatory engorgement of
the parts ;  if they extend to the distance of a line from the  angles 
       OPERATIONS FOR  DISEASES  OF  THE  CUTICULAR SURFACE.    359

of the division, unless Avhere it  is requisite to leave open at the
lower part an issue for the matters; if they enter and come out at
an equal distance from the line of the wound; if they are left in
but a short time  where the  tissues  are exceedingly vascular  or
easily cut through, (secables) as in infants and upon the face; and
that the contrary is observed in the opposite conditions; then will
the suture be Avell made.  The suture, moreover, is an  operation
which necessarily admits of but very few general rules.  It is when
treating of anaplasty, wounds of the intestines, lacerations of the
pudenda, &c, that we shall be fully enabled to appreciate them.
        PART SECOND.

COMPLEX OPERATIONS.
                      SECTION FIRST.

OPERATIONS WHICH  ARE  PERFORMED  FOR  DISEASES  OF THE
         CUTICULAR  SURFACE OF  THE  INTEGUMENTS.
                                                    f
Article I.—Operations required for Warts,  Corns, and  Diseases
                         of the Nail.

                         § I.—Warts.

  The name of warts is applied to small tumors, sometimes nar-
row and salient, sometimes flat and of considerable breadth, which
are formed upon the surface of the  skin, and principally upon the
back of the hand.  They are indolent vegetations of the epidermic
layers and of the sanguineous tissue of the skin.   A great number
of methods have been proposed for their removal,  but there are
none  of them that generally succeed, and the best thing, when
these  warts are very numerous, is to do nothing at all Math them.
No infirmity has given birth to a greater number of secret or whim-
sical  remedies.  I  know a distinguished functionary of  the realm,
Avho firmly believes himself in  possession of  one  of these secrets.
He has related to me  with the  utmost degree of sincerity, that by
means of a thread of  red silk, each knot of Avhich should  be made
to pass around and touch the base of the wart before  being tied,
and which thread he afterwards deposites and leaves to putrefy in
a mass of dung, warts can be constantly cured !  Without attach-
ing any value to such absurd notions, the surgeon may make trial 
360
NEAV ELEMENTS OF OPERATIVE SURGERf.
at least of certain remedies, that are in reality efficacious, Avhen
the aa arts are few in number, and the patient desires to be relieved
of them.
  If the tumor is salient and pedunculated, Ave may strangulate it
with a thread, and thus detach it by a ligature.
  In that case, it Mould be still better to seize it with a forceps, and
excise it with one stroke of  the scissors, taking care to touch the
small wound immediately after with the nitrate of silver.
  [This mode, peculiarly adapted to and called for in syphilitic pe-
dunculous vegetations on the glans,  or praeputium penis, is made
more effectual, and a second sprouting of the Avarts, not an unusual
thing, prevented, by drawing them  outwardly  Avith the forceps
applied to their middle, and with such force that the root or base
as it were is elevated above the plane of the skin, by which means
the curved scissors, placed flatwise  and close to the skin, is enabled
to clip them off entirely beloAV as  it were their base, leaving no
small roots or attachments  behind.  The only inconvenience, and
that is in the eye of the patient only, is that there is in this mode
of extirpating them a small hemi-spheroidal depression or pit gen-
erally left in the skin.  In this method the nitrate of silver or other
escharotic is not requisite,  and  the warts never or rarely  return,
which, however, they  are very apt to do where  they are clipped
off, as they usually  are, in a line only wdth their base, without
drawing them out, so  that the scissors may pass as it were under
their roots, as above directed in this note.—71]
  If the wart has neither pedicle nor neck, it is treated in another
manner : that is, sucked with the lips and then bitten off Avith one
bite of the^ teeth, as was done in the time of Galen ; burning it with
a tooth  cautery, or removing it layer  by layer with a  scraper, are
objectionable methods, in place  of which we should always sub-
stitute extirpation and  free cauterization.
  Extirpation, however, which  consists in removing by one stroke
of the  bistoury or scissors, applied flatwise, the whole tumor, and
the effect of which is  afterwards rendered more sure by touching
the surface with nitrate of silver, is  not a perfect guarantee against
a return.  To take off with the wart an elliptic  piece (plaque) of
the skin would  be  infinitely more  sure.  [Vide  note a few lines
above.]   With  persons who dread the application  of  a cutting
instrument, we  should  have recourse to cauterization.  The end
of a feather or a glass tube serves  to conduct to  the  tumor  a
small drop of nitric acid, which  Ave must take care not to allow to
spread upon the neighboring tissues. This cauterization, which is to
be repeated for several days in succession, acts better and succeeds
more constantly than  cauterization with the nitrate of silver.  In
fine, simple incision, aided by cauterization with  the nitrate of sil-
ver, is the mode most frequently employed.
  [Muriate of Ammonia. Rubbing frequently, says Dr. Mott, with a
piece of this, carried in the pocket, will often cure them. Also, butter
of antimony, applied wi*h a camel's-hair pencil.  So with muriated
tincture of irOn, and also tincture  of iodine.  But  every other mode 
        OPERATIONS  FOR DISEASES OF THE CUTICULAR SURFACE.     361

should now be discarded, he says, for the effectual and certain cure
oy means of the actual cautery, especially, as in the treatment of
nam, by perforating the wart, perpendicularly and horizontally, in
two or three places, with a red-hot pin, though a great degree of
heat is not necessary.—T]

                    § II.—Corns upon the Feet.

  The operations practised for corns on the feet, and which are
alike varied, are almost all of them performed by charlatans or
corn-doctors, (pe'dicures)  The  pain, however, which  results from
this disease is often so very severe, and causes sometimes accidents
of so serious a nature, as to require the aid of surgery.  Corns are
a production in the shape of a nail, (clou) whose point depresses
the skin, and are composed of epidermic substance, and not of con-
crete mucus, as some persons  appear to suppose.  Removing them
layer by layer Avith a bistoury gives temporary relief, but does not
effect a  radical cure.   There is no other mode to destroy them ef-
fectually, if an instrument is to be used, than by extirpation.  The
method which I adopt with most advantage is very simple.  With
the point of a straight bistoury  I separate a portion of the circum-
ference of the corn, then seize  hold of  this detached portion of its
border with a dissecting forceps ; then, continuing to separate it, 1
take care to hold  the point  of the bistoury constantly in contact
wdth the  surface of the living tissues.   Proceeding by small cuts,
and gently,  I thus, in the space of one or two minutes, and without
causing  the  least pain or a single drop of  blood, succeed without
difficulty in removing the thickest kind  of corns.  It is for this ope-
ration that corn-doctors have devised the instruments called quad-
rilles, furets, and navettes, and which they use with lenses,  (loupes)
or bottles filled with water, to concentrate the light upon the part
they are  dissecting.
  The corn thus unrooted (deracine) wall, nevertheless, grow out
again in most cases, if the friction of the toes continues as before.
It is only by cauterizing the cavity it occupied, or filling it Avith ad-
hesive plaster, that we can  sometimes prevent it from growing
again.  This, after all, is  but a small  operation, Avhich patients
may practise upon themselves, and w hich they have only to repeat
every month to relieve the  suffering produced by corns.
  In taking  the precaution to soften the corns, either by means of
plasters, or by immersing them for a greater or less length of time
in hot water, they are more  easily separated, and in some cases
they are detached  by  rubbing them, or simply pulling upon them
with the fingers.  It is in  this way  that certain plasters  or  oint-
ments have acquired a kind of reputation in the practice of corn-
doctors and  among  common people.
  Cauterization, also, is frequently employed for the same purpose,
It is performed either  by applying to the centre of the corn the ig-
nited extremity of a piece  of wood, or a drop of melted sulphur, or
a small roll  of spider's  web, which is ignited on the part, or sulphu-
  vol. i.                        46 
362           NEW ELEMENTS OF OPERATIVE SURGERY.

ric or nitric acid. I have seen a person even, who had the singular
idea of perforating with a red-hot pin a corn which he had on the
back of the phalangeal articulation of the fourth finger,  (doigt an-
nulare.)   The corn,  in fact, mortified, but produced an eschar,
which exposed the joint, and led to the necessity of amputating the
finger.
  The treatment of corns by caustics is, in every respect, not only
less certain, but more dangerous, especially in the  neighborhood of
the joints, than their extirpation, Avhen well performed.
  [The application of a strip of adhesive plaster, firmly embracing
the toe, after the effectual extirpation of  the corn by the knife, is
not only an excellent preventive of the  friction which  has  often
caused the corn, but also, by its compression,  prevents the new
growth, and is thus frequently an effectual cure.  This remark ap-
plies, also, to the treatment  of some obstinate  warts removed by
caustic from the fingers. A general idea prevails in the world,that
stockings of cotton thread, from the naturally irritating properties
of that tissue, are a preventive of corns.   Shoes moderately tight
are certainly preferable to those that are  loose, and which by fric-
tion  chafe  the skin and produce corns.    Corns become of a more
serious character when involved with tumefaction of the  toe joints,
which has been  produced by painful gouty affections.  Keeping the
feet  and toes  thoroughly  clean by daily  ablutions in cold water,
winter and summer, is one of the best hygeian preventives.—T.]

                 § III.—Callosities,  (Durillons.)

  Epidermic tumors, in place of presenting themselves  under the
form of a nail, are  sometimes  seen under the aspect of  scales, of
greater  or less  thickness, upon the  surface of the parts. These
plates, (plaques) which are  most frequently seen on the outer or
dorsal surface  of the little toe, and upon the corresponding surface
of the head and posterior extremity of the fifth metatarsal bone,
and  Mdthin the metatarso-phalangeal articulation of the  great toe,
&c., take the vulgar name of onions (ognon) when they are  large
and  shelly, and  of callosity (durillon) only w hen they are of little
extent and of the character of a homogeneous mass.
  Produced by the unequal compression and friction of the  shoes, (des
chaussures) these different kinds of callosities, like  corns,  cannot be
prevented or  radically cured but by the   removal  of the causes
that produce them.   They are, however,  temporarily cured by ex-
cision.  For these, however, the bistoury  must be applied flatwise,
(en de'dolan4) and the removal of the epidermis layer by layer is the
mode to be pre fen ed.  Their destruction  by the file, pumice-stone,
(pierre-ponce) or shagreen-skin, (la peau  de chagrin) is never as
complete and  prompt as by the cutting instrument.  It is  important,
also, to know that, like corns, they very often lie upon a sort of mu-
cous bursa, {bourse muqueuse) which we must take care not to open,
should they exist on the back of an articulation.  I will add, that
under the  heel, where there is found a  mucous bursa of this  de- 
        OPERATIONS FOR DISEASES OF THE CUTICULAR SURFACE.     363

scription, corns and callosities often inflame to such a degree as to
produce suppuration, and that their cure in such cases requires that
they should be  completely excised.   I have seen some in the sole
of the foot, and under the metatarso-phalangeal articulations, M'hich;
had undergone such transformation that it became necessary, also,
to remove  the  entire thickness of the skin upon which they were
situated.

                   § IV.—Diseases of the  Nail.

  The nail, or the parts which surround it, are subject to a certain
number of diseases, almost all of wdiieh derive their remedies from
operative  surgery.

                   A.  Runround,  (Tournioles)

  The suppuration known  under the name of  mal d'aventure, or
tourniole, and which presents itself under the form of a purulent
phlyctaena upon the contour of the nail, almost always, if left to it-
self, causes the destruction of this substance.
  We may, however,  prevent this  disease in two ways—1. By
opening the phlyctaena as soon as possible, then removing the whole
separated portion of the  cuticle, and afterwards dressing the denu-
ded  surface,  either with lint covered with cerate, or with simple
emollient  cataplasms.   In  order that this first means should suc-
ceed, it is necessary that  the disease should not have yet penetrated
between the  nail and  the cutaneous fold which covers its borders
or root; 2. The progress of the disease is arrested, also, by cauteri-
zation ; it is  also necessary that this cauterization should be per*
formed properly.   The most convenient  way in such cases is by a
pencil of nitrate of silver, sharpened into the form of a chisel (ciseau)
or wedge.  If we take care  to make it penetrate between the  nail
and  the cutaneous border  down  to  the bottom  of the purulent
groove, so that  all the morbid points may be effectually touched, it
is rare that the disease continues, or that the adhesions of the un-
der (profonde)  surface of the nail are destroyed.  It is a mode of
operating in wdiieh I have always been successful.
  The fungosities and vegetations which are sometimes seen on
the epidermic margin  (filet) which surrounds the nail,  and wdiieh
are a very common result of the tourniole, require the same treat-
ment, and also  are not effectually eradicated until they have been
well cauterized.  [Dr.  Mott has seen these fungoid growths under
the root of the nail burst through it, and occasionally he has had to
make an opening through the nail to let out the  blood.  A poultice
mixed with wood ashes  is  then an excellent  application to com-
plete the cure.—T.]

         B.  Nail Imbedded in the Flesh,  (Ongle Incarne)

  The disease known under the name of the imbedded nail, (ongle
incarne) narrowed nail,  (ongle retreci) the nail entered into the 
364           NEW  ELEMENTS  OF  OPERATIVE SURGERY.

flesh, (ongle rentre  dans les chairs) the  onglade, and onyxis, and
which the  ancients describe under the  name of pterigion, is un-
doubtedlv, of all diseases of the nails, the one which has most at-
tracted the attention of surgeons.  To understand perfectly what I
shall say of the operations it  has suggested, we must bear in mind
that the nail is  a  horny plate, the concave surface of Avhich is
continuous with the papillary surface of the cutis, and the sides of
which near its root are  surrounded and covered, to the extent of
two lines, by a fold of the integuments.  The lunula, (lunule) or small
white spot which is seen at the root, corresponds to a part upon its
concave surface which is but  slightly adherent to the rete mucosum
underneath.  The ridge (filet) which is around it is a simple fold
of the epidermis, and it is almost always at the expense of this that
are formed those ravellings of the skin (eraillures) known under the
name of hang-nails, (envies.)
  The portion of the integument which covers the root of the nail,
and  which, according to  some surgeons, is considered its  matrix,
does not, in reality, adhere to  it but to the extent of a line or a line
and  a half in front; farther in the nail is terminated by a thin root,
free and slightly irregular, so that  it is more especially by its con-
cave surface, and by a small  part of the  convex surface of its root,
that it is nourished  or reproduced.
  What I have just said of the tourniole applies sufficiently well to
phlyctaenae, and the  fungous growths of the tegumentary fold of the
root of the nail.
  The nail of the large toe often appears as if it had penetrated by
one of its edges, or  even by both its edges, into the thickness of the
flesh ; it is for this condition of things, which is very unpleasant, as
well as exceedingly difficult to remedy, that  an infinity of surgical
means have been devised.  The processes, in fact, for this purpose
are  so numerous that it would be easy to name almost a hundred
of them, which requires that  they should  be treated of under differ-
ent heads, if we wish to examine the principal portion of them with
advantage.
  All these processes have for their object—1. To destroy a portion
or the whole of the nail;  2. To get rid of the fungosities (fongosi-
tes)  [fungous growths] which surround the nail;  3. To narroAv or
raise the plate which wounds the flesh.
                    I. Destruction of the Nail.
  Surgeons who have advised  the destruction of the nail for the
cure of onyxes are  divided into three classes. Some, in fact, confine
themselves to excising the portion of it which seems to have  perfo-
rated into the tissues, whilst  others recommend destroying by cau-
terization  that part of it which is covered behind by the integu-
ments, and others again, that we  should tear it out by force, either
by one of its halves or entire.

          a. Destruction of the Imbedded Part of the Nail.

   1  Paul of ^Egina, (Lib. vd. cap. 85,)  or Dalechamps, (Chirurgie 
        OPERATIONS FOR DISEASES OF THE CUTICULAR SURFACE.    365

Francaise, edit, de Rouen, p. 538,) had already recommended cutting
off the imbedded edge, after having raised it with a probe.
  2. Fabricius ab Aquapendente (Opera Chirurg., Franc fort, 1620,
p. 402) recommends that we should keep the edge of the nail raised
by a piece of lint, and  that it should then be cut  off down to its
root, and the detached portion  removed with the forceps, and that
we should do this every day, until  there is no more of it left con-
cealed in the flesh.
  3. Dionis made use of  a kind of knife, cut the nail lengthwise,
and took away with the forceps the portion to be removed ;  some-
times, also, he  used  scissors to cut it from before backwards, and
applied to the wound lint wet  with lime-water, or a minium plas-
ter, (Operations, edit, de Lafaye, t. ii., p. 781.)
  4. A process, Avhich resembles very much that of Fabricius, has
been published as new by M. Somme, (Archiv. Generates de Medec,
t. i., p. 485.)   It consists in removing the  imbedded portion of the
nail, and then sprinkling the fungous growths (fongosites) and the
adjoining groove with powdered alum.
  5. M. Blaquiere has modified the process of Dionis in this way:
Before dividing the nail, he thins (amincit) it by scraping it with a
knife or a piece of glass ; after having slit  it down to its root, he
tears out the diseased third of it by turning it  over upon itself by
means of a forceps ; then dresses the  wound with lint Avet with al-
cohol, myrrh, and aloes ; and takes care to insinuate some threads
of lint under the new nail in proportion as it grows out, (Jour, du
Diet  des Sciences Med., t.  xviii., p. 208.)
  G. M. Begin, (Jardon, These, No. 101, Paris, 1836,) who, like  M.
Blaquiere, thins the nail  before  excising it, does not  afterwards
make use of lint  to  raise it up, nor of alcohol to give  tone to the
parts.
                    b. Tearing out the Nail.

  Other processes, more rapid, but which belong to  the same class,
consist in quickly removing a portion  of the  imbedded nail.
  7. M. Baudens, for example, removes from behind  forward, and
by a single stroke, with the cutting heel of  a very strong bistoury,
both the diseased border of the flesh and the entire portion of the
nail which it covers.  Among the processes  of tearing out the nail,
we have that of M. Larrey, Boyer, Dupuytren, and Ne'ret.
  The process of Boyer differs from  the  tearing out, properly so
called, in this, that, in order to prevent the return, this surgeon es-
tablished, after the operation, a point of compression upon the ma-
trix of the nail, by means of a small ball of  lint and some turns of
bandage.
  8. Process of M. Larrey. After having removed the inverted half
of the nail from the diseased part, M. Larrey made use of the hot
iron to destroy the fungous growths in the  neighborhood and the
whole surface of the wound.
  9.  Process of Pelletan, (Jardon, Thes., No. 101, Paris, 1836,) or of
Dupuytren.  Dupuytren proceeded in tMe different modes for tear 
366
NEW  ELEMENTS OF OPERATIVE SURGERY.
ing out the nail: if the disease was simple, and occupied but one
portion of the toe. he confined himself merely to tearing it out, and
adopted the following mode :  The diseased toe being held in a
proper manner by the thumb and  fore-finger, Avhile an assistant
presses his hand upon the dorsum of the foot, the surgeon immediate-
ly inserts from before backAvards one of the blades of a narroMr-
bladed and very keen-edged pair of scissors betAveen the nail and
the dorsum of the phalanx which supports it. The instrument should
penetrate  in this manner to at least two lines  beyond the Adsible
portion of the nail, which is then divided with a single cut by ap-
proximating the blades of the scissors.  A  strong dissecting forceps
now answers for seizing  one of the halves of the divided nail,
which is turned over, drawn out, and speedily detached from its
median portion to the free border, and from before backwards, and
the same  immediately afterAvards  done for the other half.   The
operation is thus composed of three stages—the  first for  the divis-
ion, the two others for the  successive  remoAral of the tvvo portions
of the nail.  The entire operation  is  so rapid, also, as not to con-
sume more than half a minute.
  If the disease should have been of long standing, and of great
obstinacy, Dupuytren preceded  the operation, of  which I  have just
been  speaking, by a semi-lunar incision, with its  convexity back-
ward, the  object of this incision being to lay bare the root of the
nail from behind forwards, and to destroy its matrix completely.
   10. Process of M. Niret  In  lieu of scissors, M. Neret proposes
to employ the ordinary spatula.  The following is the way in which
he proceeds, (Archiv. Gen. de Med., 3e serie, t. ii., p. 202:)  After
having placed the toe as in the usual manner for this operation, M.
Neret, grasping his spatula with the entire hand, glides  its blade,
the concave part of which faces downwards, under the free border
of the nail, and then forces it  on rapidly from before backwards to
beyond the root to be detached.  Then turning the instrument upon
its axis, he raises the nail from one of its borders, then  from the
other at its median part, so as to make it spring off, (faire sauter)
as it Mere, with one stroke.  If, after having detached it from its
middle part, and then upon its outer border, the spatula should not
separate it completely, M. Neret seizes it  with a pair of  stout for-
ceps, and removes it as in the ordinary process.
   [Dr. Mott says the scissors ought to be made with great care,
with very short, stout blades—one thick, the other thin and sharp.
It is, at best, he thinks, a cruel operation, and one in  which he
always feels some  apprehension of  lockjaAv.—T.]
   11. Appreciation. These processes, then, are comprised under two
divisions, which it is important not to confound ; the one, which pro-
poses only the destruction of the part of the nail that is imbedded; the
other, which has for its object the removal, also, of a part or of the
whole of its root.  Whether in  the first case we  follow the process
of Paul of _Egina, that of Fabricius, Dionis, Somme, Blaquiere, or
Begin, is a matter of little importance ;  they are such slight modi-
fications of the same method, as not to require  specific  classifica- 
        OPERATIONS FOR DISEASES  OF  THE CUTICULAR SURFACE.    367

tion.  Their  disadvantage is, that  they rarely secure the patient
against a return of the disease, and that they permit the portion
of the nail which has been destroyed to grow out again soon after,
and again to become a source of irritation to the parts.
  As to the  tearing out «of the third  or the half of the imbedded
nail, whether we effect this as Ambrose Pare  did and as M. Bona-
fond proposes, (Epidaure,  t. i., p. 135,) by removing  the  nail and
the flesh from behind forward with the bistoury; or whether in the
manner of Dionis, Boyer, Dupuytren, Delpech, and Larrey, we first
slit it from before backward, and afterwards remove  it with a for-
ceps, can in  neither case be a matter of any importance ;  I see in
these, trivial modifications only of the same process; except that the
operation is  quicker by the simple excision than by the process
of tearing the nail out, properly so  called.  This operative process,
a little more painful perhaps than the preceding, is, however, more
expeditious,  and more generally followed by  a radical cure.   By
destroying at once both the portion of the nail which is imbedded
and also its root, we run infinitely less risk  of a return of the
disease.
  But we relieve in  this manner only one of the sides of the im-
bedded nail.  The process of Dupuytren, or that of M. Neret, has
certainly the advantage  of destroying at once the whole  of the
nail, and of  putting the parts in a better condition to shrink and
resume their normal state.
  The slit of the nail being the same in both cases, is a reason why
the whole amount of the suffering is not perceptibly greater for the
complete than for the partial removal.  In addition  to this, I  gen-
erally  prefer the entire  evulsion (avulsion)  to  that  of one of the
halves of the nail.  Moreover, I do  not believe it to be a matter of
great importance to effect this  evulsion (arrachement) rather  with
the spatula of M. Neret than the scissors of Dupuytren  ; neither
has it seemed to me, if Me take care to prolong to a  sufficient dis-
tance backward the antero-posterior  slit, that it would be really
advantageous to cut posteriorly the small semi-lunar flap of Du-
puytren.  As the reproduction of the  disease is caused much more
by the back of the tissue that covers the phalanx than by the pre-
tended matrix of the nail, this small  flap does not give  a better
security against a return than the pure and  simple evulsion.

              c. Destruction of the Nail by Caustics.
  Under the belief that  the  nail  vegetates exclusively  from be-
hind forward, many surgeons have proposed  to destroy only the root
of it.
   12. Circumscribing  the whole imbedded edge in a perforated
strip of  diachylon plaster, (une fenetre de diachylon) M.  Wander-
bach (Journal de Med. Militaire, t. xxviii.) applied three grains of
caustic potash upon the  tissues, in  such manner as  to effect,  after
the  third application of this  remedy,  the destruction of  both the
fungous flesh and the corresponding  portion of nail, with its root
included. 
368
NEW ELEMENTS OF OPERATIVE SURGERY.
   13. Another  military  surgeon, M.  Kremer, (Meme  Journal, t.
xxviii.,) says he has succeeded by spreading  a layer of potash on
all that portion of the nail which is attached  to the skin, and thus
causing it to 'all off entire.
   14. This last process has  been modified by M. Troy, (Bulletin
Med. de Bordeaux, 1833, p. 199 ;  Gazette Med., 1834, p. 773,) by not
applying the potash except on the matrix  of the  nail, but not on
the fungous growths.
  Some prefer  the actual cautery to chemical caustics.
   15. M. Labat, for example, (Annal. de la Med. Phys., 1835,) cau-
terizes by means of a plate of red-hot iron, in the direction of an
arc of  a circle, at four lines behind the border where the nail ap-
pears to issue from the skin.
   16. M. Pointier  proposes that  in this process  we should only
cauterize  the  portion of the  matrix that gives  birth  to the im-
bedded border  of  the  nail,  (Donzel,  These, Strasbourg, 26  Mai,
1836.)
   17. M. Scoutetten carries the point of a straight bistoury to two
lines behind the nail upon the diseased side, makes in  that place
a longitudinal incision whose lips he keeps apart, and at the bottom
of which he fixes a small ball of lint, in order to insert in this place,
on the succeeding  day, a layer of caustic potash.   The root of the
nail  by this means mortifies, and all that remains is to wait till it
falls out.
   18.  This  process, which M. Donzel  lauds, (in  his Thesis cited.)
M. Ganderax (Donzel, These) proposes to modify as follows:
   19. This last surgeon gives less extent to the incision, and substi-
tutes nitric acid for the potash, and makes two or three applications
of it daily, until the nail softens  and falls  into a state of slough,
(putrilage)
   20. Finally,  M.  Donzel himself, reviving the plan of  M. Troy,
proposes that  we  should  dispense with the incision, and confine
ourselves  to an application  of caustic paste  upon the  point to be
destroyed, the same as if we intended to establish an issue in the
part.
   21.  Combining the process of M. Scoutetten  with  that of M.
Troy, M. Gairal makes a longitudinal incision six  lines in extent,
then, at the posterior extremity of this last, a transverse incision
upon the root of the nail to  be destroyed, and in  this  last places
the caustic potash, (Bulletin Clinique, t. i., p. 108.)

                        d. Appreciation.
   It is easy to perceive that these different processes of cauteriza-
tion tend to the same result as those of extirpation. Their ultimate
effect  is the same, but we cannot deny that their action is  more
tardy and their efficacy less positive.   The  only advantage they
seem to offer, is that of causing less dread to the patient, and of
being  attended in  reality with a little less pain.  They should not,
therefore, have the preference but in cases where, after  the destruc-
tion has been decided upon, it is found impossible to have recourse to 
        OPERATIONS FOR DISEASES OF THE  CUTICULAR SURFACE.     369

the cutting instrument.  As to the choice to be made of methods so
much resembling each other, I am of opinion that we should more
particularly give the preference to those of MM. Troy and Donzel,
that of M. Kremer, or even that of MM. Frebeau and Ganderax,
(Donzel, These, Strasbourg, 1836, p. 41,) which, besides being some-
what more simple, are full as efficacious as those of MM. Wander-
bach, Labat, Pointier, Scoutetten, and Gairal.

              II. Destruction of the Fungosities  only.

  22. In the endeavor to cure the onglade without attacking the nail,
many surgeons have supposed that they could effect this object by
acting on the soft parts only.  To this  method must be referred a
process of Albucasis, (liber ii., cap. 89-91,) who, as Fabricius after-
wards did, advises to raise the edge  of the nail with a probe, and
to excise and afterwards cauterize the flesh; that of Ambrose Pare,
(CEuvres Completes, in-fol., p. 465,) who limited  himself to cutting
off completely, and with one stroke,  the flesh lapping over (recour-
bee sur) upon the nail, and who says he has often succeeded by
adopting this mode: the process of M. Brachet and of M. Gantret
differ but little from that of Pare.
  23. Like Pare, M. Brachet confines himself to the excision of the
flesh.   Holding  his bistoury like a  writing-pen, he introduces its
point between the  nail and the raised border of soft parts, which
he  cuts through from  above below,  and separates first at its back
part; then, seizing with the forceps  the flap which has been thus
cut, he  terminates  its section forward  by a second stroke  of the
bistoury.  This  process, M.  Gantret (Donzel, These,  Strasbourg,
1836) says he has often employed with success, and M. Lisfranc
(Malgaigne, Man. de Med. Op., 2e edit., p. 98) believes he has made
an improvement upon it, in proposing to detach the flap first by its
anterior part, in  place of commencing  by the root of the nail, as
M.  Brachet does.
  The method of excising the fleshy  growths by the cutting  instru-
ment, being fully as painful  as the processes  which consist in re-
moving at once both the nail and the  fungosities which cover it,
does not,  in  reality, deserve a preference over these last.   It has
also been attempted to substitute for this the  destruction of the
parts by caustics.
  24. M.  Levrat, of Lyons, who appears to have been the first
who urged the advantages of this mode, applies caustic potash to
the fungous growths only, and through a perforation in a piece of
diapalm or diachylon plaster.  After the eschar is detached, he in-
serts between the flesh and nail  a piece of prepared sponge, which
gives an opportunity for the cicatrix to be properly formed.  It is a
modification which M. Brachet has himself adopted, and which M.
Sene (Journal Gen. de Med., 2e serie, t. xxxii.—Bulletin de  Thera-
peutique, t. ii., p.  378) thinks he has simplified by substituting  for
the plaster and  caustic of M. Levrat some filaments of lint satu-
rated with potash, and which he insinuates into the bottom of the
  vol. i.                        47 
370           NEW ELEMENTS OF OPERATIVE SURGERY.

wound Avhich  separates the flesh from the edge of the imbedded
nail.
  25. Another surgeon, Avhose name is indicated only by his ini-
tials, (Bulletin de Therapeutique, t. iv., p. 303,) has  also suggested
that it would be advantageous to make use of the  A ienna caustic
in lieu of potash. Finally, it is proposed by M. Moreau (Gaz. Med.
de Paris, 1836, p. 830) to introduce burnt alum under the edge of
the  diseased nail, instead of caustics.
  Appreciation.  It is evident that the processes of MM. Levrat, Se-
ne, and A. T., differ scarcely from that of M. Wanderbach, since
the  cauterization of the flesh  is almost alM'ays complicated with
that of the edge of the corresponding nail, and reciprocally.  Being,
therefore, more uncertain, they ought  not  to be retained  but for
simple cases, or for patients who have an excessive dread of every
kind of operation.

  III. Readjustment (Redressement) and Reduction (Retrecissement)
                         of the Nail.

  26. Many practitioners, observing that cauterization succeeded
but imperfectly, and deterred also by the pain of extirpation, have
supposed that, by reducing or readjusting the nail, we should effect
the  removal of the disease.  A process of this kind  was already in
favor in the seventeenth century. Dionis, who describes it, (Cours
D'Operat, edit, de Lafaye, t. ii., p. 281,) says it consists in scraping
the  nail every month upon its middle Avith a piece of glass, and of
thinning it (I'amincir) until it yields to  pressure.
  27. M. Biessi (Gaz. Med. de Paris, 1834, pp. 773, 774) has sup-
posed that he has invented a new process by uniting to the  attenu-
ating process, spoken of by Dionis, that of cauterization wdth nitrate
of silver.
  28. I have myself made trial, once with success, and twice with-
out  any advantageous results, of a process suggested by M. Moreau,
of Tours, and which consists in passing the point of a small silver
spoon,  (la queue d'une cuillere d'argent) heated to 60 or 70 degrees,
(Reaumur,)  [i. e. 170° to 190° Fahrenheit,] along the back of the
nail, Avhile the imbedded border is raised up with the  point  of a
horn.  With the view of forcing the nail to withdraw itself from
the  flesh, M. Guillemot (Journal de Med. Milit, 1814, t. i., p.  264)
has supposed that it would be sufficient to cut its  opposite angle
from the middle of the free border to  one-third of its length upon
the  adherent border.  Next we have  M. Faye, (These, No. 164,
Paris, 1822,) who, after having cut out a V upon the middle and
anterior  part of the nail, passes a waxed thread through  the tMe
sides of the notch, which he tightens by means of a small garrot, as
if he was operating for the union of  a hare-lip.
  [This is  certainly an ingenious suggestion, and would seem to
derive force from the efficacy of the V incision in the gum, which
I found so  successful in liberating an inverted incisor. (See the
chapter on teeth, above.)—T] 
        OPERATIONS  FOR DISEASES OF THE CUTICULAR SURFACE.    371

   In  these four processes, the surgeon endeavors  to readjust the
nail by acting on its middle part, and in some degree without acting
upon its edges.  None of them have appeared to me  to be very
efficacious; but if Ave had to give the preference to any one of
them, it would be that of M. Moreau  or of M. Faye which I would
recommend.
   29. In another series are  arranged the processes AAdiich consist,
like that of J. Fabricius, in insinuating some  soft  body under the
edge of the nail.   MM. Hervey and  others (Archiv. Gen. de Med.,
t. xxi., p. 142) make use of pieces of lint precisely after the man-
ner of  Fabricius ab Aquapendente.  I might say the same of M.
Tavernier, (Bullet, de Ther., t. ii., p. 197,) who also uses a tent of lint,
but gradually enlarged in size as it  glides  more and more deeply
under the imbedded border of the nail; and of M. Moulinie, (Bul-
let Med. de Bordeaux,  1833, p. 199,) who prefers introducing in the
same manner small balls of the same  substance ; of an anonymous
author, (Bullet de Ther., t. ix., p.  158,) who introduces carded  cot-
ton, in place of lint, between the flesh and nail;  in fine,  of M. Bon-
net, (Bullet de Ther., t. vi., p. 339,) who substitutes, for all these.
some pieces of prepared sponge.   By this process, Ave at the same
time depress the flesh  and raise the border of the nail.   It is  cer-
tainly one of the most mild  remedies that can be imagined; it is,
howevrr, unfortunate that it fails the oftenest, and is almost always
ineffectual when the fungosities have extended to a very consider-
able distance  upon the  side of the root of the nail.  AVe are  still
compelled, therefore, the same now as formerly, to look  for a more
effective power for disengaging the imbedded nail  from the flesh
which covers it.
   30. Desault,  (CEuvr. Chir., t. ii., p.  529,) who was fully sensible
of the difficulty, proposed to glide under the edge of the imbedded
nail a small plate of tin, about an inch and a half long, and three
to four lines in width,  which he then  bent back upon the swollen
flesh from the dorsal towards the plantar surface of the toe,  and
fastened in this position by some turns of bandage.   It is this pro-
cess which Boyer and  Richerand have modified by substituting  a
piece  of sheet-lead for the strip of tin used by Desault; but be-
sides the fact that these plates are easily displaced, tend to cut the
flesh, and rarely attain the object we have in view,  they also have
the inconvenience of sometimes occasioning very severe  pain.
   MM. Dudan, Aesigne, Grabowsky, and Labarraque, in their desire
to improve the many imperfect processes in use, have constructed
a  kind  of clasps, (agrafes) or hooks,  (crochets) which act on  the
borders of the nail without necessarily pressing upon the flesh.
   31. The instrument  of M. Vesigne, modified and improved by
M. Grabowsky, (These de Paris, Juillet, 1838,) is composed of two
plates, which are united by a hinge on the middle of the nail, and
terminate in  a hook  on  each side.   After having adjusted  the
hooks under the edges of the nail, we elevate them by gradually
tightening the  clasp by means of a  screw.   This clasp, besides
being liable to be displaced, acts at the same time on both sides of 
"(72           NEW  ELEMENTS  OF  OPERATIVE SURGERY.
the nail, though there be but one  side only which, is diseased, and
also makes an irritating pressure on the back of the toe; it is, be-
sides, so complicated as to require the aid of  a mechanic.
  32. The apparatus of M. Labarraque (These, No. 101, Paris, 1837)
is infinitely more simple.  I have often used  it with success.  The
plate  of tin which composes it, and which is similar to that of De-
sault, being terminated in a narrow hook at one of its extremities,
and hav ing  on its anterior part, at the  distance  of three lines, a
small notch upon its edges,  allows of our attaching to this part, by
means of some turns of thread, the end of a narrow and long strip
of adhesive  plaster.  To apply it,  we attach the hook, and make
it glide as far  in  as  possible between the nail  and flesh; after-
wards, drawing the strip of adhesive plaster in an opposite direc-
tion, we make a turn with it around the toe.  The circulars of this
little  bandage,  in  passing upon the free portion of the tin plate,
cause  it to  act  (la font basculer)  from above downward, after
the manner of a lever of the first kind; we thus raise, with all the
force  desirable, the edge of the nail. Two similar plates Avould be
necessary if the nail was imbedded on both sides.  In taking care
to  reneAV the dressing every three or four days, and at the same
time to depress the fungosities Math small rolls of lint, we generally
obtain, by means of this contrivance, a complete cure in the space
of fifteen days to a month.

                     IV. General Remarks.

  In glancing at the three methods of which I have spoken, and
upon  the numerous processes Avhich are arranged under them, Ave
are struck with the analogy  they present in  their point of depar-
ture.   Directing their remedies against the exuberant flesh, or the
edge of the depressed nail, surgeons sometimes  endeavered to de-
stroy  or repress the fungosities, and sometimes to remove or raise
the imbedded portion  of the  nail.   There is a disputed question
upon  this point,  since, according to some, the nail, being more
incurvated, narrower, and more projecting  upon its sides than
usual, in reality  penetrates into the tissues, and irritates them;
whilst,  according to others,  it is the  tegumentary parts, which,
crowding, (refoulees) and coming up from the plantar to the dorsal
surface of the foot, drive in the nail, and thus lap over upon it.  Il
would seem, in fact,  in adopting the  ideas  of the first,  that all
the efforts of art should be directed against  the nail, while, to be
in accordance with the principles of the other party, Ave should oc-
cupy ourselves with the soft parts.  The fact is, that the origin of the
disease in this matter, furnishes no means for determining the nature
of the treatment to be employed against it.
  Whether as cause  or as effect, the border of the nail and trfe
fungosities unite together to constitute the disease.  In the  end the
nail becomes the  annoyance, (repine;) this difficulty being removed,
the others almost always disappear.  If we remove the flesh without
touching the nail, the cure is scarcely ever more than palliative 
        OPERATIONS FOR DISEASES OF THE CUTICULAR SURFACE.     373

from whence it finally results, that the imbedded nail should be
treated in the following manner.  We begin by advising easy shoes.
If the disease is  slight and recent, we treat it  by lint, cotton, or
sponge, inserted between the flesh and the edge of the nail.   Should
there be fungosities, we repress them with  alum, nitrate of silver,
or even with caustic  potash, when they are of  considerable  size.
We should continue in this  manner until the nail is effectually
raised and the soft parts sufficiently restored.  If there are fungosi-
ties at the root of the nail, as well as around it, we proceed  as in
the previous case, except in giving the preference to the nitrate of
mercury as a caustic.   When the affection is of very long continu-
ance, and that these means have been tried without relief, we  have
only to choose between the readjustment and the evulsion of the
nail.   The readjustment by M. Labarraque's  process is the  most
convenient  and the most  certain  of all; it should, therefore,  be
preferred: but as it exacts delicate and repeated dressings,  it is
scarcely suitable,  except for those who have it  in their power to
remain at rest, and to nurse themselves for several weeks at home ;
so much the  more prompt would  the return of the disease be, if
these precautions were not persevered in for at least a month or
two beyond the apparent cure of the evil.   AVith laboring  people,
therefore, and in  general with the class of poor,  it will often be
preferable to proceed at once to  the evulsion of  the nail, which,
moreover, is always left as  a last resource, after all other means
fail.  This operation, which  many authors  treat of as one that is
excessively painful, and wdiieh is generally qualified with  the epi-
thet of horrible, causes in reality much less suffering  than  that of
extracting a tooth. A very considerable proportion of the patients
whom I have  operated upon by this process, have borne it without
uttering the least cry, and have told me that they suffered but in a
moderate degree, though many of them were very young subjects,
timid women and men of every age.
  In using scissors with pointed strong blades, we cut, in fact, in
an instant, from the free border of  the nail to beyond its root, ope-
rating too upon fibrous  tissues that have in reality but little sensi-
bility.  The evulsion, properly so  called, of the two halves of the
nail, being also effected with  great celerity, only wounds,  in  fact,
as a simple source of irritation, (element irritable)  the cutaneous
duplicature which surrounds its sides and root.  All this, therefore,
can be no more painful than would be  the rapid tearing off of
a small portion of skin.  After the evulsion  of the nail  and the
cauterization of the fungosities, the dressings are unimportant, and
the patient may resume his labors  at the expiration of some days.
It is evident, if the cutaneous groove, or pretended matrix of the
nail, should be ulcerated, or in a  state  of suppuration, or should
present fungous excrescences  of a bad aspect, it would be necessary
to cauterize it deeply with nitrate of mercury, the Vienna paste, or
the caustic potash.
  The proof, in fact, that the tearing out of the nail is less painful
than has been said, is that in cases where the root of this plate only 
374
NEW ELEMENTS OF OPERATIVE SURGERY.
is separated by disease, as Ave often see it in the fingers, the surgeoB
passes a branch of the forceps under it, and with a single stroV
from  behind forward, detaches it without the patient making an]
serious complaint.
  The wound that results from  it, should be  treated like ever^
other fungous Avound; only that  the  physical  cause which  occa-
sioned it having  disappeared, it  frequently happens that it  tenda
immediately to improve of itself.
  [Imbedded Nail.  In reference to the contrivances of various  kinds
of metallic or other substances inserted under the imbedded  edge
of the nail, as those of tin, lead, &c, and to which the author  gives
the preference over other means that have been suggested to  effect
a cure without coming to the more serious operation of an evulsion
of a part or of the whole nail, it  is to be remarked, that  the parts,
especially in  old cases, are often  so extremely sensitive  that none
of these  contrivances can be applied.   That of M. Labarraque
seems the  most efficient, but there  are few, it would seem, Avho
could long  endure so hard and irritating a material as a tin  plate
in such a  position.  AVe have generally found, in ordinary cases,
that a long, narrow, doubled compress of linen, inserted in the  same
manner,  and  the scraping of the nail down through the entire
length of its  middle part, to as thin a state as it aa ill bear, and ex-
tending this attenuating process as near as possible to the imbedded
edge, and preserving the anterior  corner of the nail rather long, as
an effectual point of resistance or lever upon the pledget, Avill gen-
erally effect a cure, and with the  aid of slight cauterizations, soon
repress the fungous growths  that had  covered it.   In addition to
this, another  contrivance  of a  very ingenious and efficient nature,
which may be had recourse  to where other means fail, consists
in perforating the anterior projecting  angle or corner,  and also
the middle portion  of the border of the imbedded edge, but not
too near the edge, with one, two, three or more  circular  openings
made in  the  proper place and at suitable distances; then insert
ing, successively and cautiously, through each of these apertures
one end of a  very narrow, strong, tape-like strip of  adhesive  plas-
ter, which  is to be there fastened  by a knot placed  outside of, and
resting upon the imbedded border.  Finally, carrying each  strip
obliquely, that is, posteriorly and upward, across the body of the
nail, previously thinned  down through all its middle part,  each
one is to  rest, the same as on a pivot, upon a small, narrow, gradu-
ated compress, placed lengthwise on that  attenuated part of the
nail, and the free extremity of the strip to be then passed to the
opposite side of the toe, and between that and the next toe, to the
plantar surface of the neighboring metatarso-phalangeal articula-
tions, where it is to be kept firmly and steadily fastened  by means
of one or two broad strips of adhesive  plaster, over the  outer sur-
face of the layers of which the narrow strips may be reversed for
greater security, while the broad strips are rendered more immovea-
ble by making them pass round and embrace the whole foot. These
narrow strips may thus be regulated, and made to act with such 
        OPERATIONS FOR  DISEASES OF THE CUTICULAR SURFACE.    375

force as A»s please, and as so many levers or ropes, the resistance
to be overcome being the imbedded border of the nail, and the com-
presses the pulleys.  The force of the levers may be increased with
their length, and their power acts  steadily and effectually till the
imbedded nail is ultimately completely raised up into its proper po-
sition,  Avhen it is to be  kept there by a narrow, thick, and suitable
compress, until it entirely recovers its  natural condition.  By this
very plain and easy process, there is constant relief being adminis-
tered to  the patient, and wdthout the slightest pain, and we have
none of the pressure,  hardness, and annoyance of the metallic
hinged clasps, &c.   Conjointly associated with these narrow strips,
and co-operating wdth them, we may attach the extremities  of
others, of considerably  greater width, to the  fungous groAvth itself,
and as near the nail as possible.  The other extremities of these
strips being then passed on the outside of the toe, supposing it to  be
the great toe, and the outside of its nail which is affected, and fast-
ened to its plantar surface, or extended also to  that of the foot, are
fixed the same as, or with the  others, and thus present, so far as these
last plasters are firmly  adherent to the  skin of the fungous growth,
an antagonist force to that acting upon the nail, but admirably co-
operating Avith it to separate  the two diseased portions from each
other.   In all cases, we  must  not forget  to scrape and thin the
middle of the nail, but  not its imbedded edge, for the strength and
greater thickness of that  is an  advantage, to prevent the perfora-
tions tearing out.  Leaving the angle on the anterior edge, it is a
still more powerful  purchase if much projecting.  The graduated
compress may be made adherent by diachylon.—T]

     § V.—Exostosis, with Sub- Ungual  Fungosities of the Toes.

  The last phalanx  of  the great toe sometimes presents upon  its
dorsal  surface  an exostosis, which lifts up the nail and separates
it, and MThich, once  established, rarely  fails  to take  on a fungous
character, and to give rise to a very abundant suppuration. Though
ordinarily situated under the free border of the nail, this exostosis,
which  Dupuytren (Lecons Orales, t.  iii., p. 58) was the first to inves-
tigate  with care, sIioavs itself also, sometimes, towards  the middle,
or nearer still to the root of the phalanx. But it is not the great toe
alone which may be the seat of it; I have met with it also on the
neighboring toes, and even on some of the fingers.  In its first stage,
it is characterized oniy  by dull pains ; Avhich are sometimes quite
seAere if it is placed  under the middle part of the nail.  At a
later period, it is recognised by  its fungous, red,  and purulent
character ;  it is then that it might be mistaken for the disease
known under the name of onglade, or the  imbedded nail; often,
also, it presents  itself under the form  of a  fibrous mass covered
with rugosities, and united  at  its root with the dorsum of the
phalanx.
  This affection can be cured only by the aid  of a surgical opera-
tion.  Dupuytren was in  the habit of proceeding first to the total 
376
NEW ELEMENTS OF  OPERATIVE SURGERY.
 evulsion of the nail, and of afterwards excising the fungous exosU
 sis, even down to the body of the phalanx.  In a young student ;_
medicine, I was obliged to unite cauterization by the hot iron to
those two first stages of the operation.   For the large toe, that is
the remedy to be preferred.  We proceed afterwards as has been
said above  in treating of onyxis, Math this difference, that it is not
in this case indispensable to destroy  entirely the matrix or root
of the nail. The nail being once removed, the  surgeon destroys the
exostosis Avith the bistoury, using it as we do  a knife  in cutting a
pen.  The  actual cautery is immediately applied to the wound in
the same manner as for arresting hemorrhage.
   If the disease should exist  in one of the four last toes, Ave could
proceed in another way; the  nail and the last phalanx to these not
having any real importance, might be readily sacrificed without any
inconvenience. The disease would be radically and promptly cured,
by performing amputation of this phalanx at its articulation with
the second.  Then, four or five days would suffice for a complete
cure, while in the simple  excision we require  near a month.  The
disarticulation, moreover,  is infinitely more simple and less painful
than the operation proposed by Dupuytren.  I have already per-
formed it several times, and  have had every reason to be satisfied
with it.
   [Dr. Mott has seen the nail of the great toe  degenerated to such
degree as to increase by  morbid  growth to the length of an inch,
and of proportionate thickness, resembling a  horn.  It bled when
cut, though it was entirely free from pain  or  inflammation. —7;] 
MORBID CICATRICES.                    377
                    SECTION  SECOND.

 OPERATIONS WHICH MAY BE REQUIRED FOR  DEFORMITIES.

  The operations which are to be  described in the present chapter
naturally divide  themselves into  several groups, though they a .
belong  to the  same class.   I  shall form them into five families,
which will relate : 1. To the deformities from alteration of the skin;
2. To  those  from alteration of the sub-cutaneous  tissue ; 3. Te
those from alterations  in the tendons o_* muscles ; 4.  To those fro' .t
alteration of the ligaments ; 5. To deformities from alterations in
the articulations or the bones.
                         CHAPTER I.

         MORBID CICATRICES,  (CICATRICES VIC1EVSES.)

   Cicatrices and tegumentary bridles require  the intervention of
operative surgery, either from the pain they occasion, or from their
interfering with the functions  of certain parti.   To estimate the
inconveniences of certain bridles and morbid cicatrices, Ave must
also, before all other things, consider their mechanism.

               Article I.—Anatomy of Cir vtrices.

  AAht.a solutions of continuity  close Avichout suppuration, there
usually results a pliant cicatrix, which scarcely differs in its physi-
cal characters from the  rest of the  tegumentary tissue.  AVhen a
wound or ulcer has not been enabled to cicatrize, except by the aid
of a new substance, or by second intention, Me see formed, on the
contrary, instead of natural integument, a dense, elastic, retractile
tissue, which constantly tends to  approximate  the neighboring
parts to its centre, and Avhich Delpech long since described in our
days under the name of inodular tissue, (tissu inodulaire)  But these
cicatrices, which are principally remarked as the consequence of
burns, sometimes give rise to very considerable deformities.  I have
seen them turn the toes back upon the dorsum of the metatarsus,
or towards the sole of the foot, and even to the outside or inside of
this part.  On the  instep the " bring the tarsus upward, fix it on the
forepart of the leg, and prod ice one of the varieties of the pied-bot
(club-foot) anterior or talu     AVhen inward  or outward towards
the malleoli, they cause the ..deviations of the foot known as varus
  vol. i.                       18 
378
NEW  ELEMENTS OF OPERATIVE SURGERY.
or valgus.  I have seen a patient who thus had the foot thrown to
the outside, from the effect of a long cicatrix upon the entire outel
surface of the leg.  In the popliteal  space they cause an unavoida
ble retraction of the calf towards the posterior part of the thigh,
I have seen the two thighs glued (collees) by this deformity to the
walls of the lower belly.  A young girl, whom I treated at the hos-
pital of La Charite, had cicatrices of this kind which extended from
the lower part of the chest down to the knee, and which forcibly
drew the right  thigh outwardly towards the hip.   In a woman, to
whom I was called  by M. Morisse, they formed upon the entire hy-
pogastrium, that is, from one spine of the ilium to  the other, bridles
so solid and so extended that they strangled the womb towards the
middle of its length, and became the cause of an unnatural labor. At
the anus and vulva, and in the vagina  and urethra, the inodular
Cicatrices form obstacles, of which  I shall have occasion to  speak
in treating of the operations that are performed on these organs.
  We see similar bridles on the side, (aujlanc)  so that the last rib
is sometimes brought down upon the crest of the  ilium.  The tho-
racic extremity is still  more frequently  affected by them than the
pelvic ; nothing is more common, in fact, than to  see one or many
fingers made to devdate  (devies) by this cause, either towards the
palmar or dorsal surface of the hand.  The entire metacarpus, or
the wrist, may also be turned either backward or forwards, inward
or outward, by  the action of a similar cause.  It  is Aery common,
also, to see  the  forearm drawn  towards the arm  from the flexion
caused by the new tissues.  The arm, also, is very often glued (col-
li)  to the chest by  cicatrices upon its inner surface, or by bri-
dles in the  holloAV of the  axilla.   In  the neck,  the cicatrices of
which I speak may depress the chin to near the sternum, or incline
the head towards one 01 the shoulders.   The lips, eyelids, and ears,
also deviate under the influence  of inodular tissues into every pos-
sible direction.  These morbid cicatrices, Avhich are, also, sometimes
attended with the inconvenience of  gluing together the fingers and
the toes, and the upper portions of the thighs, and of narrowing or
shutting  up most of the natural openings, claim, therefore, every at-
tention from the operative surgeon.

                    Article II.—Treatment.

  Notwithstanding the variety  and multiplicity of forms which
morbid cicatrices assume, the operations  which  are performed to
remedy them are reduced  to a very small number.   AVe confine
ourselves, in fact, to the destruction of these inequalities, or the
projecting portion of them, to incising them transversely on many
points, or to extirpating them in whole or in part.

                        § I.—Excision,

   If the inodular tissue causes no other inconvenience than the in-
 equalities it produces upon  the surface of the skin, or the morbid 
MORBID CICATRICES.
379
sensibility and pains which it sometimes occasions, we may confine
ourselves to its simple excision, or even to its cauterization.  These
small operations must not be performed out of mere complaisance,
that is, when the cicatrix, causing in reality no inconvenience, pre-
sents itself simply under the  form of a seam or small  eminence
on  some other part than  the face, hands,  and feet.  AVe  should
then, also,  forewarn the patient that a remedy of this  kind will
probably render the surface more  regular and uniform, but  that it
Mali not  remove from the part its unnatural color, nor its appear-
ance of deformity.  The cauterization wdth the nitrate of silver,
nitrate of  mercury, or nitric acid, will suffice, in fact,  to destroy
simple cutaneous  prominences or seams;  but the cutting  instru-
ment is evidently preferable.  We then shave off with a keen-edged
bistoury all the  exuberance of the cicatrix; after having dressed
the  wound for some  days with the  perforated linen and lint, we
proceed, if the diseased part admits of it, to the application of strips
of adhesive plaster.   Upon the supposition that the adhesive plas-
ters are not applicable,  we must take care to repress the vegeta-
tions of the wound frequently with nitrate of silver.
  If the cicatrix  should  form a painful nucleus, (noyau doloureux)
as often happens when the extremities of some nerves  are  found
confined in it,* the cauterization would not answer.  In the place of
shaving  it down, we should hook an erigne into the central part,
and completely excise its whole  substance.  Violent pains have
thus been  made to disappear which  had endured for many years,
and which had all the characters of true neuralgia.  It is, however,
evident, that this species of operation is not applicable  to  retrac-
tions nor to deviations of  the organs, and  that it  cannot be em-
ployed except  for the  removal of  simple and bona fide projections
and excrescences of inodular cicatrices.

                         § II.—Incision.

  Up to a late period, we possessed only one kind of operation for re-
storing to their natural direction parts that were distorted under the
influence of morbid cicatrices. This operation consisted in dividing
through the cicatrix transversely from space to space, either partially
or totally; afterwards we gradually and imperceptibly adjusted the
retracted part, either by the aid of bandages  or machines.  Care
was then taken to force the wounds of the operation to cicatrize by
the second intention, and to keep their lips wide apart.   It was ne-
cessary, also, to make every effort, even after the cure, to resist the
tendency of the organs to  resume their unnatural position, and to
cauterize the  wounds frequently  during the  course of  the treat-
ment.
  If the cicatrix was long  and very prominent, some surgeons pre-
ferred  cutting through its base with a double-edged knife, in order
to shave it off from one extremity to the other, and thus cut it out
* [See a case of this kind from bleeding, supra, as noticed by Dr. Mott.—2".] 
38           NEW ELEMENTS OF OPERATIVE SURGERY.

entire.  They afterwards incised the borders of the wound as in
the preceding case, and proceeded in the same manner for the rest
of the treatment.   Though of easy and rapid execution, this last
process has the inconvenience of sometimes causing very severe
pains, from the commencement to the termination of the cure, and
of producing, moreover, like  the simple incision, scars  and ner-
vous symptoms, and sometimes even a deep-seated gangrene; also,
of leaving in its train protuberances and inequalities of great de-
formity, and finally, of not succeeding except in a very small num-
ber of cases.   It is certain, in fact, that, in spite of the best-adjust-
ed bandages and dressings, the  new cicatrices resulting from this
mode of proceeding often resist all the efforts of  the surgeon, and
ultimately bring back the parts to the position which they were in
before the operation.  It was going  too far, howeAer, to  say that
the transverse incisions of the cicatrices had always failed.  Science
now possesses a very considerable number of authentic facts which
demonstrate its efficacy.  I have seen a young man, whose forearm
was thus detached from the anterior surface of the arm, have it
completely extended out  in the space of six weeks.   The motions
of this limb  at the end  of two years  had lost none of their free-
dom.   Similar observations have been  published by M. Hourmann
(Clinique des Hbpitaux, etc., t. i.,  No. 16, p.  4) and by M. Berard.
jeune, (Jour, des Connaiss. Med. Chir., t. ii., p. 202.)  The adhesion
of the arm to the side  of the chest, and the retraction of the fingers,
have  sometimes yielded completely to the simple  incision.  In the
young girl whom I haAe spoken of above, and Avho had such enor-
mous ridges  upon her side  and  upon the external surface of the
thigh, the transverse incisions effected a partial restoration of the
limb.   Besides, when the cicatrices are wide, or numerous, or Aery
irregular, the incision  is almost the only remedy we can oppose to
them.  It  is  a method, therefore, Avdiich should be preserved, and
one which some modern surgeons have unjustly proscribed.

                      § III.—Extirpation.

  Having shown, as a principle, that every cicatrix, by the forma-
tion of a new substance, destroys the pliancy (souplesse) of the tissues,
and tends to  retract  incessantly upon its middle  portion, Delpech
deduced therefrom this conclusion, that the  incision is rather inju-
rious  than useful when its object  is to remove the inodular bridles
In lieu of the ancient method, therefore, he  proposed to substitute
the extirpation, in fact, of the whole cicatrix.  After having raised
the indurated layer by incisions, which were made upon the sound
tissues, he carefully approximated the borders of the Avound, and
directed all  his efforts  to obtaining  immediate union ; by  this
means Delpech obtained a linear, pliant, moAeable, distensible cica-
trix, similar to natural integuments, and which could in no respect
interfere Avith the movements of the affected region.
  There is no doubt that it would be preferable to act in this man-
ner when the cicatrix is  narrow, and is situated upon a bulky part 
SUB-CUTANEOUS BRIDLES.
381
of the body.  Upon the dorsum of the foot, and upon the leg, thigh,
hand, forearm, and trunk, and even upon some regions of the face,
an inodular cicatrix, which  should  not  exceed six to ten lines in
breadth, might in this Avay be extirpated Avith advantage.  Though
the wound should have several inches  length, and that we should
be obliged to detach (decoller) each side of it to the extent, of some
lines, there Avould still be room to hope for immediate reunion, eitner
by the suture, or by means of uniting bandages or straps of adhe-
sive plaster; but it is evident that, for the fingers and toes, and for
the eyelids and nose, as for all cases where the cicatrix is large and
very irregular, the method of Delpech  would expose  to more in-
conveniences than the old  operation,  and would offer no  bett< r
chances of success.
                         CHAPTER II.

                SUB-CUTANEOUS BRIDLES.

   I separate here the abnormal bridles from cicatrices, properly s<
called, because these latter belong almost exclusively to the cuta
neous tissue, Avhile the former are very often situated in the cellu-
lar or the fibrous tissue.  There are, in fact, four varieties of bri-
dles capable of producing deformities—the tegumentary, sub-cutane-
ous, aponeurotic,  and ligamentous  bridles.  But  I shall here speak
only of sub-cutaneous bridles, those which belong  to the  skin,
blending themselves Math the morbid cicatrices of Avhich Ave have
just spoken ; those of the ligaments, aponeuroses, and tendons, be-
longing to another chapter.

         Article I.—Anatomy of Sub-Cutaneous Bridles.

  Sub-cutaneous bridles  are a fibrous transformation of the fascia
superficialis.  An attentive examination of the cellulo-adipose tis-
sue shows, that lamellae  and filaments of considerable density pass
in the natural state in a  more or less oblique direction from the in-
teguments to the aponeurosis.   These lamellae, M'hich, in fact, are
only the origin or termination of certain muscular  or aponeurotic
fibres, preserve  in the normal  state a  pliancy and distensibility
which cause them to be  constantly confounded with the  cellulai
tissue, properly so called.  Under  the influence of certain causes,
and by a  process which  is still but little understood, they become,
on the other hand, indurated, hypertrophied, and retracted, so as to
constitute inelastic bridles, which forcibly draw together the movea-
ble parts which serve for their insertion.   They are a species of
tendons or abnormal aponeurotic partitions which are formed under
the skin at the expense  of the  fascia superficialis.   Though these 
382
NEW  ELEMENTS OF OPERATIVE SURGERY.
indurations and fibrous transformations of the  cellular tissue may
take place on  most of the regions of the body, upon the  internal
surface of the  enveloping aponeuroses, in the centre of the limbs,
as well as in the sub-cutaneous tissue, and that they are seen some-
times in the substance of certain organs, as in the mamma1, lun^s,
and bladder, for example ; it is, nevertheless, upon the palmar sur-
face of the hand that we most frequently notice them.   These bri-
dles differ from morbid  cicatrices  in this, that it is not necessary
that they  should have been preceded by any solution of continuity
or weund, and  that the skin remains moveable upon their surface,
the same  as upon the aponeuroses and tendons.  Supervening with-
out inflammation, pain, or any previous recognisable  pathological
phenomena, they disturb only by the deformity which is sometimes
occasioned by them.

                    Article II.—Treatment.

  No local application, no general medication, can relieve a patient
of sub-cutaneous bridles; we must either do  nothing, or have re-
course to  the bistoury.   Bandages, forced extensions, and the  most
ingenious apparatus, are powerless in such cases.  Generally con-
founded with retraction of the tendons, these bridles had, until  later
times,  been usually ranged by most surgeons among incurable dis-
eases.   Since their independence of the tendons has been perfectly
established, Ave have become rid of this doctrine, and new opera-
tions have been proposed for their cure.
  Two general methods present themselves under this head : the
object  of  the one is to divide the bridle on one or many points.
while the  other requires its extirpation.

               § I.—Section of the Abnormal Bridle.

  When the bridles, of which I have just been speaking, show them-
selves  under the skin  in the form of the cord of an  arc,  so as to
cause retraction of certain moveable parts, we are, as it were, com-
pelled, in  spite  of ourselves, to divide them upon their most  pro-
jecting points.  Three different  methods  have been  proposed  to
fulfil this indication.

                    A. Process of  Dupuytren.

  Dupuytren, who was one of the first to draw attention (L. Mau-
det, These, No.  141, Paris, 1832) to the nature of sub-cutaneous bri-
dles, maintains, that the best Avay to relieve the patient of them is
to cut  through both the skin and the abnormal fibrous cord, some-
times on one point only, and sometimes  on many, until the readjust-
ment of the retracted part may be ultimately effected with ease and
without pain. This process, Avhich was several times practised at the
Hotel-Dieu, of Paris, appears to have almost constantly succeeded.
When we wish to make trial of it, the instrument should divide 
SUB-CUTANEOUS BRIDLES.
383
with care both the principal bridle and the small accessory bridles
which are almost always found in the neighborhood.  Dupuytren
felt himself sometimes obliged, also, to dissect the lips of the wound
a little on either side, and to glide the bistoury underneath to de-
stroy the  remaining retracted cords.  The process of Dupuytren
involves a serious inconvenience.  From the necessity of dividing
the skin freely, it may happen that the extremities of the incised
bridle will become  incorporated with the lips of the tegumentary
wound, and that the inodular cicatrix, which might result from this,
tends almost unavoidably to re-establish the deformity. It is, there-
fore, quite natural that  surgeons have sought another mode of pro-
ceeding.

                   B.  Process of M. Goyrand.

  Wishing to avoid the necessity of suppuration  and cicatrization
of the external wound by second intention, M. Goyrand (Memoires
de I'Acad. Roy ale de Med., Paris, 1834, t. iii., p. 589) proceeded  in
the following manner :  He commences by dividing the integuments
in a direction parallel with, and to the extent of the whole length
of, the abnormal bridle; in this manner the cord to be divided is
laid bare, and shows itself to the eye of the surgeon under the form
of a fibrous partition.  Then separating the lips of the wound, the
operator cuts through  the bridle transversely, as  Dupuytren did,
from space to space, or on a single point, if one incision alone should
seem sufficient.  Then  reuniting the lips of the external divdsion,
he obtains a  perfect cure by first intention ; the skin, preserving its
pliancy, in no respect interferes with the movements (glissements)
of the divided bridle, or the mobility of the part which was previ-
ously retracted.
  This process has the inconvenience of not permitting as complete
a division, as that of Dupuytren, of the  lamellae or fibrous cords
which might  exist in the neighborhood of the principal bridle.  As
a general  rule, however, it should be preferred to his.  I have used
both, and can affirm that that of M. Goyrand answers in most cases.

                    C.  Process of A. Cooper.

  A process more simple still, and which M. A. Cooper (On Dislo-
cations, &c,  Goyrand;  Gaz. Med.  de  Paris, 1835, p. 485) long
since recommended, consists in inserting by puncture on  one side
of the bridle  the point of a straight bistoury.  The instrument, held
flatwise, is then glided along to the opposite side, grazing  by the in-
ternal surface of the skin; after having turned its cutting edge down-
wards, the section of the  abnormal cord is made transversely and
from the skin toMrards the aponeuroses. The operation, thus reduced
to a simple puncture of the integuments, produces no pain, and is
followed by  no flow of blood.  Were it not that the process of
puncture is sometimes rendered impracticable by the adhesions or
want of mobility in the  parts, it certainly would be preferred in all 
384
NEW ELEMENTS OF OPERATIVE SURGERY.
eases.   It would not answer to practise in this manner several
punctures and  several sections  in place of one, except Avhere the
bridle Avas of a certain length.
  In conclusion, the three processes which I have described should
be retained in practice.  The section by simple puncture of the skin
will have the preference, as often as the pliability and mobility of
the tissues will allow of its being perfoifned.  If the insertion of
the instrument between the bridle and the integuments should ap-
pear to be attended with too much difficulty, the process of M.
Goyrand ought to be substituted for that of M. Cooper.  In fine, Ave
should return to the  process of Dupuytren in cases Avhere the bri-
dle is irregular, and of great Avidth, and has intimate adhesions with
the tegumentary tissue.

                § II.—Extirpation of the Bridle.

  Setting out from the doctrine  established by  Delpech, and  after-
wards  by M. Earle, (Abernethey, Lecons,  &c, p.  97,)  in regard to
the properties of the inodular tissue, I had thought it Meuld be bet-
ter to  slit the  skin longitudinally, and then extirpate the bridle,
rather  than to  make a  simple  section of it in the manner of Du-
puytren.  I performed an operation of this kind at the  hospital of
La Pitie, in the beginning of the year 1833.  I hoped, by acting
thus, to be enabled to close  the wound immediately, and  instantly
to restore to the retracted parts their natural mobility ; but  although
this operation Mras followed by success, and that it included the first
steps in the process of M. Goyrand, I have since perceived that the
extirpation had not  in reality any advantages over the simple sec-
tion, and that it constituted, in  truth, a longer, more painful, and
more complicated operation. I do not think, therefore, that  there
is any  use in  retaining it, except AAdiere the bridle should have un-
dergone an actual degeneration, (veritable degenerescence)
  It  is  useless  to add, that after these operations, and Avhatever
may be the process which has been adopted, the cure would not be
obtained, if bandages, apparatus,  and suitable dressings, did not
come to its aid.  It is necessary, in fact, to do all in our  poAver to
effect the union of the wound of the integuments without  suppura-
tion, and that the retracted part may resume its natural  direction
and be maintained in it, without effort, Adolence, or fatigue to the
organs, until the cicatrization is complete.   The suture,  adhesive
straps  of diachylon, and uniting bandages, to which are joined the
perforated linen and lint, refrigerants, emollients,  or antiphlogistics,
for the  period of four or five days, and according to the nature of
the case, are therefore indicated.  We make use, at the same time, of
such dressings  as will  maintain the part, whose adhesions and re-
traction we have destroyed, in that state of elongation which wo
wish it ultimately to have. 
SUB-CUTANEOUS BRIDLES.
385
Article  III.—Operations  according to the  Region in which  the
                       Bridle is situated.

                        § I.—The Hand.

  The fingers and toes are subject  to three kinds of deformities
from bridles,  or abnormal cicatrices.  They are sometimes  com-
pletely or but partially united at their sides, at other times simply
retracted into a flexed position, like segments of a circle, or drawn
backward, or forward, or sidewise.  Though the toes are not stran-
gers to these three varieties of deformity, the fingers, nevertheless,
are their favorite locality.

             A. Adhesions of the Fingers at their sides.

   When the fingers  are completely blended together at their two
sides, and  that the bones which compose this part of the skeleton
seem, so to speak, to touch  each other, there is but little prospect
of our succeeding in our attempt to separate them.  It is not that
we find  any difficulty in making the bistoury pass between them
from before backward, or from behind forward, or to separate them
from each other, but the little strip of skin which in these cases is
left upon the  palmar and dorsal surfaces, not being in all instances
sufficient to keep up the circulation, almost always has a tendency
to become gangrenous.  The wound on the  side of each finger
vegetates, assumes a fungous aspect, and, moreover, does not cica-
trize but wdth extreme difficulty, in addition to which, a new ag-
glutination of the parts rarely fails to take place.
   A young girl of fifteen years of age, wdiom I had thus operated
upon for an adhesion of the three last fingers of the right hand, was
seized with a gangrene which included the whole of the last pha-
lanx and the  anterior half of the middle phalanx of the ring finger.
Some portions also of the skin mortified upon the two other fin-
gers,  and  the cure, which  was  protracted to a long  time,  left
the  patient with as great a deformity at least, though of another
nature, as the one which I had wished to remove.   It is true that a
 roller bandage, with strips of adhesive plaster of diachylon, and a
 dressing wet  with cold water, which I had  applied to prevent all
 excess of  inflammation, concurred, perhaps, in  bringing about this
 unfortunate  result.   I should not, therefore, venture to recommend
 but Avith caution the destruction of morbid adhesions when found
 so  extensive and complete.   The want of integuments on the en-
 tire  side of the fingers is in these cases a cause of failure, which
 no means that I am acquainted with has the power to remedy.  We
 are not, however, to believe that the complete  union of these ap-
 pendages  is absolutely and  always irremediable.  An observation
 of Dessaix (Gazette  Salutaire, annee 1761, No.  22) proves the con-
 trary.  A newly-born child had the hands transformed into  two
 fleshy masses, the  entire extremity of which was covered  trans-
   vol. i.                      49 
386
new elements of operative  surgery.
versely by one single nail.  Without paying  any particular atten-
tion  to the number of the bones, Dessaix divided each  of these
masses into four parts instead of five, and thus made as many fingers
of each of them.  The child succeeded in being enabled to write
and  to work, though the metacarpo-phalangeal articulation was
the only one  Avhich existed, and that the bones of the metacarpus
did not appear to have any particular continuity of connection with
the fingers.   The author adds, that the operation was of short du-
ration, caused no reaction, and required a month to heal up  all the
Avounds.
  This fact, at most only probable, is as we see very extraordinary;
but Dessaix relates it with details so circumstantial, that it is diffi-
cult to call it in question.
  On the contrary, should the adherent fingers retain their mobility,
and  appear to haAe a tegumentary membrane between them, re-
calling to mind, in fact, the idea of web-footed (palmipSdes) animals,
there is room to hope for their  relief.  Under such circumstances,
however, we should deceive ourselves strangely, if we believed the
thing easy.  The destruction of the bridle in these cases is the least
difficult part  of the operation.   After hav ing perforated this bridle
by a  puncture  near its root, we  divide it from behind forward, or
from before backward, holding  the bistoury perpendicularly, while
an assistant  stretches apart the  fingers that are to be separated.
We  might equally well make use  of a scissors, if the partition
should have only a slight  degree of thickness.  This section per-
formed, we should, if no obstacle were interposed, perceive the two
sides of the wound reunite again imperceptibly, from the  root to
the pulp of the fingers. Even it is found that pledgets of lint, plates
of lead, strips  of plaster, and  bandages of every sort, placed  as
foreign bodies between the two separated fingers, often contend in
vain against the tendency to a new agglutination.
  Surgeons are so well convinced of this  difficulty, that  many of
them have come to the conclusion to proscribe the operation itself,
and  others have advised to associate with it a certain process of
anaplasty. M. Krimer, (Journal de Graefe et Walther, t. xiii., p. 602,)
among others, has proposed to bring  forward, between the roots
of the two fingers,  a flap of tegument detached  from the back
of the hand, in order to unite it  to the palmar teguments, and to
construct, out of all of these, a perfect commissure.  This process,
which is attributed to Zeller by M. Chelius, (Trad de Pigne,  t. ii., p.
 13,)  and which would, moreover,  considerably increase the danger
and pain of the operation, is not in my opinion necessary. I should
prefer to proceed as follows : I commence by introducing three pre-
paratory ligatures (ligatures d'attente) in the part the most remote (la
plus reculee) from the intra-digital partition, one at the middle, and
one  on each side.  Having  divided, and either by puncture from
behind forward, or from before backward, the abnormal partition,
 to within two or three lines of the points traversed by the ligatures,
 I seize hold of each of these successively, in order to make of them
 a simple suture of three stitches.  I obtain by this an almost imme- 
SUB-CUTANEOUS  BRIDLES.
387
diate coaptation of the  lips of the Avound throughout the Avhole
extent of the commissure.  The reunion on this point being effected,
makes the separate cicatrization afterwards of each of the fingers
a very easy matter.   I would also recommend  to  avoid carefully
all compression and application of refrigerants upon  the  weunds
which result from this operation, at  least during the first week.
Moreover, it should not be performed if the articulations of the
fingers should appear to be anchylosed and incapable of recovering
their natural mobility.  I may add, that during the whole course of
the treatment, from beginning to end, the fingers newdy separated
should be frequently flexed or extended, so as to render them lim-
ber (a les assouplir) by degrees.

  B.  Retraction (renversement) of the Fingers by a Morbid Cicatrix.

  I have often  seen  all the four  fingers, entire, retracted  by cica-
trices from  ancient burns, or from lesions which had  taken  place
during the  period of intra-uterine life ; I  have more frequently
from such causes seen the  retraction of only one or of some of the
fingers, either backward, towards the sides, or forward.
  AVhen the infirmity is of very old date, or when it is  complicated
with a profound alteration  of the articulations; when, in  a word,
it is  evident that, though the bridles of the cicatrix were destroyed,
the finger would not recover its former mobility,  the  disease  can
only disappear with the amputation of the finger itself.  It is, there-
fore, only in cases where the articulations appear to have preserved
both their form and a part  of their natural mobility, or where both
the extensor and flexor tendons appear to have been only slightly
(mediocrement) altered, that it  is allowable to undertake one of the
operations which I have spoken of above.  In  that case,  we may
also  take into consideration the section from space to  space of the
bridle which keeps the finger in a faulty direction.  A number of
incisions, and going to but little depth, ought to be preferred in such
cases to a single one penetrating to a considerable depth below the
thickness of the skin.  The extirpation of the cicatrix by the method
of Delpech, Meuld answer only for very narrow bridles, and is in
reality but rarely applicable to deformities of the fingers.-
  If  the retraction should be backwards, the fingers should, in such
cases, be afterwards held in a state of sufficiently strong flexion, and
should not be allowed to deviate from this direction, except at in-
tervals, until the cicatrization is completed.  The cicatrices on their
palmar surface, on the contrary, would require that they should be
kept properly extended by fixing  them to a palette of Meod or of
pasteboard  placed on their dorsal  surface.   It is easy, however, to
understand  the variety of palettes, plates,  and splints, which we
may have occasion for in such cases.

       C. Deviation of the Fingers by Sub-Cutaneous Bridhs.
  An unnatural flexion of the fingers may arise from a solution of
continuity, a paralysis of their extensor tendons or muscles, 
3S8
NEW  ELEMENTS  OF  OPERATIVE SURGERY.
an anchylosis, a deviation, certain tumors on their articulations of
phalanges, the retraction, shortening, or some alteration of their flexor
tendons, or actual  diseases either of their nerves or vessels, or of
the teguments of their palmar region ; but I design only to speak
in this article of the flexion which depends upon sub-cutaneous bri-
dles, intending  farther on to examine  other kinds of deviation to
which they are liable.
  Previous to the  observations published in the name of Dupuy-
tren in 1831 by M. Paillard, (Jour. Univers. et Hebd., t. v., p. 349, et
t. vi.. pp. 67, 364,) in 1832 by M. Lemoine Maudet, (These, No. 141,
Paris, 1832,) by MM. Buet  and Briere, (Lecons Oral, de Dupuytren,
t. i., p. 1—25  et 516—531,) by  M. Vidal de  Cassis, (Gaz. Med. de
Paris, 1832, t. i., p. 53, in8°,) and M. Avignon, (These,  No. 16, Paris,
1832,) and which have been resumed  by M. Goyrand, (Mem. de
VAcad. Royalede Med., t. iii., p. 549, et Gaz. Med. de Paris, 1835, p.
481,)  the  cause which I have here adverted to had scarcely  been
thought of. All authors confounded it with the contraction (crispa-
ture)  of the tendons, and regarded it,  moreover, as  an incurable
disease.  The observations of Dupuytren have incontestably de-
monstrated that the tendons are  generally unconnected Math  this
retraction; but they have not so  clearly proved, as this surgeon
believes, that the retraction of the fingers depends upon an indura-
tion or a shortening of some of the bundles of the palmar aponeu-
rosis.  These bridles, which present themselves under the form of
projecting cords under the skin,  extend almost always over a great
portion of the length of the finger ; they occupy especially its me-
dian line, and prolong themselves at least upon the palmar surface
of the first phalanx, very often, also, upon the  second, and some-
times even upon the third.  But anatomy teaches that the palmar
aponeurosis, properly so called, terminates at and fixes itself to the
root  and sides of each finger, becoming blended  either  with the
sheath of the flexor tendons, or with the ligaments of the articula-
tion.  Again, the aponeurosis of the  hand does not  extend itself
either to the thenar eminence, or to the root of the thumb. An ob-
servation, noted in the practice of Dupuytren himself, (Gaz. Med. de
Paris, 1833, p. 112,) makes mention of an individual who had all
the fingers contracted, (crispes) and  the palmar surface of whose
thumb presented one of these bridles in the fullest state of develop-
ment. Having myself proved by dissection, and upon a living person,
that the palmar aponeurosis sometimes remained untouched after the
incision or extirpation of these bridles, I announced, in the beginning
of the year 1833, (Anat Chir. t. ii., p. 75,2e ed., 1833,) that the abnor-
mal bridle, of which Dupuytren had spoken, was not always formed
by the aponeurosis; that in one patient it appeared  to  me to be
nothing more than the fibrous transformation of the sub-cutaneous
tissue ; and that I should not have been surprised to find that it was
often  so.   The researches of M. Goyrand have fully justified this
prediction. I will add, as I have elsewhere done, (Gaz. Med., 1835,
p. 511, et  Anat Chir., 3e edit., 1837, t. ii., p. 487,) that the opinions
of Dupuytren, of M. Goyrand, and of M. Sanson, (Mem. de VAcad. 
SUB-CUTANEOUS  BRIDLES.
389
Royale de Med., t. iii., p. 592,) would, like, mine, be inexact, if we
were to adopt one of them, and, after the manner of the ancients,
substitute it absolutely to the exclusion of the others.  If it is false
to believe, as M. Mellet still asserts, (Man. Prat d'Orthop., 1835, p.
246,) that the retraction of the fingers more 'frequently arises from
a contraction of the flexor tendons, it would be also so to maintain
that this cause never exists ; in the same way as in rejecting  the
doctrine of Dupuytren as too exclusive, Me should be wrong not to
admit it for some cases.
  In fine, the retraction of the fingers arises most  frequently from
the fibrous transformation of one or more of the lamellae of the sub-
cutaneous or superficial fascia.  In reality caused, in certain cases,
by a contraction (crispation) of the palmar aponeurosis, it also some-
times depends upon a degeneration of the skin itself, or upon some
cicatrix of this tissue, (membrane.)   It is well, also, to add, that the
fibrous sub-cutaneous degeneration, Mdiich causes the retraction of
the fingers, does not always assume the  appearance of a  cord, or
simple bridle.   In  one of the patients of Dupuytren,  it was  per-
ceived that there were transverse fibrous radiations,  at the same
time that others ran obliquely and some with the axis of the  hand.  I
have myself seen a man of fifty-seven years of age, and otherwise
enjoying the most perfect health, in whom the retraction of the  fin-
gers was kept  up by unequal bridles, whose  roots were evidently
lost in a hard, insensible layer, (plaque) covered with lumps of the
size of a small nut, and which occupied almost the entire palm of
the hand.
  However this may he, experience has now proved that this species
of retraction, which, as M. Vidal says, principally attacks the ring
and little fingers, and which in certain rare cases only invades  the
thumb and other fingers, and which is scarcely ever met with, ex-
cept in persons whose  occupation demands a certain pressure or
frequent and continued extension of the palmar surface of the  fin-
gers, or of the hand, upon certain hard bodies, is not incurable.   It
was for this, especially, that the different kinds of operations which
I  have described above  were proposed.
  If we  are disposed to follow the method of Dupuytren, we may
spread out the hand of the patient upon its dorsal surface.   While
an assistant holds it fixed in this manner, and endeavers to straighten
the fingers as much as possible, the surgeon, directing a straight or
curved bistoury upon  the most tense part of the bridle, makes a
transverse incision there, which  should include both the skin and
the sub-cutaneous fibrous tissue.  On the supposition that this first
incision suffices for the complete extension of the finger, it is  not
repeated ; on the contrary, should there still remain any of the cord
or stiffness beyond the  first section, we perform a second one, and
even a third.  Acting  upon these  principles,  M. Gensoul (Journal
Clin, des Hbpitaux de Lyon, t. L, p. 496) has shown that  the incision
of the bridles was sufficient for removing  the  retraction of  the fin-
gers and of the hand.  The hand is afterwards fixed by its dorsum
upon a palette properly padded.  A few turns of a narrow bandage, 
390
NEW ELEMENTS OF OPERATIVE SURGERY.
or strips of adhesive plaster of diachylon, passed between or ante-
rior to the incisions, take a point d'appui upon the palette to main-
tain the finger in the necessary degree of extension.  The wounds
are, in other respects, dressed by the ordinary applications.
  According  to  M. Goyrand, (Gazette Medicate  de  Paris, 1835,  p.
485,)  the hand being fixed as above, the surgeon, armed w ith a
straight bistoury, held like a writing-pen, ought to incise the skin
in the direction of the bridle itself, and to the extent of one or two
inches.  This being done, he cuts the  fibrous cord from space  to
space upon  all the points Avhich appear tense, and even excises
some portions of them, if they should seem to be too moveable,  or
floating, as it were, at the bottom of the wound.  He then unites by
the first intention, retaining the fingers in a state of complete ex-
tension.
  On the supposition that it might be possible to insert a narrow
instrument between the skin  and the  abnormal cord, Ave should
make the puncture of the integuments on one of the sides of the
bridle, which latter must be previously stretched tight. In order to
relax it a little, and to introduce the bistoury more easily under the
skin, it weuld be proper to increase the flexion of the fingers a lit-
tle, until the instrument should have reached to the other side of
the transformed tissue.  Then, having turned the back of the instru-
ment forward, we should again extend the fingers, in order that the
bridle might, in some degree, be enabled to divdde itself from be-
hind forwards.   After having repeated  this  kind of section by a
sufficient number of punctures, and from space to space, it would
become necessary here,  also, to maintain  the fingers in a state of
extension.  Only in place of agglutinative bandages, and of the or-
dinary dressing, it would be proper to apply some  resolvent com-
presses, and to establish  a moderate degree of pressure upon the
small punctures.
  As to extirpation, I have already said, that, in performing it for
the first time in the beginning of the year 1833, I proceeded in the
same way that M. Goyrand did a short time after, and that, not
being able to produce results more advantageous than by the simple
section, it did not appear to me deserving of general adoption.   I
weuld, therefore, recommend not to have recourse  to it but Mdiere
tumors or certain kinds of nodosities should be found to exist under
the skin with the bridle.
  The operation  being  performed, and the wounds cicatrized, we
should still deceive ourselves, Mdiatever may have been the process
used, if we should look upon the patient as safe against any return,
and did not  recommend to him to adopt some precaution.   Com-
plete extensions, often repeated, and suspension of the occupations
which had brought on the induration, the massage of the parts,*
oleaginous ointments, and mucilaginous baths, are  still  necessary,
if Me wish the cure to be radical, as they might also have sufficed
  * [Le massage (see supra) means, pinching, twisting shampooing, and otherwise ex
citing the parts.—T.] 
SUB-CUTANEOUS BRIDLES.
391
in the first months of the disease, if the patient had been disposed
to make trial of them.

                       § II.—The Forearm.

   When the forearm is found adherent (colle) to the front  part of
the arm, in consequence of morbid cicatrices, we remedy  the de-
formity by means of incision or excision of the new tissues.  This
operation, however, should not  be undertaken,  unless the  disease
has supervened since the period of infancy, or  that we have it in
our power to assure ourselves  that the articulation at the elbow
preserves, or is capable of re-acquiring, a great portion of its mo-
bility.   Otherwise, to  destroy  the cutaneous adhesions could, in
tact, have no object.
   When the adhesions have been formed in early life, the articular
surfaces are so modified that they no longer  permit in adult age
the forearm to be extended or  flexed, except by  a  kind  of sliding
movement, (glissement)  If the patient, however, is found in favor-
able conditions, the operation must be undertaken  as  soon as pos-
sible.
   Here the method of Delpech,  that is, the excision of the inodular
tissue, and the immediate reunion of the wound, will rarely  answer.
We  should not have  recourse  to it, except after the practice of
Benedetti, when there are only simple narrow bridles.  In this case,
also, we should guard against extirpating the cutaneous  fold in its
whole wddth; for by the extension of the limb, there might there-
by be  produced an enormous wound.   We should therefore incise
the integuments  along the borders of the bridle, from  one of its
extremities to the  other, in place of following the angle of flexion
at the  bend of  the arm.  The  excision  would be  thus  limited
to the  cord  which forms the free border of the morbid  cicatrix
or abnormal bridle.  In these  cases, where this first kind  of ope-
ration seems insufficient, it is  preferable to destroy the  adhesions
by numerous transverse sections, or  by  an  exact dissection of
the agglutinated (conglutinces) surfaces.  Malvani (Journ.  Gen. de
Med., t. cviii., p. 40) speaks of a patient who had the forearm thus
flexed in consequence of an ulcer at the bend  of the elbow joint.
He treated it by incisions.   After the extension the wound attained
the width of the palm  of the hand, but nevertheless resulted in a
perfect cure.   Demarque (CEuvres de Jacques  Demarque, 1662, p.
467) had already been tempted to perform the same operation on an
individual whose forearm, in consequence of a burn, was adherent
to the arm, up to the apex of the shoulder; but the patient, who
gained  his living  by this deformity, would not listen to any treat-
ment.   I have  said above that such an operation had been per-
formed  in 1825, at the  hospital  of Perfectionnement, on  an adult
man, with entire success, by M. Bougon.  In the two cases of the
same kind published by M. Hourmann, and M. Berard, jeune, the
success was not less complete, though  the deformity existed in the
very highest degree.  The possibility, therefore, of curing patients 
392           NEW  ELEMENTS  OF OPERATIVE BURGER'S

laboring under this kind of disease, by simple incisions, may row bfl
deemed an established truth.
  The patient being seated, or lying down, and having the elbow
supported upon a cushioned  table, or on the bed, is seized by the
shoulder and hand by an assistant, who endeav ors gently to extend
them apart.   The surgeon then proceeds to the section of the bri-
dles, taking care to guard not so much  against the number  as the
depth of his incisions.  If in the place of bridles there should be a
homogeneous agglutination of the skin, it would be necessary to
guide the bistoury in such manner, sometimes in the  direction of
the arm, sometimes  in that of the forearm, that  the two surfaces
might be rather unglued than  really cut.  It Avould be much better,
therefore, to make the dissection by proceeding from the external
and internal grooves toAvards the median line, than to proceed at
the very first from above downward.
  AVe may conceive that the success  of an operation  like this de-
pends as much upon the. after-treatment as upon  the action of the
bistoury itself.  It is important, therefore, if the arm can  be imme-
diately straightened, to extend it upon a well-padded trough, (gout-
tiere) wdiieh might reach from the neighborhood of the shoulder to
the root of the fingers, and to fix it in this trough by means of turns
of bandage  properly arranged.  By the aid of some compresses, a
long splint of pasteboard, and a bandage saturated with dextrine,
we could construct upon the spot a perfect apparatus, if the opera-
tion should not have produced too long a wound in the bend of the
arm.  It weuld suffice, in fact, to pass some turns of bandages cross-
wise (en sautoir) upon the elbow, in order to have a roller bandage
on the parts towards the hand and the axilla, which should leave the
wound in the bend of the arm uncovered. This wound, which it is
well to dress w ith the perforated linen and lint, and whose Aegetations
must be often repressed with nitrate of silver, should not be aban-
doned to the retractile power of the  inodular tissue,  until  a long
time after the cure.   It is useful, however, in order to give supple-
ness to the articulation by degrees, to exercise some movements of
flexion upon the forearm, towards the end of the treatment, at least
once a week.

                       § III.—The Arm.

  Demarque (CEuvres, fyc, p.  467) relates that a pauper had the
arm completely glued to the  ribs, and that in this  man the con-
necting parts  were  so  loose that they  followed all the  move-
ments  of the limb.   If such  an  adhesion should be met with, it
would be  necessary to proceed as at the fold of the  arm, provided
the scapulo-humeral articulation had not lost the poAver  of resum-
ing its motions.  If it Avas  a simple  bridle, we ought to divide it
either  from  above downward, or from below upward,  while an
assistant should hold it as tightly stretched as possible, by drawing
the elbow from the trunk.
  In a patient who had the  arm and forearm thus glued  to the 
SUB-CUTANEOUS BRIDLES.
393
chest,  in  consequence of a burn, M. Aertz  (Eixyclograph. Bullet
Med. Beige, 1836, p. 151,)  succeeded in  excising the bridles, and
afterwards in keeping the limb extended  upon a splint.
  The precautions *o be taken would then be the same as in the divi-
sion of the intra-digital partitions of which we have spoken above.
AVe should, moreover, take care \o approximate the edges of the
wound on the thorax as much as possible, by means of adhesive
straps, or even by the suture, if it should be found to be possible to
place them in immediate contact.  If the wound of the arm should
haAe more than an inch in Avidth, I am of opinion that we should
run the risk of gangrene of its edges in endeavoring to narrow it
by  force, (mecaniquement) and that it would be better to treat it by
simple dressing, and to favor the cure by second intention.  In other
respects, if the bridle was rather wide, there would  be an opportu-
nity, perhaps, to proceed in  a  different manner. For  example, I
should pass,  at distances  of  six lines from each other, a sufficient
number of threads  near its attachment to the arm; then I would
introduce, near the axilla, the point of a straight bistoury, which
might  shave off this bridle from above downward, keeping at the
distance of three lines to  the outside of the threads, which latter
we should then only have to tie into knots, to have, formed to our
hand, that number  of stitches of suture,  capable of uniting imme-
diately all this portion of the solution of  continuity.
  The weund being cured  on the side of  the arm, would no longer
be exposed to a return of the adhesions,  though that on the chest
might  continue  for a long time.  It is evident, also, if the thing
should appear more easy, that we ought to practise the suture upon
the thoracic wound in preference to the  other, the  object in  such
cases being  to close one of  the wounds  immediately, in order to
prevent the surfaces from having it in their power to become re-
attached.
  In case  we could not immediately close  either of the two w ounds,
it would be necessary to dress the arm  in such manner that it
could be kept constantly separate from the chest, and in a position
varying but little from that  of a right-angle ;  for at the axilla, as
at the fold of the arm, the cicatrices have an extreme tendency to
re-establish themselves, and  to reunite the parts whose  separation
has occasioned so much pain.

                       § IV.—The  Toes.

  Sub-cutaneous bridles are seen in the toes, the  same as in the
hand, but they are infinitely more rare.  They depend almost always
upon a disease of the musculo-tendinous system. I have not, there-
fore, to speak of them in this place, as they will be treated of in the
chapter on tenotomy.   I have many times met with retraction of
the  toes from morbid cicatrices on the dorsum of the  foot.  A young
girl of twenty-seven years of age, whom I operated upon in 1832,
in the  hospital of La Pitie,  by numerous incisions, was perfectly
cured of them.  I have attempted nothing in other cases.
  vol. i.                       50 
394
NEW ELEMENTS OF OPERATIVE SURGERY.
                        § Y.— Thc Legs.

  Morbid cicatrices may glue the leg to the posterior surface of the
thigh, in the same way as the forearm to the anterior surface of the
arm.  A woman had her tAvo legs thus glued together at the age of
ten years, in consequence of a chronic Pemphigus.   Having died'
without being operated upon, the case of this Woman  induced  M.
Champion (Correspondence Prioee, 1838) to study the cause of such
retraction.   While  the dead body was yet warm, this surgeon in
vain endeavored to extend the two legs.  Having adopted the sug-
gestion of incising the  aponeurosis which  separates the adductors
near the  tibia, he  immediately found that the tAvo  legs could be
extended Avith great facility.
  This unnatural flexion of the leg may arise from a great variety
of causes,  such as  pure and simple cohesion, the inodular tissue,
sub-cutaneous bridles,  and also  from the more deep  retractions,
which I shall have occasion to speak of hereafter.
  Here, as at the forearm, the deformity may present two  distinct
modifications—1.  AVhere the adhesions have  their centre  in the
hollow of the ham, and are extended from thence to a greater or less
distance upon the leg or the thign, as in the case of M.  Champion;
2.  Or, as was remarked in  a new-born  infant,  spoken of by De-
marque, (Opera Citata, etc., p. 468,) Avhere the calf had contracted
adhesions with the posterior part of the thigh, leaving the popliteal
space free.  Here the operation would offer every possible prospect
of success.   It would even be unnecessary, after the  separation of
the parts, to hold the leg forcibly extended by means of apparatus.
In the first case, on the contrary, besides that the dissection vveuld
be very delicate, in consequence of the tendons of the biceps, semi-
tendinosus,  semi-membranosus,  sartorius, and gracilis,  which it
would be important to  avoid, we should have, moreover, to contend
against  the tendency of the cicatrix  to re-establish the abnormal
adhesions during the cure of the wound.  It would also be neces-
sary to maintain the leg in a state of complete extension, by means
of a suitable apparatus, until the wound was perfectly cicatrized, and
to proceed, in other respects, in every precaution to be taken, in  the
same manner that we have described for cases of retraction of  the
forearm.   By means of the simple section of the bridle, M. Mouli-
nie (Bulletin Med.  de Bordeaux, 1836—Arch. Gen. de Med., 3e ser.,
t. i., p. 113) has thus succeeded in curing a remarkable retraction
of the ham. It is evident, in conclusion, that, during the operation,
the patient should lie  upon his belly, in order that an  assistant
may hold  the upper part  of the  thigh,  and another moderately
stretch apart the leg from it, while the surgeon divides the unnatu-
ral bands and bridles.

                       § VI.—The Thighs.

   Many facts prove that the thighs may be  glued  together upon
their inner surface  to  a variable extent,  and  particularly towards 
SUB-CUTANEOUS BRIDLES.
395
their upper part.  The child of Avhich M. Demarque speaks, (CEu-
vres, etc., p. 468,)  and which had the right calf glued against the
corresponding thigh,  presented, moreover, an adhesion of the two
thighs at their upper part, and to the extent of three inches. Though
difficult to  cure radically, this deformity, nevertheless, should it oc-
casion inconvenience or pain, should be subjected to an operation.
We  find in the thesis of M. Lelong (No. 179, Paris, 1819) an in-
stance of the union of the thighs at their upper part, which existed
from the age of eighteen months,  had been occasioned by a burn,
and  was operated upon successfully at the age of twenty-three
years by Quesnault.  It would be necessary, in such cases, to place
the patient upon his side, and to see that Ave raise up one of his knees,
while the other should be held against the bed. The disunion hav-
ing been effected from below upwards, as far up as to the neigh-
borhood  of the perinaeum, should be kept open by the means and
precautions I have pointed out in speaking of the liberation (decol-
lement) of the arm ; if the state of the parts permitted, we should
attempt  immediate union of the wound, at least upon  one of the
thighs ; otherwise, we should, in order to prevent a new aggluti-
nation of the parts, permanently retain in the upper angle of the
division some compresses, or adhesive straps—in fact, some foreign
body, until the end of the treatment. This would be a case, also,
for borrowing flaps of skin,  by dissecting them off in front and be-
hind in the neighborhood of  the anus and scrotum, and uniting them
in the form of a commissure between  the two thighs, as I have
recommended for the fingers.

              § VII.—Abdomen and Genital Organs.

  In the patient mentioned by M. Lelong, and which was one of
Quesnault's, there was, also, adhesion of the scrotum to the penis,
and of the thighs to  the   scrotum.  A careful  dissection of the
parts, and the delicate dressings, which  the results of such opera-
tions require, did not, however,  effect a complete cure.
  M. Champion has communicated  to  me the case of a child of
twelve years of age, in whom the  upper half of the left thigh was
closely glued to the Avails of the  abdomen from the age  of four
years, and in consequence of a  burn. After  haAdng separated the
thigh by dissection, this surgeon united the wound by first intention
in its three lower fourths, by borrowing teguments dissected off in
the neighborhood, and by making use of adhesive plasters, together
with several stitches of sutures.  The inodular cicatrix of the re-
mainder  of the  wound partially re-established the flexion of the
thigh upon the belly, but did not occasion a sufficient degree of re-
traction to  prevent the patient from walking almost erect. Having
practised the section of bridles  in the groin, M. Nichet, (Arch. Gen.
de Med., 3e ser., t. i., p. 114,)  in a case of this kind,  immediately
covered (combla)  the wound by a  flap borrowed from the neigh-
borhood,  by the French method, and cured his patient.
  It is well to remark, nevertheless, that, in trying to separate the 
396
NEW  ELEMENTS  OF OPERATIVE SURGERY.
penis from the scrotum, it would be important to avoid the urethra
and the corpora caAernosa on the one hand, and the dartos and
other envelopes  of the testicle on the other.  If we had to isolate
the scrotum  only, there would be less danger in inclining the bis-
toury towards the side of the thigh than in the other direction.  To
obtain a complete separation of the thigh itself, when it adheres to
the walls of the abdomen, Ave should never lose sight of the fact,
that Ave are in the neighborhood of the  femoral  artery, its corre-
sponding vein, and the saphena  interna.  The intimate cohesion
(fusion) of the parts  in this neighborhood could not, consequently,
be destroyed, but by operations of a delicate and  sometimes even
very dangerous nature.
  The most suitable dressing, to prevent  a new agglutination  du-
ring the cicatrization of the wounds, would consist of a long piece
of pasteboard, extending from the lumbar region  to near the ham,
and fastened by  a body bandage  above the hips, and by a circular
bandage above the knee; in such manner, that this latter bandage,
previously  saturated wdth dextrine, should make some turns on  the
trunk, to redescend by one or more crosses upon the outer  surface
of the breech and thigh to above the knee.  If we were treating  the
penis, Ave should take care to keep it raised up by means of adhe-
sive plasters upon the forepart of the abdomen. If it was the scro-
tum that we had detached, (decolle)  adhesiAe straps, passed cross-
Avise very near the upper part of the thighs, Avould suffice to support
and hold it up.
  As respects the bending back (renversement) of the legs upon  the
thighs, of the thigh upon the abdomen, and of the  whole lower  ex-
tremity, back, forward, or to the outeide,  as I have seen  in many
new-born infants, it is almost  always the  effect of another order of
lesions: it  is  to  diseases of the articulations or tendons that these
deformities must generally be attributed.

                     § VIII.—The Trunk.

  In no place do cicatrices and abnormal bridles  so often produce
deformities as in the head. It is to these"that Me must refer almost
all the varieties of ectropion, the  greater part of deviations and  co-
arctations, whether of the nose, lips, or ears; but, as it will be  ne-
cessary to return to this, in treating of anaplasty  and other opera-
tions that are performed upon these different parts, I will say noth-
ing of them at present.

                     A. Bridles of the Neck.

  Burns of the neck sometimes cause a depression of the lower jaw
towards the sternum, as in the  patient  of whom Rideau  speaks,
(Lecons, These, No. 179, Paris, 1819, p. 26,) and sometimes an in-
clination of the  head sidewise towards one or the other shoulder.
These deviations, which exist to a great extent, and of which frequent
examples are  met with in practice, are generally of  very difficult
cure.   A patient, mentioned  by M. Lelong, (Ibid., p. 27.)  was thus 
SUB-CUTANEOUS  BRIDLES.
397
bridled from the temporal extremity of the eyelids down to the fin-
gers of the left hand.  Some journals of medicine (L'Abeille Medi-
cate, t. iii., p. 454) described, about ten years since, a case as having
had a successful issue after operations performed for this species
of deformity; but the patient, who was then a child, and whom a
great  many persons, as well as myself, saw at  the hospital of La
Pitie, was never cured.  It would, in such cases, be necessary to
divide transversely, by  numerous incisions, all the cutaneous or
sub-cutaneous bridles. Then, to prevent all new retraction, to have
the chin held up by a species  of leather strap,  (courroie,) or  cord,
(lac) fastened firmly to a leather bonnet, which should also be at-
tached above and behind to  an  inflexible  upright,  (tige) which
should be fastened  to the lumbar region by means of a  cincture,
(Mcllet, Manuel Pratique d'Orthop., p. 98.)   The upright having a
hinge and a spring at its upper part, would also permit of the head
being moved and held,  either backward,  or to the right  or the
left, a little deviated  from its natural  direction,  until the  cica-
trization of the wounds of the operation should have acquired all
its required solidity and consistence.  The difficulty in these cases
arises from the necessity in which  the patients are placed of fre-
quently lowering the jaw, the  feebleness of the forces provided to
raise up  this bone by its middle part  and the weight which natu-
rally draws the head forwards.  If, therefore, it should not be found
possible to save the  skin of the chin, we should have little chance
of success, unless by covering immediately, by means of anaplasty
all  the Avounds with flaps of skin  borrowed from the  neighboring
regions.
  The bridles and adhesions upon the side of the neck are infinitelv;
less  unyielding to surgery than those which we have just spoken
of.   After haAdng divided them on many points, and to sufficienl
depth, all that is necessary to prevent their reproduction, is, in fact.
to keep the head held up, and»then inclined in an opposite direction
by means of a dividing bandage for the neck.  This bandage, which
could be rendered immoveable  and very solid by connecting it with
pasteboard, and then saturating it with dextrine, would have the
advantage of producing infinitely less fatigue to the patient  than
the machine of M. Mellet.

            B. Cohesion of Parts,  (Fusion des Parties.)

  Under this title, I cannot record any fact or operation in relation
to cicatrices and abnormal bridles, which  has  been the object of
the slightest attempt at surgical relief.  Nevertheless, there exists
a species of deformity which is worthy of occupying our attention
a moment upon this occasion; I mean diplogeneses.  These mon
strous associations,  which are all congenital,  and which in mv
opinion are almost  always  produced by the abnormal and pro
longed contact of tAvo  foetuses during tjie  period of intra-uterint
life, should be ranged in two great classes, in their relations to ope-
rative  surgery.  If there is a close cohesion of the two beings by 
398
NEW ELEMENTS  OF  OPERATIVE SURGERY.
 some important organ, it Avould be dangerous, and in some cases
 criminal, to attempt to destroy it.  AArhen there exist, for example,
 two heads for one trunk, two arms or a  single one for each head,
 and when the two beings possess also a distinct chest, or that they
> have only one for both, as was seen in Ritta-Christina, the surgeon
 who should wash to meddle with them would be culpable.  In ani-
 mals the head is the individual; and in man it would be as cruel
 to remove one of the heads of a bicephalous monster, in the view
 of preserving the other, as it would  be to assassinate a new-born
 infant.
  If, on the contrary, there existed four lower limbs, or some cohe-
 sion of the lower half of the body, with a single chest and a single
 head, moral obligations would not be  violated in attempting to de-
 stroy the supernumerary parts; but  then the operation in  itself
 would be too dangerous for us to venture upon.
  In fine, as often as the two bodies  should  be united in such
 manner that the  cohesion inAelved the skeleton, whether on the
 dorsal or sternal regions, or on the sides and pelvis, we should have
 nothing to do with it.  In all other cases, we may discuss the ques-
 tion, whether it is prudent to  separate the individuals  from one
 another; we may here suppose a number of cases :
   1. Where the foetuses are born united by the cranium, either ver-
 tex with vertex, or by the forehead, or occiput,  or  on the  sides;
 then we should proscribe all manner of division if the cohesion is
 large and extends to the bones.  If its  extent was small, or involved
 only the integuments, we should not  hesitate, I think, to destroy it
 by the cutting  instrument.   If it should  be  left undisturbed, the
 two beings would almost inevitably perish, without taking into the
 account that if they live, their existence must be a charge  upon
 society, and a misfortune for themselves.  By the operation, on the
 contrary, we have many chances of restoring them to liberty.
  2. AVhen the foetuses are united by* the anterior surface or their
 posterior surface.  The dorsal  and the sternal union should not be
 declared incurable, unless it should extend deeper than the thick-
 ness of the integuments, and  comprise a  great extent of surface.
 At the abdomen, also, we should shrink from an operation, if there
 should  appear to exist the  least communication between the vis-
 cera and between the peritoneum of  the two  individuals.  Other-
 wise, that is to say, if the thoracic or  abdominal cavity is perfectly
 irdependent in each of the two beings; if, as we have seen in the
 two young Siamese, the  parts  are not united but by a large bridle
 or cutaneous growth, (plaque) they may be separated.  The ope-
 ration would, in such cases,  be  performed in the manner I have
 described in speaking of adhesions of the arm to the chest, of the
 fingers with one another, and those of the upper part of the thighs.
 This, moreover, is not a mere suggestion.  Sue relates (Histoire des
 Accouchemens,  t. ii.,  p.  251)  that  Fatio had thus operated and
 effected a cure, at Bale, in 1752, in the case of two foetuses  united
 at the epigastrium.  This kind of operation has rarely been put  in
 practice up to  the present time ; 1. Because most of the foetuses 
            ALTERATIONS OF THE TENDONS OR MUSCLES.          399

thus formed die soon after their birth, if they do not die before the
termination of the  labor;  2. Because those who continue to live,
contract such a habit from their position, that they feel no need of
changing  it; 3. Because, if they attain the  age of reason, they
almost always refuse every attempt having for its object their sepa-
ration ; 4.  Because many parents use these  monstrous beings for
objects of public curiosity and sources of gain.  For these reasons,
therefore, and in order that the operation may be the less danger-
ous, we should perform it as soon as possible, and in general in the
first months after birth.
  3. When a foetus, or a portion of foetus, is  as it were implanted
into a child otherwise well formed.  When it concerns  only a fin-
ger, leg, arm, or in fact a portion of limb, no one should oppose its
entire  removal.   But if the  second foetus is  implanted upon the
head, chest, or belly, the case is more serious, and practitioners are
not agreed. On the supposition that the pelvis, a part of the ab-
domen, and the lower limbs, should be appended to  the sternum or
umbilicus of a living individual, as is related of a  case published
some years since,  (Isidore Geoffroy  Saint  Hilaire;  Histoire des
Anomalies  de  VOrganisation dans I'Homme et les Animaux, Paris,
1832-1836, 3 vol., in-8vo, fig.,) we might attempt  its extirpation,
if a careful examination satisfied us that the other portion  of the
supernumerary foetus did not project (proemine) into  the splanch-
nic  cavities, and if the operation would  not make  too large a
wound.  It is, moreover, evident  that none of these disunions and
extirpations can be  submitted to  any special rule, and that it is
for the surgeon to choose, in each case, the mode of operation which
suits the best.
                         CHAPTER III.

DEFORMITIES FROM ALTERATION OF THE TENDONS OR MUSCLES.

  The deformities which may result from an unnatural state of
the muscles or tendons are referrible to the division, adhesions, and
accidental retractions of these tissues, (organes)

                Section I.—Accidental Divisions.

  The muscles and tendons cannot be divided without producing
some disturbance in the locomotive actions.  The accidental divi-
sion of the tendons, however, should more  frequently call the atten-
tion of surgeons to this subject than that of the muscles.  I shall
therefore, occupy myself in this place almost exclusively with what
concerns the division of  tendons, persuaded that the  reader will
apply without difficulty what I shall  say of them, to wounds of the
muscles. 
400
NEW  ELEMENTS OF OPERATIVE SURGERY.
                Article I.—Tendons in General.

  All the tendons of the body, in fact, may be  divided, either by
external violence, gangrene, or ulceration.   It is only those of the
limbs, however, and some of those of the neck or abdomen, which
can require the aid of operative surgery.

                  § I.—Pathological Anatomy.

  When an  extensor tendon is completely divided, the  antagonist
muscle unavoidably draws the part  into a state of flexion.  The
disease  may then be compared to a  kind of paralysis.   If it were
to take place with certain flexor tendons, the limb, on the contrary,
would remain in extension.
  The  division  of the tendons is followed by a process,  (travail)
which differs according as there exists at the same time a wound
in the skin, or that the process takes place protected from contact
with the air.

                   A.  In Contact with the  Air.

  If the solution of continuity is at the bottom of an ulcer or a
Avound, the two ends of the tendon  remain for  a long  time pale,
like  an inert  substance, (tige;) ultimately, hoAvever, they become
vascular, and covered with reddish granulations.  These  granula-
tions, wdiieh encroach at the same time upon the surrounding cellu-
lar fibres, (feuillets) are the point of  departure and the termination
of a vegetation, which results in filling up in part the void which the
extremities of the ruptured tendon leave between them.  Here, then,
the solution of continuity is cicatrized by second intention ; cellular
tissue,  aponeurosis, vessels, sub-cutaneous tissue, and tendons, are
all finally blended together in  a single mass, which itself contracts
intimate adhesions with the skin in the neighborhood.   It is this
which is observed, when, in consequence of gangrene, large ulcers,
and long-protracted suppuration, there has  ensued an  exfoliation
of tendons at the bottom of the wound.   In this case, the mobility
and play  (glissement) of  the  principal  organ cannot  take place
without communicating the same degree of motion to all the other
tissues with which it has become associated.
  When the division of a tendon, notwithstanding it is  hidden un-
der the integuments, and that the external wound has united, is fol-
lowed by purulent inflammation, there results  from it the same
process, and consequently the same dangers. In that event, however,
it is possible that the suppuration may be confined to the sheath of
the tendon,  and to some  feAV  of the surrounding tissues, (lames;)
and that after the cure,  the  skin, and the muscles and tendons,
more or less perfectly retain the independent. use and play of
their movements.  In these two orders  of cases, as is readily per-
ceived, it is next to impossible that the disease, left to itself, would
allow of a complete restoration of the  functions of the wounded
organ. 
ALTERATIONS OF THE tendons OR MUSCLES.          40J
             B. Protected from Contact with the Air.

  If the tendon is ruptured under the  skin, or diAdded without any
inflammation supervening, we must expect results of a totally dif-
ferent nature, but which vary, according  as  the  two ends of the
tendon are kept in contact or remain apart.  The agglutination  of
the tendon  is effected either by first  intention if  the  contact  is
perfectly exact, or, in the contrary case, through the medium of a
plastic matter, which, at first  soft and gelatinous,  (gelatiniforme)
soon assumes a lamellar and fibrous appearance.   Blending itself
Avith the tendon, this material is  converted into a sort  of kernel,
(noyau) or node, (nodus) which itself rarely fails to disappear  at
the expiration of some weeks or months.   Being neither stretched
out, nor soldered (soude) to the  surrounding  tissues, the tendon
thus soon recovers all its primitive power and  mobility.  When
there is a separation of several lines between the tvve ends, there
occasionally takes place in that part an effusion of blood, of fibrine,
or of plastic lymph.  This  effusion often becomes  organized.  Its
liquid  and coloring matters are gradually absorbed; the fibrine and
plastic lymph harden as they become cemented to the tMe ends  of
the tendon, which they envelop in the manner of a ferule, (virole)
Afterwards, becoming transformed into fleshy tissue, (se carnifiant
ensuite) we may recognise, on the tenth or twelfth day, an ap-
pearance of fibres, or of a  substance  like felt, (feutrage) and an
elasticity which continues to increase.   The final result  is, that
there is formed from this a portion of  new tendon,  which appears
to have been created there for the  purpose of giving greater length
to the  old tendon.   It may readily be conceived, that from this pe-
riod a  part of the functions of the wounded tendon will be restored,
but that its  excess of length will not  readily permit it to resume
entirely all the power it possessed in its normal state.
  AArhen, w ith the separation which I have mentioned, the union of
the teguments with the cellular tissue at the bottom of the division
has been effected before the effusion has taken place, and without
any inflammation, the two ends of the tendon, if they are very far
apart,  cicatrize separately, each one in its place, and remain with-
out the new uniting medium,  (sans lien nouveau) and  as if they
were  lost in the cellular tissue ;  the  action of the corresponding
muscles is, in this  case, completely destroyed.
  The knoAvledge of this process (travail)  shows, at once, Mrhat we
have a right to expect, and what it is proper to do, wdien the  conti-
nuity of a tendon has been interrupted.

                        § II.—Treatment.

  Two classes of means are placed at the disposition of the sur-
geon to remedy the division of the tendons—position, aided by ban-
dages, and the suture.   With  this is connected a  question which
has always divided surgeons—should Ave, or should we not, practise
the suture of the tendons ?
  vol. i.                      51 
402
NEW  ELEMENTS OF OPERATIVE SURGERY
  Confounding all the Avhite  tissues  under the title of nerves, the
ancients considered that a wound of the tendons Avas extremely
formidable, and that it exposed to conv ufsions, tetanus, and death.
So Galen, who seems to allude to the suture of tendons, is far from
formally extolling it,  whatever  Guy  de  Chauliac may say  of it
(Edit de Joubert, p. 263, Rouen, 16*49,) and who, in venturing to
reject the doctrine which, according to him, had been falsely attrib-
uted to Galen, was severely reproved for it by many of his  suc-
cessors.  It was useless  for Guy (Traict III., doct.  1, chap, iv.) to
invoke the authority of Avicenna, Lanfrane, and G. de Salicet, and
then to add, that he had " seen and heard it said, that in many per-
sons the cut  nerves and  tendons had been so well restored by su-
tures and other remedies, that  no one  would have afterwards sup-
posed that they had been divided," for he did not change the prac-
tice of his cotemporaries.  To change this opinion, it was necessary
to prove that the tendons, aponeuroses, and serous membranes, were
endowed only with a feeble sensibility.  It is what Haller endeav-
ored to show, and what Castel (20 Janvier,  1753, These de  Haller,
trad, franc., in 12, t. iii., p. 280-382) was especially desirous of de-
monstrating by a variety of experiments.  Other experimenters and
practitioners (Bagieu, Examen de Plus. Parlies de la  Chir.,  p. 575)
have, nevertheless, maintained, with the ancients, that the tendons
enjoyed an acute  sensibility, and that the wounding of them ex-
posed to serious dangers.
  Some casual observations,  that haAe  been, from time to  time,
made in faver of suture of the tendons, have finally awakened the
attention of modern surgeons to this important subject.  Pare, Avho
limits himself (Livrc XXIII, chap. 10) to the recommendation of
machines to  restore the actions of divided  tendons, relates, also,
(Livre XXV., chap. 17, p. 773,) the case of a suture of the two ten-
dons of the ham, performed with complete success by Tessier. M.
A. Severin (Chir. Efficace, chap. 120, livre ii.) has no hesitation in
recommending it.  Marchetis, (Collect, de Bonct, t. iii., p. 260,) who
accuses Severin of having imperfectly comprehended  Galen and
Pare, in vain opposed the suture of tendons, for it did not prevent
Verduc (Operat de Chir., p. 256) from extolling it, and describing
in detail the process that the Surgeon Bienaise  then employed for
performing it.  AVe may also see in Heister (Institut. Chir., vel. ii.,
p. 1087, cap.  172) the enumeration of  the surgeons AAdio, up to that
time, had declared themselves for or against the suture of  the ten-
dons.  Gauthier had noticed a case of this  kind, which he related
to Wepfer, (Ephemerides des Curieux de la Nature, 1688, ou Collect.
Acad., t. vii.,  p. 524 ;) De La  Motte, (Traite de Chir., ed. Sabatier,
t. ii., p. 162.)  Balthasar, (Ancien Jour, de Med., t. Ixviii., p. 142,) and
a great  number of other practitioners, also  relate examples of  it.
[Notwithstanding these facts, the question still remains undecided.__
T.]  M. Barthelemey, (Jour. Hebd., t. ii., p. 222,) justifying himself by
the practice of M. Larrey, published  some  cases of cures  effected
by  suture of the tendon*.  If the experiments which M. Acher
made, (These, No. 112, Paris,  1834,) and the facts he has gathered 
            ALTERATIONS OF THE TENDONS OR  MUSCLES.         403

in the practice of M. Gensoul, confirm the opinion of M. Bienaise
and of Guy de Chauliac, we see M. Rognetta, (Arch. Gen. de Med.,
2e serie, t. iv.,  p. 206-215,) on  the other hand, asserting that the
suture of the tendons is  useless and dangerous ;  so that, to recon-
cile all parties, M. Mondiere (Arch.  Gen. de Med., 3e serie, t. ii., p.
57) considers that  it is sometimes useful, rarely indispensable, and
very often of no value.
  In my opinion, this question, examined in a proper point of view,
is less difficult to solve than one would at first sight suppose.   One
indisputable fact is this: the more completely in contact the ends
of a divided tendon are, the more prospect is there of restoring it
perfectly to its functions. All that Ave have to ascertain, therefore,
is, Avhether  the suture Avill fulfil this indication better than  any
other remedy.
  At the time of Pare, surgeons believed so  little in the union of
divided tendons, that,  in speaking of a noble personage, who,  in
consequence of a wound of the tendons, wished to have his thumb
amputated, this author found nothing better to sooth him, not to
cure him, as M. Mondiere thinks, (Arch. Gen. de Med., 3e serie, t. ii.,
p. 59,) than the employment of an  apparatus Avhich enabled  him
to straighten or bend in a slight degree the Avounded finger.
  An observation of Marchetis, that of Martin of Bordeaux,  and
that of Mareschal, (Arch. Gen.  de Med., 3° serie, t. ii.,) show, on the
other hand, that the surgeons of the seventeenth and  eighteenth
centuries had, at that time, made actual cures by means of position
and bandages. The rupture of the tendo-Achillis, of wdiieh Monroe
had seen sixteen cases, (Journ.  de Chir., par  Desault, t. ii., p. 50-
64,)  the instances  of this kind Avhich are related by Bagieu, (Exa-
men de Plus. Part, de la Chir., p. 461,) Thiebault,  (Jour, de Desault,
t. ii., p. 268,) and  Mothe, (Mel. de Med. et de Chir., 1812,) a  fact
recorded in the practice of  A. Petit, (Ancien Jour, de Med., t. xliii.,)
and the facts related by MM. Rognetta (Arch. Gen. de Med., 2e  ser.,
t. iv.,  p. 206-215) and  Mondiere (Ibid., 3e serie, t. ii., p.  61) are not
less conclusive.  I have  myself seen many cases of wounded ten-
dons, among which was a sausage-maker's boy, (garcon charcutier)
who had had the middle and  ring fingers almost entirely severed ;
also  a young  butcher, who had a  simple wound  in the fore and
middle fingers, and both of whom recovered the perfect movement
of the parts, though  I had  employed in their cases no other means
than position and bandages. Another case occurred in the hospital
of La Charite, in August, 1838.  The extensor tendons of the fore-
finger had been completely divided.  Bandages only were employed
to unite the wound, and the cure M^as effected at the expiration of
twenty days.  Nothing of all this, however, positively proves  that
ihe union of the tendons has been effected by the actual contact of
the ends of the division; every thing, on the other hand,  demon-
strates that there  is a sort of bridle formed  in these cases, a new
production, which extends from one end of the division to the other,
like a band added  to the original length of the tendon itself.  It is
thus that the continuity of the parts is re-established, not only after 
404           NEAV ELEMENTS OF OPERATIVE STRCP-RV.

the rupture of tendons which are acted upon by powerfL muscles,
but also after the fracture of certain bones, as.for example, the pa-
tella and olecranon.
  The experiments made in our times, and the examples of sections
of tendons wdth the view of remedying deformities, have, moreover,
most  abundantly proved, that the substance which is formed be-
tween the twe ends of a divided tendon in no respect destroys il.^
action.
  It follows, hence, that the operations which should be performed
in eases of accidental division of the tendons should vary, according
to the different circumstances—1. According  as there is, or is not,
at the same time, a wound of the skin ;  2. According as it is, or is
not, possible to  obtain a  perfect contact by means of bandages;
3. According as  the tendon, either from the position it occupies, or
the functions it performs, has need or not of being replaced exactly
in its  primitive position.
  That class of divisions of the tendons, which is not accompanied
with Avounds of  the integuments, almost Avholly forbids the use of
the suture.  AVe should not, at least, allow ourselves to think  of
an operation in  such cases until after hav ing vainly attempted re-
lief by position and bandages.   In regions where the delicacy and
multiplicity of the movements are not the principal functions, the
suture is equally unnecessary.  A separation of half an inch, or
even an inch, would not hinder the triceps or biceps from extending
or bending the forearm.  I have often  seen a separation  of one,
two, or even four fingers' width, from a transverse fracture of the
patella, together  with rupture of the ligament of the patella, or of
the  tendon of  the  rectus  femoris, produce  only a  slight inconve-
nience in the movement of the leg. In the hand and wrist,  wounds
of this kind exact a little more attention.  In these cases, however,
as well as in others, if, by means of a position properly chosen, we
can oblige the  ends of the tendons to touch each other, we  can dis-
pense wdth the suture.  In the contrary case, the suture is an ope-
ration which would be  formally indicated.   [Dr. Mott does not ap-
prove of stitching tendons ; you might  as well wire bones.  Posi-
tion, in his view, is every thing.—T]
  Compared to position and bandages, however, the suture of the
tendons has inconveniences and  advantages which the  surgeon
should carefully  weigh.  AVe may reproach  him  for introducing
into the wound  a substance necessarily extraneous, and of thus
rendering it impossible to  effect a cure  by the  first  intention; but
b; this remedy the  contact of the ends of the tendons is made more
perfect than by means of bandages, and the patient is not confined
to any position, or  to any fatiguing compression.  Dispensing w ith
the  suture, we may immediately close  the wound  of the integu-
ments, and obtain a cure without suppuration, but the union  of the
tendon is not immediate ;  Avhereas, though the suture almost una-
voidably causes suppuration, and requires more time for the  exter-
nal cicatrization, it gives, as a compensation, a direct union of the
tendinous cord.  We thus perceive, therefore, what are the casts 
            ALTERATIONS OF THE TENDONS OR MUSCLES.          405

in which we should be at liberty to resort to one of these methods
in preference to the other.

                         A. Position.

  When we have recourse to position and bandages, we must first
place the part of the wounded  limb in a state of complete exten-
sion, if it is the  extensor tendons, and  in  a moderate degree of
flexion, if it is the flexor tendons, and then proceed immediately to
the union of the wound, either by adhesive plasters, or by the su-
ture.  There is some advantage in conforming, in such cases, to the
precept of M. Champion, who recommends that Ave should, if pos-
sible, make the two ends of the tendon ride a little over each other,
(chevaucher)   It  is  also important, as this practitioner has shown,
that the bandage should make but  little pressure  opposite to the
solution of continuity, that it may not tend to displace  the extremi-
ties of the tendon which we wish to unite.  The most convenient
position having  been given to the  limb, we  immediately apply a
roller bandage, taking care to commence at the origin (racine) of
the muscle, and to act upon the parts in such manner as if to draAV
them toAvards the wound. It is often serviceable to associate splints
of wood or  pasteboard, or troughs  straight or bent, with the rest
of the dressing, in order to give it greater steadiness.   The obser-
vations of modern orthopedists  have proved, that, in order to cure
the division of a  tendon without any intermediate substance, it  is
necessary to keep their ends in contact, (rapproches) at least during
twelve  to fifteen days.   AVe should, therefore, guard  against pre-
maturely making the least movement of the part.   We should not,
therefore, lay the bandage aside until after the fifteenth or twenti-
eth day, it being understood that the hardest  portions of the dress-
ing shall have been taken away at the tenth or twelfth day.   AVe
then proceed to make gentle and gradually increasing movements
of flexion and extension of the Avounded tendon.  The other pre-
cautions are the same here as in the cases of stiffness, which suc-
ceeds to diseases  of the joints.

                        B.  The Suture.

  When we have decided in favor of the suture, it may be advan-
tageous to enlarge and equalize the weund of the tendon.  Ordina-
rily we find the lower end of this cord above  the lovAer lip of the
division of the  skin;  the other  end, on the contrary, retracted by
the action of the muscles, is raised to a considerable distance be-
neath the integuments.  If the wound is recent, and  by a cutting
instrument, we may insert the suture without previously cutting it
smooth, (sans avivement prealable)   [Dr. Mott would not touch it.
—T.]  If the Aveund has existed for some days, and is accompanied
by laceration (ecrasement) and contusion, it would be more prudent
to cut off the ends of the tendon, in order that we may have a fresh
wound to unite. 
406
NEW  ELEMENTS OF OPERATIVE SURGERY.
  It is possible, moreover, that the wound of the integuments may
have completely cicatrized, or that there has never been any.  If
as  Severin and A erduc  have advised, and as Petit has practised.
(Mondiere. Archiv. Gen. de Med., 3e serie, t. ii..) we should, in a case
like this, wish to insert a suture, it vveuld be necessary to divdde
the integuments, to bring the ends of the ruptured tendon together,
and cut  them off smooth, and afterwards to proceed as in the two
preceding cases.  As to determining whether it is better to follow
the process of Bienaise than that of any other, it is a question of
but little importance ;  we may succeed Avith all the modes.  For
seizing the tendon, I prefer the hook-forceps (pinces a crochet) to
the ordinary forceps ; I begin with the lower end rather than with
the upper ;  I use small  spear-shaped  needles,  slightly  curved at
their point, in  place of the  ordinary semi-circular needles, and I
substitute the common thread for all those of a special character.
  If the  tendon has not more than two lines of  breadth, one stitch
of suture suffices ;  and I insert it at  the distance of from two to
three  lines  from each end of  the division.   Two stitches would be
requisite for  every  tendon of three lines of transverse diameter.
We weuld only apply three, or a greater number of them, when op-
erating upon  one of the largest  tendons of the muscular system. It
is advisable that each stitch should embrace the  entire thickness of
the two ends of the tendon. The simple suture, also, is here prefera-
ble to  the tvvdsted.   After having placed  a sufficient  number of
ligatures, we  cut one of the two threads of each very near its knot,"
the same as after ligatures upon arteries ;  each remaining thread
is then brought out by the shortest direction to the skin, the wound
in which latter is then united as accurately as possible.  Nothing
is afterwards required  but a simple dressing and an immoveable
position,  to allow nature to agglutinate the parts.
  In the  suture to tendons, the threads generally detach themselves
very slowly, since they  cannot come off until  after having divided
the densest fibrous tissue  of the animal economy.   It is important,
however, not  to make  any traction upon them, but to leave them
to separate of themselves, or,  as it were, spontaneously.
  In a case where it was impossible to bring together, end to end,
the two portions of the same tendon, Missa (Gazette Salutairc, 1770,
No. 21) adopted the plan of  attaching the upper one to the edge
of the  neighboring  tendon.  Two muscles were thus charged with
the duty  of moving the  same finger.  M. Champion writes me that
he  proceeded in the same way, after the exsection of the fourth
metacarpal bone.   We shall  see, in treating of suture of the ten-
dons of the fingers, in what  cases it AAeuld be  advisable to adopt
this mode.
  In respect  to the subsequent treatment, also, we must proceed
after the suture, as  after  the attempts to unite  by bandages or the
simple position. 
ALTERATIONS OF THE TENDONS OR MUSCLEJ.
407
               Article II.—Tendons in Particular.

                 § I.—Tendons of the Fingers.

  In order that the functions of the fingers may be preserved, it is
necessary that their tendons should neither be elongated nor short-
ened, nor more nor less  adherent than in their natural state. There
is, therefore, no room here  for hesitation ; we  should, when they
have been accidentally  divided, do all in our power to re-establish
their continuity.  Formerly, surgeons contended  that the partial
section of the tendons exposed to accidents as serious as the partial
section of the nerves.  Wagert (Observ. de Med. et  Chir., p. 211) re-
lates that, in 1717, there was a great  discussion, with  the  view to
determine whether, in  a  case  Avhere the last three flexor tendons
of the fingers had been  half divided by the cut of a sword,  the sec-
tion should be completed or not.  But since that epoch, Chabert
(Observ. de Chirurg. Prat, p. 215) has related the  case of a partial
section of the extensor tendon of the  fore-finger, which recovered,
like the case of Wagert, though the complete division had not been
performed.   M. Champion and a great number of modern surgeons
have made the same observation. I myself have more than twenty
times seen  partially divided tendons  gradually  reacquire all their
functions, and I have never observed any accidents that could be
imputed to the  undivided state of a portion of their fibres. Though
ever so few, therefore,  remain, we ought to preserve them with
scrupulous care ; for, were it but a few filaments, these answer as
substitutes for the suture and bandages, and to  enable the plastic
lymph or modified cellular tissue to fill up in a very short time  the
notch  in the division.  If, therefore, the tendons of the fingers  are
only incompletely divided, we should not have  recourse either to
the suture or to fatiguing  bandages ;  all that  would be required
would be, to keep the  finger in a state of immobility from ten to
fifteen days.  In case the division of the wounded tendon should be
complete,  we should proceed in a different manner, according as it
related to the extensor or to the flexor tendons.

                     A.  Extensor Tendons.

  Whether the  division  takes place on the dorsum of the metacar-
pus, or upon  the fingers, it nevertheless includes in it, sometimes
the tendon or tendons of one finger only, sometimes the tendons of
several fingers at the  same time.  Here, more than in other cases,
it is necessary to obtain as exact a reunion as possible.
  I. Position.   By means of the position only, Mareschal cured a
soldier Avhose extensor tendons of the four fingers had been divided
by the cut of a sickle, (Mondiere, Arch. Gen de Med. 3° serie, t. ii.,
p. 60.) It was in the fingers, also, that Heister (De Sutura Tendinis
in Manibus, fyc.; Instilut. de Chirurg., vol. ii., p. 1087, caput 472)
has seen take place a  union of the  tendons without the aid of a 
408
new elements  of operative surgery.
 suture.  In the Avork of Mothe (Mel. de Med. et Chir., Paris, 1812,
 t. i., p. 813) Ave find the case of  a section of two extensor tendons
 of the fore-finger that got well in the same manner.  I have men-
 tioned above a similar fact, observed by me at La Charite, in 1838.
 A. Petit (Anc. Journal de Med. t. xliii, p.  149) gives the case  of
 three of the extensor tendons of the fingers which were completely
 reunited in ten days by the aid of simple bandages.  Similar facts
 are detailed in the journal of Desault.  Many of the cases of Bar-
 thelemey, Achcr, and Rognetta,  and the two cases recently pub-
 lished by M. Mondiere, are additional examples of this kind.
   AVhen  the solution of continuity exists in several tendons, Le
 Dran (Consult. Chirurg., p. 357) recommends that we should make
 use of a trough,  (gouttierc) with a hinge (brisee) near the wrist.
 Another gutter, more complicated, had already been proposed by
 Arnaud, (Garengeot, t. iii., p. 260,) and  M. Champion informs me,
 that he has succeeded very well with  a palette of tin Avithout a
 hinge, but which inclined the wrist and fingers backward as much
 as was desired.
   If it were the tendons of the  thumb, as in the  patient spoken
 of by A. Pare, it would be necessary, after having surrounded this
 finger with a layer of roller bandage and some turns of spica, to place
 on its palmar surface a small  splint of pasteboard, Avhich should
 reach to the root of the hypothenar eminence, and Avhich should be
 fastened by one or two more layers of the roller bandage.  In this
 manner the thumb weuld be maintained in a permanent state of
 extension, and in the most perfect immobility, without the rest of
 the hand or other fingers experiencing  any inconvenience from it.
 For the fore-finger we should also apply a layer of  roller bandage
 fixed by one or two turns on the wrist, as is done for each finger in
 the application of the gauntlet.   A splint of pasteboard, extended
 backward to the thenar eminence, should then be applied, and
 fixed upon its palmar surface, in  the manner I have just  described
 in speaking of the  thumb.  It is evident that we should proceed
 after the  same rules if we were  treating  the middle, the ring,  or
 the little finger.  The essential point is not to confine all the fin-
 gers, because there is a wound in only one of them. It is impor-
 tant, nevertheless, for greater security,  to hold them all  in a state
 of immobility during a certain time,  though there may be only one
 of them wounded ; in the four last fingers,  especially, it weuld be
 difficult to communicate motion to those that were  sound, Avithout
 involving to some extent the metacarpal bone of the finger whose
 agglutination we were desirous of effecting.
  An exceedingly easy and secure  mode  of dressing, consists  in
placing the roller bandage of each finger  in such manner  as  to
leave the  seat of the wounded region uncovered, then to besmear
the surface of this first layer of bandage with a solution of dextrine,
then to place on the splint of pasteboard saturated with the same
matter, and finally a second layer of roller bandage, also saturated
Avith  dextrine.  We haAe in  this Avay an immoveable dressing,
which does not prevent our examining and dressing the  wound  of 
              ALTERATIONS OF THE  TENDONS  OR MUSCLES.         409

 the integuments and tendon as often as we desire.   AA'hen several
 tendons are divided at the same time, it is generally better to sub-
 stitute the palettes or large splints in place of the separate tongued
. splints, of which  I have just been speaking.  On the supposition
 that the wound was upon the fingers themselves, it would be better
 to make use of a palette  with perfectly distinct digitations, than of
 a splint or one entire sole. This foreign body, which is placed on the
 palmar surface  of the forearm,  wrist, hand, and  fingers, should
 always be  separated from the skin by  some folds of linen or turns
 of bandage.   As the extension requires in such cases to be carried
 beyond the  axis of the limb, the ordinary palettes  and splints of
 wood weuld require fillings, which  in  the gutter of Le Dran and
 the splint of M. Champion are advantageously dispensed wdth.  But
 I substitute, for all these objects, palettes or pasteboard softened
 with a solution of dextrine, and fastened on by means of a bandage
 saturated with the same liquid.   AVe obtain thus an immoveable
 bandage, Avhich we  may  bend  at  pleasure, and  mould  exactly
 upon the elevations and depressions  of the region until it has com-
 pletely dried.
   II. Suture.  If the patient is intractable, and especially if we are
 treating a wound accompanied with laceration, and upon the back
 of the  fingers, the suture would offer more security than the simpi i
 position.  The surgeon Mainard made use of it  successfully to
 unite the tendons of the fingers that had been divided by a knife,
 (Moinichen, lib. iv., p.  123.)   M. Mondiere quotes from Baster the
 history of a young peasant, who had the tendon of the supinator-
 longus divided, and which this surgeon cured by means of a single
 stitch of the suture.  We find, also, in Delaisse, (Observ. de Chir.,
 p. M^,) a case of suture of the extensor tendons of the thumb ; that
 of Balthasar (Ancien Journal de  Midec,  t. Ixviii.,  p. 142) was a
 case of suture of the extensor tendon of the fore-finger.  AAe see,
 also, in the thesis of M. Acher,  that  the fortunate results obtained
 by M. Gensoul also relate  to the extensor tendons of the  fingers.
 The operation would present but very little difficulty in this region,
 the tendons there being covered only by pliant skin,  and having foi
 their foundation a solid plane.  The thread should be passed first
 through the digital end of the tendon, (which is  at  the  same time
 the least sensitive and the easiest to seize,) then through the  mus-
 cular  end, previously disengaged and  drawn out by means of a
 hook forceps.  It would suffice, afterwards, to keep the hand and
 fingers gently extended upon a common palette, or, better still, on a
 long piece  of pasteboard, fastened  by a  bandage saturated wdth
 dextrine, in  such  manner as to allow, when necessary, the points
 occupied by the suture, to be uncovered without in any manner de-
 ranging the rest of the dressing.  M. Robert de Chaumont (Com. Pri-
 vee de 31. Champion) having to treat a divdsion of the tendons, ac-
 companied with considerable retraction, nevertheless succeeded in
 effecting, by means of the suture, as I have already stated, the cure
 of his patient, without leaving any deformity.
   If, contrary to all expectation,  it should happen  that we could
   vol. i.                       52 
410
NEW  ELEMENTS  OF  OPERATIVE. SURGERY.
not join  the  two ends of the divided tendon, perhaps it woulu be
better, rather than attempt nothing, to imitate Missa, and to sew
the upper end to the neighboring tendon, and the lower end to the
tendon along side of it.   We see. in fact, in the ease of Missa. that
it was the tendon of the  middle finger;  that the muscular portion
of this tendon was united to the tendon of the fore-finger, and the
digital portion to the tendon of the ring finger; so well that the mus-
cles of this last could be used for the motions of the wounded finger.
We may still more easily comprehend the utility of attaching the
tendon of a finger which has been amputated to  one of the collat-
eral tendons,  after the manner that M. Champion adopted after the
exscction of the fourth bone of the metacarpus. It is certain, how-
ever,  that  this connecting together  (accollcment) of tendons  can
rarely be required, or, I may add, be  advantageous, on the dorsal
region of the fingers or hand.

                      B. Flexor Tendons.

  The section,  rupture, or division of the flexor tendons of the
fingers, is infinitely less common  than that of their extensors;  it
is, at  the same time, much more serious.   It is, in almost  every
case, in fact,  complicated with  division of the nerves,  arteries, or
some  other important parts; and whether it takes place on the
palm  of the hand, or on the forepart of the fingers themselves, it  is
frequently followed by an inflammation, which may be  attended
with most serious consequences.  The resources which art borrows
from operative surgery to remedy this species of injury, are here,
also, position  and the suture.
  The suture in these cases has not the same advantages as for the
extensor tendons. It is easy, in fact, to perceive that, in addition to the
difficulties of the operation, the suture of the flexor tendons, whether
in their sheath, (coulisse) or in the palm of the hand, would also incur
the risk of propagating inflammation or suppuration  towards the
wrist  and fore-arm by means of the  synovial membranes, (toiles.)
There would, also, almost inevdtably result from it  such extensive
adhesions as to interfere with the play of the tendon.   It  appears,
however, that it has occasionally been performed with success. In
Gautier's case,  for example, the  suture was applied  to the flexor
tendons.   It was  the same, also, in the old soldier whom M. Blan-
din mentions, (Diet de Med. et de Chirurg. Prat, t. xiii., p. 234.)
There are, however, but a very  small number  of such cases ;  it
must also be  added, that some of them relate much more to the ten-
dons of the wrist than to those of the fingers.
  Simple position, on the contrary, succeeds in this region with its
usual  effectual results.   In a patient  of Warner,  (Observ. de Chir.,
trad, franchise, p. 179,) the flexion of the hand, and pressure made
from  above downwards upon the forearm, allowed the flexor ten-
dons,  which had been divided by a piece of glass, to  resume  their
functions.  Martin relates (Ancien Journ.  de Med., t. xxiii., p. 555)
that a woman, who had the flexor tendons of the fingers and wrist 
             ALTERATIONS OF THE TENDONS OR  MUSCLES.         411

divided by the cut of a sabre, was perfectly  cured in three weeks
by means of  simple position.   In the first Aelume of the Melanges
of Mothe there is a similar case, in relation to the flexor tendons
of the ring and little fingers.  I have myself several times seen the
entire section of one or more of the flexor tendons of the fingers fol-
lowed by an  exact reunion of the div ided ends, solely by means of
the position of the  parts.   In truth, flexion is, to a certain extent,
the normal position of the fingers of the hand. It is, then, quite nat-
ural that this flexion, methodically sustained, should suffice to re-
place the two extremities of the tendon in contact.  There  is, also,
an anatomical arrangement in these parts Avhich is entirely to the
advantage  of position and bandages.  I allude to the kind of fibro-
synovial sheath  (etui)  which resists every deviation of the flexor
tendon, before as Avell as after its division;  a sheath  Avhich,  it is
true, does not exist in so perfect a state in the palm of the hand,
but is replaced in that part by an aponeurosis or muscular  masses,
which still, however, possesse  the power of restricting the tendons
to a very limited space.
   Consequently, the suture would not be indicated upon the palmar
surface of  the fingers or of the hand, except where  the  divided
tendon projected into the interior of the wound, or Avhere its ends,
disengaged from their  sheath, exhibited too great  a  tendency to
separate from each other, and that it should appear next to impos-
sible to cure the  Avound Avithout suppuration.
   As to  the position and dressing, Ave may proceed in two ways—
 1. After having  approximated and united the lips of the  wound,
and properly flexed the wrist and fingers, the hand is to be filled
with lint and compresses.   The Avhole is then fixed in this position
by means of a roller bandage, surrounding a dorsal splint, and a
cushion,  Avhich are prolonged to the extremity of the metacarpus.
2. AAe then  mould upon the dorsal  surface of the  forearm, wrist,
and fingers, a piece of wet pasteboard, curved into a semi-circular
shape below, and maintained by means of a bandage saturated with
dextrine. AVe thus obtain an immoveable bandage, wdiieh,  leaving
the wound  uncovered, alkrws also of our dressing it  separately, at
such time and in such manner as Ave wish.  Being moulded upon
the parts, the layer of pasteboard causes no  inconvenience scarcely,
and furnishes to the parts  a support Avhich they do not find either
in splints or in pieces of Avood or metal.
  If one finger only were wounded, there would be  an advantage
in keeping that  one only flexed, so much the greater  because the
extension of  the others would rather draw doAvn than cause a re-
traction of the upper end of the divided tendon.
  Moreover,  we must not  forget that the flexor tendons of the fin-
gers, surrounded by synovial membranes, or  close fibrous sheaths,
lose a great part  of their mobility as soon as they contract the least
adhesion with the surrounding tissues, and that, if the wound,  of
which  their division constitutes one' portion, should pass to the state
of purulent inflammation,  they would rarely reacquire the perfect
integrity of their  functions. 
412
NEW ELEMENTS OF OPERATIVE SURGERY.
                   § II.—Tendons of the Hand.

  The muscles which move the hand, without extending to the fin-
gers, are on the forepart—the flexor carpi ulnaris, the palmaris lon-
gus, and flexor carpi radialis ; and on the back part, the extensor
carpi ulnaris, the extensor carpi radialis longior, and the extensor
carpi radialis  brevior.   It is  evident that, if the  tendons of these
muscles should be divided, the power of flexion or extension of the
wrist would be greatly enfeebled.  Nevertheless, there is not on
record a known instance of paralysis of the hand  solely imputable
to the division (interruption) of these tendons.  This  is so true, that
no one has scarcely ever suggested for them the application of the
suture.  AVe  find,  however,  by a case  of Gautier,   (Archiv.  Gen.
3e serie, t. ii., p. 57,) that this operation was performed with suc-
cess in  a patient  who  had  had  the flexor  tendons of the carpus
completely divided.  Job. Baster, cited  by M. Mondiere, (Ephem.
Curios.  Nat, 1688,) speaks, also, even of a case of division of the
tendon of the supinator longus, which was treated by suture.   But
to some facts Avhich might be adduced of this kind, avc could op-
pose a great number of others which attest the success obtained by
the simple position or bandages.   In the case of AVarner.  (Observ.
de Chir., etc., p. 179, trad.,)  for example, all the flexor tendons of
the carpus had been divided at the  same time with those of the
flexors of the fingers. I have cured in the same way—1.  Two men,
who had had the tendon of the flexor carpi ulnaris divided ;  2.  Sev-
eral patients, in whom the tendons of the flexor carpi radialis and
palmaris longus had  been divdded, together with' some of the
other flexors ;  3. The same thing has occurred to me with the ex-
tensor carpi radialis longior, the extensor carpi radialis brevior, and
the extensor carpi ulnaris. These are a kind of weunds so frequent
that it would be impossible to enumerate them.
  A great number of reasons unite here to forbid the use of the su-
ture.  In respect to the supinator longus, it would be, I should sup-
pose,  an entirely superfluous precaution; for, if this tendon should
attach itself  (ccllat-il)  at an inch  higher up the radius,  it would
still act upon the forearm full as well. Nor is the action of the
flexor carpi radialis and of the palmaris longus sufficiently important
in their detailed movements  to make  it necessary to  devete any
particular care to restoring them to aperfect condition.   The flexor
ulnaris  muscle, being  fleshy to near the wrist, retracts itself but
very little; the same, nearly,  may be said of the extensor  carpi ul-
naris.  AVhether these tendons are a little longer or a little shorter,
or draw the hand inwards a little more  or a  little less forcibly, is a
matter of very trivial  moment.  The same  must  be  said  of the
extensor carpi radialis longior and brevior, Avhich, being held  in a
sort of fibrous sheath on the postero-external face of the radius, are
thus prevented from deviating either backward or forwards.   The
reasons  stated, therefore, when speaking of the  flexor tendons of
the fingers, could be those alone which  would justify the suture of
the flexor tendons of the hand. 
             ALTERATIONS OF THE  TENDONS OR MUSCLES,         413

  A bandage, whose  solid part, in order to leave some freedom to
the fingers, does not go beyond the level of the metacarpophalan-
geal articulation, is sufficient for keeping the hand in a convenient
position.  If we are treating the flexor tendons—that is to say, the
flexor carpi ulnaris, the flexor carpi radialis, and the palmaris lon-
gus—the pasteboard  splint, placed behind, will  conveniently raise
up the hand and wrist into a state of flexion. In the case of the sec-
tion of  the extensors, it is necessary to place the splint on the op-
posite surface of the limb, to raise up the-metacarpus in a state of
extension.  This pasteboard  should be fixed on the radial side of
the forearm and hand, if the  section was that of the adductor ten-
dons—that is to say, of the tendons of the flexor carpi ulnaris, or
of the extensor carpi  ulnaris only ; finally, it should be placed  on
the inner side, if the section was  that of the extensor carpi radialis
longior, or of both the extensor carpi  radialis longior and the bre-
vior. AVith the immoveable dressing, we should haAe, in these dif-
ferent  cases, to leave a space opposite the wound, in order to be
able to  examine what is passing, and to watch the process of cica-
trization, Avithout incurring the risk of disturbing the position Avhich
it has been thought proper to give to the parts in the beginning.

                  $ III.—Tendons of the Elbow.

  In the humero-cubital region there  are, in reality, but two ten-
dons Avdiich can, when divided, claim the aid of operative surgery:
they are the tendon of  the biceps in front, and  the tendon of the
triceps behind.
                    A.  Tendon of the  Biceps.

  Destruction by ulceration or gangrene, a rupture purely mechan-
ical, and a division by external violence, may occur  in  the tendon
of the biceps. As this muscle is the principal flexor of the forearm,
it is natural  to suppose, that  the solution of the continuity of its
tendon would produce in this part a manifest difficulty. Being iso-
lated from the radius to the scapula,  and detached near its lower
extremity, the biceps  muscle would seem, moreover, calculated to
undergo a considerable degree of letraction at its humero-cubital ex-
tremity.  We must, then, regard its division as a very serious matter
and endeavortoremedy it as perfectly as possible. Experience, never-
theless,  tends to show that it is less serious than one would at first
suppose.  Haller, citing Molinelli, speaks of a patient who, having
for a long time a retraction of the forearm, broke the tendon of the
biceps by a sudden extension, felt at the same moment a cracking
noise accompanied with pajps, and soon after found himseT com-
pletely  cured.
  We  find in the  Bibliotheque  of Planque, a case  related  by
Granier and requoted by Lafaye, (Dionys. Op jr., t. ii., p.  681,) the
result of which was, that the  section of the tendon of the biceps
did not prevent the movements of the arm and forearm from being
restored after the cure of the wound. 
 414           NEW ELEMENTS OF OPERATIVE SURGERY.

   Among the facts wdiieh I could adduce in support of the observa-
 tions of Granier and Molinelli, I wall confine myself to the follow-
 ing.   A young printer came to the hospital of La Charite, in 1836,
 for a large contused wound, which had divided not only the skin,
 but the aponeurosis, and the whole of the biceps, and even a part
 of the brachialis-anticus,  immediately  above the articulation.   I
 took upon myself to say. that if this young man got well without an
 amputation, he would at least remain incapable of flexing the fore-
 arm.  I was in this point deceived;  the  cure  took  place, and the
 movements of the limb were almost perfectly restored.
   AVe may, therefore, be permitted  to say, that solutions of con-
 tinuity in the  biceps do not inevitably lead'to a loss  of  the move-
 ments of flexion  at the  elbow.   These movements are preserved
 after weunds  of this kind, both  by  the  action  of the  brachialis-
 anticus,  and by the re-establishment of the  continuity,  either me-
 diate or immediate, of the divided tendon.
   The course to be pursued, under such  circumstances, varies
 according to the simple  or complicated nature of the wound.   If
 the wound is  large, if the two extremities of the tendon are easily
 seized, and if  there is a  hope of obtaining a direct agglutination,
 the suture ought to be applied. The simple position might suffice to
 bring the two extremities  of the tendon in a line with each other,
 but it would not suffice to keep them in contact without  any devia-
 tion during the time necessary for their adhesion.  In other cases,
 that is to say, when, either in consequence of the conditions in Avhich
 the wound itself is found,  or for any reason whatever,  the  direct
 union  appears next to impossible, it is better to have recourse to
 the use of bandages, Avhich ought, moreover, to  be associated with
 the suture, when it  is judged advisable to employ it.
   The bandages  required in cases where  there is a section of the
 tendon of the biceps at  the  bottom of a wound, should keep the
 forearm  in supination, and the flexion at a  right-angle, while  it
 prevents every kind of movement in the articulation of the elbow,
 during the period of treatment.  I make this dressing without any
 difficulty by means of a long bandage saturated with dextrine, and
 a piece of pasteboard behind, wdiieh  extends from the  shoulder to
 the wrist.  A  course (plan) of roller bandage is first applied to the
 skin; the pasteboard splint  comes next, then the dextrine bandage
 to make a second, or even  a third  circular layer.   The whole
 should leave  an  opening opposite the  wound, that is  to say  in
 front of the articulation.   If it  should be found necessary to in-
 crease  either the  flexion or extension of the forearm, it would be
sufficient to moisten the bandage opposite  the elbow ; then leavine
it afterwards to dry, it would be ena^ed to reassume all its immo-


            B. Tendon of the  Triceps, and Olecranon.

  At the elbow   the tendon of the triceps is liable to the same
lesions as that of the biceps.   Only one example, and that very 
            ALTERATIONS OF THE TENDONS OR MUSCLES.         415

doubtful, (M. A. Severin, Med. Efficace, Bibliot de Bonet, p. 593,) is
recorded of its rupture or section; its wounds, in fact, have, up to
the present  time, generally been passed over in silence.   In the
place, however, of rupture of the tendon of the triceps, science
furnishes numerous cases of fracture of the olecranon.  But these
fractures, also, which have so much attracted the attention of prac-
titioners, and which are accompanied  with a separation  of  from
two to fifteen or eighteen lines, do not destroy the extension of the
forearm, even when they are not submitted to any course of treat-
ment.   The case of a woman, who, in  consequence of a  fracture
of this  kind, had the olecranon for six years drawn up  more  than
an inch from the ulna, without suspecting it, or experiencing any
sensible inconAenience in the movements of the limb, emboldened
me to leave many fractures of this  kind without dressing; and I
ought to sa,j, that they have appeared to me to recover more rap-
idly and more perfectly than those that have been treated with the
most ingeniously devised bandages.  Every thing shows that the
division of the triceps ought not to lead us to form too unfaverable
a prognosis.  Either by the aid of the suture or of simple position,
we could effect its union, either direct or indirect, and so perfectly,
that the function of the forearm would be scarcely in the least de-
gree impaired.
   If the wound was smooth, or by a  cutting instrument, the suture
Avould be preferable to bandages.  We should proportion the  num-
ber of the stitches to the  Avidth of  the divided tendon, that is, it
would require from three to six, according to the age or muscular
development of the individual.   It weuld be advisable, also, that
the stitches of the  suture  should include only two-thirds or three-
fourths of each end of the tendon.
   Supposing that the wound should be contused, and  the suture
seemed impracticable, or of too difficult application,  we should
then place the limb in a  state of moderate extension, by means
of a roller bandage, and a long splint of pasteboard, adjusted  upon
the anterior surface of the arm and forearm, the  whole  having
been saturated  with dextrine, and so  arranged as to leave an open-
ing (fenetre)  opposite the wound.  It is obvious  that this Avound
should be treated, moreover, by the known uniting means, and that
the roller bandage should press down  the soft parts towards the
dbow as much as possible.
  For a fracture of the  olecranon, indeed, it would be  necessary,
in order to prevent the retraction of  the fragment, to slip between
the bandage and the upper fragment  some pieces of linen, in fact, a
graduated compress, to crowd it downward towards the ulna; but
this compress Meuld be extremely injurious if we were  treating a
division exclusively of the tendon of  the triceps.
  In the case of rupture of the extensor or flexor tendon of the
forearm, Ave must, as in rupture of  the tendons  of the wrist and
fingers, be prepared in due time to  encounter a stiffness (roideur)
in the  neighboring articulations.  If the  cicatrization appears to
progress regularly, Ave  commence at the  twelfth or fifteenth day 
 116           NEW ELEMENTS OF OPERATIVE SURGERY.

to moisten the bandage a little  opposite to the joint.  Eight days
after, we need have no fear of increasing the motions a little more ;
and the dressing is finally removed before the end of the month. From
this time we are to take the same precautions as if we were treating
a fracture Avhose callus was not completely consolidated.
  AVe  ought,  perhaps, to say a word  here of the  section of the
muscles of the axilla and shoulder, and more especially of the ten-
dons of the pectoralis-major and pectoralis-minor; but it has never
jet come to my knowledge that any one has proposed to perform
the slightest operation on them, Avith  the view of re-establishing
their continuity.  I will remark only, that those two muscles have
been very often divided, either to allow of the axillary artery being
tied, or for the extirpation  of certain tumors; and that in patients
who have survived these  serious operations, it  has not been ob-
served that the movements of the arm were perceptibly changed.
In the only case  of this kind which I have had an  opportunity of
seeing, an intermediate  substance, a kind of fibro-cellular mem-
brane of great thickness, which had restored the continuity of the
two divided muscles, explained to me how the arm had lost nothing
of its power.  No doubt the same thing would take place in the
deltoid, if it should happen to be cut through a great part of its
breadth.

                  § IV.—Tendons of the Foot.

  The  extent, variety, and importance of the movements of the
fingers, make an important distinction between them and those of
the toes.   So also has the division of the tendons  of the foot oc-
cupied the  attention of practitioners  infinitely less than those
of the  fingers.  Admitting  that the solution of  continuity of the
extensor tendons  of the  toes should render it impossible to raise
those appendages at will, we do not perceive, therefore, that this
weuld  thereby be attended with so  much inconvenience as to re-
quire any great precautions, or  an operation that is at all difficult.
It weuld suffice, then, in case of a wound of this nature, to confine
ourselves to containing  and uniting bandages, Avithout  recurring
to either a suture or any fatiguing extension.
  I should say the same, also, of the flexor tendons, whose entire
divdsion, however, appears to be a  very rare  occurrence.   Here,
moreover, the  indication would be,  to keep the toe or toes corre-
sponding to the wounded tendons as  strongly flexed as possible.
Having a great tendency to turn back upon the dorsum of the foot,
they might, wdthout this precaution, be injuriously drawn in  this
direction by the antagonist extensors.

            A. Tendons of the Tarsus and Metatarsus.

  AVe find.about the lower part of the leg the tendons of the three
peronei muscles,  the tibialis-anticus, the tibialis-posticus, and the
tendo-Achillis, besides those which extend to the toes. 
ALTERATIONS OF THE TENDONS OR MUSCLES.
417
  I.  The Anterior Tendons.  If the  tendon of the  tibialis-anticus
only was  cut, perhaps there would result from it but little incon-
venience to the movements of the foot;  but if there should exist
at the same time  a division of the extensors of the toes, we should
have to fear the loss of movement in the flexion of the tarsus, and
consequently the  formation of a pes equinus, [a variety of club-
foot.—T.]
  Surgery has consequently a part to play here.  If the conditions
of the Avound permitted it, we should apply the suture to the divi-
ded  tendons.  Supposing,  unfortunately, that some articulation
should have been laid open by the same blow, it would, in order to
avoid suppuration wdth greater certainty, be much better to confine
ourselves to the  employment  of bandages.   The  bandage  could
then consist  of a sort of stirrup, (etrier) fastened by any contri-
vance whatever  to the neighborhood  of the knee.  That which
offers the greatest security, and at the same time the greatest solid-
ity, is the roller bandage saturated with  dextrine, especially if we
take the precaution to insert between  its layers (entire ses plans) a
wide and long strip  of moistened  pasteboard.  After leaving  an
opening on the instep, and  keeping  the foot forcibly raised up  by
means of a loop of bandage, until the dextrine is consolidated, there
is nothing more to attend to.
  II. Tendons of the Peronei.   The section of the peroneus-tertius
would require the same  treatment  as  that  of the tibialis-anticus;
except that it is far from having the  same importance, and it would
be important to raise up the foot at its  outer edge at the same time
with the extension, while with the tibialis-anticus it is directly the
reverse.
   Tendons of the Peroneus-Longus and Peroneus-Brevis.  Concealed
as it were behind the external malleolus, and  enclosed there in a
kind of fibro-synovial groove, the severing of these tendons must
necessarily be a rare occurrence.  Their division would inevitably
cause the turning of the foot inward,  and would put this part of
the limb in the same state as if there were a paralysis of the outer
muscles of the leg. This occurred in a case which I saw:  one of the
tendons had been completely divided, and the other was half torn
off by large broken fragments  of a vase of Delft Avare.  The foot,
strongly turned inward, could no longer be brought to its natural
direction by the will of the patient.  We should apply to this divi-
sion, also, what I have said of the tibialis-anticus; we should make
use of the suture, if the ends of the tendons, though visible, do not
appear  disposed to put themselves in contact by the aid of position,
and provided the wound  be sufficiently smooth to leave scarcely
any thing to apprehend from suppuration.  The position only should
be reserved for the  other cases.  We should have so much the less
motive for the employment  of the suture,  from the fact that even
with an intermediary  cord, the continuity of these tendons would
be sufficiently well  established to restore to the foot afterwards  all
its required force and agility.   In a  patient I attended, and who is
a distinguished physician of Paris, I confined myself to applying a
  vol.  i.                       53 
418
NEW ELEMENTS OF OPERATIVE SURGERY.
 suture to the integuments, to keeping  the foot in abduction, and to
 subduing the inflammatory symptoms; and although some purulent
 collections were formed, and the skin seemed to contract adhesions
 with the subjacent parts, the foot, nevertheless, regained its power
 and natural mobility.
   The dressings in these cases weuld require only a slight modifi-
 cation.  The opening should be left on the outer part instead of in
 front;  the pasteboard splint should be on the inner side in place of
 behind; a large cord, fastened between the turns of the roller band
 age, on the  inner side, and passing in form of a bridle under the
 sole of the foot, weuld serve to raise the outer edge of this member,
 by being fixed to the outer surface of the knee.
   III.  Posterior Tendons.  The  tibialis-posticus and the flexors of
 the toes, in the event of being  divided, should be subjected to the
 same rules of treatment as those which I have just described, ex-
 cept that it would be more difficult to apply the suture to them ; so
 that position, associated with bandages, would, of themselves, be
 generally quite sufficent.

                     B.  The Tendo-Achillis.

   A solution of the  continuity of the tendo-Achillis has always
 seemed  a very serious matter.  Desport  (Traite des Plaies par
 Armes a feu, p. 166 ; Bagieu,Examen., <§c, p. 463) relates, that, but
 for Mery and Thibault, amputation of the leg Avould have been per-
 formed, at the Hotel-Dieu, upon a patient who had had this tendon
 divided, and who, moreover, recovered perfectly without the neces-
 sity of this mutilation.  The solutions of continuity of this tendon
 have  also  been regarded in  various points of vieAV; some facts,
 for example,  lead to  the supposition that its incomplete  divisions
 expose  to  more dangers than  those that are  complete.  Moli-
 nelli speaks  of an individual who, having a partial division of
 the tendo-Achillis,  caused by the cut of a scythe, Avas seized Avith
 a violent fever, pains, and delirium, from which no relief could be
 obtained but by completing the section of the wounded tendon.
  In another patient, in Avhom  the tendo-Achillis was almost en-
 tirely divided, who  was tormented with pains and by  a violent
 tension, the symptoms were arrested by excising a portion of the
 tendon of the plantaris, which was found in the form of a fold at
 the bottom of the  wound, (Mem. de  VAcad. de Bolo^ne  t ii   ou
 Supp. a la Trad. d'Heister.)  Clement of Avignon (Heister, ibid  p
 135) relates the case of an individual who, after having the tendo
Achilhs cut three quarters through, was seized with inflammation
gangrene and  a kind of hydrophobia,  but  in whom these symp-
toms suddenly ceased as  soon as the remainder of the tendon was
divided.
  We should, nevertheless, be wrong in concluding,  from examples
of this kind that the surgeon should always terminate the divisions
begun m the  tendo-Achillis.  If it be true, that some of the fila-
ments of this tendon may transmit the inflammation and pain both 
            ALTERATIONS OF THE TENDONS OR MUSCLES.         419

above and below, when they are found at the bottom of a large
purulent wound, it is  also true, that  they must frequently serve as
a point d'appui for the deposite of the new material which is soon
to re-establish the continuity of the  parts.   A man has two-thirds
of the thickness of the tendo-Achillis removed by the kick of a horse.
The wound, an inch and a half wide, is cleansed, purified, granu-
lates (se comble) and cicatrizes,  and the patient is completely cured
at the end of a month.  In any case, however, the tendo-Achillis,
when once ruptured, merits all  the  attention  of the practitioner;
for it cannot be  denied that, in some cases  at least, its rupture
might involve a  severe infirmity.   In a patient thus wounded by
the cut of a scythe, the reunion did not take place, and walking
was utterly impossible, when  M.  Syme, (Arch. Gen.  de  Med., 3a
serie, t. L, p. 112,) who relates the case, undertook its cure.
   Bandages and sutures haAe often been made trial  of to prevent
the  dangerous consequences which  might  result from the section
of the tendo-Achillis.   In  two cases of Molinelli, as in that of
Clement, the cure was  complete, and, nevertheless, bandages only
Avere used to effect it.   In another case, (Collect. Acad.,  t. x.; Mem.
de VAcad. de Bologne, t. ii.,) the tendo-Achillis, though  entirely cut
through, and  indurated and tumefied  at  its inferior extremity,
was redissected at two different times in the direction of the os
calcis, (calcaneum) Avithout the cure being thereby impeded.  The
heel, which Avas at first drawn upward, ultimately, in fact, became
depressed.  The following  three facts are still  more conclusive, but
resemble each other so much that  the question  might very natu-
rally be asked, if they do not relate to the same patient, though
recorded by three different authors.   One is found in the disserta-
tion of Behr, (De  Tendinis-Achillis Soluti Sanatione, Halle,  1765;) it
relates to a man aged forty years, who had the tendo-Achillis divi-
ded, from the  blasting of a rock.   When the tendon itself was
pinched, the patient was not  sensible of it, but  complained severely
as soon as the sheath  of this fibrous cord was touched.  The suture
was not applied, and the .wound was found filled up at the expira-
tion of six weeks.  The patient, who was exceedingly intractable, as it
appears, ruptured his tendon anew; incisions were made to evacu-
ate the effused blood, and the reunion took place still more promptly
than on the  first occasion.  Care was then taken against a return,
by fastening the heel to the side of the knee by means  of a leather
strap, (Gaz. Salutaire,  4  Dec., 1766, No. 49.)  The  second of these
facts is related by Juvet, (Journal de Med., Mars, 1760, ou Bibliot.
de Planque, t. x., in-4°, p. 867.)   An officer of the horse grenadiers
had the tendo-Achillis divided by a basin of Delft ware which broke
under his foot.  At the end of six weeks the union appeared com-
plete.  An imprudent  effort to disengage the foot from  beneath the
rounds of a chair, reproduced the disease.   A separation of more
than an inch took place betAveen the ends of the tendon.  Treated a
second time, and without the  suture,  the wound got well as at first,
leaving, however, a sort of ganglion, of the size of a small nut, on
the very place where  the rupture of the tendon had been  In the 
420
NEW  ELEMENTS OF OPERATIVE SURGERY.
third case, related by Herice, (Mid. Eclairee par les Scienc. Phyi.,
t. ii.,) there Avas a divided tendo-Achillis, Avhich cicatrized Avith the
aid of bandages alone. Avhich  again became ruptured, and  was
reunited anew by means of the same treatment.
  If it is certainly true that these three facts relate really to three
different persons, they prove  indisputably that the section  of the
tendo-Achillis is far from always requiring  the suture.   Lieutaud
d'Aries, (Bibliot de Planque,t. x., in-4°, p. 870.) also, relates the  case
of a patient who had the tendo-Achillis div ided by a ploughshare,
and  in  whom the cure was effected  by  simple bandages.   The
same thing took place in a man of whom Beson (Desault, Journ. de
Chir., t. ii., p. 50) speaks, and in whom the tendo-Achillis had been
divided by a  saw.
  AA e see, moreover, by the cases that Desault refers to, and by a
multitude of  other facts, that the tendo-Achillis, after its divisions,
may generally resume  its functions w ithout the intervention  of a
suture.  According to what Dupouy says, (Desault, Jour, de Chirur.,
t. ii., p. 60,) Pibrac had often seen the rupture of the tendo-Achillis
recover by rest alone.  Gauthier, (Ibid., pp. 60, 61,) Avho rejects
bandages,  gives  two  facts in support of the doctrine of Dupouy.
Rodbard, (Ibid., p. 62,) convinced that the reunion is, in these cases,
effected by the deposite of a new material, had no apprehension from
walking the day after it occurred.  Another patient, treated in the
same manner, recovered as well as he did.
  One of  the most conclusive proofs in favor of this assertion is the
fact communicated to Garengeot (Traite d'Oper., t. iii., p. 267, 2e ed.)
by Poncelet: There was a fracture of the os calcis ; it was thought
necessary to open a deposite of  blood which was  connected with
it; the surgeon cut the tendo-Achillis above, and removed its  infe-
rior extremity, with the moveable fragment of the  os calcis; the
patient got well without any deformity.  The suture, nevertheless,
deserves to be still retained in some cases of solution of continuity
of this  tendon.   Coste  (Garengeot, t. iii., p. 266)  had  long since
practised it several times with success.  A case of the same kind is
related by Cowper, (Philos. Trans., 1699, No. 252, ou Bib. de Planque,
t. x., in-4°, p. 864.)  In the article of  Desault (Journ. de  Chir., t. ii.,
p. 54) there is also a case of reunion of the tendo-Achillis obtained
by suture.  There is to be found another case in the report of the
Hotel-Dieu of Lyons for 1822.
  Recapitulation. In conclusion, the functions of the tendo-Achillis
are too important to make it prudent, where it is divided and easily
seized at  the bottom of a wound, to  rely alone upon position and
bandages.  There is no doubt  that, where there exists a contused
wound and bruised tissues, and a large surface in suppuration, Ave
should be satisfied with bandages and dispense with the suture ;
but should the wound be recent, and still free of inflammation, and
resemble wounds from a cutting instrument, and present the possi-
bility of bringing the  ends  of the tendon  in  contact, the suture
merits the preference.
  To apply the suture here, it is necessary to have needles that are 
            ALTERATIONS OF THE TENDONS OR MUSCLES.          421

very sharp and strong, because of the firmness of the tendon. Also,
it is better to use single than double threads.   However fine may
be the stitches of this suture, we have scarcely any reason to  fear
their cutting through the parts embraced by them.  Three, four, or
six stitches may be required in these cases.  As with the fingers, and
the other tendons in general, it  is better to keep  one extremity of
these threads outside, and to await its separation.  We clean  and
then unite the wound in a proper manner, before  putting the limb
in the position it requires to be kept in until the termination of the
treatment.  This position, Avhich is the  same as Avhere Ave dispense
with the suture, has for its object to relax the  muscles of the calf.
The machines  contrived for  this purpose, whether those of J. L.
Petit, (Acad, des Sciences, annee 1722, ou Bibliot  de Planque, t. x.,
p. 852,) or  of Monro,  (Jour, de Desault, t. ii., p. 52,) appear to me
to be utterly useless.  The observations of Rodbard, Dupouy, &c,
above referred to, prove even that they would be  injurious.
  If the immobility of the knee and the flexion of the  leg were in-
dispensable, nothing  would better answer for this purpose than a
long  splint of pasteboard, moulded on the forepart of the thigh,
knee, leg, and foot, and enclosed in a roller bandage, which, without
compressing the limb, would  confine it in the position in Avhich it
would be desirable to maintain  it during the  whole course of the
treatment.  But when we use the suture, this position is entirely
superfluous, and when we do not use it, a few lines, more or less,
between the two ends of the tendon is  a matter of too little conse-
quence  for the discreet surgeon to incommode his patient on  this
account.  The ordinary roller bandage, extended from the roots of
the toes to below the knee, and made more secure in  front by a
large splint of pasteboard moistened, Avill be sufficient in such cases.
A band, in the form of a strap, under the sole of the foot, and fast
ened  near  the ham,  keeps the heel raised up until the bandage,
saturated with dextrine,  has  become thoroughly  dried.  An open-
ing, expressly reserved, allows the wound to be dressed separately,
and the whole occasions but very little inconvenience.
  If we were treating  a fracture of the os calcis, this bandage
would require no other modifications than the  addition of a gradu-
ated compress, analogous to that Avhich I  have spoken of in treat-
ing of the olecranon, and which should be fixed above the heel.
  The ordinary rupture of the tendo-Achillis would do equally well
with the same dressing.  It would be sufficient, then, in order to
have  a perfect bandage, to leave no opening, and to place no grad-
uated compress between the turns;  a long splint of pasteboard,
moreover, could be applied upon the posterior surface of  the leg
and the plantar surface of the foot.
  In place  of leaving the  foot immoveable in  this position for  two
months, as  many writers recommend, it is proper, in the division of
the tendo-Achillis, whether complicated or not with wcunds of the
integuments, that we should discard the immoveable dressings and
extensor apparatus towards the end of the second week, in order
from that time to impart gradually more and more extended move- 
  422          NEW ELEMENTS OF OPERATIVE  SURGERY.

  ments to the parts.   For a long time I have used Avith such of my
  patients  as  have been affected with rupture of the tendo-Achillis
  no other  treatment than this.

             § V.—Tendons of the Femoro-Tibial region.

   The solution of continuity of the  fibrous  prolongations, that are
 destined to move the leg, should be examined,both, at the ham and
 knee.

                     A.  Tendons of the Ham.

   The projections that these make behind  in certain  positions of
 the  leg sufficiently show, that the biceps, on the outer side, and the
 sartorius, and  gracilis, and semi-tendinosus, on the inside, may be
 reached and divided  in certain wounds of the popliteal region.   I
 have found no case in authors of solution of continuity of the ten-
 don of the biceps, properly so called.  It is not so with the tendons
 Avhich form the inner border of the ham. Two facts, at least, prove
 that the division of these tendons does not involve an irremediable
 loss of the motions of the knee, when treated by simple position and
 the suture.
   A member of the ancient academy of surgery, Boucher, (Mem. de
 VAcad. Royale de Chir., in-8°, edit. 1819, t. ii., p. 205,) relates the
 history of a  wound from  firearms, Avhich included two orders of
 flexors in the leg, and which, in spite of destruction of parts  sus-
 tained by the condyle of the femur, nevertheless allowed of the per-
 fect  restoration of the movements of  flexion  at the  knee.
   Pare (CEuvres Completes, 9e edit., 1633, in-fol., p. 773) relates the
 follow ing  fact, as among strange things,  (choses etranges)  Etienne
 Tessier, says he, a master barber-surgeon, has told  me that he
 dressed Charles  Verignel, for a wound  Avhich he  had in his right
 calf, with  complete incision of  two of the tendons Avhich flex the
 leg.  He sewed these two tendons together, end to end,  and treated
 his patient so well that the weund consolidated perfectly.
   It  may  be  conceived that, in a region like this, the suture could
 not be attempted, unless it should  appear  easy to reach and ap-
 proximate together the  two extremities  of the   divided  tendon.
 This suture would be  so much the  more necessary, as the tendons
 of the  ham retract, in general, to a great distance in the direction
of the  thigh.  If, however,  it should not seem prudent  or practica-
 ble to apply it, we should have no great reason to  regret it, seeing
that  the divided tendons, ultimately becoming attached to the mus^
cles  which remain fixed upon  the  tibia, would, in fact, make use
ot these last to transmit their action to below the knee   The best
position of the limb in such cases, is that which keeps  the leg in a
state of flexion  and the thigh in a state  of extensionf

                    B. Tendon of the Knee.
  The  extensor muscles of  the leg, arriving at the knee, all unite
together to form one single  tendon.  Interrupted by the patella, this 
             ALTERATIONS OF THE TENDONS  OR  MUSCLES.         423

tendon, which is more especially the termination of the rectus fe-
moris, is inserted, as Ave knoAV, upon the  tubercle  of the tibia, aftei
having taken the name of the inferior ligament of the patella.
  AVe may thus comprehend hoAV it may be divided in three differ-
ent regions—that is, above and below the knee, and also on a line
with its  articulation.  These three different kinds of solution of
continuity are, moreover, represented by the transverse fractures of
the patella, by the ruptures of the sub-patellar ligament,  and by the
solutions of continuity of the tendon of the  rectus femoris.
  AVhether viewed in its ensemble, or in one  of its regions, the ex-
tensor tendon of the leg has never been divided without creating
great anxiety in the minds of surgeons.  The numerous dressings
devised for curing fractures of the patella are a proof of it.  As
bandages have less hold on the ligament of the patella and the ten-
Ion of the  rectus femoris, than on the fragments of the patella,
properly so called, authors have been still more alarmed with the
pure and simple division of the tendons  of the knee than with frac-
tures of the patella itself. Seeing that the muscles of the thigh had
thus lost all their attachment to the tibia, it was thought that the leg,
no  longer able  to extend itself, would then be inevitably drawn
backwards by the flexor  tendons.
  Fracture of the Patella. An attentive  observation of facts happi-
ly shows, that practitioners, on this point, have been deceived by
false inductions.  The numerous  examples, however, of fractures
of the patella remaining with an extended separation of the frag-
ments, and without the functions of the knee having thereby lost
their power or agility, ought to have awakened attention  on this
point.  For my own part, I haAe seen facts of this kind of the most
conclusive character.  An ancient officer of marine, who had a sepa-
ration  of five fingers' width between the two fragments of the pa-
tella,  nevertheless executed with  this leg all the functions and all
the movements that the other was capable of.  I have since met with
at least a dozen persons who thus had from six lines to an inch, and
even tAvo inches, of separation, resulting from former fractures, yet
experienced no inconvenience.  Also, since 1832, I haAe dispensed,
in patients  affected wdth  this fracture, with all annoying dressings;
to prevent the consecutive stiffness of the articulation, I permit
them to get up and walk about at the end of twenty to thirty days,
and even sooner, if the separation is inconsiderable.  In proceeding
in this  manner, I have seen fractures of the  patella recover more
perfectly, and with infinitely less trouble, than by the long-protract-
ed employment of the most ingenious dressings.  In this very year,
(1838,) I have twice observed this fact, and in the same patient, at
the hospital of La Charite.  A cooper's boy,  of strong and robust
make,  breaks his  patella; the two fragments of bone,  separated
more than two inches, are brought together at the distance of some
lines from each other, and kept in contact by the uniting bandage
for transverse wounds, associated with the roller bandage, which
has been rendered immoveable by the solution of dextrine.  It was 
424
NEW ELEMENTS OF OPERATIVE SURGERY.
 impossible to prevent this patient from getting up and walking on
 the tenth day, and, in fact, from quitting the hospital at the end of
 a month.  Annoyed by this bandage, he found means of getting rid
 of it before the fortieth dav.  and came from Passy on foot to shovv
 me, at the public  consultation, that he Avas perfectly cured  and
 nmped no more.  A thick and firm bridle, an inch long, united the
 ewe fragments of the divided patella to each other.  A month later
 this boy fell on his knee again and broke the patella a second time,
 or, to speak more properly, the  intermediate substance which had
 restored its continuity.  This  time we found a separation of four
 fingers' width. The same bandage was applied, and the young man
 left the hospital at the end of three weeks.   He took off  the dres-
 sing himself fifteen days later, and again came from Passy on foot
 to show me his knee at the consultation. He Avalked then without
 limping, and felt no weakness in his knee, except when he  attempt-
 ed to run, or to give a kick with his foot.  The  tAvo fragments of
 the patella,however,remained separate by more than twenty lines,
 and the patient was still only at the  sixth week from his second
wound.  I saw him two months after, and he  thought no more of
his fracture.
  AVhat I have said of the patella is applicable, in every respect,
to the superior and inferior ligaments of this bone.  AA  c see, in
fact, that the extension of the  leg ultimately becomes re-established
in patients Avho have rupture of the tendon of the patella,  or of the
rectus femoris of the thigh.  There  came into the  hospital of La
Charite, in 1838, two men with rupture of this last tendon  ; though
it was not practicable to  effect the union by immediate contact, the
cure, nevertheless, took place in  both patients wdthout the func-
tions of the leg being perceptily disturbed.  It  may  also be re-
marked, that  the patient avIio had been the longest under treat-
ment, and by the  most ingenious dressings, retained  much more
stiffness in the knee than the one avIio began to walk at the fifteenth
day from the accident.
  What makes the solution of  continuity of the extensor tendons
of the leg cause less lameness  than one Avould at first suppose is
this, that the  neAV  tissue which unites the  twe ends is itself ulti-
mately transformed into a substance wdiieh almost perfect 1)" repla-
ces  the primitive  tendon.  All,  therefore, that results  from it is
that the cord is found a little longer than it was in its natural state ;
but, as the retraction of the muscles soon compensates this excess
of length, the movements of  the limb experience, in reality, but  a
very slight degree of derangement.
  It is also very clear that, at the knee more  than anywhere else
the rupture of the  tendons with wound of the integuments must be
infinitely more serious than that which takes place under the skin.
In this last case, however, a roller bandage saturated with dex-
trine, (dextrine) with the interposition of a pasteboard splint  from
 the  ischium down to the heel, and  associated with strips of the
 uniting bandage for transverse wounds, is almost always sufficient.
 Rendered immoveable and maintained in a sufficient degree of ex- 
            ALTERATIONS OF THE TENDONS OR MUSCLES.          425

tension by this bandage, the limb allows of walking at the second
week of the accident, and the patient may, without danger, divest
himself of all the dressing by the thirtieth or fortieth day.
  In the event of there being an opening  in the skin at  the same
time that there is a division of the tendon, it would be necessary to
apply the same bandage, if we should be called before the acces-
sion of the inflammatory symptoms, but  in such manner as to leave
an  aperture, of greater or less size, opposite the weunded or in-
flamed region.   In this case, we must do every thing to obtain as
perfect a coaptation as possible ; and as this coaptation never takes
place in an exact manner by the aid of simple bandages, Avhen Ave
are treating the supra and sub-patellar ligaments, it would become
necessary to resort to the suture.   For the tendon of the rectus fe-
moris, there Avould be an advantage in inserting the needle first on
the femoral end, the only one wdiieh has any tendency to retract
and to become  concealed under the integuments ; for the ligament
of the patella, it would also be advisable to begin with the upper
end, which,  in  these  cases, is  the most  moveable and  flabby,
(flasque)
  I have no necessity of adding, that  the surgeon must  expect,
also,dn these kinds of sutures, to meet with great resistance on the
part of the tissues, and that he ought to provide himself with very
sharp-pointed needles.
  The suture being inserted, we apply upon the region left uncov-
ered by the immoveable bandage a simple dressing, or cooling com-
presses, or emollient applications, according to the indication.  If
too much inflammation should supervene, leeches should be placed
in sufficient number in the aperture of the bandage, which also al-
lows perfectly well of the application of poultices.  On the suppo-
sition  that the  wound occupies the ligament of the patella, we
should depress the bandage in such manner that, in arriving at the
knee, it Avould push down the patella with a certain degree of force
in the  direction of the leg.  For the  rectus femoris, the position of
the bandage applied to the  leg should,  on the  contrary, be raised
sufficiently high to crowd the patella as much as possible towards
the thigh.  It is, therefore, only for  divisions of the patella itself
that it would be proper to approximate the edges of the aperture
of the  bandage to an equal distance upon each of the fragments,
and to associate Avith the immoveable bandage (bandage inamovible)
the uniting bandage for transverse wounds.   On the  supposition
that the section should not  extend into the capsule of the joint, it
Aveuld  be  allowable, if there  should supervene no accident to the
vveund, not to retain the patient in bed longer than from fifteen to
twenty days.  In the contrary case, no certain  rule can be given
for the precautions to be taken.  All that we can say is, that, after
a perfect cicatrization of the wounds  of  the integuments, there
would  be no  great risk in allowing the patient liberty to get up
and perform  some movements at  the  expiration of five  or six
weeks.
  vol. i.                      54 
426           NEW ELEMENTS OF OrERATlVE SURGERY.
            S Al.—Tendons and Muscles of the Thigh.

  I have once seen a sub-cutaneous rupture of the sartorms mus-
cle, and several times the section of the muscles which gofromthe
pelv is to the leg.  But those muscles are much more apt than their
tendons to unite by the aid of a  cellulo-fibrous deposition, which
speedily and effectually re-establishes their functions.  It  follows,
therefore, that the section of the muscles of the thigh, like  those ol
the leg and arm and forearm, have no need of the aid of operative
surgery, and that the treatment it  requires is reduced to the keep-
ing of the limb at rest for the space of" a few days.


   Article II.—Deformities  by Retraction of the Tendons or
                           Muscles.

  Numerous  deviations are caused by certain muscles or tendons
becoming permanently retracted and shortened.

                       § I.—Treatment.

  ^Topical and orthopedic remedies on one hand, and the operation
on the other, are the only resources  which science at the present
time employs for the  permanent retraction of the tendons.

                    A. Topical Applications.

  The deviations produced by the retraction of the tendons, and for
counteracting  which, applications  of opium and  belladonna, also
the massage, electricity and sudden fright, (surprise) and an infin-
ity of remedies, have enjoyed a reputation, seem to have now found
a more efficacious resource in the methodical section of the tendons
or muscles themselves.  I  shall, therefore, in  this chapter, have to
treat of an operation Avhich, so to speak, is new, and not of ortho-
pedic means, properly so called ; an operation designated under the
name of enervation by some  veterinary surgeons, Avhich  is more
generally known at present under the title of tenotomy, but Avhich
would require another epithet to make it applicable at once both to
the muscles and tendons.

                         B. Tenotomy.

  The section of the tendons should  not be performed but for per-
manent dev iations that are already old, or at least of some months'
duration.  Before deciding upon it, we should be assured  that the
deviation does not proceed from  some articular rigidity, (roideur)
nor from sub-cutaneous bridles, nor inodular cicatrices ; that it de-
pends, in fine, if not  exclusively, yet in great part, upon a shorten-
ing and unnatural stiffness in some of the tendons or muscles. 
alterations  of  the tendons or muscles.
427
  Though apparently modern, tenotomy dates, nevertheless, from
an early period.  Holland was, it may be said, its cradle. Tulpius
the first who speaks of it, mentions Isacius Minius as having prac-
tised it, (Tulpius, Observationes Medicce, liber iv., caput 58, p. 372,
1685.)   It appears, moreover, that Solingen, (These de Jaeger, 1737,)
also, performed it in the seventeenth century.  Meckren,and Roon-
huysen, whose cases Heister (Inst. Chir., t. ii.,  p. 672) cites, had
also followed, together with Blasius, Tenhaaf,  (Chelius. Man. de
Chir., trad, de Pigne, t. i., p. 463,) and Cheselden, (Rust's Handbuch
der Chir., vol. iii., p. 629,) upon the steps of Minius and Tulpius.
  The dangers of wounds of the tendons were so great in the eyes
of most practitioners, that,  in spite of  such essays, tenotomy fell
into complete oblivion.  A memoir, published in 1742, by de la
Sourdiere, still terminates  in this  wise: " We ought,  therefore, to
avoid  the  section of the  tendons."  The  sensibility of these organs,
as maintained by Boerhaave, explains, moreover, the timidity of
surgeons  on this subject.  And it is not until the year 1782, that
we find any new examples of tenotomy.  Lorenz, who, according
to the  assertion of  Thilenius,  (Chirurgische  Bemerkungen, 1784,
ou Ammon,  De Physiologia Tenotomia,  etc.,  1837,) practised  it at
this epoch,  Avas but imperfectly imitated by Michaelis, (Hufeland
und Himly's Journal, Novembre, 1811,  t.  xxxiii.)   Michaelis, in
fact, only partially divided the tendon, and denies having made
a complete section of it. It is astonishing that Sartorius, (Gaz. de
Saltzbourg, t. iv.,) who put it in practice in 1812, has not, however,
succeeded in  causing tenotomy to  be adopted in Germany.  It
was no longer spoken  of in any country, when Delpech, (Malad.
Reput  Chir., t. i., p.  669,) Avho had already mentioned it in favor-
able terms,  introduced it into France in 1816.  The attempt of the
professor of Montpellier, however, had the same  fate as that of the
German physicians.  The veterinary surgeons, nevertheless, of that
period, made frequent trials of it.  From 1820 to 1836, there have
appeared the  observations  of Lafosse,  Bruchet, Debaux, Bouissy,
Delafont,  Choppin, Lortau, and Casten, (Diet d'Hurtrel d'Arboval;
Manuel de Watel; Proces Verbal de VEcole de Lyon, 1822; Journal
Pratique  de Med. Veterin.,  1826; Recueil de Med. Veterin.,  1824,
1830, 1832, 1835,) who all  demonstrate the  advantages and safety
of tenotomy.  Two observations, also, taken from the practice of
Dupuytren,  show  that this  surgeon had performed it  on men in
1822  and 1823.  There was scarcely any  notice, however, taken
of these facts, when M.  Strohmeyer (Journaux de Rust, de Casper,
de Blasius,  et Archiv., Gen.  de Med., ser. 2,  t. iv., p. 100—ser. 2, t.
v., p.  194) published successively six cases,  and made  known the
experiments which he had performed in conjunction with the vete-
rinary surgeon, M. Gunther. Since then, tenotomy has become so
general in France. England, and Germany,  that it ought to take a
definitiv e rank in the departments of operative surgery. M. Dief-
fenbach told me, in 1837, that  he himself had performed it more
than two  hundred times. M. Syme, INI. Lyttle, and some other Eng-
lish surgeons hive also had recourse to it.  In France, I\I. Y. Duval 
428
NEW  ELEMENTS OF OPERATIVE SURGERY.
 gives moie than two hundred cases of it, (T. Duval These, No. 342,
 Paris. Aout, 1838.)  MAI. Bouvier, Stoess, Serre, Scoutetten. (Cure
 Rad. des Pieds Bots. 1838 ) and Jules Guerin, also, give numerous
 examples of  it.

                      Tenotomy in General.

   Scattered facts in scientific works ought, also, to have sufficed to
 show how little dangerous is the section of the tendons.  Almost all
 those I have  spoken of, in  treating of the suture and wounds of
 tendons, are of this kind.   It has also been proposed for carrying
 out two very  different kinds of indications.  Some surgeons, in fact,
 have had  recourse to it with the view of remedying  the accidents
 from certain  weunds, while tenotomy at the present time is  em-
 ployed only for simple deformities.
               a. Tenotomy in Cases of Wounds.
  One of the cases mentioned by  Molinelli, and where the tendon,
at first partially divided, was afterAvards  completely cut  through
by the surgeon, nevertheless recovered perfectly.   In  a case Avhere
purulent collections (fusees) and gangrene were making rapid ad-
vances, the excision of a gangrenous portion of the tendon put a
termination to the progress of the mischief.  In ^i third case, the
unpleasant symptoms caused by a wound which included the tendo-
Achillis, were subdued after the  excision of the  plantaris, which
Avas  seen at the bottom of the division.   A more  remarkable case
still,  was that of a tendo-Achillis AAdiich it was necessary to dissect
off at two different times from the side of the os calcis, to preAent
the denudation and purulent collections, which continued to extend
themselves.   Under this point of vieAv, the observation of Clement,
already quoted, is equally important.   I have also said that Ponce-
let had thought it advisable to open a  deposite of blood which
covered a  fracture of the os calcis, and to cut the tendo-Achillis to
extract the fragment of broken bone.   We have seen that Desport,
also, divided the tendo-Achillis, because of an ulceration which had
invaded it, and of the serious consequences that appeared to be con-
nected with this ulceration.  It would, without doubt, be difficult to
say,  at the present time, whether, in the cases which I  have referred
to, it was  really advantageous to terminate the section, or to ex-
 cise  a  portion of the wounded tendons.   We are struck, however,
 with the termination of the difficulties as soon as these operations
were performed.  On the supposition that such  results  were not
imputable to pure coincidences, it would not, perhaps, be impossible
to give an explanation of them.   At the present time, no one, as it
 seems to me,  believes in the extreme  sensibility of the tendons,  in
 the necessity of their  exfoliation when they have been in contact
 with the air, or in the dangers of their wounds; but  when Ave con-
 sider that  they are surrounded with synovial networks, or sheaths.
 sometimes cellular, and  at other times  fibrous,  it  appears  quite
 natural that  the inflammation Avhich is established at the bottom 
            ALTERATIONS OF THE TENDONS OR MUSCLES.         429

of, or around their  Avounds, should  readily take on a  diffusible
character, and thus soon cause  extensive devastations.
  Everybody,  moreover, knows  that suppurative  inflammation,
Mdiich spreads along the tendons and  synovial membranes, is soon
accompanied with acute pains,  cerebral reaction, gangrene, or con-
vulsions.  Now is this a sufficient reason that the excision of a de-
nuded tendon, or its  section when it is found only partially divided
at the bottom of  a wound, should be  recommended 1  For myself,
I am disposed to believe not; but I admit that Ave  have, perhaps,
still further occasion of consulting experience upon this subject.

                 b.  Tenotomy,  properly so called.
   It is, therefore, for the purpose  of remedying deformities that
tenotomy should,  in  fact, be reserved.  Under this point of view
it is applied, and  may be applied, to all the tendons and long mus-
cles that are not  separated from the skin by any important organ.
It has already been practised upon the toes, around the tibio-tarsal
articulation, at the lower part of the leg, upon the ham, fingers,
and neck.  No doubt it is equally applicable to the wrist, bend of
the arm, axilla, and knee.  Hitherto surgeons have performed it
either by dividing, transversely, both the skin and the tendon, or
the tendon or  muscle, by drawing it outside  through a longitu-
dinal opening in the integuments, or by not dividing the skin except
 upon the side or sides of the tendon ; from thence  come three dif-
ferent methods of tenotomy, of which one only, as it appears to
me, should be retained, under the title of a general method.
   1. The Dutch  Method. Tulpius  and Minius scarified the skin
 (escarrifiaient la  peau)  before dividing the  tendon.  It appears
that others made use even of  fire or  the  hot  iron  for the whole
operation.   Joeger, (De Capit  Obstip., etc.,  Tubing., 1737,) who re-
jects caustics, and prefers the scalpel to the scissors, recommends,
like Heister and  Solingen, that the  incisions should  be transverse,
 and as near as possible to the clavicle.  It is in this manner that
Dupuytren still proceeded in  1822.  Lorenz. and  Michaelis also,
divdded both the  tendon and  its envelopes.  This method, which
M. Roux and M. Amussat have more recently put into practice,
ought at the present time to be wholly rejected.  Besides the pain,
 inflammation, and suppuration it may cause, it has the serious incon-
venience of making a wound which tends to the formation of an inod-
ular cicatrix, which may at a later period reproduce the deformity.
   2. Method of Sartorius.  In place  of dividing the skin  trans-
 versely, M. Reiche,  (Held,  These, Strasbourg,  1836,) adopting the
practice of M. Sartorius, divided the  skin lengtlrwise.  This first
incision, more than three inches long, as practised by M. Sartorius,
had but an inch and a half of extent in the patients of M. Reiche ;
allowing either the tendon or muscle to be raised up, and to be cut
immediately upon a grooved director, it renders the operation very
 easy.  In proceeding thus, we  should doubtless have more  chances
than by the transverse incision, of obtaining an immediate reunion
 of the wound of the  integuments, and which,  at  the same time, 
430
NEW  ELEMENTS OF OPERATIVE SUKGERY.
would not hinder  the separation of the two ends of the divided
tendon; but there would be too much to  apprehend from inflam-
mation and suppuration to make it advisable to confine ourselves
to this method, which was put in practice by M. Magendie, and
which M. Bouvier,  (Bouvicr, Mem. de VAcad. Roy ale de Med., t. vn..)
also, seems to prefer.  M. Reiche, also, himself admits that in one
of his three patients the wound went on to suppurate for several
weeks.
  3. Method of Delpech.  Delpech had recourse to another method:
having first laid it  down that the  tendon ought not to be denuded,
he believed that in order to effect its section it was necessary to
make a kind of circuit, (detour.)   A bistoury, held flatwise, was
inserted by the side of the tendon, and slipped  along  under the
skin to the opposite side, as  in the  manner of inserting a seton.
Having given about an inch in length to each of the wounds, Del-
pech introduced in  the place of the bistoury a small convex knife,
which served to divide the tendon through, in cutting from the skin
towards the deep-seated parts.
  This method differs from the two preceding in an essential point;
its avowed purpose is not to permit the tendon to remain on a line
with the wound. It  includes at present a certain number of processes.
  Practised in the  manner it was by Delpech, it gave place to two
wounds of too great length.  In suppurating, these Avounds might
transmit  the inflammation  to the tvve ends  of the  tendon.  It is
what actually took place in  his patient, since exfoliation did not
allow him to commence with the extension before the twenty-sixth
day, while  close adhesions were formed between \he sides of the
tendon and the cicatrix of the two external wounds.
  Process of Dupuytren.  M. Strohmeyer, while he adopted the
method of Delpech, subjected it, after the  example of Dupuytren,
to an important modification.
  Provided with a narrow bistoury,  a little convex towards its
point, the operator  penetrates by a simple  puncture from one side
of the tendon to the other, and then divides the tendon by a saw-
like movement from its deep-seated surface to the integuments.  In
this manner tenotomy is reduced to a simple puncture, which is not
followed by any flow of blood, and the wounds of which have all
the chances possible of cicatrizing immediately.
  This process appears to have been modified in France, almost at
the same time, by M. Stoess and M. Bouvier.  M. Duval, w ho, on
his  part,  believes  that he  has brought it to perfection, (Pivain,
These, No. 212, Paris, 1837,) gives the same position as Delpech to
his  patient, and inserts the tenotome  upon the deep-seated surface
of the tendon ;  then turning upward the cutting edge of the instru-
ment, he immediately divides the tissues from the deep-seated parts
towards the skin, as M. Strohmeyer does, taking care, as M. Du-
puytren and M. Syme had already done before them, not to let the
instrument perforate through the  skin on the side opposite to that
of its entrance.
  Process of Stoess. The simple puncture on one of the sides  of the 
            ALTERATIONS OF THE TENDONS OR MUSCLES.         431

tendon, with the precaution of not disturbing the continuity of the
integuments upon the opposite side, now constitutes the most sim-
ple process that science possesses.  So, also, does this already com-
prise at least two shades of modifications quite distinct, which be-
long, one of them to M. Stoess, and the other to M. Bouvier.  That
of M. Stoess (Held, These, Strasbourg, Juin, 1836, p. 53) is no other
than the preceding.  It  is, moreover, seen, by the details given by
M. Held, that  it Avas performed at Strasbourg in 1835, while M.
Duval could not have used it until a year later.
   In approximating dates, in fact, we  are induced to think that it
was put in practice nearly at the same epoch ; that is to  say, in
January or February, 1836, by M. Stoess and M. Bouvier.   M. Du
val, in fact, adhered to the primitive process of M. Strohmeyer in
his operation in the month of October, 1835, and has not spoken of
that which M. Pivain attributes to him until at a much later period.
I have, also, already said, that this modification of tenotomy had
previously been projected by Dupuytren in 1822, before, therefore,
the trials of M. Strohmeyer, and that  MM. Syme and Dieflenbach
had adopted it since 1829 and 1833.
   Process of Bouvier. Besides the process of which we have been
speaking, and which M. Bouvier claims, he has, also, occasionally
followed another, which consists not in gliding the instrument be-
tween the tendon and deep-seated  parts, but, in fact, between the
tendon  and the teguments, so that he divides the retracted cord in
going from the skin towards the centre of the limb. It is a process
which some other surgeons also  have used, and  which, it  is said,
was suggested by M. Dieflenbach in the year 1830. We should do
wrong,  after all, in  attaching any  great  degree  of importance to
any one of these varieties of tenotomy over another.  They are all
good, and the  surgeon should be at liberty to use each of them in
their  place, according to the indication.
   Whatever may be the mode of operation preferred, Ave hear, at
the moment of the section, a characteristic crackling sound, (cracque-
ment) which does not cease but with the division of the last  fibres
of the tendon.  At the instant  when the tenotomy is terminated,
there takes place a separation between the extremities of the divi-
ded tendon which may reach to two or three fingers' width.  The
retracted part being no longer drawn in the direction in which it
had until that  moment been confined, renders it now practicable to
restore it to its natural direction.
   The pain caused by this operation is generally slight.  We now
do all in our power, also, to effect the immediate union of the punc-
ture in the skin, and to prevent suppuration from establishing itself
underneath.

                 c. Appreciation of the Methods.
   The relative value of the different  modes of practising the sec-
tion of the tendons is easy to determine.  It is evident at first sight,
that the Dutch method, or that of Tulpius—that is, the one which
consisted in dividing successively, or with  one incision, both the 
432
NEW ELEMENTS  OF  OPERATIVE SURGERY.
 integuments and  the  tendon, belongs to the infancy of  the  art,
 and should be totally rejected.   At most, it should  be reserved
 for those cases where the tendon upon its external face  is blended
 with the integuments.
   The method of Michaelis, having for  its object to divide only a
 part of the thickness of the retracted tendon, whether  including in
 it  the tegumentary division of the method of Tulpius, or adopting
 the first stage (premier temps) of the method of  Delpech, is out ol
 the question at this day.  It  is also  clear, that the method of fear-
 torius, in which the  skin  is incised  in the direction of the axis;ot
 the tendon, and the  latter  afterwards  raised  up to be  divided
 upon a grooved director,  has all the inconveniences, without  the
 advantages, of the improved method of Delpech.  These, then, are
 the three methods that no longer merit being preserved,  except as
 applicable to some special cases.
   The two long wounds connected with  the process which proper-
 ly belongs to Delpech, would not give to his method^ a manifest
 preference over that of Sartorius, since it would be often  difficult
 in that case to obtain an immediate  cicatrization of the division of
 the integuments, and to prevent  inflammation from proceeding to
 the extent of suppuration between the two ends  of the  divided ten-
 don ; but those who have modified  it since  have remarkably en-
 hanced its  value.  It  is only necessary to add, as I have  already
 said, that the difference between the processes  of M. Strohmeyer,
 M. Bouvier, M. Stoess, and M. Duval, is not of sufficient importance
to  require that we should necessarily, and in all  cases, adopt one in
 preference to the other. M. Strohmeyer, who, in one of his patients,
only partially perforated  the skin on the side opposite to the point
where the instrument had entered, and who, on this account, Avould
perhaps be entitled to claim for himself the processes Avhich now
have the most  repute in France, were it  not that his own method
itself reverted of right to Dupuytren, maintains  that the  two punc-
tures  have no greater inconvenience  than a single one, and that
they render the section  of  the  tendon   more  easy.  After that,
 Avhether  the tendon is divided from before backwards or from be-
 hind forwards,  from right to left or from left to right,  cannot, in
 reality, be a matter of any importance. AVhether the wound of the
 integuments, the same as that of the tendon, is transverse, or longitu-
 dinal, as MM. Bouvier and Duval practise it,  is also a matter of
 secondary consideration.  In fine, whether Ave employ for the whole
 operation an ordinary and rather narrow bistoury, or  a kind of
 small  scalpel w ith a convex point, or begin by a puncture with the
 lancet, to recur afterAvards to the tenotome of M.  Stoess, M. Bouvier,
 M. Duval, or M. Scoutetten, will not, as  I conceive, in any respect,
 either take away from or add to the danger of  the operation.
   In fine, the process wdiieh  consists in making  only a single punc-
 ture in the skin, and in which Ave divide the tendon from its super-
 ficial  part  towards  its deep-seated  part, is, all other things being
 equal, the one which merits the  preference.  In  associating with it
 an incision of the integuments parallel with the  axis of the tendon ; 
            ALTERATIONS OF THE TENDONS OR  MUSCLES.         433

in making this incision Avith the point of a lancet;  in inserting af-
terwards, flatwise, through that puncture, an ordinary blunt-point-
ed (boutonne) bistoury, or one of the tenotomes of Avhich I have just
spoken, while Avith the other hand Ave raise up the skin in the form
of a fold ;  in  thus  forcing the  instrument onAvards, until  it has
passed beyond the limits of the other border of the tendon ;  and in
then turning down its cutting edge upon the cord to be divided, and
Avhich is immediately made tense, in order that, by means of gentle
saw-like movements, it may permit itself to be cut through by the
bistoury, we have an operation almost entirely destitute of pain,
which scarcely causes a drop of blood, whose puncture is generally
cicatrized upon the succeeding day, and wdiieh, nevertheless, accom-
plishes all the indications desired.
   Nevertheless, we should not be too much alarmed, if the point
of the bistoury should make tAvo punctures in  the skin, instead of
one;  or if,  in finding some difficulties in passing between the skin
and tendon, AAe should see ourselves compelled to  divide this last
from its lower to its cutaneous surface, provided  Ave take care, in
terminating the  operation, to aAeid the  internal surface of the in-
teguments.  There are circumstances,  moreover, in which one of
these processes  should  haAe the preference  over the others.  AAe
may, in fact, conceive that kind of arrangement of parts, either an-
atomically or pathologically, Avhich might render the process of M.
Bouvier impossible, Avhile permitting the application of that of M.
Stoess, and again, in some other cases,  we could scarcely dispense
with that of Dupuytren or M. Strohmeyer.
   I shall have occasion to return to this question again in treating
of the  section of particular tendons.
   The tendon being once divided, it is generally possible to straight-
en the retracted parts, unless there should be some complication in
respect to the neighboring articulations  or bones.  If that should be
the case, hoAvever, the deformity would rarely fail to be reproduced.
On this subject there are now preAeiling two principles, which are
quite opposed to each other.   M. Strohmeyer recommends not  to
straighten the parts but by insensible degrees ;  M. Bouvder, on the
contrary, that  they should immediately be brought into their nor-
mal position, when it is possible so to do.
  The practice of M. Strohmeyer, which was also that of Delpech,
and  Avhich  M. Held  also extols, is based upon this, that the two
ends of the tendon being for several days very nearly approximated
to each other, the material wdiieh fills up the space between them is
then alloAved to distend and elongate itself without disturbance;
while at an earlier period it might be ruptured or not be formed. M.
Bouvier, howeAer, maintains that AAe may from the very first, wdth
perfect safety, keep the ends of the  tendon at one or two inches
apart, and that we  can thus obtain a more certain elongation, and
one full  as solid as by the other mode.  In order to decide Avho is
wrong or right in such a question, Ave must interrogate pathologi-
cal anatomy and direct experiments.
  vol. i.                       55 
434
NEW  ELEMENTS  OF  OPERATIVE SURGERY.
                    d.  Pathological Anatomy.

   Delpech. (Cliniq. Chir. de Montp., t. 1., 1823 ;  Orthomorphie Hu-
 maine, 182N, t. ii.,) returning  to his favorite idea, asserts that the
 two ends of the tendon are united by means of an inodular tissue.
 M. Acher (These, No. 112, Paris, 1834) relates experiments which
 vveuld tend to the opinion that this union is effected by an effusion
 of lymph or glutinous liquid, (sue glutineux ;) while M. Held attrib-
 utes it to an agglutination of the walls of the sheath of the tendon.
 M. Duval, also, experimenting on rabbits, thinks he has ascertained
 that the new substance is composed of a melange of fibrine and
 plastic lymph ; but the experiments the most detailed, which  have
 been published up to the present time, with the view of elucidating
 this question, are those of MM. Amnion, (Tenotom., etc., ou Exper.,
 t. i., p. 155,) and Bouvier, (Bullet, de  I'Acad., Nos. 5, 6,  8, 11,  20, t.
 i., et 15, 16, t. ii., ou Mem. de VAcad. Roy. de Med., t. vii.)
   1. Ammon. Operating on  horses, M. Ammon has, at  the expira-
 tion of twenty-four hours, found the  twe ends of the tendon lost, as
 it were, in the midst of a mass (magma) of strongly adherent blood.
 At  the end  of two days, the extremities of the tendon were  sur-
 rounded with a clot of blood, (caillot) one portion of which seemed
 already imbued with plastic vitality. On the fourth day, the inter-
 vening  space (I'ecartement) of the division of the  tendon was  still
 filled with blood.  On the upper end was perceived a small cone of
 sanguinolent plastic lymph ;  a similar cone was also found upon the
 lower end.   On the seventh day, the two ends of the tendon havdng
 become tapered doAvn into a conical shape, Avere  considerably ap-
 proximated to each other. Plastic, thread-like exudations extended
from one to  the other.  In a fifth horse, examined at the end of a
month, the tendon appeared to be all of one piece; the  intermedi-
ary substance was an inch long, and differed but little from the
structure of the tendon itself.
  Repeated upon rabbits, these experiments have not been  con-
ducted with sufficient rigor to enable us to deduce any thin°- of a
positive nature from them.  The author thus sums up the results
of his observations:  After the section  of a  tendon, the Avound is
filled with a compact clot of blood, which soon becomes confounded
with the neighboring tissues  and tendinous  surfaces.   A  clastic
lymph, which exudes from the  cut of the tendon, gives  birth in its
process of organization to filiform prolongations, which go from one
end of the divided part to the other.   At a period somevvhaUa^er
this lymph  is replaced by a tissue very analogous to that of the

a bmiTtinf ^^ FeSerVeS  * bl°°dy aSpeCt' and fina% a™
  2.  Bouvier.  In the manuscript which he  has had the kindness
to send to me M. Bouvier speaks in a different manner.   FromThe
second to the third day this physician has found the cellular sheath
thickened, more consistent than in the  natural state, and foimnig
a species of canal^ which embraced by its extremities the two end!
of  the tendon.  Ecchymosed as it were, or of a bright red color 
             ALTERATIONS  OF  THE TENDONS OR MUSCLE3.          435

internally, this sheath was also in contact Avith itself, (en contact
avec elle-meme)   On the ninth day M. Bouvier found it of a gray-
ish color, and destitute of fibres. At a later period, and towards the
twelfth day, the canal of  this sheath began to be effaced, and the
two ends of the tendon Avere still distinct in its interior.   It pre-
sented the form and nearly the size of the tendon towards the
eighteenth day,  though it  still contained  a certain  quantity of
serous liquid.  By the twenty-fifth day, it was almost entirely sim-
ilar to the tendinous tissue itself, at least in consistence.  M. Bou-
vier concludes,  from these  experiments, that the  neAv tendon is
formed at the expense of the surrounding cellular tissue, Avhich,
converted at first into a canal with contiguous walls, changes, little
by little, into  a  solid cord of fibrous substance.  In this, M. Bou-
vier differs essentially, as is seen, from M. Ammon, and approxi-
mates much nearer to M.  Held or M. Acher.
   According to M. Ammon, the union of tendons could be explained
by the doctrine of Hunter.  The blood effused between the ends
of the fibrous cord would, in concreting, attach itself to them, and
vveuld become organized by mingling with an exudation of plastic
lymph, capable of acquiring, by degrees, the consistency and a part
of  the other anatomical characters of the  tendons.  The  experi-
ments of  M. Bouvier vveuld  conduct us rather to the doctrine  of
Bichat, since, according to the satement of this author, the inter-
mediate substance should be no other than the cellular tissue which
naturally surrounds the tendon, and which, by a nutritive  process,
(nutrition) incidentally increased,   (exageree) becomes thickened
and hardened, and transformed by degrees into an actual  fibrous
tissue, and ultimately converted into a true tendon.
   3.  The Author.  For myself, I ought to avow, that the  experi-
ments of M. Ammon have not to me appeared conclusive;  almost
all of them, in fact, have been complicated with  some accident,
whether in relation to the tegumentary wounds, or to the  division
of the tendon itself.  The clots of blood which the author speaks
of,  are  themselves nothing but an accident.  Tenotomy, as it is
practised at Paris, has not produced any thing similar to them.
  Without having made  direct experiments on animals, I believe
that I may be allowed to speak of the union of tendons  accord-
ing  as  I have observed  it in man.  One  of the  patients whom
I  attended for a  rupture of the tendo-Achillis, had, for a few days
only, a very slight  ecchymosis opposite the  wound.  I did not
observe in this  point  any trace, either of effusion or of clots  of
blood.  The rupture, which was recognisable with the aid of  the
finger, filled up little by little, while it preserved the characters of
a. cellular tissue, gradually passing into a fibrous transformation.
Having watched with much attention the process of consolida-
tion in fractures of the patella, I had  here  also satisfied myself,
that the bridle, which finally re-establishes the continuity of the
bone, does not. result from an effusion of fibrine, or an  effusion of
plastic lymph, at least in  a majority of cases, but that it results in
reality from the approximation, concentration, hypertrophy, or fibrous 
436
NEW ELEMENTS OF OPERATIVE SURGERY.
 transformation of the cellular lamellae in the neighborhood.  I havei
 also had it in my power to observe and watch this action, in a
 manner to leave no doubt of its nature, in tvve cases of rupture of the:
 tendon of the reetus-femoris, in many cases of fracture of the ole-i
 cranon, and in an individual who had had the os calcis shattered.  ,
   The  action of which I have just spoken, is  connected, also, with
 a great question in anatomy, or organic evolution, properly so;
 called.   Minute dissections and observations, detailed in the last:
 edition of my Treatise on Surgical Anatomy,  prove, if I do not de-:
 ceive myself, that cellular tissue may be transformed into fibrous
 tissue, and this latter into muscular tissue, and vice versa.
   If this be the fact, not only the section of the tendons, but also the
 treatment of accidental ruptures of these parts, should be subjected
 to rules that the doctrine of Hunter, sustained by the experiments of
 M. Ammon, and  by  some of those of M. Duval, would  reject  as
 imprudent or dangerous.
   Every thing shows, also, that the union of the tendons is effected
 nearly in the  same  manner as that of the bones.   At the bottom
 of wounds, or where the division of the tendon enters into suppu-
 ration, or remains a long time in  communication Avith the atmo-
 sphere, it is by a sort of cellulo-vascular vegetation, by the produc-
 tion of  a kind of inodular tissue, that the union takes place.  If no
 inflammation  nor accidental suppuration supervene, and the two
 ends of the tendon are kept in exact contact, the cicatrix is formed
 by a true callus, that is to say, by a direct agglutination, or a kind
 of imbrication of the fibres of each divided end.  When  a perfect
 state of immobility has not been maintained,  this union is effected
 by a kind of fibro-cellular thickening, (renfiement) in some degree
 analogous to the ferrule (virole) of Duhamel or of Dupuytren.  This
 species of swelling which I speak of, and which sometimes remains
 during life, on the point of contact  of the two ends of the tendon,
 is not alone seen, as M. Mondiere believes, in cases where the suture
 has been employed.   I have observed it twice after the rupture of
 the tendo-Achillis, once in the extensor tendons of the fingers, and
 once after the section of the tendon of the  flexor carpi ulnaris.
 Some observers  mention  it even in  certain cases where the two
 ends of the tendon were decidedly united by  an intermediate sub-
 stance, (Lenger, Encyclograph. des Sc. Med., 1838, p. 145.)
  When the union of a ruptured tendon is effected under the skin
 which remains unbroken, and without our endeavoring to approx-
imate its two ends, the effusion of blood  or plastic lymph between
them would only be  incidental.  The cellular sheath yields, elon-
gates itself, and is converted into a kind  of canal, more or less
flattened  Connecting itself with the common  sheath  above and
below,  this canal seems as if it were strangulated in its middle
portion.  In a short  time it becomes the centre of an afflux [of
blood,] which augments its  nutrition ; the cellular filaments in the
 neighborhood attach themselves by degrees to its external surface.
 The cellular tissue of each end of the tendon  swells, and thickens
 at the same time, which gives rise  there to a kind of enlargement. 
ALTERATIONS  OF  THE TENDONS OR MUSCLES.
437
(renflement)  The more it progresses, the more the hypertrophied
sheath of the tendon approximates to the form of a ligament, and
loses its attributes of a canal.  Projecting in form of a cone, each
end of the tendon becomes imperceptibly blended with the kind of
double funnel (double entonnoir) wdiieh covers (embrasse) its extrem-
ities.   The molecular process continuing, the entire mass finally
forms  a  cord, sometimes  strangulated in its middle, and as if em-
bossed (comme bossele)  at  its two ends,  and which  in other cases
acquires such density and force of resistance, that the muscular
action is transmitted  through this part in the same  manner  as
through the sound tendons.   Perhaps, says M. Bouvier, the sheath
in question would remain  too weak, and would retain the charac-
ters of cellular tissue towards its middle, if the separation of the ten-
don was too wide, or  exceeded, for example  two or three  inches.
I will remark, however, that in a patient who had taken no repose
after  the accident, and who, in  consequence of a  fracture of the
patella, had, in front of the  knee, a separation of at least five fin-
gers Avidth, the supplementary bridle had, nevertheless,  sufficient
force to transmit  to the leg  all the power of the  anterior muscles
of the thigh.
   After these facts, I regard it as very important  to practise tenot-
omy:  1. By a narrow puncture into the skin; 2. By cutting through
the tendon as effectually as it is possible to do it, while taking care
to avoid its cellular sheath; 3. By avoiding with care the  vessels
that might cause the  least  effusion of blood; 4.  By straightening
the leg  immediately, should it not be  necessary to obtain a sepa-
ration of more than an inch and  a half: 5. By augmenting this
separation little by little, after the tenth  or fifteenth day; 6. By
immediately applying a bandage or apparatus, which prevents the
deformed part from reassuming its morbid position; 7. By mode-
rating with the dressing every species of movement in the divided
region, for the space  of some ten days ;  8.  By proceeding after-
wards, by degrees, to movements more or less  extended,  in the
direction opposite to that of  the flexion or extension which we have
wished to overcome.  We shall also see  that the  employment of
apparatus, or auxiliary mechanical means,  should be continued
much longer for some tendons than for others.
   Perhaps, after all, there would be fewer inconveniences than ad-
vantages in allowing the  patients, immediately after the operation,
to make repeated movements every day ;  but experience not hav-
ing yet determined this question, it  appears to me prudent not to try
the extension until after  the time when  the new production has
already attained a certain degree of force and density.  Even  on
the supposition that the tendon had not only been cut in the exterior
of its sheath, but that this sheath itself Avas  also comprised in the
section, this ought not, as I think, to be a source  of disquietude.
The approximation of the deep-seated lamellae of the sub-cutaneous
fascia, and of the other lamella; which  are found in the neighbor-
hood, would secure us from all inconvenience in this respect.  So
that if it is better, in fact,  to adopt all the  precautions required 
43a
NKW ELEMENTS fll  OPERATIVE  SURGERY.
 by the method of Delpech, as simplified by Dupuytren, and after-
 wards by MM. Strohmeyer, Bouvier, and  Stoess, it must also be
 conceded that the operation would not necessarily fail, merely be-
 cause we had deviated from the most simple processes.

                     Tenotomy in  Particular.

   Certain deformities of the foot, leg, hand, forearm, and  neck,
 may find their principal remedy  in the section  of the tendons or
 aponeuroses.

                         a. The Hand.

   It was formerly believed, that the deviations of the  fingers and
 of the hand were almost all caused by the retraction of the tendons.
 AA e have seen, in one of the  preceding chapters, that  the  greater
 part of these deformities are at present ascribed to cutaneous or
 sub-cutaneous bridles. But in this  question, as in many others, one
 error has been destroyed only to give place to another.   It is cer-
 tainly true, that the retraction of  the fingers, whether  backwards
 or forwards, is sometimes produced  by the shortening of the ten-
 dons or muscles.  Consulted in cases of this kind, the surgeon ought
 not to hesitate.  The section of the diseased tendon weuld present
 every possible chance of success.
   1.  Extensor Tendons. In the fingers and on the  back of the hand
 it would, if it were practicable, be  advisable to take up a fold of
 the skin behind the retracted tendon, to insert a narrow bistoury or
 a small tenotome on one of the sides of the fold, and to turn it im-
 mediately towards the tendon itself, the tension of which should be
 increased by trying to straighten the finger.   On the  second pha-
 lanx  no vessel  could be  wounded, while on the  first  and on  the
 metacarpus  it  would be important  to avoid  the veins, Avhich  in
 these places  are sometimes of considerable size.  If there  were
 many retracted tendons, Ave should have recourse to the same ope-
 ration for each.  On the metacarpus, however, it Avould not be im-
 possible  to insert the bistoury sufficiently  deep under the skin to
 divide two and even three  tendons by the same puncture.   Here
 the rule  advises that  we should  incise  the tendon upon its most
 projecting portion, taking care, nevertheless, to avoid the line (ni-
 veau) of the articulations.
  If the case was one of the retraction of the radial tendon* viz
 of the extensor secundi internodii pollicis, or the extensor ossis meta-
carpal pollicis, we could effect the  section without danger, in spite
of the neighborhood of the radial artery, by taking care, while  the
bistoury  is being introduced under  the  skin, to  force  the thumb
strongly into extension and abduction.  Nevertheless, for the radial
tendons only it would be much better that the hand, turned slightly
^n 7Z: f fUW  bf,comPietely s^.  We ought also, in  fhose
two  cases, to force  the tendons, in a certain sense, to make their
own division against the bistoury.  The extensor carpi ulnaris, not
having in its neighborhood any large artery, weuld exact fewer pre- 
             ALTERATIONS OF THE TENDONS OR MUSCLES.         439

cautions.  It would be necessary to make its section between the
head of  the ulna and the upper extremity of the fifth metacarpal
bone.  After the section of these tendons, Ave straighten the hand,
and incline it slightly into a flexed position by means of a prepared
splint, which extends upon  the palmar region of the  forearm and
hand : a pasteboard splint, properly curved, would constitute a sup-
port evidently preferable to a weoden splint, if we should associate
with it  some turns of bandage  saturated with dextrine.  At the
end of six or eight days, we should have to increase the inflexion
of the parts, if the opposite tendency still existed ;  but we  should
take care to stop as soon as the extension ceased to predominate.
From that period, moderate movements of flexion and extension
should be persisted in, until the hand should have recovered the free-
dom of its motions.
   2.  Flexor Tendons. The section of the  flexor tendons of the fin-
gers is evidently more delicate than that of the extensors.  On the
one hand, it might involve an opening into the fibro-synovial sheath,
whose inflammation is extremely dangerous; and, on the other, I do
not perceive how, in effecting it by the process of simple puncture,
we could be assured of the certainty of avoiding the collateral ar-
teries.   In all cases it should be performed only on the  palmar sur-
face of the first  or second phalanx.  In place of perforating the skin
altogether upon the outside, it would be better to enter on the side
of the finger near its anterior surface, and afterwards to divide the
tendon,  while separating it as much as possible from  the  bone,
without  carrying the point of the instrument to any great distance
towards the opposite side.   Supposing, however, that one of the
arteries  should have been wounded, its hemorrhage probably  could
be easily arrested by compression,  properly made, upon the two
borders of the upper part (de la racine) of the finger, or above the
wrist, upon the radial and ulnar arteries.  If it Mere  necessary to
apply a ligature to the vessel, I would  prefer seeking  for it at the
upper part of the finger  than enlarging the  first puncture for that
purpose.
   If the  retraction of the tendons occupied the palm of the hand,
tenotomy weuld also be attended wdth real danger ; to perform it,
it  would be necessary to  cut  through the  aponeurosis, and to ma-
nipulate  in the midst of nerAes and vessels of large size, besides
that the synovial membranes render the inflammation far more for-
midable here than on the forepart of the fingers. Only that the re-
tracted tendon, being so  stretched as to become sufficiently promi-
nent, weuld allow of our directing the  point of the bistoury upon
its opposite border, and of cutting the tendon from one side to the
other, rather than  from before backwards, and without encounter-
ing the branches of the superficial palmar arch.  The retraction of
the radial muscles, especially of the palmaris longus, would be one
of the easiest things to remove by tenotomy. The hand being mod-
erately flexed, while the patient endeavors to approximate the
thenar and hypothenar  eminences,  or, better still, the upper part
(la racine) of the thumb to that of the little finger, renders the ten- 
440
NEW  ELEMENTS  OF  OPERATIVE SURGERY
 don of this last mentioned muscle so projecting that there vveuld be
 neither risk nor difficulty in dividing it.  If the section of the flexor
 carpi radialis should be necessary, it could be effected by avoiding
 the palmaris longus by means of the  indication which I have just
 given.  The puncture of the teguments should then be made on the
 outside of the tendon, but inside of the radial artery   Carried hori:
 zontally under  the  tendon of the  palmaris brevis,  the bistoury,
 whose  handle should  be held a little raised, weuld then, without
 difficulty, effect the section of the  flexor carpi radialis with very
 little danger to the radial artery.  As to the section of the tendon
 of the  flexor carpi ulnaris, Ave may conceive that the neighborhood
 of the artery Aveuld render this operation above the wrist somewhat
 dangerous.
  After the operation,  also, in whatever region it may be perform-
 ed, Ave  must do all in  our power to close up the small wound im-
 mediately.  The same splint as'the preceding  would serve, also,
 after the section of the flexor tendons.   In the palm of the hand it
 weuld suffice, in order  gradually to increase the extension, to add to
 the number of paddings  (remplissages) on the lower  extremity of
 this splint.  Prolonged towards the fingers,  it would elongate them
 also, at the pleasure of the operator.

                 b.  Elbow and Bend of the Arm.
  At the  humero-cubital articulation we find only two tendons—
 that of the triceps posteriorly, and that of the biceps  anteriorly
 —which might by their retraction become  the sources of deformi-
 ties.
  1. Triceps. I know no case of permanent extension of the fore-
 arm produced by the shortening of the triceps; but should  it be
 met with, the  manner  in Avhich ruptures of the anterior tendon of
 the thigh or of the ligamentum patella? are  cured, sufficiently show
 that its section Avould be  clearly indicated.  Nothing, in fact, could
 be more simple than this  section.  Inserted by puncture from the
 outer side towards the  inner, or from the inner towards the outer,
 the instrument, passed under the skin, weuld cut the tendon from
 behind forwards, without incurring the least danger, since there is
 no important organ to  avoid.  It weuld be  necessary, however, to
 take the precaution to  make this section at about an inch above
 the olecranon, in order to be  more  sure of avoiding  the synovial
 capsule of the joint.  We should also take care  to avoid the ulnar
nerve, which is found [running close to] the  posterior surface of
the  inner condyle, (epitrochlee.) The forearm, placed immediately in
 quarter flexion, should be brought into semi-flexion in the space of
from eight to fifteen days.  AVe  should,  after that, give it slight
movements of flexion, extension, pronation, and supination, not
forgetting, m the  interval  of these exercises, tc support  it by a
scarf for the space of about a month.
  2. Tendon of the  Biceps.  The retraction of the biceps is met with
quite frequently;  I have  already seen  seven or eight cases of it,
some congenital, others resulting from disease.   I have not learned 
             ALTERATIONS OF THE TENDONS OR MUSCLES.         441

 that this retraction, which holds the  forearm, to a greater or less
 degree, in a state of permanent flexion, which is characterized by
 a cord in a strong state of tension, whenever we endeavor to ex-
 tend the  arm—a cord which descends from the anterior region of
 the arm into the  hollow of the forearm, has up to the present time
 ever been submitted to tenotomy; but science at the present day-
 possesses facts sufficient to justify its trial. I have already recurred
 to an  observation of Granier, and to two facts of my own, from
 which it results that the complete division of the tendon of the bi-
 ceps, causing thereby  the  destruction of a part of the  muscle,
 does not destroy the functions  of the limb.  An observation  still
 more conclusive  has been published in England  by M.  Ballin-
 gall, (Edinburgh Medical and Surgical  Journal, January,  1835 ;
 Archives  Generates de Medecine, 2e serie, t. vii., p.  264;  Revue
 Medicate, 1835, t. i., p. 393.)   It relates to a  sub-cutaneous rup-
 ture of the tendon of the biceps, Avhich Avas in some degree left to
 itself,  but Avhich, notAvithstanding, soon got  well, leaving only a
 slight weakness in the limb. In the case of retraction of the biceps
 which Molinelli speaks of, (Haller, Mem. sur Vlrritabilite, etc., t. iii.,
 p. 33,)  a sudden extension of the forearm, accompanied with  a
 crackling sound and with pain, relieved the patient of his infirmity.
 It is, moreover, one of those sections of tendons which are the easiest
 to perform; I have many times practised it  on the dead body with-
 out the least embarrassment.  When stretched tense, and strongly
 projecting, the biceps, in such cases, is separated to a very consid-
 erable distance from the brachial artery.  The point of the bistoury,
 inserted at its outer side by puncture, and afterwards raised so as
 to glide under the skin till it reaches on a line with the inner edge
 of the  tendon, allows of our then immediately turning the cutting
 edge of the instrument  baclavards.  AVe  then increase the rigidity
 of the  muscle by trying to extend the  forearm.   With these pre-
 cautions, Ave have only  to press moderately, and in a sawing move-
 ment from before backwards, in order to divide the whole thickness
 of the  tendon, Avhile we are at  nearly the distance of half an inch
 from the  artery.   In operating too low down, we might not reach
 the fibrous  expansion which  goes from the biceps to the  inner
 muscular mass at the fold of the arm ;  but  this bridle is ordinarily
 unconnected with the deviation. Nothing, however, would  prevent
 our dividing it in its turn with a second stroke, if it appeared to
 interfere, in any manner Avhatever, with the extension of the limb.
 It is unnecessary  to remark here, that  Ave should put ourselves on
 our guard against the puncture of the median basilic and median
 cephalic veins, and that it would  also be well to avoid the trunk
 of the  cutaneous  nerves, both internal and external.   To keep the
 limb afterAvards extended,  nothing Avould be more  effectual than
the bandage saturated with dextrine,  which I have already spoker.
of in treating of  sutures of the tendons  in the bend of the arm.
This extension Ave should also be under the necessity of protract-
ing for  seAeral weeks, in order to overcome  the tendency of the
parts to resume their morbid position.
  vol. i.                      56 
442           NEW ELEMENTS OF OPERATIVE SURGERY.
               c. Tendons or Muscles of the Axilla.
   The permanent depression (abaissement) of the arm which may bo
 caused by cutaneous cicatrices,the formation of fibro-cellula.r bridles
 or by a complete or incomplete consolidation of the scapulo-humeral
 articulation, have appeared to me to be also produced in many pa-
 tients by a retraction of the tendons  or  muscles.  The pectoralis-
 minor, the pectoralis-major, the  teres-major, the latissimus-dorsi,
 and the  edges of the deltoid itself, are. in my  opinion, susceptible
 of being thus retracted.  In some  cases, I have remarked that these
 different muscles or their tendons  always took on the appearance of
 hard, inelastic, though indolent cords, at the  moment when I tried
 to separate  the  arm from  the thorax; and  this in two  patients,
 among others, one of whom had had, several years before, a severe
 wound in the forepart of the shoulder, and the other an extensive
 abscess in the fold of the axilla.  AVould it not, then, be allowable
 to perform the section of these parts after the modes above pointed
 out?  For the pectoralis-major,  or the anterior border of the del-
 toid, a sharp-pointed bistoury, passed either upon the cutaneous or
 deep-seated surface of the  muscle, would, without difficulty,  allow
 of our dividing it from behind forward, or from before backward.
 The pcctoralis-minor weuld require that the point of the bistoury
 should be carried down to its lower border, that Ave might there
 divide it by a swinging  movement from below upward, and from
 behind forward.  We might reach the latissimus-dorsi, or the teres-
 major, or the posterior edge of the deltoid, by dividing them either
 on their posterior or anterior surface.  In whatever way performed,
 it would be  necessary afterwards to keep the arm elevated almost
 at a right-angle, by some apparatus or bandage,  for the space of
 three weeks or a  month.   Up to  the present time, no one appears
 to have treated of this kind of operation.

                    d. Tendons  of the Toes.
   In the toes, as in the fingers, there may be retraction both of the
 extensor and flexor tendons.
   1. Extensors.  The retraction of the extensor tendons of the toes,
 existing to such an extent as to elicit the attention of the surgeon,
 is a rare occurrence.  I have, however,  seen  some examples  of
 it; some  in  which the retraction  comprised,  at the same time,
 all the  tendons;  others, in Avhich  it Avas only the  tendon of the
 little toe, or that of the great  toe.  which  was thus  shortened.
 If the deformity  should  exist to so great a degree as  to  cause
 any  real inconvenience, either in  exposing the skin to excoriations.
 or by rendering it difficult to Avear shoes, (des chaussures) it Avould
J_e necessary to have recourse to  tenotomy.  As  there are neither
 imtxes nor arteries of large size  on the dorsum of the metatarsus,
 the only place where it would appear to be advantageous to divide
 the extensor tendons of the toes, tenotomy in that locality would be
 extremely easy; it should be performed in the same way as on the
 back of \he  hand, by a puncture for  each tendon, or even by one 
ALTERATIONS OF THE TENDONS OR MUSCLES.         443
single puncture for the whole of the retracted tendons, preferring,
as everywhere else,  to  make the instrument act from the skin
towards the deep-seated parts.  M. Dieffenbach  (Bouvier, Mem. de
VAcad. Roy. de Med, t. vii.) is the only person, I believe, who,  up
to the present time, has had recourse to this operation on the living
subject.  M. Davidson (Gaz.  Med. de Paris, 1838)  has also per-
formed it, but by excising a portion of the common extensor, and a
cicatrix on the dorsum  of the foot, rather than  in the light of an
operation for tenotomy.
   2.  Flexor Tendons.  The retraction  of the  toes,  in the sense of
flexion, can but very rarely occur to such a degree  as to constitute
it a disease.   These appendages are so  short, and are so well pro-
tected (abrites) by the sole  of the  foot, when they are strongly
flexed, that their  retraction can hardly claim the  aid of surgery. It
is ne "* rsary, however, to  observe that  the great  toe, both by its
size  and  length,  and its importance  as an  organ  of  sustension
and  progression,  is  excluded from  this  remark; so, also, has it
been the object of some special attentions under this point of view.
M. Syme  (Archiv. Gen. de Med., 3e serie, t. i.,  p. 115)  is the first, as
it appears to  me, who has divided its flexor tendons, to remedy a
retraction  produced by a  previously existing inflammation.  The
operation, performed on the first  phalanx, was followed by entire
success.  It  weuld  appear,  also, that  M.  Dieffenbach, (Bouvier,
Mem. de VAcad.  Roy. de Med.,  t. vii.,) on his part, has once had
recourse to it, with results not less satisfactory.
   It would be preferable to perform the tenotomy of the great toe
on the plantar surface of its first phalanx ; but if the retracted ten-
don should be more particularly prominent upon the inner border
and  at the sole of the foot, nothing would interfere with our dividing
it at this point.   As in the  fingers, we should  here have to fear the
lesion of some vessels ; but being of infinitely less  size than in the
hand, the plantar arteries and the  collateral arteries of the toes
could not, in such cases, occasion any very serious apprehension.

                     e.  Tendons of  the Fo9t.
   The foot may  be deviated  by the  shortening of many orders
of tendons.  I shall  proceed  to  examine, under this  head,  the
retraction of the  peronei and  the tibiales, then  that of  the tendo-
Achillis and the plantar aponeurosis.  These retractions give rise
to the deformity  known under  the name of  club-foot, (pied-bot) a
deformity which  may equally proceed from  an alteration in the
bones or articulations, but  of which I do  not  now intend to speak,
except so far as it is caused by the action of  the tendons,   j.   *?
are four principal kinds of  club-foot: the foot  turned inwa^  ."'.'
varus ; outward,  or valgus; upward, (en avant) or talus; and Da„ J-
ward, or pes equinus, (pied-equin.)                            ,f*
  The pied-equin, one of the most frequent, depends, almost alvr* ys,
on a shortening of the tendo-Achillis.  In that  case, the heel ignore
or less raised  towards the  calf, and the patients walk on th.€f point
of the foot, that is, on the  heads  of the  bones of  the metatarsus 
444
NEW ELEMENTS OF  OPERATIVE SURGERY.
 and  the plantar surface of the  toes.  It may  even happen, as I
 have seen in three instances, as in the example  M.  Stoltz (Repert.
 d'Anat. et de Physiol. Pathol..  1S27) has described,  the  five eases
 cited by M.  Duval, (These eitce,  p. 7,) and  as has been observed,
 also, by M.  Scoutetten (Op-r. Ci/af.. p. 107, pi. 2) and other prac-
 titioners; it may happen, I say,  sometimes, that the foot is so turned
 backward, as to oblige the  patients  to support themselves on the
 dorsal surface of the tarsus.  The three patients  submitted to my
 examination, walked on the dorsal surface of the tarso-metatarsal
 articulations of the cuboid and third  cuneiform  bone.  The whole
 three had in that part a large sub-cutaneous bursa-onucosa.  In one
 of them, Avho was  an in-door pupil of the  hospitals of Paris, this
 variety of the pes-equinus appeared  to me to depend  upon  the
 retraction of the plantar aponeurosis, Avhich extended itself, under
 the form of a very hard and distinct cord, to the head of the second
 and third bones of the metatarsus.   It is, hoAvever, rare that the
 four  kinds of club-foot, which I have  just mentioned, remain per-
 fectly distinct, or that one of them is not soon  complicated,  in a
 greater or less degree, with some one of the others.  In the pes-
 equinus, the  metatarsus, also, may be strongly bent back upon the
 tarsus, as happened in the case of the young physician I  have just
 mentioned, at the same time that  the heel was drawn  up by the
 muscles  of the calf.   The pes-equinus is often, also, complicated
 with varus or valgus.  It is so much the more important not to for-
 get this remark, that  the number of tendons to be divided, when
 we wish to remedy club-foot, is always in proportion to the varieties
 or  combination  of the deformities which it is  our intention to
 destroy.
  Perhaps, also, it would be necessary to admit two simple varie-
 ties of pes-equinus, that  which results from a  retraction  of the
 aponeurosis or muscles of the plantar surface of the foot, and that
 which is caused by a retraction of the tendo-Achillis.
  1. Plantar Surface  of the Foot  If, as occurred in the  young
 plrysician above  mentioned, an instance  of  Avhich M. Duval, (Pi-
 vain, Thes., No. 212, Paris, 1837, p. 24,) on his part, appears also to
 have  met with, the plantar surface (la plante) of the foot is found
 in a certain sense folded upon itself, it  is possible that the  deformity
 may arise from a retraction of the  plantar  aponeurosis, or of the
 flexor brevis  digitorum pedis,  much  more than  from a shorten-
 ing of the tendo-Achillis.  In this case it Avould  be necessary to
 begin by an operation which, up to the present moment, has not  I
 beWe, been advised by any one, that is, by the section  of the re-
1 or, 5°rd ?f, th<T S0le of the fooL   The Patient having the foot
1^ .Jed, and held so by an assistant, Avould enable the surgeon to
 reduce the instrument by puncture between the teguments and
 fl/ous bridle, from right to left, or from left to right, almost indif-
  V^- Jrtei\ ,YinS tUmed the cuttinS ed%e of the tenotome, it
 W°% SU?T  t0     itS handle a little  ^low the plane of the lower
 sulfa .2 of the foot, to prevent all danger while  dividing the cord
 from  its cutaneous towards its deep-seated surface.  As  it is quite 
             ALTERATIONS  OF  THE TENDONS OR MUSCLES.         445

difficult in this region to distinguish what belongs to  the aponeu-
rosis, and what to the short flexor muscle, or to its tendons, it would
be better to carry the incisions as far backward as possible, unless'
the bridle should be  much more  projecting, or more conveniently
raised up in front than towards the os calcis.  The important part
of it weuld be, not to carry the cutting edge of the instrument too
much outward nor too much  inward, seeing that  nearly the whole
of the  plantar artery lies under the borders of the foot.  If, after
having divided the principal bridle, we should be enabled by the
finger to discover others in the neighborhood of the first, we should
endeavor to reach them without stopping the operation, (desempa-
rer) and divide  them through  the same opening in the integu-
ments.
  As this variety of the pes-equinus is almost always accompanied
Avith a greater or less degree of luxation of the  second range of
the bones of the  tarsus upon the first, the section of the tendon, or
of the  plantar aponeurosis, Avill rarely allow of an  immediate re-
adjustment (redressement) of  the foot.  We must look, therefore, for
some difficulties in this direction, and rely upon the aid of an appa-
ratus to complete the success of the operation.  If, however, the
difficulty of adjusting the foot in such a case should arise from the
concomitant retraction of some other tendon, it would be advisable
to divide that, as  well as those of the sole of the  foot.   It is  thus
that the  section of the tendo-Achillis,of the  flexor longus pollicis
pedis, and of the  peroneus longus, or of the flexor digitorum com-
munis, might be  requisite after that of the flexor  brevis, or of the
plantar aponeurosis.
  In conclusion, I have, up to the  present time, seen but one  case
where the operation which I describe has appeared to me to be prac-
ticable;  I am aware, moreover, that M. Duval (Pwain, These citee,
p. 24) has cured club-feet with reversion of the dorsal surface of
the metatarsus, by confining himself to the division of the tendo-
Achillis.
  2. Section of the Tendo-Achillis.  The section of the tendo-Achillis,
Avhich it  is said was long ago practised in the Limosin. (Scoutetten,
Mem. sur la Cure Rad. des Pieds-Bots,  Paris, 1838, p.  12,)  is now
one of the most important operations in surgery.  In the cases of
Poncelet, Desport, Molinelli,  and some  others, of whom I have spo-
ken above, it  was performed for reasons altogether different than
for those of a deformity of the foot.
  A.  The history of this operation, however, is not  difficult to
be given at  the  present time.  The first surgeon who has spoken
of it, in relation to club-foot,  is Thilenius, (Obs. de Med. et Chirur.,
Francfort,  1784.)   It was Lorenz, moreover, who performed it
March the 26th, 1782, and not Thilenius  himself, as has generally
been often asserted among us.  More  recently, in 1809 and 1810,
Michaelis, a surgeon  of Marbourg, published a memoir, (Gaz. de
Saltzbourg, et Journal de Hufeland, 1811.) tending to demonstrate the
advantages of the partial section of the  tendons in certain cases of 
446           NEW ELEMENTS OF OPERATIVE SURGERY.

old deformities, and more  particularly  the  section of the tendo-
Achillis.
  Sartorius (Journal de Siebold, t. iii.) also made known, in 1812, a
case of section of the tendo-Achillis for the removal of a pes-equi-
nus produced by a previous suppuration in the posterior part of the
leg.   Up to that time there had been nothing said of tenotomy of
the tendo-Achillis  in France; and when Delpech had recourse to
it in 1810, on a boy then six years of age, and whom M. Bouvier
afterwards met Avith in Paris, in 1837, it was everywhere t^ou5
that it was an operation absolutely new.  Having been badly de-
scribed, or badly understood, the section of the tendo-Achillis was
a second time forgotten, both in France and Germany, though ma-
ny veterinary surgeons (Miquel, Debaux, etc.; Blanc, Jour. Pratiq.
de Medec. Veter., 1826, p. 202; 1828, p.  283; 1830,  p. 346) soon
availed themselves of  it, and demonstrated  its advantages in  the
horse ; but the six cases, collected from 1831 to 1834, and published
by M. Strohmeyer, (Magas. de Rust., t. xxxix.; Arch. Gen. de Med.,
2e serie, t. xii., p. 116, etc.,) finally brought back public attention
to this subject.   It was  from that  time  performed, on the 23d of
October, 1835, by M. Duval, the  15th of January, 1836, at Paris, by
M. Bouvier, and about the same  epoch by M. Stoess, at Strasbourg,
(Held, Dissert sur le Pied-Bot, p. 69.)  To set out from this period,
the tenotomy of the tendo-Achillis has been performed anew by M.
Strohmeyer on M.  Little, an English physician, (Bouvier, Mem. sur
la  Section du Tendon  d'Achille  dans  le traitement  des Pieds-Bots;
Mem. de VAcad.  Royale de -Med., t. vii.,  p. 411;) by M. Reiche, a
surgeon of Magdebourg,  (Held, These, Strasbourg, 1836 ;) by M.
Dieffenbach, at Berlin ; by M. Serre,  (Correspond. Privee, 1837,) at
Montpellier; by MM. Roux, Blandin, and  Laugier, at Paris ; by
M. Lenger, (Ency olograph, des Sc. Med., 1838, p. 145,)  in Belgium ;
by-M. Little, in England; and by M. Scoutetten, (Mem. sur la Cure
Radicate des Pieds-Bots, 1838, in 8°, avec 6 pi.,) at Metz.  M. Pi-
vain asserts  that, up to the month of July, 1837, M.  Duval  alone
had performed it more than eighty times ; his brother, M. T. Duval,
(These, No. 342, Paris, Aout, 1838,) now claims for him as many as
two hundred cases ; and M. Dieffenbach told me, in the month of
October, 1837, that he had performed it one hundred and forty-five
times.   In his last memoir, M. Bouvier also claims about twenty as
the number of his cases.  It is, therefore, an operation which may
count at the present day more than four hundred examples.  Nor
does it appear, up to the present time, that the life of a single per-
son has been sacrificed to it, and, if we believe to  the letter what
its declared partisans say of it, it  has never, so to speak,  been un-
successful.   Every thing at least shows, that it has in the greatest
number of cases  succeeded, and that the only accidents that  have
accompanied it have  been vdolent pains, as in the patient of Sar-
torius ; an abundant suppuration, as in that of Delpech; and some
gangrenous  eschars, of which examples  have been mentioned by
MM. Duval Blandin, and Bouvier.
  It would be in vain, then, that surgeons should raise the objection 
            ALTERATIONS OF THE TENDONS OR  MUSCLES.         447

of danger of destroying the continuity of the extensor tendon of the
foot.  Modern experience, on the contrary, tends to prove, that the
fatiguing dressings, so difficult to maintain, and  devised by J. L.
Petit, Monroe, Desault, and so many others, to remedy the rupture
of the tendo-Achillis, are only calculated to aggravate the disease.
From the year 1832, I began to treat the rupture of the  tendo-
Achillis by no other means than simple rest and the immobility of
the limb for the space of three weeks or a month.  The two first
cases which I submitted to this kind of treatment, the one in 1832,
the other in 1833, did so well, that it was not  possible to keep them
in the hospital over three weeks.
  B.  Appreciation.  The tenotomy of the tendo-Achillis is not prop-
er, except in the pes-equinus, whether that  be simple or compli-
cated with deviation of the foot towards one of its borders;  also,
there must  not be any consolidation (soudure) between the bones
of the tarsus, or in the  tibio-tarsal articulation.   AVe should not
perform  it until after the section of the plantar aponeurosis  and of
the flexor brevis digitorum pedis have proved ineffectual, in cases
where there  is pes-equinus  wdth  the  turning  under  (renverse-
ment inferieur) of the dorsal surface of the metatarsus.  I  should
add, that the section of the other tendons around  the joint  should
sometimes be associated with that of the tendo-Achillis.  The ob-
servations hitherto collected show, that it  is applicable to all ages
and to both sexes, since  it has been performed with e'qual success
from the age of two years to that of fifty, and upon women as well
as  upon men.  By the modern  processes, a  month or two is suffi-
cient to put the patient in a condition to walk, with the foot rest-
ing upon the ground throughout all its plantar surface.  It is true
that some patients,,treated by the section of the tendo-Achillis, could
have been cured wdthout that operation. I have myself cured many
by the aid of the apparatus constructed by M. Mellet. . We effect
the same results with the apparatus of Bruckner, Jcerg, D'lvernois,
and Dieffenbach.  By enveloping the limb, while it is stretched out
straight, in a  mould of plaster, as M. Guerin has done, or in  a
dressing rendered immoveable by starch, as M. Seutin has proposed,
or by dextrine, as I have twice done, while making use of the bus-
kin (bottine) of M. Stoess, extolled by M. Held, we should, without
doubt, be enabled, with time and patience, to render the section of
the tendo-Achillis unnecessary in a great number of cases.  But
this operation is so simple, so little painful, so easy, and so little
dangerous, and its results are so prompt and so perfect, that, unless
there is a very decided repugnance  on the part of  patients, it de-
serves to be almost universally substituted for the employment of
those apparatus and dressings wdiieh, up to our time, had, in truth,
so imperfectly supplied its place.
                     c.  The Operative Process.
  All the processes I  have  mentioned, in speaking of tenotomy in
general, have been applied to the section of the tendo-Achillis.  It
was the  method of Tulpius which the surgeon Lorenz followed 
448
NEW  ELEMENTS OF OPERATIVE SURGERY.
 Sartorius made a long longitudinal incision on the posterior surface
 of the tendon, and it is this method which M. Reiche still prefers.
 The method of Delpech relates only to the tenotomy of the tendo-
 Achillis.  It is the  same with the processes of MM. Strohmeyer,
 Bouvier, and  Stoess ; M. Bouvier, indeed, says he had  practised it
 in  four different ways.  At  first  he made use  of a very narrow
 curved bistoury, convex upon  its  cutting edge,  which bistoury he
 inserted by puncture between the tendon and the deep-seated parts,
 in the manner of M. Strohmeyer, but w ithout piercing the integu-
 ments upon the opposite side.  The second process tried by this
 practitioner consisted in a transverse puncture, which was made
 in the skin  near one of the borders of the tendon by means of an
 ordinary bistoury or lancet, and into which was  introduced a nar-
 row bistoury with a blunt point.  In the third process,  M. Bouvier
 pierces the  skin  lengthwise with  a straight or curved bistoury,
 having a narrow blade, which  he glides flatwise between the ten-
 don and the integuments, and  Avhich is then turned to divide the
 parts from the skin towards the deep-seated tissues.  His last pro-
 cess is composed of two stages.  A longitudinal puncture, of one
 or two lines in length, being made wdth the point of a lancet, or a
 simple bistoury, on the  side of  the tendo-Achillis, allows of intro-
 ducing therein a blunt-pointed tenotome, which then  divides the
 tendon  from behind forwards,  or  from its superficial  towards its
 deep-seated Surface.  The tenotome that  M. Bouvier noAv uses is
 a kind of cutting needle, a line  in breadth  at its  base, a little nar-
 rower  and  rounded at its  point,  and shaped  (disposee) nearly-
 like the cystitome of the cataract case.  We see that the processes
 of M. Stoess and  M. Duval belong  to the same  order as those of
 M.  Bouvier, and that all have been designed for the  tendo-Achillis.
 M. Scoutetten, (Cure Rad. des Pieds-Bots, p. 75,) who operates like M.
 Duval, insists  strongly, but erroneously, as I think, that the punc-
 ture should be made inside and  not outside the tendon.
  The Operation.   Whatever  may be the method adopted, it is ad-
 visable to place the limb on its  tibial surface, and in such manner
 that the foot, remaining free,  may be inclined by an assistant
charged with holding it, in this  or that direction, according  to the
pleasure of the operator.  The  surgeon having  the posterior sur-
face of the limb before him, places himself opposite to  the plantar
surface of the  foot.   With the  right hand, armed with the lancet,
with a straight bistoury, or a straight needle like the ancient cata-
ract-needles, he pierces  the skin on the external or internal side
and in a direction parallel with the tendo-Achillis.   If he has used
a bistoury or lancet  he  immediately seizes one  of  the tenotomes
of which I have spoken,  and glides it by slight movements forward
and backward[(vaetvient) under the skin, grazing (rasant) rather
the surface of the  tendon than  that of the tegumeYts, until he ar-
rives upon the  opposite side, carefully avoiding wounding the skin
'\  \!  Tt urtCtl°n-   At this P°int of the operation, the surgeon,
who had held his instrument flatwise, turns the cutting edge upon
the axis of the  limb.  It is then that it becomes advantageous to 
ALTERATIONS OF THE TENDONS OR MUSCLES.
449
 lower the heel.   We in this manner give such a degree of rigidity
 to the tendon, that its section is, to a certain extent, made of itself.
 Gentle saw-like movements with the bistoury then quickly complete
 it, and the operator marks the moment that it is finished by a
 crackling sound, and by a sudden separation, which he instantly
 perceives.   Turned  back again, flatwdse, the instrument  is with-
 drawn through the puncture by which it entered, so as to make no
 additional wound of the skin.
   If there should be any particular difficulties in the way, to  pre-
 vent our passing between  the  teguments and the subjacent parts,
 the  operation would differ from the preceding only in this,  that
 after the puncture we would  cause the bistoury to glide flatwise
 upon  the anterior [i. e.,  the deep-seated or internal—T]  surface
 of the tendon, which Avould then be divided from before backward.
 I need not add, that the  operation weuld be the same, if, in place
 of a special instrument, we should prefer employing the straight
 bistoury, or  the  ordinary blunt-pointed (boutonne) bistoury.  The
 wound in the  integuments being longitudinal, closes of itself by
 the adjustment of the foot; being reduced to  the state of a simple
 puncture, it generally disappears in twenty-four hours.  The slight
 ecchymosis, also, which  is sometimes seen under the skin, should
 create no apprehensions.
   When the tenotomy is finished, we straighten, and may Avithout
 danger readjust the  point of the foot in such manner, that the  two
 ends of the tendon are separated at least an  inch asunder. If, in
 order  to replace the foot at a right-angle upon the leg, it should be
 necessary to carry this separation to more than an inch and a half,
 prudence would dictate that Ave should not proceed any further for
 the moment, and that we  ought not to endeavor to increase this
 separation until after ten or fifteen days.
   Moreover, the buskins and apparatus for straightening the  foot
 may be applied as Lorenz and Sartorius have already done, immedi-
 ately after the operation.   MM. Bouvier, Duval, Lenger, and Scou-
 tetten, (Cure Radicale des Pieds-Bots, p. 90,) who have adopted this
 course in a great number  of cases, have proved by their success
 that the scruples of Delpech on this point, and the fears of MM.
 Strohmeyer and Stoess, are not well grounded.
  Patients who have undergone the section of the tendo-Achillis,
 begin to walk, with a certain degree of freedom, from the tenth to
 the twentieth day,  and  they are nearly perfectly cured  in  the
 course of the second month.
  3. Club-Foot  turned forward, or Talus.   Club-foot with the  foot
 turned upward towards the front part of the  leg, is rare.  I haAe
 seen it twice in foetal monsters.  I have  not, as yet, seen any ex-
 amples of it  in living persons.  M. Duval says he has seen  two
 cases of it, (Pivain, These citee, p. 7,) Delpech, (Orthomorphie, fyc.)
 M. J. Lafond, (Difformites du Corps Humain, Paris, 1829, in-4°, p.
 300,) and M. Stoess, (Dissert, sur le Pied-Bot,  p. 3,) each give an
 example of it, and M. Scoutetten, (Cure Radicale du Pied-Bot, pp.
27, 28, pi. v.) appears also to have seen several cases.  Though
  vol.  i.                       57 
450
NEW  ELEMENTS OF OPERATIVE  SURGERY.
one of the patients mentioned by M. Duval was cured by means
of plugs (tampons) of lint and simple tractions, it is not the less
probable, that in individuals more advanced in age, the section
of the tendons would be the best, and perhaps the only remedy for
talus.  In these cases, the infirmity is  imputable evidently to the
retraction of the tibialis-anticus only, or to that of the tibialis-anti-
cus and peroneus-tertius, or that of the extensors of the toes
  I have not learned that the tendons of the extensor-communis
and of the  peroneus-tertius  have, up to the present time, been
designedly divided to remedy any deviation of the foot.   It would,
however, be an easy operation,"and of little danger.  AAe mig^ht
perform it either above or below the anterior annular ligament of
the tarsus.   It would be much better above, inasmuch as the ten
dons below, being  already more  or less  separated, could  not be so
easily divided Avith the same stroke of the bistoury.  The anterior
tibial artery, or the commencement of the dorsalis-pedis, could alone
create any apprehension; but the tendons in  such  cases are so
much the farther removed from these arteries, in proportion to the
greater degree of retraction.
  The leg being supported upon its posterior surface against some
sort of prop, (soutien) and held in this position by assistants, would
alloAV the surgeon to place himself by the side  of the  foot, in the
same manner as for the section of the tendo-Achillis.  Armed with
a straight bistoury, the  operator should puncture the skin on the
inside or outside of the bridle, according as he should make use of
his right or left hand, or operate upon one or the other leg.  Guided
between the tendon and the integuments till it reaches the opposite
side, the instrument  should be used in other respects precisely as
has been said in speaking of the section of the tendo-Achillis.  If
the extensor tendons of the toes  only are implicated, the operation
in general  should  be performed at the distance of half an inch
above or below the instep.  For the peroneus-tertius we should be
obliged to do it a little lower down.  After all, we must not forget
that it is the tendinous projection (relief) which more particularly
points out the place where it is  most advantageous to  apply the
instrument.  On the  supposition that  the  tendon of the tibialis-
anticus has also been divided, there would remain  nothing more
than to straighten the foot, then to force it, by means of buskins,
(brodequins) or appropriate apparatus, to acquire the proper degree
of extension, and to lose its tendency to abnormal flexion.  It is, fur-
thermore, presumable that this species of club-foot Avould be one of
the most difficult to cure radically, and one of the least favorable for
the section of the tendons.
  4. Varus.  AVhether it is found alone, or is complicated with pes-
equinus, the varus, which sometimes  exists to such degree as to
compel the patient to walk almost exclusively qn the external edge
of his foot, very  frequently requires that we should divide not only
the tendo-Achillis. but the tendon of the tibialis-anticus, the tendon
of the tibialis-posticus, and even  those of the long extensors or long
flexors of the toes. 
             ALTERATIONS OF THE TENDONS OR  MUSCLES.         451

                 A.  Section of the Tibialis-Anticus.

   We may conceive, from what I have said  in the preceding par-
 agraphs,  that  the section  of the tibialis-anticus may  be useful
 in two varieties  of club-foot, that is to say,  in the Talus and the
 Varus.  This operation, Avhich M.  Held formally  advises, (These
 citee, p. 64,) Avhich M. Duval appears to have practised, (Pivain,
 These citee, p.  22,) and Avhich, according to M. Bouvier, (Mem.  de
 VAcad. Roy. de Med., t. vii., p. 411,  et suiv.,) has also been per-
 formed by M.  Dieffenbach  and M. Strohmeyer, might be resorted
 to at once, if it should appear that in the distortion of the foot for-
 ward or hrward,  the tendon of the tibialis-anticus was more forci-
 bly retracted than any other.  Up to the present time, however, it
 has not been had recourse  to, until after having ascertained that
 the section of the tendo-Achillis was insufficient.
   The Operation. Inserting itself at the  posterior and inner part
 of the first  cuneiform bone, this tendon naturally makes a consid-
 erable projection in front of the internal malleolus.   It would be
 advisable to place the leg in the same position as for the section
 of the extensor tendons of the toes, taking care to turn out the foot
 a little in the direction of its external border.  If the puncture were
 made under and  in front (en avant)  of the  apex of the malleolus,
 and behind the tendon, the bistoury should proceed along the inter-
 nal  surface  of the skin, from behind forAvard, and from below up-
 ward, before its cutting edge has been turned  toAvards the instep, to
 effect the  section of  the retracted tendon.  But  this manner of
 proceeding, Avhich should not be adopted but with- the view of
 being enabled  to  avoid, wdth the utmost degree of certainty, both
 the  extensor tendon of the  great  toe, and  the  arteria  dorsalis-
 pedis, would be  manifestly more  embarrassing and more difficult
 than  that which  consists in making  the puncture on the outer side
 and  in front,  in  order to penetrate  afterwards  from the instep
 towards  the tendon.   By this  last  process, it would be almost
 always practicable to  insert the  bistoury far enough towards the
 inner side (en dedans)  to be certain of not wounding either the ar-
 teria dorsalis-pedis, or the long extensor muscles of the toes.

                       B. Tibialis-Posticus.
  The section  of the  tibialis-posticus,  also  recommended by M
 Held, seems not yet to have been performed but on the dead body.
 We  cannot,  however, discover any advantages from it, except as
 an auxiliary to the section of the  tendo-Achillis in the pes-equinus
 complicated Avith varus; for it Avould be difficult for  the tibialis
 posticus itself to give existence to any kind of club-foot whatever.
 Though tenotomy of the tibialis-anticus and of the extensors of the
 toes be as practicable above as below the instep, it is not so with the
 tendon of the tibialis-posticus. Adherent as it Avere, (comme colle) to
the posteriorborder of the internal malleolus, and almost immediately
 in contact with a large artery, namely, the posterior tibial, this ten-
don could not be  cut without danger before its entrance into the in- 
452
NEW  ELEMENTS  OF  OPERATIVE SURGERY-
tcrnal groove of the os calcis.  It is only, therefore, near its attach-
ment to the  postero-internal extremity of the scaphoid bone, that
we should endeavor to reach it.  For that purpose, we should place
the leg upon its outer  side, (face externe.)   A bistoury should be
inserted by puncture, at some lines in front of the internal malleolus,
a little under or behind the tendon of the tibialis-anticus.  Carried
afterwards almost  directly downward,  the  instrument should be
turned upon the tendon  [of the tibialis-posticus] at about half an
inch under and in front of the  apex of the malleolus.  Taking care
not to lower the point of it too much, and to incline it as little as
possible towards the plantar surface of the foot, we should be cer-
tain to avoid the internal plantar artery, the only one that can in
terfere with us in this region.

                 C.  Tendons  of the Great Toe.

  The flexor tendon of the  great toe has been divided upon the
first phalanx of this toe, as I have already said, by M.  Syme, for a
retraction produced by inflammation.  Michaelis appears  also to
have  advised the section of this, as of all  the other tendons, but
with  the injunction to  do it partially only.  It was reserved for
MM.  Strohmeyer and Dieffenbach to associate it with  that of the
tendo-Achillis, to remedy the pes-equinus varus.   In that case, also,
it weuld be more proper to perform it, like M. Syme, upon the first
phalanx of the great toe, than to endeavor to accomplish it under
one of the  points of the internal border of the foot.  The tendon,
divided  in its fibrous groove, would retract Avith as much freedom
as if we had  divided it in the neighborhood of the heel.
  The foot, presenting its plantar surface to the operator, AAeuld
give him an opportunity to raise  the  great toe, and  to cause
the instrument to penetrate from one side  of the  retracted tendon
to the other, as has been  said  in speaking of the tendons  of the
instep.  In taking the precaution to insert the  instrument a little
nearer the plantar than the dorsal surface of the toe, we should, as
in the fingers, avoid the  lateral arteries ; nor can we see that this
operation Avould be  in the least degree dangerous.
  The section of the extensor, also, of the  great toe, has been per-
formed  by  MM. Strohmeyer and Dieffenbach,  (Bouvier, Mem. de
VAcad. Roy. de Med., t. vii., p.  411, et suiv.,)  to aid, as in the case
of the flexor, in the success of the division  of the tendo-Achillis.
It would also be evidently more easy, and could be performed
upon the Avhole extent of the tendon, from above the instep to near
the last  phalanx of the  toe.  In making the puncture on its outer
side, in order afterwards to reach its inner border, we might divide
it with  a single stroke  of the instrument, AAdthout having to fear
the wound of any important organ.
  5. Section of the Peroneus Longus and  Brevis, in Valgus.  The
valgus form of  club-foot, in itself a  rare occurrence, and rare also
as complicated with pes-equinus, has, up to the present time, offered
but few occasions in  Avhich the section of the <endons could be 
ALTERATIONS  OF  THE TENDONS OR MUSCLES.         453
applied to it.  M. Pivain, (These citee, p. 23,) however, cites an ex-
ample of it, where M. V. Duval thought it advisable to undertake
this section before proceeding to that of the tendo-Achillis.   I also
possess a fact which proves that Ave should be wrong in having
any fear from it in regard to the re-establishment of the action of
the muscles.  M. D*** had a deep wound  made in the leg by some
fragments of Delft ware.  The wound in  the integuments, which
extended from the anterior  surface of the fibula to the  posterior
median line of the leg, a little above the heel, comprised the whole
thickness of the peroneus-longus, and the half of that of the pero-
neus-brevis and of the tendo-Achillis.  The separation of the divi-
ded tendon was near two inches in Avidth.  The integuments Mere
united by the twisted suture, and the foot adjusted by a prepared
splint, which I fastened upon the entire outer side of the limb. This
severe wound, which ultimately cicatrized, was followed by a very-
considerable degree of feebleness in the power of abduction of the
foot, for six to eight weeks; but at  the end of some  months  the
patient recovered from it, and it is now a long  time  since he  has
thought no more of it, and that the functions of the foot have been
perfectly restored.
  It is said in the thesis of  M. Held, that  M. Stoess was upon  the
point of performing the section of the tendons of  the peronei in
1836.  I do not knoAV if this operation has, in our time, been intro-
duced into surgical science.   However that may  be, it  may be
performed, like that for the tibialis-anticus, aboAe or below  the
malleolus.   In the first  point, it would be better to divide the two
tendons at one stroke.  This could be done with most ease at about
an inch above the base  of the external malleolus.  As for the rest,
I do not think there would be any great advantage  in penetrating
from before backward, rather than from behind forward.   I am of
opinion, however, that, in going from the fibula towards the tendo-
Achillis, we should render the operation a  little easier, and that, in
strongly raising the handle of the bistoury, at the moment of ma-
king the section of the  tendons, we should have the advantage of
finding a point d'appui on the postero-external surface of the fibula
itself, which would  be so much the more to our advantage, that
there would  be no risk of penetrating to the  bone.   Below  the
malleolus, we might divdde the twe peronei together, or make their
section separately.  It would be at the distance of six lines in front,
and below the apex of this process, that it would be necessary to
insert the instrument, if we wished to divide the twe tendons at  one
stroke. We could reach the tendon of the peroneus-longus, by itself,
at the middle of the space which separates the point of the malle-
olus from the external tubercle of the cuboid bone.  As to the  pe-
roneus-brevis, we should have to look for  it at the external border
of the fleshy mass of the extensor-brevis  digitorum pedis.  In all
cases the puncture should be made upon the inner side (cdte interne)
of the bridle  to be diAdded, that we may carry the instrument from
within outward, between the teguments  and the tendon, before
making its  cutting edge act  from the skin  towards the bones. 
454
NEW  ELEMENTS  OF  OPERATIVE PtRGERY.
  These sections being performed, it will be necessary, as afier the
section of the tendo-Achillis, to make use of buskins, gaiter-boots, or
bandages, to ensure their successful result, and to adopt, also, all
the precautions required in respect to the cicatrix,  and in wha
concerns the re-establishment of the movements and readjustment
of the foot, to prevent these dressings from doing any injury.
  [Talipes, or Club-Foot  A circumstance of importance, generally
overlooked, and one which greatly diminishes  the  danger, even
where the  large arteries are wounded, in operations for retracted
tendons or muscles in any part of the limbs, and especially lor
club-foot,  is  the  atrophy or  shrivelled  state of  the limb from
defective motion and nutrition, as noticed by Dupuytren.  So little
was known or  thought of the section of the tendo-Achillis in the
United States as  late as KS34, that,  according to Dr. Reese, (see
his  last edition  of Cooper's  Surgical Dictionary, Ncav York, 1842,)
an  eminent surgeon of NeAv York had recourse that year to the
amputation of the limb, in a  gentleman affected  Avith club-foot.
In connection Avith what  we  shall say farther  on of the Ameri-
can pioneers in this part of tenotomy, viz., Drs. Dickson,  Smith,
and Detmold, Ave  have also to state, that Dr. C. B. Gibson, of Bal-
timore, has described a fifth variety of club-foot, in addition to the
four divisions generally enumerated  by authors, viz., talipes pna-
langealis, Avhere, (according to the accounts given in the last edi-
tion of the Institutes of Surgery,  by his father,  Professor Gibson, of
Philadelphia.) the patient stands on the dorsal face of the cuboid
and cuneiform bones of the  tarsus, the toes and metatarsus being
turned under  the heel, and the forepart of the foot beneath the axis
of the limb.  Dr.  C. B. Gibson, and his father,  the  professor, attri-
bute much  more importance to the apparatus used after the division
of the tendons,  than is generally admitted.  The first-named phy-
sician extols,  for this purpose, the  apparatus  of Dr.  Heber Chase,
of Philadelphia.  From an examination of its principles.  Ave  do
not think it can obtain a preference over  the  very ingenious con-
trivances of this kind, for every  species  of deformity, osseous, ten-
dinous, or muscular, perfected by M. Jules Guerin, of Paris, and now
successfully imitated by  Tieman  and other  surgical instrument
makers of  New York, after the  models and patterns which Prof.
Mott brought with him to  this country, and Avhich Avere made  at
Paris under the supervision of M. Guerin himself.
  Dr. Detmold, (New York Journal of Medicine and Surgery, 1840,)
by an estimate of the  cases of  club-foot Avhich have fallen under
his  care, makes the proportion  of males  somewhat  greater than
that of the other  sex, and  also  the number of cases where both
feet were  affected  about  equal to that of each foot separately,
the right foot in the latter being rather more frequently the  seat
of the disease  than the left.  A very large proportion were  con-
genital, and almost all of these were otherwise well formed.   In
the whole number of cases upon Mdiich his data were founded, (viz.,
at that time one hundred and sixty-seven) tAvo only had the whole
limb shortened, in one case of Avhich the deformed leg Avas one-half 
ALTERATIONS OF THE TENDONS OR MUSCLES.
455
 shorter than the other.  In one, there was also hare-lip ;  in seven
 strabismus ; in one, the toes were web-footed ; and one had an addi-
 tional thumb on  the  hand corresponding  to  the  club-foot.  The
 proportion of hereditary cases were on the father's side, because,
 perhaps,  as  is  said,  club-foot females  seldom marry.   Of the
 whole number of  cases, (93 being double,) two hundred and thirty
 of the feet were talipes varus; eleven, valgus ;  seventeen, equinus;
 one only of talus, but existing in both feet.  For this last variety.
 Dr. Detmold ingeniously suggests the  name of  equestris, as  it
 resembles the position of the  foot in the stirrup in riding.   In a
 great majority of cases, the division of the tendo-Achillis is, in his
 opinion, all that is required, especially in young subjects ; that in
 most  cases, this, with  subsequent apparatus, generally suffices for
 the cure; and  that the divdsion of other tendons  may be  made
 afterwards, if necessary.   Dr. Detmold  is opposed to the immediate
 extension of  the foot  by any apparatus, and prefers waiting two
 or three days, till the effusion of plastic lymph is perceived between
 the extremities of the tendon. He prefers, also, his own improvement
 upon Strohmeyer's foot-board, and thinks well of Scarpa's shoe, but
 rejects the mould of  plaster recommended by Guerin.  In justice
 to M. Guerin, it should be added, that his admirable boot, as it may
 be called, in  all its modifications, wdth  all the necessary screws,
 straps, and steel supports, covered Avith  leather cushion paddings,
 is the one which  he now most uses; this surpasses, in ingenuity
 and practical utility,  (in the opinion of Dr. Mott and others,) any
 thing known.  In twe hundred and thirty cases of club-foot, Dr.
 Detmold divided the tendo-Achillis in one hundred and sixty-three,
 and in seventeen  of these, he  made also the section of the other
 tendons and of the plantar aponeurosis.   In three cases only was
 the tendo-Achillis divided a second time.  In eleven cases of val-
 gus, two of talus,  and  forty-five of varus, mechanical means only
 were used.   Dr. Detmold has now performed more than four hun-
 dred operations on club-foot, and divided more than one thousand
 two hundred tendons,  on Strohmeyer's plan.   We have frequently
 seen him operate, and  must do him the justice to say, that he per-
 forms these sections with admirable adroitness and astonishing ra
 pidity.  Dr. Detmold'has divided, also, a large number of  tendons
 for other deformities in the limbs, &c.
  Dr.  Mutter, of  Philadelphia, who has, next to  Dr. Detmold,
 treated more cases of  club-foot than any other American surgeon,
 enumerates  now two  hundred  patients  of this description, who
 have fallen under his care within a very few years past.   He has
 also treated numerous  other cases of distortion, as  torticollis, con-
 tracted knees, eighty of strabismus, &c.
  Dr. A. G. Walter, of Pittsburg, Pennsylvania, (according  to Dun-
glison's American Medical Intelligencer, May, 1840,) has made  more
extensive sections in the lower extremity,  in the same patient, than
any other American practitioner.  In a case of complicated deformi-
ties of the lower extremities, he is said to have made, with success-
ful results, the sub-cutaneous section of the tendons and  muscles 
456
NDVV  ELEMENTS OF  OPERATIVE SURGERY.
of the hip,  knee,  and ankles, viz., the adductor-longus, gracilis..
fascia-lata, sartorius, semi-membranosus, semi-tendinosus, and the
tendo-Achillis and peronei  of each foot.  For the peronei he pre-
fers cutting below the external malleoli.  In this case, mechanical
means were  afterwards  used.  The ultimate issue is not given,
though the  stature  of the  patient had been,  by the  statement,
increased six inches.
  Dr. Little, of London,  mentioned in the  text of this Avork, and
who, himself a subject of this disease, was cured by Strohmeyer,
remarks, in his published treatise  on  club-foot, that in numerous
cases of the congenital description  it is frequently found associated
with  the  concomitant deformity of a  club-hand, and in some, as
remarked by Dr. Detmold, with that of strabismus ; also, in certain
other cases, with congenital  stammering.  All these clearly indi-
cate, in our opinion, an organic, pre-existing, contractile diathesis
of the voluntary muscles.
  Non-congenital cases of club-foot may lead to the clew of the
causes in congenital cases.   In most of the former cases, Dr. Little
seems very justly, as we  think, to connect them with the period of
dentition, as being that  when they most usually first  make  their
appearance.   He might  have added, moreover, that a ready ex-
planation is here found  in the intimate, if not intense, organic or
metastatic sympathy naturally subsisting (and now actively exci-
ted by the irritation of dentition) between the peculiarly sensitive
mucous membrane of the alimentary passages,  especially during
infancy, and the organs of voluntary motion.   A  fact well known
to practitioners, as illustrative of the  last mentioned sympathy, is
the violent spasmodic contraction  of all the bulky flexor muscular
tissues of the  limbs in Asiatic cholera, responding intimately and
directly wdth the equally violent convulsive cramps of the muscu-
lar coat of the stomach itself.  This, too, is faintly seen in ordinary
cholera morbus, and often, also, in  the production of temporary or
even permanent contractions of the flexors of the thumb and fin-
gers,'and also strabismus,  which  all are equally well known in
childhood, more especially,  to be  directly imputable  to  chronic
cases of derangements of the intestinal tube from atony, acting di-
rectly through the ganglions or indirectly through the cerebro-spinal
system.  And also to this are to be ascribed the permanent con-
tractions of the flexors of the thumb and fore-finger, noticed even
in adult age, and, as  mentioned long since by Moseley and others
as a characteristic feature in Avhat is known  as the dry belly-ache
of the West Indies.   In the cases from dentition, varus, coming on
gradually, is the most frequent variety.  Dr. Little mentions ca-
ses, also, of club-foot in young women from habitual spasms of the
gastrocnemii, and of the anterior and posterior tibial muscles from
attacks of hysteria, [here too often primarily imputable to intesti-
nal derangement, no  doubt.]  He  properly remarks, that  this  de-
formity may thus be produced non-congenitally, from any paralytic,
spasmodic, or nervous cause whatever, which  permanently or forci-
bly disturbs the equilibrium or antagonism of the muscles of the 
            ALTERATIONS OF THE TENDCNS OR MUSCLES.          457

limb, &c.   This rational etiology  will, of course, properlv direct
the attention of the practitioner first to a judicious course of patho-
logical treatment, founded upon the functional derangement exist-
ing in the cerebral and cerebro-spinal centres, and in the ganglionic
system, as connected with the splanchnic viscera.  The general
medication, therefore, and mechanical means, should precede the
sub-cutaneous section of the tendons.
   Dr. Detmold has operated for club-foot as early as at the age of
three months.  Dr. Mott, and also Dr. Carnochan, of New York,
have  operated as  early as one month or six  weeks.   The earlier
the period of life after tAvo months, the more  successful generally
is the operation, because of the pliancy of the parts.
   Mr. Braithwaite, in his valuable Retrospect of Practical Medi-
cine and Surgery,  (January to July, 1840,) to illustrate the natural
curative power of the tendinous tissues, mentions a case of his, in
which a woman, by some violent exertion, tore off a portion of the
os calcis, whioh, with the tendo-Achillis attached, protruded through
the integuments.  The bone was cut  from the tendon,  and the lat-
ter replaced.   The  parts then healed kindly, so that  she walked
almost as perfectly with this leg as with the other.—T.]

    [Excision of a portion of the Tendons of the Leg for Paralysis.
   There would seem to be no end to the admirable uses to which
this branch of surgery  is extending  itself.  Mr. James Braid, of
Manchester, England, (see  Medical  Gazette,  April 23, 1841,) has
proposed an entirely new application  of tenotomy, which promises
to be of great value. The cases were as follows: In a female, the
left leg was comparatively powerless for two years from a para-
lytic stroke ; it hung dangling by the side of her crutch, and in-
clined to varus. After every effort at medication had failed, Mr.
Braid made a longitudinal incision  along the course of the peroneus
tertius, which he elevated, and then excised a portion of it to the
extent of three sixteenths of an inch,  closing the weund with plas-
ter, and applying bandages and splints to approximate  the edges of
the division and maintain them in contact.   In twenty days she
walked perfectly.   In a boy aged six and a half years, Avith talipes
varus ever since he was one year  old, such Mras the relaxed or par-
alyzed state of the extensors of the foot, that the latter could with
ease be placed against the forepart of the leg.  He had no power
over it.  Three eighths of an inch of the tendo-Achillis were ex-
cised.   On the tenth day the Meunds were closed.  At the end of
three weeks, in consequence of a  fall, inflammation and suppura-
tion came on, which soon ceased and  the wound healed.  In three
months he  could walk perfectly Mell, and extended  his  foot with
ease.   Caution, Mr. Braid says, is  required, that neither too much
of the tendon is excised, for fear of producing too great an excite-
ment upon the contractile power of the muscular fibre, nor too little
of it, for fear of the opposite  effect.   Here is a new  process, the
reverse of ordinary tenotomy, in respect to retraction  of the part,
exclusion of air, and inflammation and separation  of  the divided
  vol. i.                       58 
458
NEW ELEMENTS OF OPERATIVE SURGERY.
 parts, yet deriving its utility from the leading principle of tenoto
 my—that of the division of the abnormal tendon.  It is founded on
 sound pathology, but the operation may prove hazardous, from the
 necessity of laying bare the  tendon.
   Mr. Braid remarks, that in pure talipes equinus, with rigid con-
 traction, it will generally be found that, besides the tendo-Achillis
 and plantaris, there are also implicated  the  flexor longus pollicis
 pedis and flexor longus communis, tibialis posticus and peroneus
 longus and  brevis.   He admits  that  powerful extension may ulti-
 mately bring the foot  into  its  natural position, where the tendo-
 Achillis is divided, but this will be attended with much more tor-
 ture, and not accomplished  so  soon, as Avhere such of the other
 named muscles as are rigid are  also divided.  In this latter case, a
 sufficiently  firm reunion will have taken place in four or five days
 to enable the  patient to extend the foot, if the operation has been
 properly performed and the patient is a healthy subject.   This di-
 vision of the abovenamed muscles was suggested to Mr. Braid by
 seeing a patient  instantly walk across the room, with his toes out
 and soles flat  to the  ground, after he  had divided the tibialis posti-
 cus and flexor pollicis pedis in a case of slight varus. The  division
 of these muscles wdth that of the tendo-Achillis is the more neces-
 sary, because, from  their antagonists being more or less feeble, if
 extension only is used, the disease will often return.  In  equinus
 and all other varieties the leg should be bandaged to the knee, to
 keep the  foot in its morbid position and to prevent the  muscles
 contracting, and  thus making the  separation too great before the
 plastic lymph is deposited.  Gradual extension should begin in twe
 days. In varus, also, he divides at once every tendon that can pos-
 sibly retain the foot  in its morbid position ; also, the plantar fascia
 and short flexors, should there be  much contraction in the sole of
 the foot.   The muscles he generally divides in varus are the Achil-
 lis, tibialis anticus and  posticus, flexor longus pollicis pedis, flexor
 longus communis, and abductor  pollicis, if required.   In valgus, he
 frequently divides at once the peroneus longus and brevis ;  some-
 times, also,  the Achillis, peroneus tertius, and the extensor longus
 communis, and propius pollicis pedis.  In calcaneous talipes, (i. e.,
 talus,) he sometimes divides at  once the tibialis anticus, extensor
 proprius  pollicis  pedis, extensor longus digitorum pedis, and pero-
 neus terri'iis.  In  most  cases  of equinus, even after the restoration
 the leg i/k found a little shortened, which must be compensated b>
 a high-heeled sole.  For adults, Mr. Braid  uses a straight  teno
tome. «me inch and a quarter long, and about a twelfth of an inch
broad ; the  point, being cut off  at  an angle  of about sixty, is less
 apt to transfix the tendon and  leave any portion of it undiv ided
 than the curved or sharp-pointed  blade.   Also, it  is less liable to
 make a counter-opening in the integuments.   For infants and chil-
 dren, a much smaller blade will suffice.
  Mr. Braid prefers the division to be  made as follows :  For  the
 tendo-Achillis, about an inch and a half from its insertion  in  the
 adult, and proportionably less in younger patients—and he prefers 
ALTERATIONS OF THE TENDONS OR MUSCLES.
459
cutting  from without inwards;  the tibialis anticus, near its inser-
tion  in  the os cuneiforme internum ;  the  tibialis posticus, near its
insertion in the os scaphoides; the flexor  longus pollicis pedis and
flexor longus digitorum pedis, at  the point of decussation in the sole
of the foot from within outwardly; and from this same wound, the
plantar  fascia, also, when necessary.  The peroneus longus and
brevis are best divided together above the malleolus externus, but
separately  below it, near their points of insertion; the extensor
longus digitorum pedis, before the point of separation into distinct
tendons; the extensor proprius pollicis pedis, a little more inward-
ly ; and the peroneus tertius in the same line, or near its insertion,
as may be preferred in the respective cases;  all these latter from
withyi outwardly.
  Instead of Strohmeyer's foot-boards and Scarpa's shoe, which are
rather too costly for the poor,  Mr. Braid recommends for extension
a  sole-piece of  hard-wood deal, about three eighths of an  inch
thick, and to be  of the length of the foot and breadth of the sole at
its greatest width, with an edge two inches and a half deep to rest
upon the inside of the foot.  The two pieces are  fastened together
with screw nails, and a notch cut in the sole pieces anterior to the
malleolus  externus, and in the side  piece behind the root of the
great toe, to allow  the bandage  the better to embrace the foot and
make it lie  close  to the wooden sandal.  This should be covered
with sheet M'adding or a pad, and be bound firmly on the foot with
a roller, or with two or three straps and buckles.  A piece of wood,
from two to three inches wide,  and sufficiently long to reach from
the foot to  a little below the knee, with a notch at the bottom cor-
ner,  and wdth an arm extending forwards to about three quarters
the length  of the foot, is now to be made: fast to the foot and sole
piece, by means of a bandage passing from  the front of the leg
piece under and round the sole piece  and  foot, and then under the
posterior notch from without inwardly and over the dorsum of the
foot, passing again  round the foot and sole piece, and placed at.an
acute angle with the sole, so  that it  may have sufficient leverage
to elevate the foot  when the upright stem is carried back to the
side  of the leg. An  assistant is now to be requested to place a little
wadding or pad  at the inner edge of the leg piece, and carry it
back against the top of the tibia, the surgeon regulating the exten-
sion  to the  degree that the patient can bear by allowing the ban-
dage to give  way in the mean time more or less, as  he judges ne-
cessary. He is now to pass the bandage round the foot, ankle, and
leg,  from the foot upwards, embracing, also, this lever, wdth such
a degree of tension as he may judge requisite to secure and main-
tain the necessary degree of extension the case requires and ad-
mits of.
  The above is a combination of the lever and inclined plane, and
is capable  of great  power.  It is applicable to every variety of ta-
lipes.   It should at first be undone  and applied once or twice a
day, and the foot bathed  with  spirit lotion.  Afterwards it is to be
kept on a longer time. 
 460          NEAAr ELEMENTS OF OPERATIVE SURGERY.

   Mr. Braid, in recommending the above practical precepts, says
 he does  so wdth the greater confidence, from hav ing tested their
 utility in a more extended practice in talipes than any other person
 in the United Kingdom.
   As permanent rigid contraction of the muscles and tendons pro-
 duces exhaustion of the muscular and nervous energy of the limb,
 coldness, and loss of feeling, so  is their division  immediately fol-
 lowed by an  increase of temperature, not only in club-foot, but  es-
 pecially in the hand and arm; and in  such cases such has been
 the almost miraculous restoration of strength, that patients over
 thirty years, Mdio have not been able to raise their arms in five or
 six years, have in two or three minutes been enabled  to lift them
 to their heads.  A patient aged seventy, who had paralysis of. the
 right side, and had been dumb for three years, was, in eight  or ten
 minutes after the operation, enabled to raise the arm pretty freely,
 and on the following morning spoke for the first time since his
 paralytic seizure.  As connected with this subject and Mr. Braid's
 neAv process of curing paralytic limbs by excision of the relaxed or
 elongated tendons and muscles, (already referred to,) he mentions
 the case of a boy  aged ten, with a dangling paralytic leg, and his
 head hanging down on the shoulder, and general muscular weak-
 ness, requiring crutches, and Avhose Achillis he had divided for ta-
 lipes.  The patient made out to walk in three Aveeks, soon after to
 support himself on his  leg and raise  his head, and finally  threAV
 aAvay his crutches  and walked with a stick.  " I could,"  says Mr.
 Braid, " adduce other instances Avhere weak and withered arms,
 almost from  birth, have  thus been restored both to  power and  in-
 creased size."
   Under this point of view, Mr. Braid notices three  varieties  of
paralysis—1. Where one class of muscles was in  constant rigid
contraction ;  2. Where there was not morbid tension, but morbid
relaxation of one or more muscles ; 3.  Where there Avas a morbid
relaxation of the Avhole  member, say a leg or an arm, w ith wast-
ing of its substance.
   In cases of withering of the muscles and paralysis of the limb for
years, Mr. Braid  also speaks of another extraordinary remedy
which he has discovered besides excision.  It is merely a continued
friction for a short time by rolling a smooth cylindrical body (as a
strong ounce  vial)  over the limb, from the roots of the nerves and
trunks of the blood-vessels  in a direction  towards their extreme
branches, establishing thus a free use of the limb  in some cases in
the space of ten minutes !   The cases he gives seem almost incred-
ible ;  and his treatment  is based upon the pathology of a deficient
supply of nervous  fluid, Avhich  he  by this process forces into and
accumulates in the part.—(Vide Edinburgh Med. and  Sur* Jour
Oct., 1841.)
   Professor Gross, of Louisville, United States, (see his edition of
 Liston's Elem. of Surgery, Philadelphia, 1842,) deprecates Avhat he
 calls  the rage or monomania for tenotomy, " carving of the ten-
 dons," &c, and  seems to agree Avith  Dr. Chase, of Philadelphia, 
            ALTERATIONS of the tendons or muscles.         461

that, in two thirds of the cases under two or three years of age, an
apparatus properly constructed and applied is  quite sufficient for
the cure.  It  happens that orthopedy, tenotomy, and myotomy, in
Europe, have, in the hands of such masters as Strohmeyer, G uerin,
Dieffenbach, Bouvier, Duval, &c, on the continent, so immeasura-
bly surpassed their advancement in all other countries, even in Eng-
land, that the profession,  so to speak, with some one or two rare
exceptions, perhaps, in  our own country, and Avhich will  be found
in the proper place, have been left behind the rapid march of this
department of science abroad.  Many,  therefore, with a natural
feeling, decry or disparage such revolutionizing innovations as fear-
ful ; and as an illustration of this, it may be remarked, that even in
what are termed standard and perfect works on surgery, published
up to the present moment, either in England or America, the sub-
ject is scarcely  adverted  to ; or in such a trivdal Avay, we must be
allowed to say, as to have rather a tendency to  cast doubts or ridi-
cule upon, than to inspire confidence in its efficacy. This is a radical
and unpardonable error. For, to believe such authors, it were only
necessary to  make a few  slight  reminiscences of, and devote some
five or ten pages to, club-foot and torticollis, and enough  is done to
satisfy the inquiring minds of the present  generation on a subject
which is in every one's mouth  for its brilliant  results, and which
already covers an immensity of space, to say nothing of its kindred
discovery, Anaplasty.  The truth is, that  the study of the whole sub-
ject of the surgical anatomy of the muscles, tendons, aponeuroses,
fasciae, ligaments, capsules, &c,  which had hitherto been almost
slurred over as a waste of time, has to be thoroughly gone into by
medical men of  the present day to make them capable of compre-
hending properly the nature of this great  department of  operative
surgery.  Hinc illas lachrymae !
   Professor Fergusson, of London, (System of Practical  Surgery)
says of the operation for  club-foot, that, in the  young  subject, the
tendons and muscles are all so near to each other that either of the
tibial arteries may occasionally be wounded, and that he is under
the impression  that in children they are frequently wounded, in
which he has been confirmed in his own practice by the subsequent
flow of blood.  He adds, that a little pressure with a pad and ban-
dage has effectually restrained the hemorrhage, as I have also had
occasion to see  in the case of a child, in which one or both these
arteries were unquestionably wounded in this operation.  Pressure,
he remarks, is equally effectual in divisions in the sole of the foot.
In adults, the wounding of the tibials might cause more trouble. P
every case the arteries should be carefully avoided.
   In the apparatus afterwards to be used, and which is an impor-
tant part of the  cure, Mr. Fergusson hassometimes found a common
pasteboard or wooden splint, placed along the  outside of the leg
more  effectual, or at  least more  manageable,  in children  than
any other contrivance. He Avould not apply any  apparatus imme-
diately after  the operation, if it causec  much pain, or was done at 
462
NEW  ELEMENTS  OF  OPERATIVE SURGERY.
the risk of laceration or inflammation; but he believes the sooner
it can be applied the better.
  In accidental ruptures of the tendo-Achillis, Mr. Fergusson has
seen the parts, kept in proper contact, become united as firmly and
appear as strong, even in very heavy individuals, as any other por
tion of the tendon.—T]

                    f. Tendons of the Leg.
  The flexor tendons only of the  leg are  those which have  been
charged with producing a deviation of this limb, and whose divi-
sion has attracted  the  attention of surgeons.  AVhat I have said
above, however, in relation to the reetus-femoris and the ligament-
um-patella3, would  authorize us to undertake the same operation
in front, (en avant)  if the qaudriceps extensor muscle should in real-
ity become the seat of a permanent retraction.   As the operation
in  that case would be  more  easy,  and fully as  effective, and
expose  us to  less  risk of opening  into  the  articulation, below
than above the patella, it  weuld, in consequence, be the  liga-
mentum-patellae, rather than the tendon of the reetus-femoris, that
we should divide, either from before backward, or from behind for-
ward, but always by one of the modifications of the process of Du-
puytren.
  Indications.   Tenotomy in  the  ham should not be undertaken,
except where the joint at the knee is not anchylosed, the flexion of
the leg free from luxation, and the infirmity dependent in reality upon
a retraction of the  muscles, rather than upon an alteration of the
ligaments, or a paralysis of the quadriceps extensor muscle of the
thigh. Examined under this point  of view, the unnatural flexion of
the leg has not been sufficiently studied to enable us to know precise-
ly whether it is one of the tendons of the ham only, rather than the
others, or  all of them combined together,  that generally produce
it.   This, however,  presents no difficulty in the operation, since the
surgeon limits himself to dividing those tendons  only which pre-
vent the natural mobility of  the limb.  Many practitioners, doubt-
less fearful of thereby destroying the internal and external muscles
of the  thigh, would  still hesitate  to perform it  for a simple de-
formity which does not  prevent the  patient from Avalking either
with crutches or on a wooden leg.
  The tAvo cases taken from Pare and Boucher, which show that
in one case these tendons, when divdded and then reunited by means
of suture, and in the other in spite of the loss of substance they
had undergone, have both, nevertheless, reacquired their functions,
ought to have been quite sufficient to have given  us confidence on
this subject, in addition to that which practitioners might also derive
from the details into Avhich  I have entered, upon the reproduction
of tendons and their mode of cicatrization.  Science, at the present
time, possesses facts of a still greater value.  MM. Michaelis, Stroh-
meyer, and Dieffenbach, (Bouvier,  Mem. de VAcad. Roy. de Med., t.
vii., p. 411,) have for a long time applied their methods of tenotomy
to the tendons of the ham.  M. V. Duval  (Bullet, de VAcad. Roy. de 
            ALTERATIONS OF THE TENDONS OR MUSCLES.         463

Med., t. ii., exper. t. ii.) gave, in 1837, positive  proof that this ope-
ration  may be practised with as much success about  the knee  as
upon  the  tendo-Achillis and the  other tendons  of the foot   The
memoir addressed by this  orthopedist to  the  Royal Academy  of
Medicine, contains facts which  do not any longer permit a doubt
upon this  subject.  The seven persons thus operated upon,  and of
whom M. T. Duval (These, No. 342, Paris, 1838) speaks, were all
cured or relieved.
  The Operation.   The patient, lying upon his  belly, has the thigh
extended  and  supported by assistants. Placed on the side of the
tendons to be  divided, the surgeon, Avho  has already examined
them, inserts a straight bistoury, by puncture,  on the outer side of
the thigh if it  is the biceps, or on the inner side  when the tendons
of the pes-anserinus are more particularly retracted.  After haAdng
conducted his instrument to the opposite side  of the tendon to  be
divided, either by grazing  along the internal surface  of the skin,
which always  seems to me the best  mode, or by passing in front
(au devant) of the stretched cord,  he causes the aid  to extend the
leg of the patient with a certain degree  of force.  Turning then
the cutting edge of the instrument downAvard,  (en bas.) or upward,
(en trovers) he divides, as  I have said of the tendo-Achillis, the
whole thickness of the shortened tendon.  The section of the biceps
would be then  terminated, and there would be nothing  remaining
but to Avithdraw the bistoury, and proceed to the dressing.
  On the  inner border of the ham, the operation Avould be more
complicated.  There we may have to divide the tendon of the gra-
cilis muscle, the  semi-tendinosus,  and the  sartorius, successively.
Nor ought the  semi-membranosus itself,  as it is the largest, to be
spared in  this case, if it was in reality retracted.  We  should do
wrong, on the other hand, to cut  those four muscles, if they Avere
not ali  diseased.  The section of one of the first three, or of the
whole three together, would not in reality be much more dangerous,
nor perceptibly more  difficult, than that  of the biceps.  Provided
the  bistoury should not be carried too far towards the popliteal
space, or the posterior surface of  the femur, it  would incur no risk
of wounding any important organ, the popliteal  artery, vein, and
nerves, being too deeply seated to be reached in this way.  The
internal saphena vein and nerve alone would  run some risk; but
we know how easy it is to avoid them. Unfortunately, it is not the
same Math the semi-membranosus muscle.   Being very near to the
posterior surface  and internal border of the femur, as far up as its
termination, this muscle would require that the  instrument, intro-
duced by a puncture between its posterior surface and the tendons
which I have just mentioned, should be held so as to divide it from
Avithin outward, and  from behind forward, going at the distance
of an inch at farthest above the internal condyle of the femur.   I
ought, however, to  add, that by introducing through the puncture
in the integuments a blunt-pointed bistoury, or one of  the blunt-
pointed tenotomes which I have already mentioned, there would in
fact be little risk incurred in the neighborhood of the popliteal 
464
NEW ELEMENTS OF OPERATIVE SURGERY.
  vessels and nerves.   It is, after all, at this height, or a little lower,
  that it is  advisable  to perform the  section of the tendon of the
  biceps and of those at the pes-anserinus, (patte d'oie.)
    The operation being  performed, we immediately give the leg a
  certain degree of extension.  If, in straightening it completely, there
  should not be produced a separation  of over two inches between
  the ends of the divided tendon, we  ought not to hesitate to do it.
  In the contrary case, it is better to  increase this extension by de-
  grees, than to risk the formation of a  cellular cicatrix only, by being
  too hasty.  In  the place  of the dressings and  apparatus, more or
  less complicated, which the orthopedists employ in such cases, the
  surgeon may use a long  splint provided with  a cushion, which is
  to be applied upon the  forepart  of the thigh and  leg,  and which
  serves as a point d'appui for the turns of bandage intended to draAv
  the limb into  a state of extension.   A roller  bandage, with the
  interposition of a  long  strip  of pasteboard, upon the posterior
  or anterior surface  of the part, which bandage should be rendered
  immoveable by dextrine, and should be left to harden while the leg
  is being stretched to the  proper degree of extension, is, however,
  the dressing most  to be  preferred  in these cases.  In order  to
  increase from time to time the extension of the limb, we may soften
  the dressing by moistening it with tepid water  on its middle  por-
  tion, or  renew it every six or  eight days.  It  might probably be
  advisable, also, to stretch the limb, either  suddenly or by degrees,
  into as great a degree of extension  as possible, and to keep it so
  from one to two months, in order to secure it more effectually from
  all consecutive retraction.
    [Division  of the  Tendons at the Ham.  In the division of the
  tendons  at the  ham, as  when retracted in white-swellings,  and
  where there  is  no  anchylosis,  Prof.  Fergusson enjoins here, also,
  great caution, especially in young subjects, for fear of wounding
  the popliteal vessels and  the posterior tibial nerve.  He considers
#  Amesbury's double-inclined plane a very good apparatus  for the
'  gradual extension.   He severely censures  the recommendation of
  M. Louvrier to stretch out the limb by actual force  applied within
  the  space  of a  few minutes, and that of Dieffenbach, to do the
  same immediately after the operation.   He considers that this vio-
  lence, of bringing the foot suddenly up to the hip, and then as  sud-
  denly straightening out  the limb, might fracture the femur;  and
  asserts that death has been thus produced by the excessive inflam-
  mation and suppuration which  had ensued, while amputation has
  been required in other cases.—Pract Surg., he. cit
    Mr. B. Phillips, of London,  recently effected a perfect cure  of
  extreme and permanent flexion  of the leg on the thigh, which had
  existed for years, in  a woman aged twenty-nine, from rheumatism
  affecting the  knee-joints  and  hands.   A  straight blunt-pointed
  knife,  introduced through a small wound flatwise between  the
  tendon of the biceps and bone, divided those cords, and an inch of
  separation was obtained.  A modification of Amesbury's apparatus
  was used for aiding extension,  and in a short time a perfect  cure 
            ALTERATIONS OF THE TENDONS OR  MUSCLES.         465

was effected, and  the  leg slowdy recovered its motions.—Medical
Gazette and Edinburgh Medical and Surgical Journal, 1810.—7'.]

                    g. Tendons of the Head.

  Like  the limbs, the head is sometimes  drawn into an unnatu-
ral  direction  by the retraction of some of its muscles.  The  de-
formity which  results  from this, and wdiieh  is  generally known
under  the name  of caput  obstipum, wry-neck,  and torticollis, is
of such frequent occurrence as to have caused it  to  be  noticed
by  authors of  the highest  antiquity.  Most surgeons, however,
have neglected to  define the cause of it. Some of them had already
remarked, that torticollis might arise from a retraction of the pla-
tysmamyoides, the trapezius, the scaleni, or the sterno-cleido-mas-
toid muscles.   But it is now almost demonstrated beyond dispute,
that this  last muscle,  if not the  only cause, is at least by far the
most frequent source of it, (le point de depart.)
  Whether the torticollis be congenital or accidental, recent or an
cient, spasmodic, convulsive, intermittent, or  permanent, this is not
the place to examine the relative value of the different modes of treat-
ment that have been devdsed to effect its cure.  The internal remedies,
and the different topical applications which  the  ancient surgeons
were in the habit of using in such cases, are not, in truth, of any value
in the treatment of an  ancient and permanent torticollis.  The mas-
sage, still recently extolled by M. Seguin, (Revue Med.,  1838, t. ii.,)
the sudden movements  forcibly  and unexpectedly applied to the
head of the patient, as in the young girl, who, in her eagerness to
look out of the window at some  fireworks, was suddenly cured by
violently turning her head to the side opposite to that of her torti-
collis, could not succeed but in a very small number of cases. There
is generally, therefore,  where Ave do not Avish to abandon the  infirm-
ity  as incurable, no other remedy but a surgical operation which can
remove it.
  A. Indications.  This operation, already repeatedly performed in
the seAenteenth century, and Avhich some  surgeons had continued
to make mention of, remained, nevertheless, out of general practice
until in these latter times.   Embarrassed (arretes) by the idea of a
concomitant deformity in the cervical region of the spine, or of even
a consolidation of the  vertebra?, and believing, 'also, that the atro-
phied or shortened muscle, when once cut, could no longer act on
the head or chest, practitioners were  induced to regard this opera-
tion as useless, and one of considerable danger.  Such apprehen-
sions have noAv passed away.  Positive facts have proved, that the
section of the muscles of the neck allows of the  head being easily
straightened, however ancient may be the torticollis.  I have seen
M. Bouvier, at the Royal Academy of Medicine,  divide the  sterno-
mastoid muscle on the dead body of a girl aged twenty-two years,
and Avho had had a  torticollis  from birth.  The head could be
straightened immediately, and the vertebrae were  scarcely in  the
least degree altered.  It is nevertheless true, as M. Guerin has par
   vol.  i.                       59 
466
NEW  ELEMENTS OF OPERATIVE  SURGERY
ticularly endeavored to prove. " that in ancient torticollis t^ere ex-
ists, in a direction opposite to that of the inclination of the head, an
inclination of the whole cervical column upon the first dorsal verte-
bra."  But it was not this slight deviation of the spine, which, more-
over,  disappears either spontaneously or under the influence of the
proper kind of apparatus after the section of the muscle, which had
embarrassed  surgeons.   AAe now have cures of torticollis  by the
section of the sterno-mastoid tendon in  individuals  deformed for
more  than twenty years  ; so that  it is a question  definitively de-
cided.
  The history of the section of the muscles or tendons of the neck,
in cases of torticollis, is that of tenotomy in general; it was, in
fact, Avith this operation that surgeons commenced.  The observa-
tions  published in Holland in the seventeenth century all relate to
this.   It is the only one which Avas spoken  of  before  Thilenius,
Michaelis, and Sartorius.  The facts mentioned  by Tulpius, Job a
Meckren, Blasius, Tenhaaf, and Chesselden, all relate to  torticollis.
Nevertheless, in spite of what has been  said of it by Riehter, M.
Richerand, and Boyer, and notAvithstanding the operations performed
by Dupuytren, M.  Dieffenbach, M. Syme, and M.  Strohmeyer, teno-
tomy, in cases of torticollis, scarcely attracted attention until MM.
Guerin and Bouvier, in 1838, reawakened  the public mind upon this
subject. But the last modification (phase) of this operation, Avhich
goes back only to 1820,  had already reached  to the highest point
of perfection and  simplicity of which it is susceptible ; while the
section of the tendo-Achillis, though it was first  practised in 1784,
was not enabled to attain the same perfection until 1837.
  B.  Operative Methods.  All the processes of  tenotomy  have been
applied to torticollis.   The operation of Tulpius, and that of other
Dutch surgeons, was performed in the following  manner. A caus-
tic was applied upon the skin ; at a later period the bistoury Avas
used  to divide the muscle above the clavicle.   Others occasionally
dispensed with the caustic, or with the bistoury,  and had recourse,
some to a transverse incision, which should include both the tegu-
ments and the  muscle,  and others to  a scarification   (escarifica-
tion)  of the  parts.  It appears that no other than this method was
practised up  to 1821, and that Dupuytren,  for still using it at
that  epoch, was strongly censured by M. Ammon, (Parallele de la
 Chirurg. Francaise et la  Chirurg. Allem.,  etc., Leipsic, 1822.)   Re-
cently, also, there are distinguished surgeons who have still thought
it advisable to follow this mode.   M. Amussat had adopted it in a
case which he communicated to the Academy, Avith this difference,
that,  like Michaelis, he contended for a partial section of the mus-
 cle.   In 1836, M. Roux also div ided the teguments transversely be-
 fore dividing the sterno-cleido-mastoid muscles.  It  appears  that M.
 Magendie, who, after the manner of Sartorius, made first a longi-
 tudinal incision  in the skin, thought it necessary, in order to reach
 the muscle more readily, to change this wound into a crucial incis-
 ion, (Experiences, t. i., pp. 511, 541, 542.)   It is easy to recognise in
 the midst of these facts that the incision has been sometimes made 
            ALTERATIONS OF THE TENDONS OR MUSCLES.         467

upon the body of the muscle, and at other times towards its extrem-
ities ;  that  it has occasionally comprised  the  whole, and at other
times only a part of it, without there having existed in this respect
any fixed plan of proceeding in the minds  of the operators.
  The second method, and which M. Guerin has thoroughly inves-
tigated, is  composed of three essential particulars—I.  To divide
the tendon of the muscle, and not the muscle itself   2.  To divide
only one of its  portions (faisceaux)  when, as frequently happens,
they are not both retracted ; 3. To  perform this section by punc-
ture,  and not through an incision of the integuments.
  Heister (Institut Chirur., t. ii., p. 673) had already indicated, in
a formal  manner, the place where  it  vveuld be proper  to cut the
tendon of the sterno-mastoid muscle ; he has even had the precau-
tion to mark this point  in  figure  12 of plate 21 of  his book.   So
also  has Joeger.    M.  Chelius, (Traite  de  Chirurgie,  trad,  par
Pigne,  Paris, 1835, t. i., p. 463,) who  also designates  it, recom-
mends that it should be at an inch above the sternum, and that the
incision should be transverse. On the other hand, Richter had  said
that in torticollis it sufficed to cut the portion  of the  muscle which
is attached to the sternum, and that  Ave should proceed to the sec-
tion of the second portion, Avhen that of the first did  not  appear to
answer, (Exper., t. i., p.  539.)  Every thing, also,  show's that  Du-
puytren (Coster, Manuel de Med. Oper.) had used in 1822, and with
entire success, the process of puncture for  the section of the sterno-
mastoid muscle.
  The operation which Dupuytren  performed in this manner, in
1822, was not published by him; but  tha, account of it was given
in France by M. Coster, (Ibid.;)  in England by M. Averill, (Treatise
on Operative Surgery, 1823 ;) in German)' by M. Ammon,  (Parol, de
la Chir. Franc, et de  la Chir. Allem., 1823 ;) and then by M. Fro-
riep,  (Notizen, &c, t. v., p. 142.)   M. Michaelis also  mentions  it in
the Journal of  Graefe and Walther.   According  to these different
authors, Dupuytren, operating  on  a young  girl, made a puncture
into the skin on the inner side of the  sterno-mastoid muscle,  and
through that introduced upon the posterior surface of the muscle a
blunt-pointed bistoury, the  cutting edge  of which he afterwards
turned forward to divide the retracted  muscle  from its deep-seated
to its cutaneous surface.   Dieffenbach, (Rust's Handbuch der Chir.,
t. iii., p. 629,) Avho knew this method, announced, in  1830, that he
had followed it with success in an entire series of cases, and  that
Avith  him the division  of the sternal portion only of the muscle  had
been  generally  found to answer.   A  surgeon of Edinburgh, M.
Syme, (Edinburgh Med. and Chirurgical Journal, t. xxxix., p. 321,)
haAdng imitated Dupuytren, published all the details of his opera-
tion in 1833. It appears, also, that M. Strohmeyer (Experience,  t. i.,
p. 511) had had recourse to the same method in 1835.   I have re-
cently seen, by a letter dated June 1,1838,  that M. Dieffenbach has
for ten years performed  tenotomy upon the neck after the method
of Dupuytren, and that he has, up to the  present time, had thirty-
Uvo cases of it.  M. Bouvier affirms, on his side,  (Ibid.) tta.t he 
468           NEW ELEMENTS OF OPERATIVE  SURGERY.
had put it in use at Paris in the course of the year 1836.  It is nev-
ertheless true,  that this operative  process, applied to the tendons
of the neck, had hardly attracted attention at the period Avhen M.
Guerin proposed it as a new method, sustaining himself upon facts
and reasonings that produced entire conviction.
  The text of the authors who have first spoken of this  operation
is not sufficiently clear to authorize us to maintain that Dupuytren
confined himself to a single puncture.   The  narration of  MM.
Coster and Froriep  (Ibid., p. 590) would admit of the belief, that,
after having inserted the point of the bistoury upon one side, he had
also perforated (traverse) the skin with it  on the other side.   M.
Guerin, (Exper., t. L,  p. 589 to 592,) who strongly insists that we
should confine ourselves to  a single puncture, has, moreover, modi-
fied the operation in two  other  points.   In place of incising the
tendon  from behind  forward, like  Dupuytren  and his imitators,
he divides it from before backward, or from the skin towards  the
deep-seated parts. In fact, he first makes the puncture on the outer
side of  the tendon, in order to penetrate under the skin from Avith-
out inAvard.  In  reality, this discussion is a matter of very little
importance;  although the  process of M. Guerin, in fact, is prefer-
able to the others, when the  teguments are sufficiently pliant to
permit of its employment, it cannot be denied that in operating like
Dupuytren, or M. Dieffenbach, or M. Syme, that is, in perforating
the skin on both sides, (qu'en traversant la peau des deux cotes) and
in dividing  the tendon from behind forward, Ave should obtain a
result almost fully as  advantageous.  I should add, that there must
be cases Avhere each  one of these processes would be found more
particularly applicable, and that it Avould be absurd to wish to adopt
one to the exclusion of all  the rest.   AVho does not, also, see that
these modifications in the  operative process, for tenotomy of the
neck, resolve themselves into a simple repetition of what has been
done and said upon the occasion of the tenotomy of the leg,  and
more  especially of the section of the tendo-Achillis ?
  In conclusion, the sterno-mastoid  muscle, like the tendo-Achillis,
ought to  be divided  whenever by  its retraction it produces an
abnormal deviation.   When we are to divide it, it is advisable to
ascertain if it is retracted by one of its portions, or by both at the
same time.  On the supposition that in the vicinity of the clavicle
there should be adhesions,  morbid cicatrices, or any circumstance
whatever that might interfere with its section in this place, it would
he advisable, as  M. Dieffenbach informs us was done  in a  case
operated unsuccessfully upon by M. Graeffe some time previous, to
divide the body of the muscle itself: but I do not think it would be
proper to divide this  muscle  in  its  upper part, as M. Bouvier has
recommended, nor to  make a previous incision in the skin which
covers it, either after  the Dutch method, or in  adopting the  mode
of Sartorius, as M. Magendie still did in  1838, at the Hotel-Dieu.
Nor has the  process  of Delpech any greater claim to be adopted
for tenotomy of the neck.
   As to the  processes by puncture, I have  already said that  that 
             ALTERATIONS OF THE TENDONS OR MUSCLES.          469

 of Dupuytren  could be  adopted, if it  should appear impracticable
 to divide the whole breadth of the retracted muscle without pene-
 trating (atteindre) the skin on the opposite side.   Otherwise the
 process by simple puncture, in the manner MM. Stoess, Bouvier,
 and V. Duval, have  for a  long  time employed it  for the tendo-
 Achillis,  Avould be preferable.  For  myself, I should also, unless
 there were particular difficulties in  the way, adopt the improve-
 ment made in  this process  by M. Guerin; that is to say, I should
 prefer to make the bistoury pass under the  skin than along the
 deep surface of the tendon.  Also, I regard as a decided improve-
 ment, the precaution of dividing sometimes the sternal branch only,
 and sometimes the clavicular branch, and in other cases both these
 tAvo branches  at one stroke, according as the retraction comprises
 a part only, or the Avhole of the  muscle.  We see, indeed, that M.
• Strohmeyer (Arch. Gen. de Med., 1838,  t. ii., p. 94)  found himself
 obliged to perform, successively, the section of the  sterno-mastoid
 muscle, then that of the claAdcular bundle, (faisceau) and finally
 that of the clavicular portion of the trapezius muscle, and, in addi-
 tion to all these, a cellular bridle, which extended from the sterno-
 mastoid  to the scalenus muscle.
    As to  the question, whether if after the operation it is proper to
 employ the apparatus or bandages, either to adjust the  head or
 prevent  a new retraction, and wdiieh appears, in fact, to have oc-
 curred in some patients of M. Dieffenbach, and as has doubtless
 happened also with others, I do not think it can be decided upon with
 absolute certainty. A young girl operated upon by M. Fleury, (Ibid.,
 p. 78,) and whom I saw, was not subjected to that  treatment, and
 yet recovered  promptly.  If the reunion of a divided tendon should
 in consequence  of  a suppuration result in the  formation  of an
 inodular bridle,  these mechanical means Avould be indispensable,
 not only to carry on  the cure, but, as M. Guerin recommends, to
 complete it.   Should the deviation of the cervical  portion of the
 spine prove an impediment to the perfect  straightening of the
 head, mechanical expedients in this  case, also, should be had re-
 course to, after the operation.
    In short, the operation having been performed, those mechanical
 contrivances should  be made use of as often as it should  seem
 difficult for the head to  sustain itself in a proper position by the
 spontaneous action of the muscles.  In  the contrary case, we  may
 dispense with  them wdthout any risk, and even with advantage.
    C.  Operative Process.  The sterno-mastoid muscle, in its whole
 length,  is surrounded with organs Avhich we  could not avoid the
 danger of wounding. In its upper half we could not divide it, with-
 out  implicating many branches of nerves  of  the cervical plexus.
 On its middle third there would be danger of  wounding the exter-
 nal jugular vein, and some filaments of the same plexus.  Its lower
 fifth is in the  neighborhood of some small veins, which there cross
 its insertion as they course under the skin; then, deeper still, it is
 approached by the sub-clavian and internal jugular veins, without
 taking into account that the carotid and sub-clavian arteries,  also, 
470           NEW  ELEMENTS  OF OPERATIVE SURGERY.
 are not far distant.  It is not, therefore, a matter of indifference to
 perform its section on this or that point of its length. In selecting the
 lower portion, we have not only the advantage of being enabled to
 cut its two roots separately, but of also easily ascertaining through
 the skin the condition of that portion of it which we wish to divide.
 We have, besides, a kind of hollow, or void, which separates it from
 the large vessels which I have spoken of, and which in depth corre-
 sponds to the entire thickness of the clavicle.   Without, however,
 participating in all the fears of M. Bouvier, (Exper., 1838, t. ii., p.
 275,)  we ought not to be ignorant of the fact, that the arrangement of
 the veins of the shoulder or neck which come to this region, to open
 either into the internal jugular or into the sub-clavian, is liable to
 very  great modifications, so that it is impossible to say at first that
 we shall not  wound any of them.  In this point of view, therefore,
 the section of the sterno-mastoid muscle is an operation  of rather •
 more difficult character than that of the tendo-Achillis.
   We begin by causing the patient to lie down, unless we  should
 prefer to seat him on a chair, taking care to  keep his chest in a
 state  of semi-flexion.  The surgeon, placed in front, or on one side,
 makes Avith  the right  hand for the left side, and the left hand for
 the right side, if he adopts the process of M. Guerin, a puncture on
 the outer border of the sternal tendon of the muscle, at the distance
 of six or eight lines above the sternum.   Then, gliding the instru-
 ment flatwise under the skin, as far as to the inner border of  the
 muscle, he turns  its cutting edge backAvard, and thus divides  the
 tendon  from  the  teguments  towards the deep-seated parts.   If
 it is useful to relax the muscle a little while gliding the instrument
 under the skin,  it  is advisable  to extend and stretch it at the mo-
ment  of making the section of the tendon itself. As the bistoury acts
on a firmly-stretched fibrous tissue, the cessation of resistance soon
informs  us when there is nothing farther to divide, and  thus guards
us from inclining the cutting edge of the tenotome too far in  the
direction of the deep-seated vessels of the neck.
  For the clavicular portion, it would be necessary to make  the
puncture at an inch to an inch and a half farther to  the  outside,
and rather close to the clavicle, than at a distance from it.  As
this portion is wider (plus large) than the other, it would be neces-
sary,  also, to  insert  the bistoury farther in, from without inwards.
This  tendon, which should be divided as thoroughly upon its inner
as upon its outer border, upon its cutaneous as upon its deep-seated
surface, is surrounded, but at a greater distance than the  sternal
portion,  by the veins and large arteries.
  If, in place of thus dividing the muscle  by beginning on its sub-
cutaneous surface, we should  prefer  dividing  it from behind  for-
Avard, it would be more convenient, but not indispensable, to make
the puncture of the tegments on the inner side of each tendon  and
the puncture  being made, I  should consider it a matter of great
prudence to substitute the blunt-pointed tenotome or bistoury for
 every kind of sharp-pointed instrument, in order that we might with
 greater certainty avoid the veins in that region.  Afterwards, cutting 
            ALTERATIONS OF THE TENDONS OR MUSCLES.         471

from behind forwards, with gentle saw-like movements, we should
have to watch the successive separation of the div ided tendinous
bundles, in order to run no  risk of coming through the skin itself.
  This precaution, also, it would be well to take, even when we adopt
the method of passing the instrument from the outer to the inner bor-
der.  We may also perceive, that in dividing this muscle from before
backward, there would be but little inconvenience  in inserting the
"nstrument from its inner to its outer border.  The best course in
all this, is first to make a puncture with a lancet, then to introduce
into this puncture a tenotome, or a narroAv blunt-pointed bistoury,
and which could glide  flatwise between the  skin  and the tendon,
or between the tendon and deep-seated tissues, without incurring
the risk of perforating the vessels or the skin itself.
   As soon as the tendon is cut, it leaves a void on a line with the
separation which takes place betAveen  its two extremities.  The
head may then be straightened Avithout  difficulty.  Among the
accidents mentioned as consequences of tenotomy in  the neck, is
ecchymosis, which  exists sometimes to  a considerable extent, but
which, in the patients treated by M. Guerin, was always promptly
relieved.   M. Dieffenbach, (Exper., Aout, 1838, t. ii.,  p. 276,) who
says he has performed this operation thirty-seven times, has failed
in only one single case.  The young girl, of whom M. Fleury speaks,
fell into a state of nervous delirium, of a very peculiar character,
which lasted three days, but from which she  afterwards very rap-
idly recovered.  We see, also,  that the  young man operated upon
December 2d, 1837, by M. Guerin, (Gaz. Med. de  Paris, 1838, p.
529,) experienced some of the symptoms  which appeared  to in-
dicate the introduction of  air into the veins, but wdthout  any un-
pleasant consequences resulting from them. The small wound has
always cicatrized in the course of a few days.   Up to the present
time, there has been no mention made that it has suppurated or
caused inflammation  underneath.  The effusion and fluctuation
which M. Dieffenbach speaks  of, (Exper., t. ii., p. 276;  Gaz. Med.
de Berlin, 1838,) and which he  overcomes or prevents by compres-
sion, is no cause for any alarm.
   As to the mechanical means to be employed, if  these should be
necessary, I should advise the simple dividing bandage of the neck
to begin with, and would not proceed to an apparatus, properly so
called, until after being convinced  of its being  indispensably ne-
cessary.
   [Dr. Mott divides the sterno-cleido-mastoid at the junction of the
two roots. It is narrowest there.—T]
   [Torticollis.  The sub-cutaneous  section of the sterno-cleido-
mastoid muscle, whose retraction is the almost exclusive source of
this well-known deformity, has yet been but seldom  practised in
America.  But few have had the courage or experienced tact of a
Guerin to  operate by the sub-cutaneous section in the dark, in a
region so dangerous; and  although Dr. J. M. Warren, of Boston,
and Dr. N. R. t>mith,  of Baltimore,  have performed it in several
sases, Dr. Mott of New York, notwithstanding the now general con- 
472
NEW  ELEMENTS OF OPERATIVE SURGERY
demnation of the  old method, or open transverse incision through
the integuments, and after all  that he has been an eye-witness to
at Paris, of the admirable skill of Guerin in the sub-cutaneous sec-
tion, still adheres to that ancient, and, as he deems it for the gene-
rality of practitioners, safer praetice.   As a  professor of surgery,
Dr. Mott believes it  to be his conscientious  duty, not so much  to
teach what can be done by adroit manipulation, as what  may he
done by ordinary operators to extend  the usefulness of their profes-
sion.  He has divided the sterno-cleido-mastoid muscle twelve  times
for torticollis, incising cautiously the whole breadth of the retractea
parts from without  inward,  and  keeping the  lips of the Avound
carefully apart by  lint, and by the position of the head moderately
inclined to the opposite side, until the Avedge-shaped fissure is filled
up with  granulations.  This mode has certainly one great  advan-
tage over  the sub-cutaneous, viz., that  it never or  very rarely re-
quires  to be repeated, as the sub-cutaneous often  does, from the
tendenc}r, in this last  process,  of the extremities of the divided
muscles to reagglutinate.
   Professor Syme  of Edinburgh has recently published some very
interesting observations upon this subject.  The first case of sub-cu-
taneous section of the sterno-mastoid in Great Britain for wry-neck,
Avas performed by that gentleman Avith perfect success, on a boy
aged six, at Edinburgh, Nov., 1832.  (See Braithwaite's Retrospect, No.
7.)  The tenotome was inserted on the tracheal margin of the ster-
nal portion, an inch above the clavdele, and the hard cord instantly
divided with a loud snap, and  perfect and immediate restoration
of the head to its place.  M. Syme justly remarks, that lateral de-
viations  of the  spine are produced by way-neck from muscular
retraction of the sterno-mastoid,  the  dorsal  vertebras on the re-
tracted side assuming  a corresponding convexity, and the lumbar
bending in  an opposite lateral direction to preserve the balance of
the trunk.   The operation for the torticollis  readjusts the column,
unless the  disease  has continued  so long as to alter the shape of
the bones, which alteration generally consists in a compression of the
bodies  of the  vertebras and projection of the  sternum.   In these
cases, however, the division of the  sterno-mastoid gives great relief,
and the spine may recover its natural condition in time, if the pa-
tient is not arrived at  maturity.   Professor Syme gives a recent
instance of this kind in a young lady upon whom he had operated
in 1841, and Avhere the back and ribs Ave re much distorted, and the
constitution so much affected that he scarcely hoped for success.
In two years, however,  she  became, from  being a pale,  sallow,
and crooked looking girl, a  hale, ruddy, healthy looking  young
woman.
  There is  another case he mentions of Avry-neck and lateral cur-
vature of the spine, Avhere the  sterno-mastoid  appeared soft and
relaxed until the patient attempted to  straighten his head.   The
division Avas effected, and the next day the patient's back was com-
paratively straight.
   Thirdly,  caries  at the  occipito-vertebral  articulation, that is- 
            ALTERATIONS OF THE TENDONS OR MUSCLES.         473

between the occiput and  atlas, generally a fatal disease, must not
be mistaken for wry-neck. (London and Edinburgh Monthly Jour-
nal of Science, April, 1843.)
  M. Liston, on the other hand, (Add. his Elements of Surgery, Lon-
don,) imputes most cases of wry-neck (erroneously, as we conceive)
to some vice  in the bones, as curvature from softening, attended
with deformity of the trunk or of the limbs, the twist in such cases
being generally to the right side, the ear approaching the shoulder.
He therefore  in such cases recommends the use of apparatus, to
restore the perpendicularity<of the vertebral column, before, as we
understand him, as Avell as after the sub-cutaneous  section of the
sterno-mastoid.—71]

h. Section of some other Muscles of the Neck, in cases of Deviation
                          of the Head.
   There is no doubt that  most of  the muscles on the sides of  the
neck  may become  the  cause  of a permanent retraction, and con-
tribute  in this manner to  some of  the deviations of the head.   Up
to the present time, hoAvever, the  trapezius and platysma-myoides
are the  only ones besides the  sterno-mastoid, which in this respect
have  attracted the attention of surgeons.
   In becoming indurated, and in retracting itself, the clavicular por-
tion of the  trapezius muscle  vveuld draw the head towards the
corresponding shoulder.   Thus M.  Strohmeyer (Arch. Gen. de. Med.,
1838, t. ii., p. 96) perceived that  he could carry the bistoury by
puncture under the anterior border of this muscle, and divide it from
the deep-seated parts towards the  skin, in  a young girl in whom
the torticollis had been but imperfectly removed by the section suc-
cessively of the two branches  of the sterno-cleido-mastoid  muscle.
As the object of the operator in such a case would not be to cut the
whole breadth (largeur)  of the muscle, the ordinary narrow bistoury
inserted by puncture would be preferable to the blunt-pointed  bis-
toury, and to the different kinds of tenotomes ; and I do not see that
it would be very  important whether we made  it cut rather from
the skin towards the deep-seated parts, or in the contrary direction.
It is an operation, moreover, whose utility it Avould at  the  present
time be difficult to  appreciate, as  it does not yet appear to haAe
been put in practice but in one single case.
   The Platysma-Myoides,  (Peaucier)   The platysma-myoides, ex-
panding (s'epanouissant) upon the  loAver part of the face  in  one
direction, and upon the apex of the thorax and shoulder in the
other, might, if it should  be retracted, produce a  deformity of a
sufficiently complex character.  The loAver  lip and the correspond-
ing commissure would  necessarily be drawn downward and out-
ward by means of the  risorius muscle.  We  may conceive, also,
tnat the lower jaw would have a constant tendency to be depressed,
and consequently that the mouth of the patient might remain per-
manently open ; the whole head, in fact, would be drawn forward,
and to one side.  It is a species of  deformity which Gooch says he
has met with.  Perhaps in the patient mentioned by this surgeon, as
  vol. i.                      60 
474
NEW ELEMENTS OF OPERATIVE  SURGERY.
well as  in the one  that  M. Lelong (These,  No. 179,  Pans, 1819)
speaks of, there were sub-cutaneous fibro-cellular bridles, and cer-
tain inodular cicatrices of the  skin, rather than  actual retraction
of the platysma-myoides.  Be  that  as it may, Gooch divided the
abnormal cord transversely, was  then enabled to  straighten the
head, and ultimately, he says, cured his patient.
  If such a deformity should be met with at the present time, it
would be advisable, above all, to ascertain whether it arose from a
muscular retraction  rather  than from cutaneous bridles.   In this
last case, in fact,  we should have  recourse  to transverse  and re-
peated incisions,  or to the extirpation of the bridle itself,  after the
manner I have pointed out in another chapter.
  If the deformity in reality depended either upon a cellulo-fibrous
bridle, or upon the platysma-myoides, and the skin above remained
free from adhesions,  the processes of tenotomy should be  had re-
course to. It weuld be advisable, especially, to raise up the integu-
ments, in order to separate them as much  as  possible from  the
bridle, and that, the puncture being made, the bistoury might glide
in the sub-cutaneous  tissue to beyond the  cord to be div ided.  This
manner of proceeding would evidently be preferable to  the pro-
cesses of M. Strohmeyer, or those of MM. Stoess and Bouvier.  The
only part which could run any risk in this operation, weuld be the
external jugular vein ;  but it is  sufficient to recollect this, to enable
us to avoid it with  certainty.  The section  of the bridle having
been effected in one or several places, it weuld at least be quite as
necessary here as after the section of the  sterno-mastoid muscle, to
call to our aid an  apparatus or  bandages  to complete the cure, and
restore to the head as straight a position  as would be desirable.
                        CHAPTER  IV.

DEFORMITIES IN CONSEQUENCE  OF ALTERATIONS OF THE  DEEP-
        SEATED LIGAMENTS OR DEEP-SEATED APONEUROSES.

  It having been remarked  that certain deviations, independent
of diseases of the articular surfaces, or of alterations in the  direc-
tion of the bones, could not in any manner be explained by morbid
cicatrices, sub-cutaneous bridles, or the retraction of the muscles,
practitioners  asked themselves the question, if the cause might not
be in  the shortening or rigidity of the ligaments.  This is a ques-
tion altogether new in operative surgery.  MM. Ghidella and Fro-
riep, who appear to have been the first who have given  considera-
tion to this subject, have not accompanied  their descriptions wdth
details sufficiently precise to know exactly to what kind  of lesions
they in reality directed the treatment of which I am about to  speak.
Nevertheless, as we do in fact sometimes  meet with tetractions 
DEFORMITIES FROM ALTERATIONS OF LluAMENTS, ETC.
475
which it is utterly impossible to explain, otherwise than by the rigid-
ity of certain ligaments, and the shortening of certain aponeurotic
bridles; and  as it is now impossible, after one of the observations
communicated to  me by M. Champion, and after that  published
by M. Froriep, to call in doubt the power that th_ aponeuroses have
of retracting themselves, I think we should not, in too absolute a
manner, reject the practice of the surgeons of whom I have spoken.
I ought  also to add, that  each  of the three surgeons who as
yet have endeavored to call  attention to  this point  of surgical
pathology,  extols  a different  method.  M. Ghidella, (Bulletin de
Ferussac, t. xiii.,  p. 67,) for example, recommends that we should
divide all the retracted bands (rubans) by means of large (large)
and numerous incisions.   He gives many cases  of rigidity, and
one of a very ancient semi-anchylose state of the lower jaw, which
were cured by this kind of operation.   On the  contrary, in the
process of  M. Froriep, (Encyclog.  des Sciences Medic,  t. i., p. 252,
ou Gaz. Med. de Berlin, No. 12, 1836,) we are advised to  rely upon
mechanical means,  when the simple incisions after the method
of Dupuytren do  not appear  to be  practicable.   In fine, we per-
ceive, by the researches of M. Nanzio, (Bullet, de VAcad. Roy. de
Med. t. i., p.  60, et t. ii., p. 135, et suiv.,) professor of hippiatrique
at Naples,  that in horses, where this kind of retraction appears to
be very frequent, the operation should consist of deep (large) inci-
sions, which  should penetrate to  near  the joint,  and  of the iron
heated to whiteness, which should be applied directly to the cap-
sule or the ligaments.
  The authors who have proposed these operations are  men that
are known and esteemed ; they relate facts and successes in sup-
port of their  practice ; we should, therefore, act discourteously to
reject their recommendations without examination.  It  seems to
me, however, that the method of M. Nanzio, transferred from the
veterinary art to  surgery, properly so called, would incur the risk
of serious dangers, without authorizing us to expect from it any spe-
cial  efficacy;  that of  M. Froriep would hardly have  any  more
chances of  success in the deviations produced by retraction of the
ligaments,  than in those caused  by retraction  of the muscles;
on the other  hand, it  would  scarcely be  allowable to  apply the
method of Ghidella, except upon the ligaments situated superficial-
ly.   Nevertheless, simplified as this method has  been for tenotomy,
it might be made  trial of without great danger, upon the articula-
tions of the fingers and toes, the wrist and instep, the knee and el-
bow, as well as upon the temporo-maxillary articulation.

                              §1-

  In the fingers,  this method,  which had already been proposed in
some cases of luxations of the phalanges difficult to be reduced, and
Avhich Bell performed with a cataract needle, might be effected
wdth the point of a very narrow  bistoury,  or, better still, with a
strong arrow-headed needle.   Passed from one of the surfaces of 
476
NEW  ELEMENTS  OF  OPERATIVE SURGERY
 the finger to the other, as it  grazes along the deep-seated surface
 of the skin,  so as to avoid the lateral vessels and nerves, the in-
 strument,  whose cutting edge  should  be soon turned crosswise,
 would, Avithout any great difficulty, divide the lateral ligaments of
 each of the phalangeal articulations, or those of the articulation
 of the fingers Avith the hand.

                             §11.

  At the wrist, Avhere the operation Avould be a little more danger-
 ous, because of the ulnar and radial arteries,  it Avould be better,
 after the puncture has been made beloAV, and upon the cubital side
 of,  the styloid process of the radius, to cut  the ligament  from the
 deep-seated parts toAvards the exterior, rather than from the skin
 towards  the  articulation.  It would be the same for the internal
 lateral ligament, although it  may not be quite so  near the  ulnar
 artery as the preceding one is to the radial artery.

                             §111.

  The lateral ligaments of the elbow Avould be Aery easy  to divide
 by this method.   Nothing Avould prevent us from passing the nee-
 dle or the bistoury between the skin and the other tissues, in order
 to cut the ligament from without inMerds. We must,  nevertheless,
 remember, that, in  proceeding thus with the external lateral liga-
 ment, we should run the risk of partially dividing the supinator
 radii brevis, while, in cutting  from the  deep-seated parts towards
 the exterior, we could avoid  this muscle with  greater ease.   The
 instrument, moreover, should be  introduced at the distance of three
 or four lines beloAV the  external condyle.  We could render this
 separation of the ligament more  easy, if Ave could possibly keep the
 forearm in  a state of semi-flexion during the operation.  The inter-
 nal lateral ligament would be difficult of division under the ante-
 rior origin of the  flexor carpi ulnaris; Ave should, moreover,  recol-
 lect that  the ulnar nerve passes betAveen the inner condyle and the
 olecranon.
  As to the anterior ligament of the humero-cubital articulation, I
do not think that any surgeon would have the boldness to  attack it
in such cases.

                             §IV.

  The section of the ligaments of the toes, should it  ever become
necessary, ought to be made like those of the fingers.

                             §V.

  At the  tibio-tarsal articulation, it would be easy to divide the  in-
 ternal lateral ligament by passing a bistoury under the  skin, and
 from before backwards, then turning its cutting edge soon after in 
         DEFORMITIES FROM ALTERATIONS OF LIGAMENTS, ETC.     477

the direction towards the astragalus, in order to divide the ligament
transversely at the distance of some  lines below the apex of the
malleolus.
  The external lateral ligaments could be reached in  the  same
way; there would be  no other risk incurred in such cases than
that  of wounding either the tendons of the peroneus longus and
brevis, or those of the tibiales; but it is yet doubtful if the indica-
tion for such an operation could present itself in the feet.

                             § VI.

   It is especially to the articulation of the knee that the remarks of
M. Froriep apply.  It  is true, that bridles of the fascia lata some-
times take on  in this neighborhood a thickness and hardness alto-
gether abnormal, and that the necessity of dividing them has sug-
gested itself to the mind.  It is also true, that both the internal and
external ligaments  of  the  knee  are situated quite superficially
enough to  enable us to divide them without difficulty, if they were
in reality retracted., Thus, with a lancet to make the puncture, and
a blunt-pointed tenotome introduced under the skin from before back-
wards, commencing at the distance of two fingers' width  inside the
apex of the patella, and extending to a level Math the anterior border
of the pes anserinus, and then brought opposite to the articular inter-
stice, we could divide without difficulty the whole breadth of the in-
ternal lateral ligament. Carried in the same manner outwardly, the
bistoury would have difficulty in dividing the ligament without di-
viding  also the tendon of the  biceps, since those parts  are, so to
speak,  enclosed one within the other ;  but  the division of both
might be rather beneficial than injurious, for  how are we sure  at
first that the ligament  only is retracted ?
   As to the aponeurotic bands, their  section does not  require that
we should  trace out rules for them, since it must vary according to
the form, seat,  or degree of elevation  of the bridle to be divided. It
is unnecessary to say, that the ligaments of the shoulder and of the
hip will probably always remain exempt  from any  attempt of this
kind.

                             § VII.

   It remains to speak of the articulation of the jaw.  I do not know
to what extent the rigidity or shortening of the temporo-maxillary
ligament might produce an anchylosis of the jaw.   In all cases, a
cataract-needle, introduced by puncture from before backwards, or
from behind forwards,  would without difficulty effect its  division ;
but  I  ought to repeat, in terminating this article, that such opera-
tions do not offer any special remedial benefits, and we may be al-
lowed to doubt if they will continue in practice. 
478
NEW ELEMENTS  OF OPERATIVE SURGERY.
Remarks on  Immobility of the  Lower Jaw, with a Report of Cases.
  By Valentine Mott, M. D., &c.

  Immobility of the Lower  Jaw.— This malady, as far as I know, has
never formed a distinct chapter in any systematic work on surgery. I
therefore, perhaps, may claim some originality for introducing it to the
notice of the profession.  The more so, from my having  for the  last
thirty years and upwards, met with many cases of this kind and treated
them  successfully.  The means which I have resorted to, may possibly
have  been used by others  before my time, but I am not aware  of the
fact.  AVe are sure that many of the cases wc have met with, had  been
abandoned by others as altogether hopeless and irremediable.
  All surgeons no doubt would, or ought to think of expedients to re-
lieve difficulties and embarrassments connected witli the full and normal
functions of organs.  But as  this  subject  has not claimed  that share of
attention  which its  importance  demands, we think  no  apology on our
part need bG  offered  for here introducing it in a distinct article.   And
we know of no epithet more appropriate to the affection, than that which
is implied by the name  we  have  given to it.   It is, in our  opinion, an
important surgical subject, and especially so, as it is one which frequently
is very difficult to treat. The difficulty in this affection depends, accord-
ing to my observation,  upon three different causes.
  First.—The  first  and most frequent cause is the formation of firm
unyielding cicatrices, resembling as it were adventitious  ligaments, con-
necting the upper and  the lower jaw bones,  in such a way as utterly to
prevent any downward movement of the lower jaw ; which fastenings
if they have continued for a number of years, as we have seen in several
instances, create a positive  deformity in the configuration and symmet-
rical  proportions of the features  of the face.  As, for example, iu the
remarkable disproportion in the development of  the chin and the entire
lower jaw bone, as compared with the rest of the  face.   And from the
long  continued fixedness of the lower jaw bone, we find that besides
this outward deformity, the front teeth also frequently present, especially
in the cases of long  standing, an  irregularity, and also a disproportion,
which is utterly un-human in appearance.   AVhen  not opposed to each
other, they grow to an  inordinate length, and exhibit a carniverous or
canine aspect, as though they were intended exclusively for tearing pur-
poses, instead of fulfilling the functions of incisors.
  Second.—The second cause appears to lie  in the muscles themselvea.
in the form of a preternatural rigidity or dynamic  contraction, as is
evident to the sight as  well as to the touch.   'Most of the cases I have
seen and  treated of  this description, have been young persons, in whom
the disease was the  result of the violent action of mercury  upon the
mouth and adjacent parts, exhibited  for some form of fever, for scarla-
tina, &c.   I have traced these cases to that  cause, though it is difficult
to understand how such an effect  should be produced by it; unless it is
from  the unwillingness in the individual to exercise the  muscles of the
lowar jaw, while in the engorged condition which exists in the tis«uo_
during meacurial actian ; the muscles from this quiescent state seeming
by  degrees to  take on an unnatural spastic rigidity.  In all the cases 
          DEFORMITIES FROM  ALTERATIONS OF LIGAMENTS, ETC.      479

but one which we have encountered, there was more o ■ less of a normal
action  in  the  pterygoid  muscles, by which a trifling  lateral  movement
of the  lower jaw was perceptible.  In the case in which none of these
movements could in any way be detected, all  my  efforts, which were
varied  and very powerful, were utterly unavailing in opening the mouth ;
as will be seen in the details farther on.
   Third.—It may be proper to enumerate a third cause.  This, accord-
ing to recent pathological observations, as is seen in a note in the text,
has been found to consist in an osseous union, by means of  a bony plate
which  extended from the  coronoid process to the superior maxillary
bone, by which the lower jaw became  perfectly immovable.   These, we
hope, are rare instances, but it is possible that the irremediable case we
have above alluded to, may  have been rendered  incurable by such an
adventitious  formation.  If such a condition  of things could be known
at the  time, probably some  sort of an operation might be  devised to
sever or exsect this  bony communication, and thereby at once  open the
 jaws.   In all my cases but one, even  though there was not any appre-
ciable  movement of  the jaw  downwards, I have been enabled to ascer-
tain by a careful examination, that there still existed some trifling lateral
motion.   As far as my experience has gone, I would therefore  consider
this as the best diagnostic or test for justifying the  process of opening
the  jaws  which I have  adopted so frequently with  success.  Indeed, I
should be unwilling to offer a favorable opinion of the  result of the
operation, without this prevdous evidence of the natural condition of the
articulating surfaces.   My  process of surgical  treatment  for the relief
of this distressing  difficulty will be better understood by the details of
the  following cases ; by which it will be found, that almost every case
has  had some peculiarity which has made it necessary to vary the steps
of the operation.  The instrument upon which I have relied, after pre-
paring the patient by the  necessary  previous  incisions, is constructed
upon the  screw and lever  principle.   It is one  which I got up to meet
the exigencies of the third case, without ever having seen or heard of
any  thing of the kind.  Though I confess I have since met in the Arma-
mentarium  Chirurgicum of Scultetus, the figure of one  of a similar
construction.
   Case I.—The first case occurred about the year 1812, in a little girl.
There  was extensive exfoliation of all the alveolar margin on the upper
jaw on both sides.   The lower jaw was  quite firmly fixed.   After re-
moving the necrosis, and waiting until the gum healed, the cicatrices
were then freely  divided from within the mouth.   Then, by forcibly
seizing hold of the chin and side of the  jaw with both my hands,  and
putting my thumbs on the teeth of the lower jaw through  the  opening
made by the removal of the necrosis, while the  head  was very  firmly
held, I succeeded in depressing the lower jaw so as to open it sufficiently
wide.   The  little  girl was about nine years old, and of good healthy
constitution, and the  disease was produced  by the  action  of  mercury
given for a remittent fever.  She entirely recovered the use of her jaw
by the process mentioned.
   Case II.—The second case was an officer of the U. S.  army, from
Green Bay.  His lower jaw was almost immovable from a cicatrix ex-
tending from  the  last molar tooth, to some distance forward.  It had 
480
NEW ELEMENTS OF  OPERATIVE SURGERY.
been of several months' duration, and was, I think, also the result of
mercurial action.   The cicatrix was divided with a scalpel, and the jaw
forcibly depressed at the chin, by which means the mouth  was opened,
and the cure was perfect.
   Case III.—During the winter of 1828,  a young  man  about 21 years
of age, from North Carolina, called upon me with the lower jaw almost
immovably  fixed to the upper.  There was not the least motion to be
discovered  in a downward direction, nor was the most  powerful effort
with the hand upon the chin, able in the slightest degree to alter its situ-
ation.
  He had been in this deplorable state for between ten and eleven years.
Unable during that time to chew a mouthful of food, he introduced all
the solid aliment which -passed  into his stomach through an opening on
the right side, occasioned by a small aperture from an irregularity of the
bicuspides teeth.
  On the left side, just within the angle of the mouth, and opposite the
situation of the cuspidatus  tooth,  a very firm band was  to  be  seen and
felt, reaching from this point along the alveolar ridge to the  coronoid
process.  It was of more than ligamentous hardness.
  Along the whole course of this adhesion of the cheek to the gum of
the lower jaw, there was not the vestige of a tooth ; and he stated that
from this part a large piece  of the jaw had been formerly separated with
the teeth attached to it.  This morbid adhesion had been several times
freely divided, but no depression  of  the lower jaw could be  effected.
It was cut  from within the mouth in different directions, but never al-
lowed the least motion  to the jaw.
  From his being  able to give a little lateral motion to the  lower jaw, I
felt encouraged to hope, that some  relief might be afforded him, and that
his mouth, by some powerful efforts, might yet be opened.   He consented
with  great  cheerfulness to any operation which I thought could be per-
formed, to enable him to receive food with more satisfaction, and restore
the power of speaking, which was also very much impaired.   If this
could be accomplished, it would, moreover, very much improve his expres-
sion generally, as his face had  become very much contracted and mis-
shapen.
  Seated in a chair, I made an incision from the angle of the mouth on
the left side, through  the cheek, and carried it to near the edge of the
_oronoid process, dividing the firm  cicatrix within completely.  Then cut
the adhesion freely from the upper and lower jaws, so as to relieve the
jaws entirely from all  restraint from that cause.  A piece of very broad
tape  was now conveyed  between the teeth by means of a probe and
spatula, and tied  some distance below the chin.   The  head  was now
firmly held, and with all the force  I could exert in the loop of this tape,
not the least yelding of the  lower jaw could be discovered.
  As no force which I could exert would  enable me to open the mouth,
I was prepared to apply the mechanical principle of the screw and lever!
For this  purpose we had  prepared the instrument already alluded to,
and which is composed of two steel plates, about three inches in length!
\AThen applied to each other they were of a wedge shape.  To the lar<e
end  was attached a screw, with a broad handle, which, when turned
caused the  thin extremity of the plates to expand.  (See figure.)   This 
         DEFORMITIES FROM ALTERATIONS  OF LIGAMENTS, ETC.      481

powerful combination of the lever and screw enabled us to open  the
mouth completely.
  With considerable difficulty we succeeded in insinuating this vice be-
tween the range of teeth on the left  side, being  careful to have it rest
along their whole  course  as  much as- possible.  It was then expanded
by turning the screw, and such was the report that attended the yielding
of the lower jaw, that several exclaimed that the jaw was broken ;  but
to me the noise was like the laceration of ligaments, and not  such as at-
tends the fracture  of a bone.   The mouth was immediately opened to a
sufficient extent.  The wound of the  cheek was  closed  with three in-
terrupted sutures,  aided with strips  of  adhesive plaster.  From  the
mouth  being kept constantly open  for several days, by the  instrument
secured between the teeth, it occasioned much strain upon the stitches,
and made the adhesives strips of material importance.
   Either the instrument or a soft  piece of wood was placed constantly
between the jaws to keep the mouth sufficiently open until the cheek had
healed.  During this time he received his drinks  and liquid nourishment
from a spoon or the spout of a  tea-pot.   When  in this way they were
conveyed well towards the base of the tongue, he was enabled to swal-
low without much  inconvenience.
   As soon as the external wound in the cheek was healed, the instrument
was removed, except at night, and  occasionally  during the day, and he
was now permitted to move the  lower jaw.   To  prevent the  cheek from
adhering to the jaws internally, pieces of sponge were constantly inter-
posed.  To enable the jaws to approximate, it was necessary to remove
the last molar tooth of the upper and lower jaw of the left side.   Several
of the incisors were of the most extraordinary  length, and  required to
be filed off, before  a proper use could be made of the others.
   He gradually acquired the power of closing the jaws, and was greatly
delighted with the result of an operation which enabled him  to chew his
food, and enjoy his meals as other persons, which had given proportion
to his  features, and the  ability to converse and articulate distinctly.
[See this case in Am. Journ.  Med. Sc, 1829, vol. V., p. 106.]
  Explanation of the Figure.— aa, the two levers bent at right angles,
and united to the fulcra cc, by a joint,   d, the screw passing through
the centre of the bar, and acting upon the angles bb, which are notched
to receive its point.
  ArOL. I.                    61 
482
NEW ELEMENTS OF  OPERATIVE SURGERY.
   Case IV.—A merchant from Louisiana, and  also the result  of mer-
cury.   There was not, nor had there been, any necrosis in either jaw.
When dividing the bands of adhesion with the narrow straight bistoury,
the screw instrument, found  so  efficient in the last  case, was passed
between  the  incisores, and the  mouth readily  opened.  The cure was
perfect.
   Case Y.—The  fifth case was that of the young lady from Massachu-
setts, where I found  it necessary also to procure a large  patch for the
whole side of the cheek, from the neck, by a geno-cheiloplastic process;
previously exsecting  all the cicatrix, and unlocking the jaw by the screw
lever.  See  this case in a note  under Anaplasty, in Vol. I., p. 706 of
this work.
   Case VI.—This (1831) was an interesting young lady from Louis-
iana, about eighteen years old, who  for six years had  had the  jaws
closed.   The cause was  the action of mercury.  The adhesions  were
firm on each side.  They could  easily be got at from  within the mouth
and divided, but the jaw could be opened only a little way, although a
screw  instrument was used  on each side instead  of in front, as in the
previous  cases.  In  order to get access, several of  the teeth were filed
or sawed off.  All efforts, however, were  ineffectual.   Three  different
attempts were made  at intervals  of several weeks, and each were perse-
vered in for some time.   In no instance  have I used half the force em-
ployed in the present case.   The last attempt I made almost brought on
convulsions  from the pain produced, and I only  wonder that the  lower
jaw did not break.   I regret that  the knowledge of  myotomy we now
possess, was not at that  time understood; for I am persuaded,  that if I
had then known as much of  the  benefit of dividing or excising  muscles
and tendons, which we now have, I might have restored this interesting
young  lady.   The sub-cutaneous division by a straight bistoury of the
maseter muscles, would  in  all  probability, with a moderate amount of
force, have opened the mouth.—I had previously, on several  occasions,
divided in part this  muscle, where I was obliged to lay open the cheek.
All this disagreeable deformity might in her case have been avoided by
the complete sub-cutaneous division of these muscles.  I was grieved to
abandon  this  case, the only one in which I had  then,  or have  hitherto,
failed in effecting a perfect cure.
   Case VII.—This  was a young man, who when a boy eight or ten
years before, had a necrosis and ulcerations  from the operation of mer-
cury.  A7arious attempts  had  been made some years antecedently to open
the mouth, but they all  failed.   I removed the  adhesions  freely with
the probe-pointed bistoury, and with the screw-lever readily opened the
mouth  to its full extent.
   Case VIII.—An eighth case,  (also 1831,) was a child from  the Dis-
trict (now State) of  Maine, who had had six months  before, scarlatina
anginosa.  Considerable ulceration took place about the cheek and gum,
followed  by necrosis of  the upper  jaw.   When the ulcerations healed
the jaw became closed.  The necrosed portion of the bone was loose,
containing  several of the teeth, all of which were taken away.   The
screw was then applied,  and  the  mouth opened.
   Case IX.—A  little girl  from South Carolina.   It was the  effect of
salivation and necrosis.   The adhesions were divided  within the mouth
the instrument applied, and the jaws readily opened. 
         DEFORMITIES FROM ALTERATIONS  OF LIGAMENTS, ETC.      483

   Case X.—(Dec., 1841.) A little girl from Dutchess County, aged ten
years.  From the free use of calomel for a supposed inflammation of the
intestines, a profuse ptyalism was the  consequence.   The  ulcerations
which took place on the inside of the cheeks were followed, on healing,
with a perfect  closure  of the jaws, since  the month of  Feb., 1840.
There was no necrosis of either jaw bone.  After dividing the adhesions
on each side freely, with a straight probe-pointed bistoury, within the
mouth, I was enabled  by means of my fingers to depress  the lower jaw
sufficiently to admit one finger.   The instrument  was now  placed  be-
tween the incisor teeth,  and the mouth  opened to the full extent.   This
case resulted in a perfect cure.
   Cases XL, XII., XIII., XIV., XV., XVI.—These cases were all of
a similar nature to the generality of the cases above described, and all
resulted in a perfect cure by the means above employed.  One of these,
(1843,) I will remark was a fine boy, aged  twelve years, son of Bishop
W----of Maryland, whose jaws had been firmly closed for eight years.
The cause was a fall upon his chin on the  banister of a staircase.  In
the fall, he was received under the chin, from which the inability to  open
the mouth ensued.  About a year before I saw him, a ladder in falling,
struck the anterior and upper part of  the chin, which suddenly opened
his mouth; but after a  short time the rigidity returned, and the  jaws
were again closed.  There were no morbid or  adventitious  adhesions or
bands to be found.  The masseter muscles on each  side were remarka-
bly small and hard.  The most trifling  lateral motion only was percep-
tible.  The lower jaw  was so closely shut that it was difficult to intro-
duce a half dollar  between the teeth.   In this case there was the  least
lateral motion I ever saw, except in the  young  lady above, in whom
alone I did not succeed  by my process.  This case had  been  given up
as hopeless by all the surgeons whom he had consulted in different parts
of the country;  none of whom had recommended any mechanical power
to overcome the difficulty.  The case required a great depressing  effort
upon the chin, and a small lever  between the  teeth, to enable me to in-
troduce the blades of the screw-lever between them.  As soon as it was
barely between them, the action of the screw readily made room enough
to place the instrument  fairly between the  incisores.  The mouth was
then sufficiently opened.  I gave him an instrument, with a request that
it should be used at night  between the molares  teeth, while asleep, in
order to keep the  mouth open.   After a  week or two, I had made for
him a small instrument  on the same  principle, which he used from  time
to time for many months, in order to continue  the success of the treat-
ment.  In all the cases  upon which I have operated, my plan has been,
for some time after opening the mouth, to use the  instrument from  time
to time, either between  the molares, or between the incisores in front;
and particularly, where the instrument was not thus employed, to intro-
duce a piece of soft wood  or fine piece of cork on either side, between
the molares, at night, securing it by a string  around the neck.   During
the day I have insisted  upon the practice of chewing hard crackers or
hard bread, or sea-biscuit, in order  to initiate the muscles into  their
normal functions.
   It may be intresting to those who have not seen  these cases, for me to
state, that  it is my opinion, that where there is no lateral motion what~ 
 484            NEW ELEMENTS OF  OPERATIVE SURGERY.

 ever perceptible, from the action of the pterygoid muscles, then it may
 reasonably be inferred that anchylosis has taken place, and that but lit-
 tle hope can be entertained for the  success  of this treatment.  Where
 there is the least lateral motion, there will then be the greatest dfficulty.
 I may say that my last  case  occurred  between two and  three  months
 since, (Nov., 1846,) in a little girl who was successfully treated by the
 mode above described.  Ar. Mott.]
   New. York. Feb., 1847.

   A recent  case is related  by Mr.  French, (London Med. Gazette,
 1845, also Londen Lancet, September, 1845, p. 352,) in which  Anchy-
 losis of the  lower jaw had  existed  from infancy up to the age of 22,
 when the patient died of apoplexy.  He had taken his food through an
 opening made by the removal of several of the incisor teeth.
   In this case no attempt appears to have been made to overcome the
 immobility, and the  post  mortem  disclosed  a thin osseous lamellated
 plate or expansion of the left ramus extending upwards and uniting by
 intermediate cartilaginous substance only, with a  corresponding lamella
 from the upper jaw.
   Here was a case in which a cure, as Mr. French hints, could undoubt-
 edly have been readily effected, if the true locale  and character of the
 anchylosis could have  been  accurately  diagnosed, as  certainly could
 have been done with equal facility by a careful inspection.
   M. Serre, in  his twenty-ninth case, (p. 329 et seq., Atlas, PI. xxiii.,)
 upon a youth with immobility of the jaws, excised, by means  of two
 vertical triangles united to their base on a horizontal incision, the whole
 of the tissues then circumscribed, in order also to excise  thereby the
 thick cicatrices and bridles they included, and by which, it  appears, the
jaws were held together. He was obliged to tie several vessels of some
 size, and the  flaps were a long time in  uniting.  Finally, the separation
 and movement of the jaw were not obtained over half an inch to an inch
 in width, and that could only  be maintained by the employment of a di-
 lating apparatus.  This operation was performed by M. Serre at  La Pi-
 tie, Paris, 1830.  T.]
                          CHAPTER  V.

          DEFORMITIES FROM ALTERATIONS IN THE SKELETON.

  I shall  divide the deformities to be  examined in this chapter  into
two orders—those which result from an anchylosis of the articulations
and those which depend upon a deformity in the body of the bones.   '

                     Article I.—Anchylosis.

  Three  kinds of operations—the fracturing of the anchyloses the ex-
cision of one of the neighboring bones, and the establishment of a false 
           DEFORMITIES  FROM ALTERATIONS IN THE SKELETON.      485

joint—might, strictly speaking, be undertaken to remeay the anchylosis
of the joints.

                  § I.—Fracturing the Anchylosis.

  When, in consequence of any disease whatever, the joints  become
anchylosed, there results from it an infirmity which is generally incura-
ble ; the idea, then, of breaking the anchylosis in such cases is altogether
natural.  Thus have there existed in all times surgeons who, in accord-
ance with the vulgar opinion, have recommended destroying in this man-
ner the different kinds of articular  rigidities.  Some ancient  observa-
tions,  also, would  seem to encourage this practice.   Fabricius of Hil-
danus relates the case of an anchylosis of the fingers and of the wrist,
which was cured by a fracture of the forearm produced by a fall.  We
see, on the other hand,  in Meckren,  that a stiffness in the elbow, caused
by an abscess, disappeared in consequence of a fracture  of  the  forearm
from a fall.  Bartholine (Trad, de Bonnet, t. iv., p. 410) mentions the
case of a patient who,  having  had  his forearm  dislocated, was seized
with  gangrene at the elbow to  such  extent as to prevent any attempt at
reduction, and who, by a fall from a horse in the succeeding year, had
the  movements of the  articulation  re-established ; but, supposing that
in  these  cases  there was in reality an anchylosis, we  should  have to
oppose to them facts of a totally opposite character,  and well calculated
to discourage practitioners.  A  woman (Arch. Gen. de Med., t. xxv.,
p., 569) had the femoro-tibial articulation anchylosed for a year, in con-
sequence of a white swelling.  It was thought advisable to endeavor to
break the anchylosis;  but this rupture was  succeeded by an inflamma-
tion so violent, and  symptoms  so serious, that death took  place at the
end of a few days.
  The  question relative  to the rupture  of  anchyloses  will always bo
difficult to solve in a definite manner.  If, in some cases, everything in-
dicates that the mobility of the joint might  thus be re-established, it is
also certain, that, in  performing it, we are exposed to an inflammation
which might seriously endanger the life of the patient, or at least com-
pel us to amputate  the  limb.   As an  anchylosis, moreover, in  no way
prevents the patient from enjoying  good health, it  appears to me that,
in a general point  of view, the  practice of which I have just spoken
ought, from prudential considerations, to be proscribed.

                     § II.—Excision of the Bone.

   If  the anchylosis should be accompanied by a deviation too fatiguing
for the diseased limb, perhaps it would be practicable to apply to it an
operation which has not hitherto been proposed, except by M. R. Barton,
(American Jour, of Med. Sciences, Feb., 1838,) and of which I  wish
to say  only a few words.   I will suppose an anchylosis  of the  knee,
with  deviation  of the  leg; would it not  then be allowable to lay bare
the point  of the femur nearest to the skin, and to remove from it by two
cuts of the saw a fragment, which should have the form of a wedge, or
of a slice of melon ?  Afterwards bending the leg in an opposite direc-
tion from  the  articulation, we should  obtain the consolidation in this 
486
NEW ELEMENTS  OF OPERATIVE SURGERY.
 position  by means of an  immovable dressing.   The leg, thus adjusted,
 would permit the  foot to come in contact with  the ground.  It is true
 that the limb would, in  that case, take, to a certain extent, the form of
 a Z ; but, besides that this double curvature would be but little noticed,
 if it was made very near the knee, it would not  deprive  the patient of
 the use of his foot.  AVe see, also, that in place of selecting the thigh,
 we could operate on the tibia itself, directly under the knee.
  ^  I do not disguise from myself the inconveniences of such  an opera-
 tion  ; but I have tried it upon  the  dead body, and it does  not  appear
 to me to be of very difficult execution.  I therefore believe it practica-
 ble in certain deviations of the foot and those  of the  knee, wrist, and
 also  of the elbow.

                            A.  The Foot.

   If a pes-equinus, for example, arose from a tibio-tarsal anchylosis, I
 do not see why we  should not attempt the removal of a wedge from the
 tibia and  fibula.  For  that purpose there would be required a longitu-
 dinal incision extended from the anterior edge of the internal malleolus
 to three inches above.   After having isolated the bone from all the soft
 parts, we should shove  the latter apart on each  side  by means of a
 blunt hook, which an assistant should at the same time  force backward
 or outward.  A half-circular saw, directed  transversely, would  divide
 the bone  perpendicularly  for the upper cut, obliquely from below up-
 wards for the lower cut,  to the  distance of some lines from its posterior
 surface, and in such  manner as to circumscribe a wedge, whose base of
 greater or less width, according to the degree of deviation in the foot
 would be turned forward.  After having repeated  the same operation
 on the fibula, we should succeed  in breaking the bones of the le°- by act-
 ing on the foot.  This  latter being then raised  up, would puf the two
 surfaces of the section into  contact, and give a horizontal direction to
 the plantar surface of the distorted foot.  The dextrine dressing  as in
 fractures of the leg, should be immediately applied, and we should
 moreover, attempt the immediate re-union of the wounds   As this one'
 ration has  nothing to do with re-establishing the mobility of the ioint
 we  may without any  actual danger include the tendons of  the reo-ion in
 the flap of the soft parts.                                     &
  B.  At the Knee, the section of the tibia would give every  oossiblo
 prospect of success:  a  semilunar incision, with  the  convexity down-
 wards and extending from  the  lower part of one  of the condyles of
 the tibia to  he other would  allow of circumscribing a laro-e flan of in-
 teguments which would include in its base the extremity of the liUnW
 of the patella.   This flap  being raised up by an assist ,fte !Ztt
would saw  perpendicularly through the head of the tibia,  a little above
 the tuberosity, until he  reached near the neighborhood  of the  ham
 Bringing back  the saw to an inch or an inch and a half underneath  he
would direct it obliquely  from below upwards, in order to SSko'fte
posterior terminus of the first section, and thus  separate a wed-from
the bone.   We should  thus avoid wounding the anterior tibialarte?^
and the necessity of  operating upon the fibula.   The fracture would be
easily completed  by making tractions upon the leg. The void created 
          DEFORMITIES FROM ALTERATIONS IN THE SKELETON.       487

in this manner would enable us to restore to the limb a  great  portion
of its natural perpendicularity, without either shortening or deforming
it to any considerable extent.
  The immovable dressing  for complicated fractures, and the approxi-
mation of the lips of the wound by means of the suture or strips merely
of adhesive plaster, would be immediately had recourse to.  The recur-
rent artery of the knee is  the only one which runs any risk of being
wounded when we operate in this manner, and upon this a ligature  may
become necessary.
  In the event that it would be required to saw the  femur rather than
the tibia, we should have to select that part of the thigh where the oper-
ation would offer the greatest  number of  advantages and the  fewest
dangers.
   The most suitable place in that case, would be immediately  above the
knee.   A semilunar incision,  with its convexity downwards, and the
free border of which should  come down to half an inch above  the patel-
la, would allow of cutting a flap which should be raised from  below up-
wards, and which would lay bare  the anterior surface of the bone.   The
saw would  then  separate from it a fragment  shaped like that which I
have described  in the  preceding article.   Then adjusting the leg, the
notch in the bone  would be made to disappear  by  approximating the
lower  plane of the cut  of  the saw to its superior plane.  The flap of
the soft parts, then brought  down and retained in  its place  by  means
of the suture or  agglutinative bandages, would  immediately cover all
the parts; and there would remain nothing more to do than to surround
the limb with an immovable dressing.
   M. Barton  (Arch. Gen. de  Med., Juin,  1838,  p. 357) has recently
made an application of this method to the lower part of the thigh for
an anchylosis of the knee.   M. S. Deaz, the young physician who  sub-
mitted to it, May  27, 1835, wrote on the 6th of  November, 1837 : " I
have the satisfaction of saying that the operation which  you performed
on my leg has completely succeeded.  I walk well, attend to my affairs,
mount my horse, and sometimes  travel  from thirty to fifty miles a day
without any fatigue; the entire  sole of my  foot touches the ground,
and I scarcely limp any."
  The author cut upon the soft parts a triangular flap, the apex of which
corresponded to the  antero-internal part of the ham, and terminated at
its base on the  outer part of the  same region.  Having thus laid  bare
the anterior surface of the femur, he  exsected from it, by two  cuts of
the saw, a cuneiform fragment, as in the cases of  straightening which I
have supposed above.   M. Barton (Southern Med. and Surg. Journal,
Vol. II., p. 471, March, 1838) proceeded also in the  manner I have de-
scribed, as relates to the  reunion of the wound.   For myself, I should
prefer in this case the semilunar flap, described in the preceding para-
graph to the triangular  flap of M. Barton ;  I will also  add, that  the
immovable  dressings used with us, would  render the subsequent treat-
ment and success of this operation infinitely more  simple.
  We could, it is true, lay bare the femur on another part of its length;
but at a greater  distance from  the knee, the straightening  of the  leg
would make too projecting an  angle  upon the thigh, and  a considerable
shortening of the limb; whilst immediately above or under the condyles, 
488            NEW  ELEMENTS OF OPERATIVE SURGERY.
 the straightening is effected to a certain extent without a new deviation.
    C. If the thigh  only was anchylosed, and at the  same time  inclined
 forward or inward, perhaps it would also  be possible to attempt its re-
  adjustment.   It would in that case be immediately below the quadratus
^ femoris, that I should advise the operation to be performed.   The semi-
j lunar  flap, mentioned in  the  two preceding cases, should have its base
 on a level with the  root of the great trochanter, and the middle of its
 free border at two inches below.   [Dr. Mott suggests a straight incision
 on the outside of the thigh.— T.]   This flap should be extended trans-
 versely from the outer side of the  great trochanter, to a level with the
 tuberosity of the ischium ;  but in making it, we should  carefully avoid
 wounding the great sciatic  nerve.  The bone, once laid bare, should be
 sawed upon its outer and  posterior part, if the limb was in a state of
 adduction as well as flexion.
    If there was only a simple flexion, without any deviation inwards, it
 might  be useful to  detach the fibres of the triceps  adductor muscle, then
 to crowd all the soft parts inwards and forwards by means of a plate of
 horn, pliant  wood, or tin, in order to remove  the wedge directly from
 the posterior surface of  the  femur.  We would  complete the fracture
 of the bone by drawing the thigh  backward, the flap of the soft parts
 would  be brought down, and  supported  as  in  the preceding case,  and
 the whole limb be  immediately placed in an immovable dressing.
    The advantages of the operation I describe are not as obvious in the
 upper  as in the lower limbs.
    D. In the fingers, for example, it could hardly be practicable, except
 on the dorsal surface.  But I do not  know which  is the most annoying,
 flexion or extension, when there is an anchylosis of the phalanges ;  and
 we should also recollect, that the straightening of a finger is not a  res-
 toration of its movements.   If, however, it should happen that one or
 more of the fingers are bent like hooks, so as to destroy the functions
 of the  hand, there  might, I think, be some  utility in practising on the
 dorsum of the  angular phalange the kind  of cxsection which I have
 proposed to apply to the tibia and  femur, since it might be  possible in
 this  way to  bring the deformed fingers into an  intermediate  position
 between flexion and extension.
   E. For an anchylosis with  extreme flexion of the hand, the operation
 should be performed at three fingers' width above the wrist.   The radius
 would  be  laid bare  in this place, immediately above  the deep-seated
 muscles of the region, by an incision of two inches in length, and parallel
 to the direction of the bone.  The two lips of the  wound being properly
 separated, and each protected by a piece of pasteboard, would allow of
 the surgeon removing a cuneiform fragment from  the  radius, by means
 of the  semicircular saw, as  I have said in speaking of anchylosis of the
 foot.
   We should proceed in the same manner with the exsection  of the ulna
 We should afterwards adopt, in respect to the straightening  of the limb
 the union of the wounds,  and the consolidation of the fracture, the same
 mode which I have  described above.  A semicircular incision, to form
 a flap, which should include  all the soft parts on the dorsum of the region
 would render the operation more simple, and ought to have the preference'
 if the tendons have lost their mobility. 
          DEFORMITIES FROM ALTERATIONS IN THE SKELETON.      489

  F. The anchylosis of the elbov) is not of a nature to require this species
of excision  of the bones.  If the forearm is in flexion, it is the least
inconvenient position  that it can  take;  if it were  found in extension,
we could not remedy it but by dividing either the humerus or the bones
of the forearm  in front; which  doubtless no person  would have  the
hardihood to do for a simple deformity.   Nor do I see any  contingency
that could require the  cuneiform  excision of the bones in the neighbor-
hood of the scapulo-humeral articulation.
  In conclusion, the  cuneiform  excision is not, as it appears  to me,
suitable as a remedy in anchylosis, but for re-establishing the flexion or
extension of some part of the limbs.
  G. In place of attacking the body of the bones, we may carry the saw
upon the articulation itself, and remove from it a semilunar or cuneiform
fragment.   This process, which might be applicable  to  the  knee, and
even to the fingers, where it would have  the advantage of not producing
any new  deformity, while it would happily admit of correcting the old
one, would not,  however, be always suitable.  The soft  parts, besides
being generally  altered in this point, are almost always unfavorable iii
such places to the formation of flaps.  If suppuration  should take place
at the bottom of the wound, the dangers would be manifestly greater in
the articulation than on  the continuity of the bones.
  I would  not  like, moreover, to practise such operations, unless all
irritation and every trace of inflammation had, for a long period before
disappeared from the anchylosed joint;  also, it would be  necessary that
the curvature should be  excessively annoying, and that the patient him-
self should have a strong desire to be partially relieved of it.

                 § III.—Supplementary Articulations.

  Another  operation,  which has been suggested to my mind by that of
which I have been  speaking, would consist in  establishing artificially
an articulation above or below that which is anchylosed.   It would  be
no  longer, then, for the  purpose of straightening a distorted limb, but
for restoring the movements of the part.  We perceive, therefore, that
its  object then is the  relief of anchylosis, even  when  the direction  of
the limb is as little disturbed as possible.
  To perform this operation, it is necessary to lay bare the bone in such
manner as to interrupt its continuity.   In order to prevent  its consoli-
dation afterwards, we should  take care, from time to time,  to impart to
it gentle movements, and to employ all those means which could  contri-
bute to the  production of a false  articulation.  In  the course of time
the two ends of the bone partially mould themselves to each other ; the
movable end is rounded and  blunted, and the other, as it enlarges, be-
comes slightly  excavated; the muscles  soon adapt themselves to this
new  joint, which ultimately allows the  patient to use it to some extent
in the manner of the old one.
  At the first glance,  nevertheless, the operation will be rejected, both
because it sems dangerous, and because we do not see  that it could pro-
duce the result which the surgeon would desire.   Do not false joints,
the  consequences of ununited fractures, it will be said, put  it in  the
power of  practitioners to estimate their value and to justify their rejec-
    Vol.  I.                   62 
490
NEW ELEMENTS  OF OPERATIVE SURGERY.
 tion ?   Nevertheless, if we reflect, that ununited fractures are compos-
 ed of pieces whose ends are uneven and slide over each other obliquely,
 whilst here the bone is divided transversely, we soon  perceive  that we
 ought  not to judge of  one of these  cases by the other.  Then,  also, do
 there not exist examples of accidental articulations, which have ultimately
 ended  in re-establishing a great part of the functions of the  limb ?  M.
 Larrey (Caron, These, No. 83, Paris, 1826)  mentions  a patient who
 had a false joint of the thigh, the result of a  fracture, but who, never-
 theless, walked with  it without  crutches.   M. Sanson told  me he had
 met with a similar case;  and I have myself seen a woman, who walked
 with a cane only, though she had had for fifteen years  a false joint near
 the middle of the femur.  [Dr. Mott has operated for ununited fractures
 in the femur, by the seton, in three or four  cases: in one, the false joint
 had existed  for more than a year, and was cured.—T.]   A tailor, whom
 Saltzmann (Reissessen, de Articul. Analog., chap, ii., §  5) makes men-
 tion of, and  who easily moved  the foot backward  and forward, limped
 only in consequence of the  shortening, though he  had a false joint in
 the middle of the thigh.  Sue (Sur quelques Mai. des Os, 1803) says
 the same  of a patient in whom he  had not been  enabled to effect the
 consolidation of a fracture in the femur.
  As to the dangers, they would be infinitely  less than those of ampu-
tation or exsection of the bones.  At the present day, the establishment
of an artificial joint, with  the view  of  remedying an anchylosis, is no
longer  a mere speculation; two examples  of  it, at least, have  already
been performed upon man.
  There are, however, only certain portions of the limbs which might
require it.   I do not think, for example,  that it is suitable for the foot
or the  toes; I doubt, also, if it could be of any great utility  for the
shoulder ;  but there are some anchyloses of the fingers  and of the elbow,
of the  knee  and the hip, which might sensibly  be benefited by it.

                    A.  The  Upper Extremities.

  If the phalangeal articulation was anchylosed, without the neighbor-
ing tendons having lost their mobility, nothing  would prevent our laying
the bone bare on its dorsal  surface, sawing transversely through it near
its middle, afterwards  uniting  the wound  by  three  stitches  of  suture,
which should include both the skin and the extensor tendon, then*  leaving
this wound sufficient time to become cicatrized, and not commencing the
artificial movements of the  two  fragments of the phalanx until at the
 end of eight or ten days.
  If the movements of the fingers were not destroyed by the anchylosis
 of the  wrist  we might also  endeavor to  establish a new articulation at
 sdme lines above the styloid  processes of the forearm.   An opening on
 tHe radius, and another on the  ulna, would, in  fact, allow of their  being
 divided by passing the  chain-saw  around  them
  For  the elbow  the operation should be  performed by preference im-
 mediately  above  the joint.  AVe should  make an incision from two to
 three inches long on the external  border of the humerus,  and  then  after
 having separated  oy a  proper  dissection  the brachialis-anticus and the
 triceps, we  should pass around the bone  the chain-saw, which  bein<* 
           DEFORMITIES FROM  ALTERATIONS IN THE  SKELETON.      491

 well guarded and carefully directed, would  easily effect its section.   I
 do not know that I deceive myself, but it seems to me that this opera-
 tion would be neither very difficult nor very  dangerous, and that it pre-
 sents real chances of success.

                      B. The  Lower Extremity.

   It was for the abdominal limb, and, so to speak, for that exclusively,
 that the idea of an  artificial articulation first suggested itself.   An
 American surgeon, Mr. R. Barton, ( Western Med. and  Phys. Journal,
 vol. I., p. 108,) is the true inventor of it; it was on the  22d of Novem-
 ber, 1826, that he performed  it for  the first  time.  On  his patient, the
 young Coyle, aged twenty-one  years, M. Barton incised and  detached
 all the soft parts which surround the great trochanter; he afterwards
 effected the division of the femur by means of a small saw.  The wound
 being brought together by suture, the limb was placed in the extension
 apparatus of  Desault.  The cicatrization  of the soft parts required two
 months to be completed; and the boy died nine years afterwards from
 pulmonary disease, after having made use  of his limb  for five or six
 years.   This boy,  abandoned  to  drunkenness, and giving himself  up,
 says M. Barton, (Amer. Journal of Med.  and Surg. Sciences, February,
 1838,) to all kinds of excesses, w&s attacked with a pain in the thigh,
 and with an anchylosis  in the  new articulation, two  years before  his
 death.   The examination of the  dead body afforded an  opportunity of
 proving that there had taken place the anatomical arrangement which
 I have spoken of above.
   A surgeon of New York, M. Rodgers, performed the same operation,
 November 24th, 1830, in presence of Doctors Mott and Stevens.   At
 the end of six or eight days, some  serious symptoms  supervened; but
 six weeks later the wound cicatrized, and the patient  left the  hospital,
 completely cured, four months after the  operation.  This man, whom,
 from some incorrect  information, I had in the first edition of  this trea-
 tise  represented as having died, was still in very good health in June,
 1833, the epoch at which M. Rodgers  had the  goodness to transmit to
 me the history  of the case.   In that part,  therefore, where  it would
 seem the most difficult and the least capable of succeeding, the operation
 for an artificial articulation has been attempted, and in both cases with
 success.
  I  ought not, however, to conclude this article without making the re-
 mark, that in the lower extremity such operations should  be performed
 but  seldom.   An anchylosis of the knee, even an anchylosis of the hip,
 if the limb preserves its rectilinear position, inconveniences the patients,
 but does not actually prevent them from  walking, and  gives  them no
 suffering.  The  establishment of a new articulation  may,  on the* contra-
 ry, endanger their life.   Supposing even  that the operation has every
 possible  success, the artificial joint  would not probably in many cases
 afford any great security, cither in standing or walking.   Such articula-
 tions, also, must have a great tendency to become reconsolidated.  The
 case of M. Barton is conclusive proof of it.  While admitting, therefore,
that  it should be retained, we should guard ourselves against adopting,
with too much enthusiasm, this new conquest in surgery. 
492
NEW ELEMENTS OF  OPERATIVE SURGERY.
 Case of Exsection  of the  Knee-Joint, by Dr.  Gurdon Buck, of
   New York; as revised and corrected by the author for this volume
   of the American Edition off Velpe.au's  Operative  Surgery.

   William Keith, a farmer, of healthy and robust constitution, aged 22
 years, born in Canada, was admitted  September  12th, 1844, into ward
 No. 7, north building, New York  Hospital, with the right knee anchy-
 losed at a right angle, in consequence of violent inflammation and sup-
 puration of the joint, produced by a wound inflicted  seven years pre-
 vious with  an axe, that had grazed the bone over the inner condyle, and
 was followed  by  a confinement of seven months to the house;  the limb
 continuing in the deformed position already noticed.
   The joint was immovable though the patient imagined he was able to
 produce a slight  degree of motion.  The  condyles of the femur were
 prominent, and stood in advance of the tuberosity of the  tibia  with the
 patella deeply and immovably imbedded between them.  An irregular
 boney projection was observed over  the inner condyle where an exten-
 sive scar marked  the  situation of the original wound.  Several other
 scars of openings were visible from which  matter had been discharged
 in the progress of the  inflammation  consequent  on  the injury, for in-
 stance, one on either  side in the ham and  three on the anterior and la-
 teral surfaces above the condyles.  The tendons in the ham stood out in
 prominent relief from the limb.  The skin and subjacent soft tissues en-
 veloping the joint were supple and healthy.   Since  his recovery from
 the effects  of the injury, the  patient  had enjoyed uninterrupted good
 health, and had been free from pain or tenderness in the knee; he  had
 been accustomed to walk with one crutch, though sometimes he dispensed
 with it and stooped to accommodate himself to the shortened condition
 of his limb.  The deformed limb was shorter and in every respect  less
 developed than its fellow.
  It was explained to the patient  that from the condition of the joint,
 the limb did not admit of being improved in its position, by any ordina-
 ry surgical operation, but that in a few similar cases, an extraordinary
 operation  consisting in removing a wedge-shaped portion  of bone from
 the femur above  the condyles  had been resorted to with  favorable re-
 sults.
  There  being some  weighty  objections to this  operation, it was pro-
posed to modify it in its application to his case, and as the joint  itself no
longer existed in its normal condition, with secreting articular surfaces,
it was judged equally safe to perform a similar operation upon the parts
pertaining to  the joint which, to all appearance, were free  from disease.
  Theadvantages contemplated  by this modification  were that more
extensive surfaces of  contact for bony  union  would be  obtained,  and
greater strength of limb secured with less remaining deformity than was
practicable in the operation of Dr. J. Rhea Barton,  of  Philadelphia,
already alluded to.
  The patient was fully apprised of the  serious nature of the proposed
 operation, and the dangers incident to it.
  Being, however, exceedingly desirous of relief from his  deformity, lie
 decided after a few days' reflection, to submit to it.  It was accordingly 
         DEFORMITIES FROM  ALTERATIONS IN THE SKELETON.       493

performed with the concurrence and  aid  of the other surgeons of the
hospital, the 12th day of October, 1844, as follows:—
   Operation.—Preparatory  to the operation, the tendons of the biceps,
semi-tendinous, semi-membranosus and gracilis muscles had been divid-
ed five days before, in the usual manner, by two sub-cutaneous incisions,
in doing which the peroneal nerve was unintentionally cut  across and
was  followed  by numbness  and  pain extending to the foot; the punc-
tures, however, had healed and no inflammation remained in the ham.
   The tourniquet having been applied to the upper part of the thigh, an
incision was made from the outer to the inner  condyle, across the  mid-
dle of the  patella, and a second  incisiqp  from the middle of this, per-
pendicularly downwards to  the  tuberosity of the tibia.   The included
angles of integument were  dissected  down to a finger's breadth  below
and  parallel with the margin of the articular surface of the tibia.  The
ligamentum patellae and the  fibro-ligamentous tissues on either side were
cut through on the same level to  the extent of nearly two-thirds of the
circumference of the bone.  With the amputating saw a section of the
tibia was made at three-fourths of an inch below the joint anteriorly and
directed with a slight  obliquity upwards  so as to terminate at the mar-
gin  of the  articular surface  posteriorly.   Two-thirds of this  section
was accomplished with  the amputating saw.   The second  section was
then commenced  through the upper  part of  the patella, parallel with
the  first, and  on a plane forming an angle with it, .less than a right an-
gle, and continued to about the same extent as in the first section with
the  same saw.  The remainder of the section through the tibia, as well
as through  the  condyles, was completed with a metacarpal saw  and
chisels.  The included wedge-shaped portion of bone being removed, it
was found the section had not been carried far enough backwards, the
posterior portion of the condyles still remaining consolidated with the
tibia.
   To include  this a new section  was undertaken, commencing upon the
cut surface of the femur, three-fourths of an inch anterior to the angle
at which the sections, already made, met, and directed backwards and
upwards on a plane  more oblique in reference to the axis of the femur.
This new section being removed the remaining points of connection were
ruptured by cautiously  flexing the  leg on the thigh, after which the ir-
regular prominences were pared away with  the bone forceps.  An at-
tempt was  now made  to extend the leg upon the thigh, when it was
found that the boney surfaces could only be brought to within a finger's
breadth of each other  anteriorly.   The  soft  parts in the ham being
rendered tense and opposing great resistance to the extension, the at-
tachments  of  the ligaments  were dissected up posteriorly from the tibia
while the leg was held  in a  state of extreme flexion, and, in addition to
this, a further section of five-eighths of an inch thick was removed from
the  anterior two-thirds of the femur.
   The leg could now be extended to the required degree with the boney
surfaces in  contact at every  point, and the soft parts posterior to the
ioint in such a state of tension as to  give steadiness and solidity to the
coaptation.
   The section of the condyles exceeding that of the tibia in its antero-
posterior diameter, caused an overlapping in front of about half an inch. 
494            NEW ELEMENTS  OF OPERATIVE SURGERY.
 The hemorrhage was very moderate, and only two ligatures were required
 to  small  branches  given  off by the popliteal  trunk.   The  soft parts
 posterior to the joint, and separating it from the artery were very little
 disturbed.  The angular flaps of integument being redundant in the new
 position of the limb, were pared away to the required extent and secured
 in contact by seven sutures.  The limb was then placed on an inclined
 plane with a slight angle at the knee, and after the patient was removed
 to his ward, adhesive straps were  applied between  the sutures  and a
 compress  of dry lint laid loosely over the whole.
   The  operation  exclusive of the  dressings occupied 40 minutes, and
 though very painful, was borne.with remarkable fortitude.
   At evening  the  patient had felt  somewhat chilly,  and on moving his
 arms experienced  twitchings in his limbs;  the knee was  becoming pain-
 ful ; pulse scarcely accelerated ;  a pretty  copious oozing of  blood from
 the wound was taking place.  Ordered flaxseed  poultice and tinct. opii.
 gutt. xl, pro hausta.
   October lWi.—Passed a very comfortable  night, and  slept after
 midnight; chilliness continues;  pulse 112 ; tongue but little changed;
 occasional twitchings continue, and pain in  the  joint increases ;  oozing
 nearly ceased;  scarcely  any swelling has  taken  place ; temperature
 moderately increased.
  At 6 P. M. Febrile reaction was fully established ; pulse 120. Twenty-
 four leeches have beqn applied around the knee, and are bleeding freely.
 Ordered tinct. opii. gutt. xl, at bed time, and to be repeated at midnight
 if necessary.
  14^/i.—Patient  more  comfortable; passed pretty  good  night after
 midnight; pain  in the  knee  very much diminished ;  twitchings not in-
 creased ;  pulse 108; countenance good; has tenderness and swelling of
 the lymphatic glands in the groin; ordered cold water dressing.
  23d.—General condition continues favorable ; twitchings of the mus-
 cles  are the greatest source of  suffering ; they  are not  confined to the
 limb, but  extend to other parts of the  body ; two or three  times they
 have attacked the  bowels with great violence.   Some displacement has
 been the consequence, so that the anterior edges  of the condyles of the
 femur are about an inch  in advance of the tibia; pulse 88 ; appetite
 good: tongue clean ; bowels confined ; suppuration moderate and healthy ;
 edges of wound  cicatrizing except at  the  angles of the wound over the
 condyles.   Take sol. sulph.  morph. gutt.  xv. ;  aquae menth. pip. §  ss,
 at bed time, and repeat, if  necessary, ol. ricini §  i.
  Nov.  1st.—Progress  for the most  part favorable;  at  times, pain in
 the knee  is very  severe;  twitchings continue, but in a less  decree;
 position of limb  improved; less riding of the excised ends of the bones
 past each  other; discharge from outer angle of wound copious
  Dec. 9th.—Wound has been healed for more than a week ; pain and
 twitchings after diminishing gradually, have now entirely ceased.  Union
 is taking  place between the bones; a slight degree of motion  only is
 perceptible ; patient's general health, after suffering considerably from
 protracted pain, privation of rest, &c., has been  steadily  improving for
 some time past; pulse 90 ; tongue  clean; appetite good; bowels°re"-
 ular ; rests well  at night with only an occasional anodyne  For the re
lief of the twitchings from which patient  suffered so much, anodynes 
          DEFORMITIES FROM ALTERATIONS IN THE SKELETON.       495

were  the  most effectual remedies.  Solution of sulph. morphium  was
given in 15 drop doses, twice repeated at bed time, besides which he
took a mixture containing  71 drops at a dose, at discretion, when his
sufferings  rendered it necessary.   The limb  throughout the treatment
was supported on a double  inclined plane, with lateral splints and pads
above and below the knee.
  Patient left his bed the first week in January, with the limb supported
in the apparatus  that is used  for forcible extension  of the knee-joint.
At this time a slight degree of motion in the direction of flexion  and
extension was still perceptible, but none in a lateral direction.  Ho was
soon able to support himself on crutches and placed his foot on the floor,
and, after a while,  left off the apparatus and only  applied a bandage.
As the patient's general health  improved he acquired strength in his
limb, so that for two or three weeks preceding his discharge, he walked
about the hospital grounds with the  aid of a  cane only.  The difference
in the length of the two limbs was compensated for by a stirrup-shaped
frame secured to the sole of his  boot by means  of an iron plate.   The
boney union at the knee, had become firm without any perceptible mo-
tion, and the cicatrix of the skin as well as the subjacent tissues  was
supple and  movable.  The only uneasiness felt  from exercising was re-
ferred to  the calf of the leg and instep.  The difference in the length
of the limbs was about 5 inches, at the heel, of  which not more than
one-half could be ascribed to the operation ; the remainder depending
on defective growth in the limb subsequent to the inflammation of the
joint.
   On the 22d of April last, patient took his discharge, to return home
to Canada, near Niagara  Falls, well pleased with the improved condi-
tion of his limb.
   Three  days before leaving the hospital he walked a distance of two

              Fig. 1.                                Fig. 2.
 
496            NEW ELEMENTS OF OPERATIVE  SURGERY.
Fig. 3."
 miles with the aid of a cane only, and without pain or unusual  fatigue.
 The accompanying drawings taken from plaster models, show the condi-
 tion of the limb  before the operation, (see fig. 1,) and at the  time the
 patient, left the hospital, (see fig. 2.)  The full length view (fig. 3,) is
 from  a  Daguerreotype taken three  days  before his  discharge.  The
 models have been deposited in the  Museum of the University of Penn-
 sylvania, as well  as [in] the pathological  museum of the New York
 Hospital.
                         Description of the excised Bones.—The in-
                       ferior two-thirds of the patella had been remov-
                       ed by an oblique cut from  above downwards and
                       roni before  backwards, and was found  consoli-
                       dated with the outer condyle by  bony  growth
                       without any  trace of the line of junction.  It
                       was adherent to the inner  condyle  by condensed
                       cellular tissue.  Both condyles were buried into
                       and consolidated with the articular surface of
                       the  tibia.
                         The cut surface of the condyles, for the most
                       part,  presented  a compact eburnated  texture
                       with only slight remains of cellular tissue inter-
                       spersed.  The space between  the patella and
                       tibia and  behind the ligamentum  patellae  was
                       filled wdth condensed adipose and fibrous tissue.
               p'^     No vestiges  remained of cartilage or synovial
                * Y^ membrane.
                         The cut surface of the tibia presented its nor-
                       mal  cellular  texture, except a single  large cell
 capable of holding a filbert near the outer edge of the bone and  havin*
 for its upper wall  the thin compact shell of the articular surface.  The
 section of the patella  was also of normal cellular texture, with a similar
 large  cell  of three-eighths  by three-fourths of an inch in extent.  A
 third and much larger cell capable of containing a hickory  nut, occupied
 the inner condyle near its articular  surface.   These  cells were lined
 with a thin reddish membrane and contained an oily and fatty matter of
 reddish color.  Another  incomplete  cell was  also found  in the  outer
 condyle, intersected with septa, subdividing it into smaller compartments
 lined and filled like the rest; none of these  cells perforated the outer
 shell of bone, though  at some points  they approached very  near it
 from each16^' long"continued maceration  separated the several parts

  Remarks.-Though  this  operation  was  severe and protracted, the
 subsequent  inflammation and  suppuration were by no means excessive
 and were confined  to the parts immediately involved  without spread^
 to a distance.  Primary union of the edges of the  wound took place to
as great an extent  as was  desirable;  openings  remaining over the con-
dyles at the extremities and  in the middle ofthe transve?se7ne sion for
the  discharge of matter.  At one time a small opening formed  Poste-
riorly in the ham, and after discharging a few dayPS, clofed  sponUeous-

  * In the Daguerrotype from which this  wood-cut was engraved, the figure was reverb
which was not  observed by the Editor until the engraving was finished.           reversed,
 
•
          DEFORMITIES FROM ALTERATIONS IN THE SKELETON.      497

ly; with this exception, there was no burrowing of  matter between the
muscles, and at no time did the discharge exceed two ounces in 24 hours.
  It had been my aim in the  operation to disturb  as little as  possible
the soft parts beyond the limits of the joint, especially those posterior
to it, so as not to establish any direct communication between the wound
and the loose intermuscular cellular  tissue by which inflammation is so
readily propagated.  The long  continuance of the pain in the knee and
the twitchings, notwithstanding the  generally  favorable  aspect of the
parts  themselves, were the principal cause of solicitude in this case.
  Though the patient's  condition at no  time could be viewed as  critical,
yet his protracted sufferings, mitigated  only without being controlled  by
anodynes, necessarily kept alive apprehensions as to the ultimate result.
It may be reasonably questioned whether these  painful symptoms were
necessarily chargeable  upon this operation or were not rather to be at-
tributed  to  certain  peculiarities in this case  that might be avoided in
another.  For instance, the division of the peroneal  nerve in the section
of the tendons and the subsequent stretching of its recent cicatrix, to-
gether with the general state of tension  of all the tissues in the ham pro-
duced by the altered position of the limb.   This is more probable, from
the fact that  the  patient complained of  pain  along the course of the
peroneal nerve, and of twitchings of the posterior muscles of the limbs
as more severe than elsewhere.  In  concluding this report it is due to
Drs. Cook and Jones, the resident surgeons who successively had charge
of this patient, to express my indebtedness  for their  efficient co-opera-
tion in the treatment of  his case,  the favorable  result of which, is in  no
small degree to be attributed to  their  untiring patience and devotedness.

Article II.—Deformities from Deviation in the Body of the Bones.

  It is not the place in this work to treat of torsions and deformities in
the body of the bones, developed under the influence of mollifies ossium
or rachitis.   It is from orthopedy, and not from operative  surgery, that
such diseases demand relief; but it may happen, that in consequence  of
fractures badly consolidated, the limb remains deformed, either by being
too much  shortened, or by deviation from its axis, or from  the arrange-
ment  of the callus.  Hence operations  have been proposed and put in
practice to remedy this kind of deformity.   Among  the operations sug-
gested for this purpose, there  are two whose merits it appears  to me I
ought to examine: the one consists in breaking the deformed bone anew,
in order to restore to it a better direction; in the other, we confine our-
selves to excising a portion of the angular bone, in order to straighten
it,  and afterwards effect its consolidation by  means of  the ordinary
dressings.

                    § I.—Breaking of the Callus.

  The breaking of the callus in fractures badly consolidated is a very
ancient practice, which  has long divided the opinions  of surgeons.
Though, after the recommendation of Hippocrates, we find that it was,
to a certain extent, adopted by  Celsus, (lib. viii.,  cap. 10,) we  soon
after  see that Galen, Paul of iEgina,  and Avicenna, scarcelv venture to
  Yol. I.                   63" 
498            NEW elements of operative surgery.

sanction it.   Guy of Chauliac, who advises it, does not  appear to have
been satisfied of its advantages, nor Yigo, Pare, nor Fabricius ab Aqua-
pendente, who consent to its  trial only in the first months of  the frac-
ture.   Fabricius of Hildanus also formally proscribes it; and whatever
Munnick may have thought proper to say of it, Petit and Heister so
strongly objected to it, in the beginning of the last century, that Hevin,
and afterwards Boyer  and  Callisen, easily succeeded  in causing it to be
generally proscribed.   There is scarcely any other person than M.  Rich-
erand, among modern  writers, who  believes  in its utility; even this
practitioner also confines it to cases in which the deformity i3 excessive,
and to those in which it is urgently demanded by the patients.  It seems,
then, that it is an operation definitively adjudged.  So that, in spite of
what  MM. Jacquemin  (These, No.  140, Paris,  1822) and  Torchet
(These, No. 271, Paris, 1830)  have, upon  the authority of Dupuytren,
felt themselves warranted  in saying in its favor, M. H.  Berard, never-
theless, concludes,  in  the  words of Fabricius of  Hildanus: Ergo non
diffrigendum callum habemus,  (Reformandum-ne Callum  Vitiosum?
Paris, 1827.)
  If with us a verdict like this  has been without appeal, it has not been
so in Germany.   A surgeon  of that  country, M.  Oesterlen, (Rupture
du  Cal, trad, paurer, Strasbourg, 1828,) in his endeavor to demonstrate
the  advantages of the  rupture of the  callus,  has collected  in  his  book
more than forty examples of it, derived from his own practice, or from
that of surgeons in neighboring cantons.   In  analyzing the observations
of M.  Oesterlen,  relatively to the adjustment of the callus, I have found
that there are eighteen  for  the femur, seven  for the  leg, three for  the
arm, one for  the  forearm, and  one for the clavicle.   In  every case, we
see  that  the  operation, which,  according to the author, is quite easy to
perform, and one which the famous Ignatius  Loyola  was not afraid of
submitting to, was unattended with danger, and  almost constantly suc-
ceeded.  M. Jacquemin, who borrows similar facts from De la Motte,
Guillon,  and  Desgranges, and who takes four of them from the practice
of Dupuytren, proves on his side that the  dangers of these kinds of
operations had been singularly exaggerated.
  M. Riecke (Journ. Analitique  de  Med., Septembre, 1828, p.  466)
goes still farther.  An  incision, which extends from the great trochanter
to the  external condyle of  the  femur, enabled him to lay bare a callus
of the size of the head.  The saw, gouge, and mallet, were  then put
into requisition.   There was a  shortening  of  eight inches, and  yet the
dressing by permanent extension, nevertheless, succeeded afterwards
in restoring to the limb its natural length.
  In supposing a callus which  had  not existed over  three months, the
breaking of it would not in reality be either very difficult or very painful.
The ends of the  bones, by  means of the fracture  bandages newly  in-
troduced into practice, being adjusted, and their  extremities placed in
coaptation with each other, would almost inevitably  become consolidated,
without exposing to more dangers than a simple fracture.  If the morbid
callus was of much longer duration, we should, without doubt, experience
greater  difficulties  in  breaking it, and  the  consolidation, moreover,
would have fewer chances of  success, than in the preceding case.
  It is important on this subject to divide the  deformities into two class- 
           deformities from alterations in the skeleton.       499

 es, according as they  are  merely a  shortening  of the  limb, or where
 the bone is consolidated with  an angular deformity.  The rupture of
 the callus in the first case, should not be attempted after the third month
 of the fracture.  At a later period we  should have to fear the fracture
 of the  bone in a sound  portion as well as in the  diseased part, and  we
 may  well  conceive  that there  would then result no advantage from it.
 Supposing even we should succeed in separating the two fragments, so
 as to be able to destroy  their lapping  over, we  should at least have to
 fear that their extremities formerly cicatrized would be incapable of be-
 coming cemented together, and of reuniting by a genuine consolidation.
 In such a case, however, at the present time, when we have the improved
 immovable  dressings, I  should  not hesitate to break the callus.
   When  the callus is  angular, to the degree  of interfering to a con-
 siderable extent with the functions of the limb, I see  no reason why we
 should  object to breaking  it, however ancient the consolidation may be.
 For this kind of deformities, in fact,  we are always in time for breaking
 the bone, and always have it in our  power to fracture it at its most an-
 gular point.  Numerous apparatus and various processes have been con-
 trived to arrive at this result.  M. Oesterlen has  given a figure of one
 of them, which would fulfil the indication very well;  but it is too com-
 plicated.  It almost always answers, in such cases, to fix the deformed
 limb on its concave  part to a solid plane, while we suddenly  press down
 upon it with the  knee or the  two hands placed  upon its  convex part.
 Having effected the rupture, we must extend the part as much as possi-
 ble, or  until it has  acquired its natural length.   The  limb should after-
 wards be kept in a dextrine dressing until it  has consolidated anew.
 In conclusion, this  rupture of the callus, which has  originated rather
 from pathology than from operative  surgery, does not, as it appears to
 me, expose in  reality to but very little danger.  The  skin not being
 divided, there results a fracture in  every respect analogous to simple
 fractures;  and it is  certain, whatever may be said of  it, that the bones
 newly consolidated  are  much more  easy to  break where the callus is,
 than on either side of it.  It is also  proved that these new fractures in
 general consolidate more easily  and more promptly than the primitive
 fractures.   In a patient  whom I had  had for two months under dressing
 for a simple  fracture in  the  body of  the femur, and who in a fall broke
 the thigh afresh eight days after, a  month longer only was  required to
 obtain a new consolidation.  Another  individual, who left  one  of the
 hospitals of Paris with  a shortening  of five inches  from a very oblique
 fracture in the femur, broke his limb a second time in his efforts to walk.
 Admitted into La Charite, ten months  after this accident, he was sub-
 mitted  to a readjustment and  re-extension of the limb  by means  of a
 bandage saturated with  dextrine, and required but two months only to
 obtain a perfect consolidation, with only an inch of shortening.

               § II.—Excision of the Angular  Callus.

   It may happen that the bones, during the consolidation of  a fracture,
 become cemented together at a very acute angle.   The kind of deformity
which results from it, is  sometimes of such extent as to give  the patient
considerable trouble.  Uo  to the present time, no  one had suggested % 
500
NEW ELEMENTS OF  OPERATIVE SURGERY.
 remedy for it;  but a distinguished surgeon  of Rochefort,  M. Clemot,
 has made known an ingenious method, which it appears to me ought to
 be preserved in practice, and which promises another triumph for modern
 surgery.  M. Clemot's operation was performed the first time on a young
 child, and the second  time on an  adult.  In both cases it was a femur
 bent into an angle in consequence of former fractures badly treated.
 The surgeon laid bare  the osseous projection by an incision sufficiently
 extended, removed  by  two cuts of the saw a wedge  from the femur, as
 I have said  in the  article on  anchylosis, completed the  breaking of the
 bones by tractions, readjusted the  limb, reunited  the wound, and after-
 wards  applied the  ordinary  dressings for fractures of  the thigh.  The
 two  patients recovered perfectly,  (Archiv. Gen. de  Med., 2e serie, t.
 xi., p.  235.)  In such cases, no doubt, the method of M. Clemot should
 be adopted ; this operation appears to me to be a valuable resource, in
 every respect  worthy of being  adopted in general practice, more espe-
 cially now, since the immovable dressings  have been  simplified in such
 manner as to assume any form or direction we may require.
   [It must not be left  out  of sight however, that this  operation of M.
 Clemot is, in strict  truth and in principle, nothing more nor less than a
 close imitation of  that devised and originated, and first performed  by
 our  countryman, Dr. Rhea Barton, of Philadelphia, to whom, in  fact,
 as will be seen in the  preceding pages, the author had previously, with
 his accustomed  ingenuousness, frankly  conceded  all the honor and im-
 portance which this rich conquest for surgery is entitled to.  The wedge
principle is precisely the same, whether to remedy a permanently angular
 or flexed position of the limb from an anchylosed joint or badly-treated
 fracture.—T.]

                     Article III.—Appendix.

 # Should I not say, in conclusion,  that this long  chapter on  deformi-
ties—a  chapter  which  modern surgery has the right to claim entirely
as its own—might allow at  the present day of our grouping  and classi-
fying a crowd  of isolated facts, which, up  to  this  time, have remained
without any  connection or explanation in science.
  Valleriola (Obs.  Med., lib. ii., obs. 4; et Saucerotte, Med. de Chir.,
t. i., p. 225) speaks of a permanent flexion produced  by convulsions,
and which resisted for six years all remedies applied to it, but  of which
the patient was one  day cured by leaping from his bed in a fit of an°-er
  In an invalid, says  Wurlz,  (Chirurgie, 8rc, p. 368,)  the  limb°re-
mained flexed, in consequence  of a wound in the knee ; but bein°- sud-
denly under  the necessity of running, the patient was cured of it imme-
diately.  One of the women  of the  calif  Haroun-al-Raschid had, it is
said, a retracted  arm, which she could not  use.  A physician offered to
cure her.  Having  caused  the  woman to make her appearance in the
court of the  calif, he stooped  down  as if in   the  act  of lifting un her
dress, in a manner that shocked her  modesty ; the patient threw  out
her arm violently, to prevent this outrage, and the cure was complete!
Might we not attribute cures  thus obtained, to the rupture of certain
tendons or retracted ligaments, or of imperfect anchyloses ?
  My intention was to  avoid  all discussion of priority, in'speakino- of 
TENOTOMY AND MYOTOMY IN AMERICA.
501
the section of tendons, and to confine  myself to  the  pure and  simple
narration of dates ; but I see, in a Journal in which M. Little gives an
account of four cases of section of the tendo-Achillis, and one of sec-
tion of the flexor  tendons of  the leg, (The Lancet, Jan. 27, March 13
and 31, May 19 and  26,  1838,) that be  claims, in opposition  to  the
French  surgeons, the totality of sub-cutaneous  tenotomy for M. Stroh-
meyer.  M. Dieffenbach, (Lettre d VAcademie des Sciences, 10 Septem-
bre, 1838,) who had at first  generously ascribed it to its true source,
has also changed his mind, and at  present claims the invention for him-
self.  Now the  progress  of this operation ought to  be understood, as
follows:—1.  Bell  divides the  ligaments of the fingers through a punc-
ture in the skin ; 2.  A. Cooper -does  the  same  for bridles in the palm
of the hands; 3.  Brodie operates in  this manner for  varicose veins;
4.  Dupuytren applies this process to the tendon of the sterno-mastoid ;
5.  M. Strohmeyer tranfers it  to the tendo-Achillis; 6.  From thence  it
is applied  to other tendons  by MM.  Strohmeyer,  Dieffenbach, Stoess,
Duval, Bouvier, and Guerin.   That is its history.
          [TENOTOMY AND MYOTOMY  IN AMERICA.

  Dr. Mott, during his residence at Paris and his visit to Berlin, Dres-
den, etc., had carefully studied the rapid and almost magic progress of
this  department of surgery, to whose very birth, as it we're, and  almost
masculine (if not too precocious) maturity, it may be said he was an eye-
witness, at the great orthopedic establishments of Guerin, Bouvier, and
others.   And  to him belongs, in great part, the credit of having imme-
diately on his return  to America, in 1841, by his  publicly expressed
approbation of these processes, and his repeated  practical exemplifica-
tions of their utility at the clinique established by him at the University
of New York, (the first in the United States,) infused among our prac-
titioners a general knowledge and desire not to lag behind their brethren
of Europe ;  and thus, in fact, may be said to have been most instrumental
in domiciliating in our  country this most important  branch of surgery.
Anaplasty and tenotomy require some general remarks in respect to the
claims of those who  were the first to lead  the way in these operations
in America.
  The earliest case  of tenotomy  performed  in America, is that of the
section of the tendo-Achillis, by Dr. Dickson of North Carolina, in the
year 1835.   As this case of pes-equinus by  Dr. James H. Dickson, of
Fayetteville, North Carolina, was the first operation for  club-foot  in
America by the  sub-cutaneous section, and the first operation, probably,
of any kind ever attempted on this continent,  it is proper to give a brief
abstract  of it from  the  operator's own account, as published  in the
American Journal of the Medical Sciences (Philadelphia,) for Novem-
ber,  1838.  R----D----, a lad  aged fourteen, of  delicate make, was
born with his limbs and feet apparently perfect—but when he first began
to creep, was observed to drag the right leg after him in a very awkward 
502
NEW ELEMENTS OF OPERATIVE SURGERY.
and  peculiar manner.  He was late in learning to walk, and had never
been able to get more than the toes and  corresponding metatarso-pha-
lanjreal articulation to the  ground.  The left side of the body, and left
leg "and foot, were well developed;  the right arm and leg  perceptibly
smaller than the left, and the right  leg half an inch  shorter than the
left.   The heel was  drawn up to full three and a half inches from the
ground.   The tarsal  bones of the right foot were very prominent, and
when the  patient stood erect, their dorsal surface was nearly in a line
with the anterior surface of the leg.  The patient's mode of progression
partook at once of a hop and a walk.  There was but little motion in
the ankle joint, and  the power of the limbs  over the flexor muscles
seemed entirely lost.   The heel was small and narrow, and its skin, from
never having come in contact with  the ground,  was delicate and tender.
  The  operation was performed at Fayetteville, (N. C.,) January 10th,
1835, in presence of Dr. Benjamin Robinson of that place.   Dr. Dickson
inserted a sharp-pointed narrow bistoury two and a half inches  above
the insertion of the tendo-Achillis  and underneath this tendon, and di-
vided the  fibres  from within outwards, merely cutting  through the ten-
don, without  wounding the skin except at the point where the bistoury
was introduced—following the process of Strohmeyer.  The foot almost
immediately  came down to a right angle  nearly  with  the leg, the only
dressing  consisting of  a bit of adhesive plaster on the small  wound, a
compress on each side of the  divided tendon, secured by a roller, while
the foot was  kept in its position by a splint to the front of the leg and
foot.   There was so little pain produced,  that an anodyne  administered
once or twice was all  that  was required  during  the treatment.   Five
days after the operation, Strohmeyer's apparatus was  applied, and ex-
tension very  cautiously and  gradually made from day to day until the
expiration of the fourth week, when  the foot was found to be at a rio-ht
angle with the leg.  A laced boot was now substituted for the apparatus
during the day, and the latter worn only at night.  This was continued
for a week.   Dr. Dickson says he applied  extension sooner in this case
than he should have done, from having seen, in the Medico-Chirurgical
Review, that Strohmeyer attributed  his  failure in one of his cases to
delaying it too long.  At the end of the second month, the patient could
Walk with very little  limping, the deficiency in the length of the le<*
being in a good degree remedied by a high-heeled boot,  the deformity
was entirely removed, and the flexor muscles now became  obedient to
the will.   When  Dr. Dickson saw the  patient  again, in May, 1837, he
walked with ease, and  with scarcely  any  perceptible limp.  'The limb
had become much more  developed, and its muscular power  greatly in-
creased.   This  surgeon has  informed  me, if I recollect  right, that he
has since repeated this operation with success in other cases__T 1
   [The operation was next repeated by Dr. N. R. Smith, of Baltimore,
in 1836, since which period it has become a common operation through-
out the country.  Prof. Parker of this  city,  operated for strabismus
in 1840, about  one year after  Dieffenbach's first operation at Berlin
                                                       G. C. B.] 
STRABISMUS.
503
                          STRABISMUS.

  [When the last edition of Professor Velpeau's work on Operative Sur-
gery was published  in Paris, (1839,) the operation for strabismus had
not become known.  In 1842, M. Yelpeau published a small octavo on
the subject.
  We  have, therefore, deemed it no more than just to M. Yelpeau, to
give in this place an abrege of all the most useful and essential portions
of this supplement, to which will be added whatever in the rapid march
of surgical discovery at the present time (when a few years only furnish
more matured results and  more surgical triumphs  than  long centuries
had hitherto achieved) is justly entitled to be deemed  new acquisitions
in this brilliant department  of  (as it may be called) Myo- Tenotomy.
The copy from which we abridge, is one  recently transmitted to us by
the learned author.—P. S. T.]
   All that has been hitherto  done to relieve strabismus, by various me-
chanical contrivances of glasses and spectacles of different degrees of
opacity,  and by forced positions given to the direction of  the axis of
vision, has proved, with very few exceptions, totally unavailing.   Now,
however, surgery can remove this  disease as it does cataract or fistula-
lachrymalis, by an easy operation, unaccompanied by  any danger, and
which consists in the section of the  muscle or muscles which give  to the
eye a morbid direction.
   Those who wish to consult  what  ancient authors have written upon
the varieties, causes, nature, and treatment of strabismus, may refer to
the  treatises of MM. Yerhaege  (on Strabisme, Bruges, 1841,) Florent
Cunier,  (Myotom.  Appliq. au  Strab., 8rc. Brussels, 1841,) Dufresse,
(Strab. et Begaiem., 1841,) and especially to the work of  M. Bonnet,
(Sections Tend, et Muscul., SfC, Lyon, 1841,) and  that of M. Boinet,
(Journal Medico-Chirurgical, Janv.,Fevr., Mars, 1842.)

                        Article I.—History.

   Though this operation is  unquestionably a modern invention, some
surgeons of the last century made special  mention and  recommendation
of it, and to all appearance it had already been several times performed
before the present  epoch.   The famous charlatan and  empiric, Taylor,
frequently had recourse to it, as Hewermann in his Surgery expressly
says that Taylor professed to cure  strabismus by the section of the ten-
don of the superior oblique muscle.   Lecat, also, in the Transactions of
the Academic  Society of Rouen, says,  "the charlatan Taylor pierced
the conjunctiva with a needle threaded with silk, and divided with a cut
of the scissors, the  membranous fold  included in the  noose of the silk .
thread;  the  sound eye was then  covered with a plaster, the diseased
eye was restored, and  it was  pronounced a miracle."   Taylor, when
asked for his  reasons  for the operation,  replied, that strabismus was
caused only by the inequality of the muscles, and  that to cure it  one of
them must be weakened.
   Taylor, in fact, according to M. Giraldes, came to Paris, and  every-
where announced his intention to  cure strabismus by  a surgical  opera- 
504
NEW ELEMENTS OF  OPERATIVE SURGERY.
 tion.   He called himself oculist to the king of Great Britain, and in his
 advertisements claims that he had discovered the mode of restoring the
 direction of squint-eyes by a prompt operation, almost without pain, and
 without the fear of any  accident, (Mercure de France, 1737, Juin
v page 1180.)
   M.  Cunier  (1st  Supplement  to the Ann. d'Oculist., p. 258) also
 points  out, in  the  Dissertation of Yerheyden, supported in 1767, this
 surgical phrase: strabones permultos ferro sanatos apud anglicos vidi.
   Whether Taylor  really cured strabismus and divided the muscle, or
 not, it  is certain  that  he indicated this operation for the cure, in the
 middle of the last century.
   The operation, however, was forgotten until M. Strohmeyer proposed
 it as one that was  absolutely new.  Sammels of Courtray, however
 (see Memoir of Verhaege,)  claims to  have  performed it twice in 1824
 or 1825, and M. Carron du  Villards says it was suggested to him by a
 hunter having accidentally been cured of an old strabismus from a leaden
 shot detaching the pulley of the great oblique.
   M. Cunier (op. cit., p. 126) says M. Gensoul of Lyon had proposed
 the section of the  muscles of the  eye  before M. Strohmeyer.   But all
 this is mere assertion, and of no importance, and the labors of M.  Stroh-
 meyer  are those alone which  have really  awakened attention  to this
 subject.
   In 1838 he described his operation which until then he had only per-
 formed on the dead body.  In the beginning of 1839 M. Pauli attempted
 it on a young girl, (Schmidt's Jahrbucher, 1839, vol. xxiv., n 3  p 351
 or Verhaege, p. 39,) but it was unsuccessful.   On the 29th of October'
 1839, it was performed on living man, by M. Florent Cunier, (Supple-
 ment eye, p. 264.)                                          v   il
   Though M. Yerhaege assigns the date of M. Dieffenbach's first opera-
 tions to December, and M. Phillips Strabisma el Begaiement, p.  8 • De
 ?Jont°mie sous-™ta™ei Paris> 1841, p. 223) places them at Oct.' 26,
 1839 they were undoubtedly the  first that  were  known and that drew
 attention.  In  fine, this operation was definitively created bv M  Stroh-
 meyer, and made practically useful by M. Dieffenbach
   Before this  remedy,  which had been so  long  thought of could be
 brought into use it, was  necessary to establish completely  the success
 of the section  of the muscles, as for  club-foot,  wry-neck  &c   wlfich
 was not triumphantly effected until the year 1830               '

 in qi?stiomratiOQ ™ ^ natUrallj SUg§eSted to remedF tbe deformity
   Such  doubts  however  still existed, that  even the  first letter  of M
Dieffenbach (Gazette Medicate, 1840, p. 107) nroducod  b»J 1  ■{■ m
sensation in France.   At a later' period, 5r. oL^rfn hav " been su ct

fai^n^^                       P- «« ^« K


™T^ £$?£]££ tahisS°aseTnatthSetrSR   ^—f
Academy of Sciences, Paris, June 29 %«.  it* Md'Z $>?? * th°
a practitioner speaks of having made/our cures, and immediatelv XS
confesses that three of the patfents continued to squint         7   QV 
STRABISMUS.
505
  M. Phillips, who had affirmed that the  operation always succeeded,
who at least did not mention a  single failure in a hundred operations
performed by him in Russia, and  who has published  that  in over four
hundred cases, the operation  has  always been successful in the hands
of M. Dieffenbach, finds a decided opponent in M. Melchoir, (De Myo- t
tomia Oculi, Sfc, Hafnim, Mars, 1841,) and some incredulous  persons
also in the Medico-Chirurgical Review.
  The residence of this young surgeon at Paris seemed to change his
views, as in his last work, (Tenotomie sous-cutanee, p. 321,) he relates
one hundred cases as performed upon by him, and attended by M. Bou-
vier, out of which twenty-five proved unsuccessful.
  M. Baumgarten, also,  (Operative Behandlung, etc., Leipzig, 1841,)
had admitted that of fifty-two cases, only  thirty-three were cured ; and
of these last, ten had to be  twice operated upon.  Of the  seventy-two
operations, also, performed at Dresden by MM. Ammon, Zeis, Warnatz,
and Baumgarten forty-five only were successful.  M. Guthrie, also, who
in his Annals of Surgery, vol. i., p. 492, mentions his  having had only
two or three failures in three hundred and forty cases, afterwards speaks
with less confidence of the final results of his practice.
  In Belgium  M. Dumont, in fact, says  (Cunier, Myot. Ocul., 1840)
the frequent failures discouraged operators themselves ; and M. Blariau
declared,  before the Society  of Medicine at Gand, that he had never
seen a single squint-eyed person cured,  (Cunier, p. 42, 44.)
  Finally, the authors of the  exaggerated  accounts  themselves com-
menced handling each other with  no little severity, as was seen in the
remarks of M. Phillips (De La Tenotomie, p. 318) on one  of his rivals,
who professed not to have failed once in eight hundred cases !   M. Phil-
lips himself declares these assertions lies.
  M. Cunier writes to M. Yelpeau in December, 1840, that out  of twen-
ty-nine  operated upon, he had seen twenty-one relapses, in periods vary-
ing from fifteen days to five months, and  that he knew of only six per-
fect cures.  Since that, he states (Ann. d' Oculiste, Fevrier, 1841) that
the deviation was reproduced in forty-seven cases out of  one  hundred
and sixty-nine, and that  he failed twelve times in  seventy-one cases.
In June of the same year, he announces that he had succeeded two hun-
dred  and  thirteen times out of two hundred and eighty-six;  and M.
Fleussu (Ann.  d'Oculiste, le  suppl., p. 308, 309) maintains, that  out
of six hundred cases M. Cunier obtained  constant success.   Out of one
thousand four  hundred  operations,  (Suppl., etc., p. 288 and 312,) our
confrere of Brussels scarcely admits of  any reverses.
  M. Dufresse, also, while calling in question the results of others, avers
himself, that he partially failed only in a few cases, and that the disease
returned but in three cases out of forty-seven.   The same language ap-
pears in the treatise of M. Josse, (Considirat. sur VOpir. du Strabism.,
1841,)  and in that of M. Kup, (Ann. d'Oculist., t. vii., p. 44.)
  In recommending  caution in pronouncing upon success  immediately
after the operation, M. Yelpeau complains  that his language was impro-
perly interpreted  by M. Guerin, in the Gazette Medicate, as  meaning
opposition to the operation.   M. Yelpeau, in 1840, October 14, (Gaz.
Med., p. 87,) estimating  the proportion of failures  to cures, etc., lays
down two important principles on this subject: to determine accurately
  Yol. I                     64 
506
NEW ELEMENTS  OF OPERATIVE  SURGERY.
the existence and nature of the strabismus before the operation, and to
exhibit the patients as cured at the end of three months.  Pompous an-
nouncements of success in political journals the day after the operation,
discredit our  profession and favor the extension of  charlatanism.  In
this lio-ht, also, M. Yelpeau views the asseverations of those who, in at-
tempting to give plausibility to their  exaggerations, declare  that their
successes depend upon the peculiar perfection of their modes of operat-
ing, and, vice versa, the failures of others, on their awkward or vicious
processes.
  M.  Yelpeau is exceedingly  severe  on these self-puffing, ambulating
operators.   He declares that  he has seen at Paris some of those who
had been operated upon  by these pretenders, squint  outwardly after
having squinted inwardly; some who squinted even  after being twice
operated upon, and others who  were  disfigured  by enormous  denuda
tions of the eye, &c.
  These  things at Paris  have brought odium upon  the operation, so
that its intrinsic value, after unexampled popularity, begins to be mis
trusted.
  Experience  taught  the crowds, who, misled by the reports of  never-
failing success, thronged  the  operative chambers, that  they had been
deceived, and  that the  deformity in  many instances only  becomes
changed  from one side to another.  Thus, from  one extreme  of confi-
dence, they have passed to the other of distrust, and the real efficacy of
the operation for certain cases is overlooked, and the patient prefers his
deformity to the hazard  of an operation.
  M.  Yelpeau excepts M. Guersant fils, M. Jobert and M. Bouvier, and
others at Paris, as among those who have  spoken  and acted with  frank-
ness ; also, the essay of M. Boinet, (Du Slrabisme et de son Treatment,
1842,) and that of  M. Bonnet of Lyon.   After all that may be said of
the inconveniences that may attend ocular myotomy as well as any other
operation, M. Y., in conclusion, says, that it will  be preserved in prac-
tice, and not  only  does honor to human  genius, but is one from which
the organ of vision will derive great advantage in future time.

                       Article II.—Anatomy.

  To appreciate the respective processes, we must examine the  tissues
which fill the orbit, viz., the conjunctiva, globe of the eye, its muscles,
and the cellulo-fibrous tissue which forms a more or less perfect  sheath
to each ball.
  Before  strabismus attracted notice, surgeons rarely noticed the apo-
neuroses of the orbit.   Since that, however,  the researches on  this sub-
ject have been extensive.   Layers and sheaths of various form, density,
thickness, and number, have been described with  a care and minuteness
which leave nothing apparently to desire.
  It is found  that the ancients were aware of the fibro-cellular  tissues
in the orbit. Galen was acquainted with the layers or cellular  coverings
of the muscles of the eye, and Zinn described them  with  some  care m
the last century, after  Colomb,  Casserius, and Riolan, (Belie  These,
Paris, 1841.)   It is, however, to Tenon  to whom we owe the  first ex-
tended article on the aponeuroses of the eye, (Memoire sur I'Anatomie 
STRABISMUS.
507
la Pathologie, et la Chirurgie, etc., Paris, 1806, t. i., p.  193.)   Since
this memoir, which was read to the Academy of Sciences, there has been
such a total silence upon the subject  among  anatomists as well as sur-
geons, that up to 1839, in spite of the essay of M. Briggs, published in
1835, (Boinet, Journal des  Connaissances Medico-Chirurgicales, Jan-
vier, 1842, p.  9,) it was no longer spoken of.
   Since strabismus has occupied public  attention, we have seen the de-
scription of the aponeuroses of the orbit resumed in all its bearings, by
M. Lucas of London, (On  Strabismus, London, 1840,) M. Bonnet of
Lyon, Des  Sections  Tendineuses, etc., Lyon, 1841, p. 1,) M. Guerin,
(Gazette Medicate, 1842, p. 12, 97,) M. Dufresse, (Treatise  cited,
pages 32, 40,) M. Helie, (These, Paris, 1841,) and M. Boinet.
   M. Yelpeau thinks it not  surprising that in former times so little was
known apparently of the lamellar coverings of the  eye, inasmuch as
they had no special relation to operations  performed  on the ball, or in
the orbitar cavity, or to the  diseases that may exist there.
   These fibro-cellular sheaths, which surround the muscles of the eye,
and the lamellae which unite or separate them, present in their mechan-
ism  and distribution  in  the orbit much  greater simplicity than some
think.

Improved  Eye-Speculum, by  George Tiemann,  Surgical Instrument
   Maker,  New-York.  Designed particularly for operations for
   strabismus, &c.

   This instrument, invented by George Tiemann, of New York, appears
to us to possess a decided preference over the common spring speculum,
as described by Prof. Pancoast in  his work on surgery, as well as over
some of the more complicated but not less objectionable specula used
by others.  The instrument of Dr. Pancoast  will not, when applied to
the eye-lids, open them at equal distances, for the outward points of the
hooks will stand farther apart than those of the inner  side.
  The above eye-speculum, by  means of the spiral  spring within the
silver  cylinder, opens the two  hooks in a direction perfectly parallel to
each other, and the regulating  screw secures them at any  distance the
operator chooses to set them.   This will much alleviate the pain of the
patient; for the continued pressure of the  spring speculum upon the
muscles of the  eye-lids (there  being no check to the spring of the in-
strument) is considered by some, and no doubt often is, far more painful
than the operation itself. 
508            new elements of operative surgery.

  The profession for many years owe much to Mr. Tiemann for the very
perfect workmanship, not only of all the  ordinary instruments employed
in surgery, midwifery,  <fcc, but also for the very great improvements he
has made in some of them, and for those more remarkable instruments
of his own  invention (as his tonsil-scissor-forceps, &c, all of which will
be given in their proper place) which have justly given to this very scien-
tific and intelligent artist an enviable reputation.—T.]

                    § I.—Muscles of the  Orbit.

  Of the seven muscles contained in the orbit, there are but six which
serve for the  movement of the eye ; these alone, therefore, can be^ con-
cerned in the subject of strabismus.  Six of them, being attached to the
bottom of the bony cavity, where they are  confounded with the perios-
teum around the optic foramen, and on one of the borders of  the
sphenoidal  fissure, terminate in front by a true  tendon, expanded on the
sclerotica, which they assist in forming.   Four of them—the four straight
muscles—extend to within about the one twenty-fifth or one twenty-sixth
part of  an inch of the  cornea on their anterior surface ;  but their deep-
seated surface terminates at three or four millimetres behind, so  that
this extremity appears  a little curved  and thickened like a leech, which
attaches itself to the skin by its posterior extremity.
  The superior oblique behind the upper  eyelid, passes within the supra-
orbitar  foramen,  through a fibro-cartilaginous ring, before it passes
from before backward, and from within outward, under the levator mus-
cle of the eyelid, in order to attach  itself to the posterior and upper
part of  the globe of the eye.  The inferior  oblique  muscle passes from
the  external side of the nasal canal, outwards, backwards, and upwards,
between the floor or the orbit and the inferior rectus muscle, to terminate
at the outer and posterior part of the sclerotica.
  It follows from this arrangement-:
  1. That the four straight muscles, (the recti,) when too short or too
contracted, tend to  shorten the  transverse and vertical diameters of the
sclerotica, and at the  same time to give prominence to the  cornea, from
whence  we  have one cause of short-sightedness, and the idea of dividing
these muscles to elongate the field of vision.
  2. The inferior oblique, in contracting itself singly or disproportion-
ately, turns the  eye outward and upward, which gives it a certain influ-
ence in the production  or continuance of  external strabismus.
  3. The superior oblique turns the eye inward and downward;  at other
times it aids  rather the action of the external rectus muscle, and the in-
ferior oblique, in external strabismus.
  4. By their simultaneous  retraction, the two  oblique muscles draw
the  globe of  the eye forward.  Becoming in this  manner antagonists of
the  four straight muscles, they may also cause the cornea to protrude,
and produce myopie, from whence  proceeded the  suggestion of their di-
vision to remedy this deformity.

                         §  II.— The Nerves.

  Of the nerves  of the orbit, the sixth  pair and the third only require 
STRABISMUS.
509
notice.  The pathetic, that of Willis, and the  ciliary  nerves, are  not
specially concerned in strabismus.  The optic nerve is to be recollected
as representing the  axis of the orbit  behind the eye, that we may not
divide it, a3  was  done by an orthopedist of Paris, in the operation of
strabismus.   The nerve  of the sixth  pair, supplying only the external
straight muscle, would, if paralyzed, cause an internal strabismus.  The
patient, though he could then turn the eye upward, downward, and in-
ward, could not, though  the other eye was shut, turn the pupil towards
the temple.
  The other muscles of the eye, being supplied by the nerves of the third
pair, show how, when this nerve is diseased, it  is followed by an exter-
nal strabismus.  In  this case the eye, fixed outwardly, can neither be
moved  inward, upward, nor downward, and the strabismus is compli-
cated often with a more or less marked depression of the upper eyelid.
   Thus, as all these nerves are appropriate to the different muscles, and
as those of the globe of the eye come from another source, it may readily
be  conceived that the operation  for strabismus ought not to cause any
nervous disturbance in the ocular functions.

                         § III.— The  Vessels.

   The  vessels of the orbit are of greater volume in proportion to their
distance from  the globe ; the arteries  all arising from the ophthalmic
trunk, and being situated posteriorly, and encircling the  optic nerve, are
so small when  they arrive in the neighborhood of the conjunctiva, or .the
anterior extremity of the muscles, that their section at the place where
the instruments should be applied  in the operation for strabismus, incurs
no  risk of any serious  hemorrhage, and is generally attended with but
a  very slight discharge of blood.   The case of  threatening hemorrhage
mentioned in England, (see Phi/lips, 1841, &c.,) must have been an ex-
ception, and from a hemorrhagic predisposition.
  The  large veins which proceed from the internal angle of the eye,
and from the  eyelids and root of the  nose, and which pass along the
internal wall of the  orbit, into the cranium, must be ovoided,  as must
also the ethmoid bone, in convergent strabismus.

                        § IY.—Aponeuroses.

  The  nerves, vessels, muscles, the eye itself, and the conjunctiva, and
superincumbent layers of the  eyelids, are all enclosed and lined with
lamellse and layers  foreign to their  appropriate structure: all known
under the name of the cellulo-adipose tissue  of the orbit, and apparent-
ly complicated, but in reality simple.
  I have established, in my Surgical Anatomy :
   1.  That the  fibrous tissue is but a transformation of the cellular.
   2.  That all the membranous and fasciculated parts are formed in their
place, and not  contiguously, as many  authors  still  seem to believe, in
conformity with the figurative language of Bichat.
  3. That all the movable organs are enveloped  or lined  with a cellular,
fibrous, or fibro-cellular layer.
  4.  That the  interval of all the parts  thus sheathed, is filled with fatty
pelotons, or cellular, lamellar, or filamentous tissue. 
510            NEW ELEMENTS OF OPERATIVE SURGERY.
  In  conformity  with a great law  of the organization, all  the vessels
and  nerves have a kind  of cellular sheath, independent of their own
coat • there is no muscle or tendon which is not surrounded  by a sheath
or encasement, either of purely fibrous plates, simply cellular, or cellulo-
fibrous ;  the same as with all the glandular or other viscera, and all the
organs contained in the splanchnic  cavities, and in the mouth  and the
orbit.
  The ball of the eye, nerves, muscles, vessels, even the internal surface
of the conjunctiva,"and the deep-seated surface of the  palpebral  liga-
ment, are all enclosed in this duplicature or pocket of slightly condens-
ed cellular  tissue, which, moulded  upon  the eye  and optic nerve, and
forming a flattened sheath on the recti and oblique muscles, and on the
levator of the eyelid, and each of the nerves and vessels, becomes, from
the constant motions of the parts upon each other, in every direction,
more and more isolated and hardened, until it has acquired the character
of true fibrous tissue, or simple cellular lamellae, of greater or less den-
sity.  These lamellae are  thus much more cellular than fibrous in early
life, and  much more fibrous than  cellular in adult age.   There is thus
an aponeurosis for each part.

            A. Aponeurosis of the Eye,  Proper or Globe.

  This, commencing at the cornea, is a simple, somewhat dense lining,
enveloping the whole sclerotica and optic nerve.   In front it is continu-
ous with  the aponeurosis of the conjunctiva, and behind with the internal
layer of  the sheaths of the muscles.  It is interrupted by the required
number of openings for the passage of the oblique and straight muscles.
Its mobility, and  the fine  texture of the cellular  tissue of its inner sur-
face, admit of its being detached from the eye, either from behind for-
ward, or from before backward, in the manner of a purse.

                B.  Aponeurosis of the  Conjunctiva.

  This is also a dense cellular tissue, which  strengthens this membrane
as the fascia-propria strengthens  the adherent  surface  of the serous
membranes.  Setting out from the periphery of  the cornea, where it is
continuous at a very acute angle with the aponeurosis of the eye, it pro-
ceeds  backward  to the conjunctival border, which corresponds to the
oculo-palpebral groove.   It is  then reflected from behind  forward, to
follow the  palbebral conjunctiva, and to contract adhesions  with the
convex border of the tarsal cartilage, or to terminate  between this car-
tilage and the conjunctiva, upon the meibomian glands.

                    C.  Aponeurosis of the  Orbit.

  This lamella, seemingly continuous with the preceding, or the upper
expansion  of it, passes  upward at  the base  of the orbit, as if to line
the posterior face of the  palpebral  ligament, and to bend from before
backward, to serve  as an inner  layer to the periosteum, which it covers
in its whole extent, soas to convert the orbit into a cavity  completely
closed before and behind, in which latter position the  aponeurosis of
which I speak is continuous with that of the muscles. 
STRABISMUS.
511
                   D. Aponeurosis of the Muscles.

  The fibrous, or rather cellular and somewhat dense and  lamellated
encasements of the muscular system of the orbit, are composed of small,
unequal, flattened sheaths, which  are adherent to the  muscles, and ex-
tend between them, under the form of membranes, that spread out from
one muscle to another.  All these sheaths, composed of an external and
internal layer, reach  to the  sclerotica,  and are continuous with the
aponeurosis of the  eye, where it has  united itself with the aponeurosis
of the  conjunctiva in front,  and with  the aponeurosis  of the  same
organ,  as  it passes backward  towards  the optic nerve ; that of the
oblique muscles, also, loses itself in the aponeurosis of the eye.  There
results  from this arrangement, as M. Guerin has noticed, (Gaz. Mid.,
1842, p. 84,) a kind of compartment, formed by the funnel-like expan-
sion of each one  of those sheaths for the insertion of each tendon of the
muscles in question.
  As to the sheath of the levator muscle of the upper eyelid, it is blend-
ed in front, and above and  downwards, with the palpebral aponeurosis,
rather than with the aponeurosis of the conjunctiva.
  It results  from this, that the oblique  muscles seem to have wrought
out the aponeurotic net-works, which extend from one border to the
other of the straight  muscles, and that  they have lent to these last a
part of'their own proper sheath at their  point of contact or crossing.
  Upon the  entire white of the eye, the aponeurosis of  the conjunctiva
rests in contact, when we look at it in front, with the anterior portion
of the aponeurosis of the globe and a certain extent of the aponeurosis
of the muscles.   But according as the eye is turned more or less in one
direction or in an another, this contact diminishes or totally  disappears
on one side, while it  proportionately increases on the opposite  side.
Between the aponeurosis of the globe and the straight muscles there is
nothing posteriorly but fat, cellular  filaments, vessels, and nerves.  It
is the same between the oblique and the straight  muscles, between the
levator muscle and all the others, between the whole muscular system
of the eye  and the aponeurosis of the orbit.
  In no part, moreover, is the fibro-cellular system of the orbitar cavity
as dense and complete as at the place where the tendons of the straight
muscles abandon  their fleshy tissue to be inserted in the sclerotica, under
the oculo-palpebral circle of the conjunctiva, which latter seems to be
retained there by the  aperture of a large purse, analogous to  that which
holds the  peritoneal cul-de-sac of the lower pelvis to the aponeuroses
of the perinasum  or the prostate.

                 Article III.—Operative Methods.

                   §  I.—Method of Strohmeyer.

  In convergent  strabismus of a spasmodic character, M. Strohmeyer,
guided  by his operations on the dead body, advises the sound eye to be
covered, and the  patient to keep the squint one turned out as  far as pos-
sible.   The operator  then  inserts into the conjunctiva,  near the inner 
512
new elements of operative surgery.
 limit of the protuberant part of the eye, a small double hook, which he
 immediately passes to  the  assistant, in order to hold the eye outward.
 The surgeon then raises the conjunctiva with a forceps, and with a cata-
 ract  knife  makes  a vertical incision  through it,  so as to open into
 the orbit on the inner side of the bulb or globe.   The assistant now draws
 the globe more outwardly, which immediately brings into view the rectus-
 internus muscle.   Having passed a small probe underneath this muscle,
 it is divided with the curved scissors, or with the same knife with which
 the incision was made  into the conjunctiva.
   Cold fomentations and an anodyne are then used, and  the  sound eyo
 afterwards kept occasionally closed, that the motions of  the  other may
 become re-established by exercise.   The operation of M. Strohmeyer is
 the trunk or base from which all the others  branch off.

                     A.  Process of Dieffenbach.

   M. Yerhaeghe, who was one of the first cases of strabismus operated
 upon  by M. Dieffenbach, says the latter in his first essay, December,
 1839, in following out Strohmeyer's  directions, encountered much  diffi-
 culty in exposing the rectus-internus muscle, as  well as in  seizing it.
 The operation, however, was completely successful.  The process of M.
 Dieffenbach, as described by M.  Yerhaeghe, (Mem. sur le Strab., See,
 Bruges, 1841, p. 41,) is as follows:—
   The instruments are  composed of the elevator of Pellier, a double
 blunt hook, (supported by a slender handle,) in order to depress  the
 lower eyelid, two  small  sharp-pointed  hooks to seize the conjunctiva,
 scissors curved on their flat sides for the incision of this membrane, and
 a blunt hook to pass underneath the muscle,  which is cut with the curved
 scissors;  finally, a small, sharp-pointed double  hook, reserved by  the
 operator for cases where  the eye is turned convulsively inward, to such
 degree  as to endanger tearing the  conjunctiva.  The hook in that case
 is inserted into the sclerotica, to control the eye.   A sponge and hot
 water complete the articles required.
   The surgeon, being seated in front, and a little higher than the patient,
 places under the upper eyelid the elevator of Pellier, which the assistant
 who supports the head then takes charge of.   Another assistant in front
 holds the depressor of the lower lid.  The patient having turned his eye
 outward as  much  as possible, the small sharp-pointed hook is inserted
 into the conjunctiva near the  caruncula-lachrymalis ; the other hook he
 inserts in the conjunctiva near the cornea, and holds it in  his left hand-
 While the conjunctiva is  thus raised up in a fold, the operator, armed,
 with a curved scissors, makes an incision into it, and successively divides
 the other tissues until the muscle is laid bare.
  Then passing the blunt  hook between the sclerotica and  the muscle,
 he divides this latter with the scissors.
  The eyes are examined to see if they  are straight
  The only difference of Dieffenbach's process from Strohmeyer's, is that
 he former, instead of seizing hold of the conjunctiva with a forceps near
the lachrymal  caruncle,  in order to stretch the membrane, as M  Stroh-
meyer does,  employs a second hook. 
STRABISMUS.
513
B. Process  of M.  Cunier, (Myotomie  Appliquee au  Traitement  du
   Strabisme, etc., Bruxelles, 1840, et Ann. d'Oculist, Juin, 1840.)

  In Belgium, MM. Yan Rosbrooeck, de Meyer, Claeysens, and most of
the surgeons, adopt the process of M. Strohmeyer.   M. Cunier, however,
one of the first, if not the first who operated for strabismus, makes some
slight modifications, using the speculum of Lusardi, as well as the eleva-
tor of Pellier, and making a semi-lunar incision into the conjunctiva of
the breadth of the muscle, which latter he divides at one stroke with the
small blunt-pointed scissors, curved on their flat sides.   He uses, also,
blunt hooks, to keep apart the eyelids at the angle on the diseased side.
   M. Yelpeau sees no preference in this process over the German modes,
and M. Cunier himself has  substituted for it that of M. Phillips, using
likewise M. Yelpeau's blephareirgon and the suture of the conjunctiva.
(Annal. d'Oculist., ler Supplem., etc., p. 271.)

                        C. English Processes.

   England  was the first after Germany to adopt the processes proposed
for strabismus, as seen in the numerous operations by MM. Lucas, Ferrall,
Liston, &c, before M. Yerhaeghe, in the beginning of 1841, gave vogue
to it in Belgium.
   M. Guthrie, junior, claims three hundred  and sixteen cases  before
April, 1841, (Ann. de la Chir. Francaise, t. i., p. 492,) and MM. Hall,
Grant, Eliot, and Duffin,  had already published instructive  treatises
upon  this  subject.   All  operate  differently,  but by modifications so
slight that  they  cannot be separated  in reality from the  method of
Strohmeyer.

      D.  Process of M. Lucas, (Cure of Strabismus, Sec, 1840.)

   M. Lucas, after  separating the lids, at once  seizes  the  conjunctiva
with a forceps, and dividing it, inserts through the opening the  double
hook into the sclerotica to hold  the eye, and then  divides the muscle
with a curved scissors.                                              •

                      E. Process of M. Ferrall.

   M. Ferrall seizes the caruncle with a sort of double hook, and  pushes
it inward.
   After having seized with the forceps a portion of the conjunctiva near
the cornea, and  divided it with a small pair of angular scissors,  he lets
the eye repose for a few moments.
   He afterwards raises the tendon of the muscle  with a blunt hook, and
divides it very near the sclerotica with the angular scissors.
   M. Ferrall, by applying  his forceps  outside, while  Strohmeyer  uses
his on the inside, has made the  operation  somewhat more difficult, by
thus  dispensing with  two of its instruments. Nor is there any advantage
in the angular scissors.
   Yol.  I.                   65 
514
NEW ELEMENTS OF OPERATIVE  SURGERY.
                      F. Process of M. Liston.

  M. Liston, using one assistant only, who raises the upper lid with his
fingers or Pellier's elevator, seizes a large fold of the conjunctiva, in the
oculo-palpebral groove, with a spring  forceps, whose weight alone, left
to itself, depresses the lower lid.   This method, we shall see, is exceed-
ingly defective and objectionable.

                        G. French Processes.

  The operation was  first  attempted in France in June or July, 1840,
and first performed by M. Huard and others at Havre, the particulars
of which  M. Yelpeau is not  in possession of.  After that, it was  per-
formed  by MM.  Guerin, (Lettre a VAcademie des  Sciences, 29 Juin,
1840,) Roux, (Communication a Vlnstitut., 20 Juillet,)  and  Amussat,
by methods which completely failed, and which have not been published.
Finally, in the hands of M. Simonin, at Nancy, it proved, for the  first
time, perfectly successful.

H. Process of M.  Simonin, (Du  Strabisme, Sec, Nancy, 1841, in 8vo.)

  This does not differ materially  from that of Strohmeyer and Dieffen-
bach, only in adopting the  best parts of each.

                      I. Process of M. Roux.

   liter M.  Simonin  and M. Guerin, it was M.  Roux, according to M.
  elpeau, who was the first, he thinks, to  perform  this operation pub-
licly in France;  viz.,  at the Hotel  Dieu in July, 1840, on two patients,
who, however, continued  to remain squint-eyed afterwards.   His op-
eration  differed  from the German, only in  having  the blunt  hook  for
raising  the  muscle, grooved for the direction  of the small bistoury  that
divided it.

                     J. Process of M. Sedillot.

  M. Sedillot performed the  operation of  strabismus, at  the Yal de
Grace, Paris, a few days after it had been  performed by M.  Yelpeau.
In order to hold the eye, he inserted  into  the  sclerotica a hook  with
three prongs, instead of  the double hook of M. Cunier, and the simple
one of Strohmeyer, (see Gazette des Hdpitaux, 1841, Sept. 15.)

                     K. Process of M. Phillips.

  Up to November, 1840, there still prevailed  great doubt as  to the
utility of the operation for strabismus.  Notwithstanding the constant
successes  announced  at Berlin,  Petersburgh, and  London, it was seen
that many failures occurred among the practitioners of Belgium, while
in France no one obtained results  entirely  satisfactory.   But a'young
physician, M. Phillips, who had acted as an assistant to M. Dieffenbach 
STRABISMUS.
515
and had  himself performed the operation a number of times in Russia,
having arrived in Paris, M. Yelpeau interrogated him as to the cures
made at Berlin, and if the failures in France were to be imputed rather
to the processes  followed there, than to the operation itself.  He ascer-
tained from M. Phillips that he used an erigne in the conjunctiva, not
only to hold the eye outward, and which erigne was passed to an assist-
ant, but  another erigne to secure the fold in the conjunctiva near the
caruncula, dividing with a bistoury between the two erignes, enlarging
the wound up and  down with a small pair of curved scissors, then sepn-
rating the muscle  from the globe by a small probe, and subsituting for
this last  the  blunt hook, and lastly, dividing  with a small scissors al-
ready mentioned.   He is in the practice  also of excising the  anterior
end of the divided muscle, to be more certain of preventing its reunion,
which Dieffenbach was also in the habit of doing, but has now abandon-
ed, (De  la Tenotomie Sous-Cutanee, p. 245.)
   Emboldened by the  safety which they  saw in the dissections of M.
Phillips, the Paris surgeons obtained the same results with the  German
practitioners.

           L. Process of MM. Amussat and Lucien Boyer.

   They use a toothed forceps instead of the erigne  to fix the eye.   Two
of these being held in  their place by an assistant, the operator incised
the  conjunctiva with a  bistoury, raised up the muscle by a separated
hook, (the one,  according  to M. Phillips, invented  and  afterwards dis-
carded by  Dieffenbach—see  Du Strabisme, p. 27,) and divided it by a
straight  pair of  scissors.

                     M. Process of M. Baudens.

   M. Baudens performed the operation at the close of December, 1840,
and imagined he was  the first, though he was only the fiftieth.   His ope-
ration is the same  as Dieffenbach's.

                        N. Other Processes.

   It remains to speak only of the modifications made by M. Dufresse,
(Du Strabisme et du Begaiement, Paris, 1841 ;) by M. Boinet, (Journ.
des  Conn. Med. Chir., Mars, 1842;) and by M. Bonnet, (Des  Sections
 Tend, et Muse, See, Lyons, 1841.)  M. Dufresse raised the muscle
with a flat and  slightly-cutting hook.   He seized the conjunctiva and
muscle together by a forceps, and divided the whole of the tissues  inclu-
ded between the two  forceps, and then removed a portion of the tissues
thus  divided.  This part of  the process he borrowed from M. Yelpeau
himself,  as adopted by him in Dec. 1840.   M. Bonnet holds the eye with
the forceps, and cuts the  muscle  with a small scalpel, (Sect. Tend, et
Muse,Sfc, p. 97-100.)

                  0. First  Process of the Author.

   The failures met with by some of the Paris surgeons, caused  the oper 
516
NEW ELEMENTS OF OPERATIVE SURGERY.
 ration to be generally laid aside, till revived by M. Yelpeau in August
 and September, 1840,  at La Charite, (see his lectures there  Sept. 11
 and 12,) of which the Gazette des Hopitaux gave (Sept. 17,1840) but
 a very imperfect description.
   The eyelids  were separated by  the  elevator of Pellier and a triple
 blunt  hook, the patient being  directed to turn his eye as much  outward
 as possible.   A small double drigne was inserted in the sclerotica, and
 held by an  assistant if it was the  left eye;  and with another  similar
 erigne, a little less curved and more blunt, he seized the muscle through
 the  conjunctiva as deeply as possible, bringing it forward with the right
 hand in the  manner of a cord, and  with a small curved  knife divided
 the  whole at one stroke, viz., retracted muscle, fibro-cellular envelope,
 and conjunctiva.
   The advantages of the operation  are—its rapidity, the dispensing of
 any  dissection  whatever, and  the very  small opening it leaves in the
 conjunctiva, besides that of the cure being speedily effected without any
 inflammatory reaction in the eyes.  Of ten patients, however, upon whom
 he thus operated in September, October,  and November, only three had
 their eyes continue perfectly straight.  In four others the disease  was
 reproduced as severely as before.

                    P. Process of M. Andrieux.

   M. Andrieux  (Gaz. des Hop., 1840, Sept.) proposed to  change M.
 Yelpeau's erigne into a cutting-hook to divide  the tissues while it raised
 and secured them :  the  eye was  held by a double erigne with cutting
 points.                                                           6

                  Q. Second  Process of the Author.

   Having  seen  M. Phillips operate on the dead body, M. Yelpeau im-
 mediately conceived that, in imitating him, success might be hoped for
 where  there had hitherto been  complete  failure.  In reflecting upon the
 free and bold dissections of M. Phillips in denuding the sclerotica, and
 which  had hitherto appeared formidable to M. Velpeau, he perceived that
 by his own operation numerous lamella might be left remaining undivided
 in the  eye.  M Phillips  soon  having an  opportunity to  p?ove on the
 living subject that there was no danger to be apprehended, greater con-
 fidence was  produced, and  the  question  assumed a new aSpect; (Du
 Begai. et du Strab., Paris, 1841.)                        v   ' ^
  M. Yelpeau now  modified his  process by seizing with a claw forceps
 a large fold of the  conjunctiva, and the attachment itself of the muscle
 at the  sclerotica, in order to hold the eye and  turn it outward   If U is
 the right eye, he holds this first forceps in his left hand.  Then wi ha

 Kf Za^o8aSTr,h°-pr^oded t0  embrace d4"tb
 it   Thislas?Sri- con>™<*™>in order to raise it and stretch
 a smrdl blunlrSntS    •  immedia el7 confided to an assistant.  With
 sidesandShffihUZT'^f^/l^^  CUrved on tlieir flat
 sines, ana new in the right hand, he divided the whole bridle comorised
between the two forceps.   After  making  the  division  M vSn fn
serts one of the blades of the scissors between the^ scleroticaand" ocular" 
STRABISMUS.
517
aponeurosis, and freely cuts away all the adhesions there, to the extent
of about four fifths of an inch,—the two ends of the divided muscle,
«fec., being still held tense by the two forceps while this detachment is
being made. ^  He terminates the  operation by excising a portion of the
tissues, to wit, that portion of the conjunctiva and of the tendon of the
retracted muscle held by the first forceps, having first, with the beak of
the blunt scissors shut, cleared away all the remaining adhesions on the
globe of the  eye, till a denuded  space is made on the sclerotica, which
is recognised by its smooth shining surface.

                   R.  Variations of the Process.

   The above process was put into practice by M. Yelpeau in Dec. 1840,
since which  period he has employed it in two hundred cases.   The in-
strument with which the eyelids are kept asunder during the operation, is
termed the blephareirgon.  It is the invention of M. K. Snowden, as modi-
fied by M. Yelpeau, and the latter gentleman prefers it to all others—the
pesculum of Lusardi, the elvators and depressors of Dieffenbach, M. Pel-
lier, and others, the flat forceps of M. Liston, the dilatators of M. Cunier,
&c.  It is made of iron wire.   The two forceps he uses are preferable,
he thinks, to the erignes.   His are strong and short, and have two small
hooks at the extremity of one branch, and one on the other, which hooks
catch into each other.  Those of the anterior forceps converge a little,
so that they may not catch into the sclerotica.  Erignes expose to lace-
rations.  On the left eye he  inserts the first forceps with his right hand,
and  hands it to an  assistant, and then holds himself the posterior or
deep-seated  forceps with his left hand.  Generally M. Yelpeau excises
the portion  or fold of the  conjunctiva, and of the  termination of the
muscle in the sclerotica, which  are  grasped by the first forceps.  He
does this  to prevent consecutive  engorgement  there.  The scissors
should be straight  and  blunt;  they cut better than the curved.  The
first forceps are directed upon the point where the tendon of  each mus-
cle is inserted into the sclerotica, and the  parts  grasped in it are the
conjunctiva,  conjunctival  aponeurosis, muscular  aponeurosis, and the
tendon itself.  This gives the operator full control over the ball.  The
second forceps, which should be a little stronger and longer than the
first, and are directed upon  the  bottom of the  oculo-palpebral groove,
beyond the transverse axis of the  eye, and  grazing the sclerotica, em-
brace the rectus muscle in all its thickness, with  the different mucous
and cellulo-fibrous layers which  naturally envelop it, while pressing the
lachrymal caruncle towards the nose.  These forceps have this advan-
tage, that their firm pressure on the vessels prevents hemorrhage when
the section is made.   The grasp of the  tissues with the  first forceps
 should rather be made below than above the  transverse axis of the eye,
for it is easier afterwards to dissect with the scissors the adhesions from
below upward,  than in the opposite direction.  The whole portion of
the tissues included  between the two forceps, or, what is the same, a
portion of the  extremities  of these tissues, after the division, may be
excised whenever judged advisable, as  was the practice of Dieffenbach.
   Another modification  which'  M. Yelpeau  proposed in his method is,
to make at first a partial incision only into the bridle between the tw# 
518
NEW ELEMENTS  OF OPERATIVE SURGERY.
forceps;  then he  separates the  conjunctiva  from the  aponeurosis and
muscle with a blunt hook, or the  blunt scissors shut;  then detaches the
ocular aponeurosis from the sclerotica, and raises up the muscle, in or-
der to divide all the fibro-cellular or muscular tissues which  separate
the globe from the conjunctiva, doing this without enlarging the incision
just made.

                     S. Process of M. Daviers.

   M. Daviers, of Angers, uses what he  calls an  erigne-forceps, with
four hooks  at the points  to  fix  the eye, taking care to embrace in the
fold the sub-conjunctival and  muscular  aponeuroses, and even some of
the tendinous fibres.  This fold is raised up as much as possible, and
divided  perpendicularly to the  direction of the muscle, and in such
manner, that the  erigne-forceps remains implanted in the  anterior or
corneal lip of the division, and thus serves to keep the  eye firmly fixed.
The blunt hook is  then immediately passed  under the muscle, and the
forceps is removed.  The division of the muscle is  then made with scis-
sors of short and blunt blades,  and either straight or curved on their flat.

                   §  II.—Process of M. Guerin.

   M. Jules Guerin, who denominates this operation the sub-coniunctival
method, has two processes:

                   A.  First Process of  M. Guerin.

   At the close  of October, 1840, M. Guerin had operated five times in
the following manner :—The  patient lying in bed or on a table, and the
lids  being  kept separate by  proper instruments, a small erigne, single
or double, was inserted into the conjunctiva near the cornea, and an aid,
taking charge of  this, drew the  eye outward.  Then, with a large for-
ceps seizing the conjunctiva near the caruncle, he incises this membrane,
dissects a flap and turns it inward, and thus exposes the muscle.  Raised
up by another forceps, the muscle is then immediately divided by a blunt
scissors.   The conjunctival flap is  now replaced on the wound, and the
operation is thus terminated.
   M. Yelpeau perceives  disadvantages  in this method ; says it differs
but  little from  those  of MM. Ferral, Lucas, and Simonin ;  that in two
of the five cases only was it successful; and finally, as M. Boinet remarks,
that none of the other methods require a greater denudation of the mus-
cle, or larger incision into the conjunctiva, than this docs, (see Boinet,
Du  Strab., p. 39.)

                  B.  M. Guerin's  Second Process.

 ^ Not satisfied with the difficulties by the last process, of detaching the
tissues under the conjunctiva, M.  Guerin, to date  from Oct. 26, 1840.
(see  his letter to  the Academy of Sciences,) proposed  a new modifica-
tion, the germ of which M. Yelpeau finds in that of his own, or of M.
A.ndrieux or M. Lucas, and the  first  idea of which may, m'. Yelpeau 
STRABISMUS.
519
thinks, be  traced to the sub-cutaneous method of M.  Ammon, (vide
Cunier, Myot.  Ocul., p. 107 ; 1840.)
  The modification consists in puncturing with a lancet the conjunctiva,
below the muscle to be divided.   A small scalpel, shaped like a Z, with
its cutting edge convex, is then introduced, to detach from the eye both
the ocular aponeurosis and the shortened muscle.  In the next, or third
stage of  the operation, the cutting edge of this knife is pressed forward
and outward against the internal surface of the muscle, which latter is
made more tense, by drawing upon the conjunctiva with the erigne in
the opposite  direction.   Withdrawing the knife through the puncture
in the conjunctiva, there remains, says M. Guerin, scarcely any percep-
tible wound between the eyelids,  (Gazette Medicate, 1842, p. 148.)

  Article  IY.—Comparative Yalue of the Operative  Processes.

   Under the title of methods, M. Yelpeau compares only the usual meth-
od, viz.,  that by dissection, or Strohmeyer's, with the sub-conjunctival.

                    § I.— The  Sub-Conjunctival.

   Besides  objecting to the name of this method, which M. Guerin  has
given to  it in following out the principle of sub-cutaneous sections, M.
Yelpeau says it does not exclude the air, and besides, sometimes involves
serious infiltration, or ecchymosis and  tumefaction, both of the conjunc-
tiva and  the  entire thickness of the eyelids; that it is also more difficult
and painful, and that it is less certain than the other process, as  the
divisions are made in the dark and out of sight.
   M. Guerin, on the other hand, considers its advantages to lie in these
particulars:  that it prevents a return of the disease, or a strabismus in
an opposite direction, also an abnormal separation of the lids, and that
protuberance of  the  eye known as  exophthalmia.  M. Guerin also es-
teems it  the most easy and rapid process.   M. Yelpeau  says, however,
that the  same accidents occur after M. Guerin's as after other methods,
and that so far from his (M. Yelpeau's) own  method, or most of  the
others, exacting ten to fifteen minutes, they are generally terminated in
less than a minute ;  besides  that, the formidable inflammations, loss of
the eye,  &c, which M. Guerin charges upon other methods,  all resolve
themselves into a very  trifling degree of inflammatory reaction.   " If
(says M. Yelpeau) I did not know M. Guerin as well as I do, I  would
in truth  believe that his intention, in charging  other methods with so
many imaginary imperfections, was in reality to mask those that are in-
separable from his own.  Ardently  desiring, as he does, that sub-cuta-
neous surgery, and the  sub-cutaneous section of tendons in  particular,
should take their birth from his peculiar ideas about muscular  retraction,
[see long note on the Paris  Discussion upon Tenotomy, supra,] he has '
extended his theory also to strabismus, in a round of illusions upon which
he uselessly  expends his logic and talent."
   The only real advantage of the  sub-conjunctival  method  is, says M.
Yelpeau, that  it generally   prevents the small reddish vegetation, or
species of ocular polypus, which is  frequently formed at the bottom of
the  wound, at the expiration  of from fifteen to thirty days after  the 
520
NEW ELEMENTS  OF OPERATIVE SURGERY.
 processes of Strohmeyer's method.  But this is a trifling inconvenience,
 and easily removed: besides, 11. Guerin's method is not entirely exempt
 from it.  It is a method, moreover, which is followed only  by himself
 and a few other surgeons.  M. Yelpeau, however, does not declare that
v: M. Guerin's method is positively bad ;  only that it is not in reality bet-
■ ter, but at  least as dangerous, and  certainty  more difficult, than  the
 usual method.

          § II.—Method of Strohmeyer, or by  Dissection.

   Though it must be confessed, that there is no one of the methods yet
 devised which in the strict sense of the words  may not be both practi-
 cable and successful, and that the pure  process of M. Strohmeyer, hav-
 ing as yet been performed only on the dead body, is incomplete and but
 imperfectly described, still the improvement upon  this by M. Dieffenbach
 is now  the fundamental process.
   A. Whether the erignes and the forceps should be applied in this or
 that place, or manner, either according to M. Lucas, Strohmeyer, or M.
 Ferral, is a matter  of little importance.
   B. Whether the erigne  should  be single  or double,  placed  near  the
 cornea  or the  caruncle, is equally unimportant.
   C. Those who, like MM. Yerhaeghe, Cunier,  Simonin, Andrieux, and
 others,  fix the crotchets  (hooks) of the erigne into the  sclerotica, have,
 M. Yelpeau thinks, the  advantage, while producing no serious wound,
 of holding  the globe more steadily, than when the anterior erigne is in-
 serted into the conjunctiva only.
   D. M. Liston's forceps to depress the  lower eyelid, is only applicable
 where assistants or a convenient dilatator are wanting.
   E. In a very docile patient, the fingers of  the assistants are  sufficient
 to keep the  eyelids  apart.   The two-branched depressor of Dieffenbach,
 the elevator of Pellier, and some other instruments of  the cutler  Char-
 riere, (at Paris,) are, however, less embarrassing, and  enable  us  to act
 with more  freedom and  certainty.  The hooks extolled by M. Cunier,
 for  separating the lids  at the  angle where  the operation is to be per-
 formed, might sometimes be of advantage.  The  specula both of Lusardi
 and M. Cunier are  no longer in use.  M. Yelpeau again  gives a decid-
 ed preference  to the blephareirgon of M. Snowden, but  says the mode
 of applying it upon, or outside of the lids, is not as secure, or  attended
 with as little pain, as under the lids.
   F.   M. Yelpeau  sees no advantage in the recumbent posture of  the
 patient, as enjoined by MM. Guerin and Sedillot; and  thinks also, in
 opposition to M. Guerin, that the operator should stand up, and not be
 seated.
*   G.   M. Yelpeau prefers the toothed forceps  of M. Lucien  Boyer to
 the erignes, because they fix the eye and tissues,  &c. more steadfastly,
 and expose less to a laceration of the parts.
   H.  M. Yelpeau, being desirous of embracing in om grasp  both the
 conjunctiva and tendon of the muscle with one forceps, and the conjunc-
 tiva and body of the muscle itself with the other, found  that he required
 forceps almost as strong as a dissecting  forceps, and having one or two
 solid teeth at their points.  He has no doubt that they  will one day en- 
STRABISMUS.
521
tirely supersede the  erignes.  MM. Bonnet, Dafresse, Boinet, and Da-
viers, have already adopted them.
  I.  The incision of the conjunctiva may be made with a cataract-
knife, as is done by Strohmeyer and Dieffenbach, and the English sur-
geons, or by any small scalpel  or bistoury that is  at hand.   But  the
blunt scissors are best for this, and  also for the ulterior, dissection of
the tissues.
  J. The isolation of the muscle is as practicable with a small blunt-
pointed  knife, the extremity of a  pair of small scissors, or  a curved
probe, as with Dieffenbach's  hook.  M. Boyer's  forceps to raise  the
muscle first before cutting it, is superfluous.
  K. The division of the muscle  may be readily  made with a cataract
needle,  any kind of bistoury, small concave  knives, the  little rondache
of M. Bonnet, the crotchet of M. Andrieux, the cutting-probe, the bis-
toury of Dieffenbach, or the small serpette which I used in the beginning,
with a botton to it like  that of M. Yan Steenkiste, revived by M. Dou-
bovitski.  The small  blunt-pointed scissors is, however, most secure and
most handy.
   L. The erigne slightly blunted, to grasp the muscle  through the con-
 junctiva, and bring it forward like a loop, causes  more  blood  than the
claw-forceps.
   M. The erigne-bisloury proposed by M. Andrieux, and having a sort
of cutting-hook  on its concavity, though  it might  sometimes divide the
conjunctiva and muscle with  one stroke, exposes to the risk of wounding
the eye, is moved  with less freedom in destroying the bridles, and may
leave some of the  fleshy fasciculi undivided.
   N. From all this discussion it follows:
   1. That a  surgeon  should follow his own taste and practice.
   2. That the whole  matter in this business is reduced to a trifling con-
sideration, either way.
   3. That the choice of the mode, among so great a variety, is a matter
more of taste than necessity.
  4. That, in fine, the  process of M. Yelpeau is, as he conceives, the
most simple,  easy, and sure.

           Article Y.—Treatment after the Operation.

   In this we  must prevent or  subdue the  accidents,  and endeavor to
establish a sound direction to the eye.
   Practitioners  have gone to two extremes; either totally abandoning
their patients, or pursuing too rigid a regimen.
   In the great majority of cases, the mildest kind of precautions are all
that is necessary.
   For the first two days, lotions with cold or warm  water, according to
the  season, &c,  are all that is  requisite.   They may  be  made  more
emollient with lettuce, plantain, &c, if desired.  Alum water, as advised
by M. Dufresse, may do at a later period.   Linen kept on the eye, and
wet every few minutes, as M. Yerhaeghe advises, is useless.  Foot-baths
nightly, and  made stimulating or not, as M. Simonin advises, are unne-
cessary, except  there should be severe cephalalgia, or symptoms of con-
gestion in the head.  Tepid  emollient lotions are properly substituted
   Yol.  I                  66 
522
NEW ELEMENTS  OF OPERATIVE SURGERY.
 for plain  water, after  the second  day.   Leeches to the temples, behind
 the ears, or to the anus, or  general  bleeding, are rarely  required.  So
 of laxatives, purgatives, injections, and  debilitating diet and  regimen.
 The inflammation at  the wound is a simple conjunctivitis, extending to
 the cellular tissue there, but rarely to the cornea.
  The swelling, engorgement, and inflammation of the wounded tissues,
 are generally at their height on the third or fourth day.   Resolvents
 arc then better than emollients.   Lead water, a weak solution of nitrate
 of silver, &c, are, in the opinion of M. Yelpeau, of less efficacy than a
 collyrium  made with a weak solution of sulphate of zinc in lettuce-water
 and mucilage ; thus :—

          Eau de laitue )                  nn
          — debleuetj   •  •  •  •   aa. 60 grammes.
          Sulfate de zinc.....20 centigrammes.
          Mucilage de psyllium  .... 3 grammes.

  The eye being  frequently cleansed during the day with warm water,
 some  few  drops of the above are let to fall into its angle, morning and
 evening.  In ten  to twenty days all further treatment may generally be
 dispensed  with.
  In most patients the eyes  should be left uncovered, and exposed to the
 air.   The patient, however, should not use them until after three or four
 days,  and  then with caution.  He should  also avoid every imprudence,
 all fatigue, &c.   In many cases no precaution  is required, and  the pa-
 tient resumes his  usual pursuits.  Covering the diseased eye, or hinder-
ing  its  movements, would  be apt to  irritate and  inflame the wound.
Motion has also the advantage of maintaining the pliancy of the tissues,
 and of preventing too close an adhesion  of the divided lamellae to the
 sclerotica.
  The covering of the sound eye is useful only where the  one operated
upon still slightly deviates.  In forcing  the Tatter  alone to receive the
impressions  of light, it is compelled to maintain its proper position in
the centre of the  orbit, and is much more  comfortable  under the action
 of the three muscles remaining, than under  the pressure of compresses
 and bandage.

          Article VI.—Consequences of the Operation.

  The consequences are either immediate or remote.  Among the first are •
the incomplete restoration of the eye to its natural position, or its devi-
ation to an opposite direction, immediately after the section of the mus-
cle; chemosis, and symptoms of phlegmonous inflammation in the orbit,
or the lids ;  a vegetation, to greater or less extent,  at the bottom of the
wound ; fever, and certain disturbances in the gastro-intestinal functions.
Among  the  consecutive accidents, are:  the return of the disease:  a
strabismus the reverse  of that which has  been removed ;  deviation of
the eye upward or downward ; exophthalmia ;  the separation, or flaring
 open  of the  eyelids ;  the  unequal motion of the  eyes; diploDV  for
 double vision,) &c.                                       r  vj* \ 
STRABISMUS.
523
                   § I.—Incomplete  Restoration.

  This occurs more frequently in divergent than convergent strabismus.
M. Phillips is in error in saying that this is always owing to an incom-
plete division of the retracted muscle.   The smallest bridle, fibrous, cellu-
lar, or muscular, will effectually retain the eye in a morbid direction, which
M.  Velpeau believes to  have been the cause of the great proportion of
failures in the first trials at  Paris ;  but, even since the practice of freely
incising the tissues has  come into use, and the proof has been  given that
the aponeurotic lamellae, which go from one muscle to another, are suffi-
cient to keep up the strabismus, he has, nevertheless, seen this accident
supervene, and that, too, though he had  convinced himself, by means of
the blunt hook and the blunt point of a small scissors, that  every thing
had been divided on the strabismus side  of the eye, and though more
than one-third of the sclerotica had been perfectly  denuded back to the
optic nerve.
   As to the question now of dividing another muscle, the great oblique,
for example, in convergent strabismus, M. Velpeau is possessed of no
authentic evidence in favor of  this section, and on this  subject inclines
more to the opinion of  MM. Bonnet  and Phillips, than  to that of MM.
Yerhaeghe, Kuh, (Ann. d'Ocul., t. vii., p. 44,) and Gairal, (Mem.  sur
le Strab., 1840,) and certain itinerant  operators.   M.  Velpeau, where
he has deemed it advisable to proceed farther with the operation, has con-
fined himself to dividing the border  of  the superior and inferior recti
muscles.
   The difficulty he explains in  two ways :—
   1.  By the fact that the superior and inferior recti  muscles  each form
a small riband of about two fifths of an inch in breadth.  Two millimetres
only  of this  width,  represent the  antero-posterior axis  of the eye.
The remainder necessarily exists outside and inside of this median part.
Is it not probable that  the inner bundle of fibres, having become iden-
tified with the rectus muscle, may be sometimes found contracted in that
part, to the degree, in that case, of partially keeping up the  deformity,
though  the muscle which has been the essential source of the deviation,
has been completely divided ?
  In  support of this, he adduces  a  considerable  number  of cases, in
which the eye was not effectually restored to its straight  direction, until
after the division of the inner third or half of the superior and inferior
recti  muscles.
   2. A circumstance which  has hitherto been overlooked, is the small-
ness of the space which separates the  root of the  optic nerve from the
cornea on the inner side.  It is, in fact, easy to show, (vide Cunier, Myot.
 Ocul., etc. p. 49, fig. A.,) that a line which  would directly prolong the
optic nerve, through the globe of the eye in front, would leave much more
of the sclerotica outside than upon the side towards the nose.   May it
not therefore  result from this, that this space being naturally less, may be
still further diminished  from imperfect development, in individuals whose
strabismus has been of  long standing ?   The external rectus  muscle, in
such cases, being necessarily much longer  than the  internal, would  ex-
haust its power of retraction before  having  brought the cornea to the 
524            NEW  ELEMENTS OF  OPERATIVE SURGERY.

centre of the orbit, and would be incapable of bringing the eye freely to
the outer commissure of the. lids.   (M.  Marchal  communicated to M.
Yelpeau an explanation of the persistence of the deviation, founded on
the nature of strabismus itself, namely, that it is the result of a spasmo-
dic contraction, and not that of a contraction with shortening.   Thus,
in most of the cases, the division of the muscle modifies the nervous con
dition, and the  spasm ceases.  In others,  the spasm remains, and repro-
duces its effect  as soon as the adhesion of the posterior end to the scle-
rotica has taken place.   This explanation is deserving of attention.)
   But M. Yelpeau  remarks,  that in some cases (in convergent strabis-
mus)  the eye will still continue to be turned  slightly inward, even after
the above  divisions he has recommended have been superadded to the
others—excepting from this remark, unnatural adhesions, cicatrices, and
paralysis.
   M.  Velpeau cautions practitioners in these cases  against too extensive
a denudation of the eye at first;  they would incur the risk of a divergent
strabismus, flaring of the eyelids, or an exophthalmia, to remedy an in-
convenience which sometimes disappears of itself, and which may be at-
tacked in another manner.  In five cases, he saw the  eye, which obsti-
nately retained a  degree of convergence during the  operation  or the
next day, perfectly restored to a correct position  in four or five  days.
He explains this, in  some cases, by a certain spasmodic action in the
muscles, excited by the operation itself;  in others,  the rectification has
been unquestionably caused by the tumefaction of the cellular tissue and
conjunctiva, in pressing from within outward and  against the globe of
the eye, in consequence of the resistance opposed to this tumefaction on
the side of the  orbit.
   M. Velpeau advises, therefore, to  keep the sound  eye perfectly covered
and at  rest, and to have the inner  half of the glass of the spectacles to
be used over the diseased eye, made opaque.   A certain species of com-
pression, however, and certain kinds  of permanent tractions exercised
upon the eye, are the  most efficacious.

                          A. Compression.

   To  effect this he uses small balls of lint,  or pieces of agaric or mild
plaster, collected together in  form of a cone, and made to press directly
on the  extremity of  the  eyelids, at the inner angle of the eye, where
they are firmly fastened by diagonal arcs of diachylon plaster, or turns
of bandage properly  applied.  This dressing, when properly arranged,
produces a compression which prevents the eye from turning towards the
root of the nose.   To  do this, it  is not necessary to compress the eye
itself, which in  fact it is important to guard against.  We must make of
the dressing  a sort of dike,  in the  form of affixed  body, making resist-
ance against the inner side of the orbit.
   M. Velpeau speaks  in complimentary terms of the neat manner of ap-
plying this dressing, by a young  pupil  of medicine,  M. Gouraincourt.
It may be left on for eight days, and need not be changed, unless it becomes
displaced or  produces inconvenience.   If badly put  on, it may cause
tumefaction and inflammation of the conjunctiva  and lids  and of the
vascular tissues of the orbit.  In one  case, it thus produced phlegmon- 
STRABISMUS.
525
ous erysipelas  of the face, a  most violent conjunctivitis with chemosis,
and finally, purulent suppuration of the cornea.'  In this patient, too, the
strabismus was divergent, with partial  paralysis of the upper lid, and
incipient paralysis of the three remaining recti muscles.
  B.  A  noose  of thread passing through the conjunctiva, or the root of
the divided muscle, naturally suggested itself to effect tractions upon the
globe.   This mode, which originated with M.  Dieffenbach,  and was
brought to Paris by M. Phillips, has been used by M. Yelpeau with suc-
cess.   Thus, in internal strabismus :
  1.  He  seizes with his claw-forceps a fold of the conjunctiva, and of
its  cellulo-fibrous lining, near the cornea, and  passes through it a fine
needle armed  with  a double thread, which he immediately forms  into a
noose.   This is  attached to the cap, or elsewhere near the ear, in such
manner  as to  keep the eye fixed as near to the temporal angle of the
orbit as  may be desirable.
  2.  Or, having  in the  same manner passed the thread through the root
of the divided  tendons  or as many of the lamellae of the tissues remain-
ing on the sclerotica as possible, the noose is fastened under and outside
of the chin, or to the eyebrow above.  If it were made to pass over the
surface of the cornea, it would chafe it, or ultimately  render it opaque.
To avoid this, we must place small pieces of linen or agaric, or a rouleau
of lint or diachalon, on some point of the circumference of the orbit, to
serve as a fixed pulley.
  With  care, the difficulty of maintaining an equal degree of traction
all  the time, is  overcome, and  this  need not be continued over two to
five days, as the thread usually, by that period, cuts through the includ-
ed tissues.
  The same rules apply, in a converse sense, to divergent strabismus.
If this mode prove unsuccessful in either form of the  disease,  all other
treatment must be renounced, and  then the question arises as to a second
operation.

             § II.— The Eye turned too much Outward.

  Because the  eye, upon the day after  the operation for convergent
strabismus, may slightly diverge outwardly, this is no reason for the im-
mediate  division  of the rectus externus.  In some cases, I have  seen
this soon disappear without any treatment:  nor is compression, though
applicable in divergent strabismus, as efficacious here as for preventing
the convergence  of the eye ;  but, on the other hand, the  application  of
the thread is more easy and effectual, and the opposite  side of the bridge
of the nose furnishes an excellent  point of attachment for the noose.

            §  HI.— Other Accidents from the Operation.

  The laceration of the eye by eringes and hooks, and plunging a knife
by  mistake  into the globe, with  other  mal-practices  of  operators are
no  argument against the use  of  the proper remedies.  Thus therefore
these, and also wounds  of the cornea, perforation of the  sclerotica he-
morrhages, neuralgia, (Dufresse, p. 65,)  etc., do not properly constitute
any of the accidents of the operation for strabismus. 
",26           NEW ELEMENTS OF OPERATIVE SURGERY.
                        § IV.—Inflammation.

   The inflammation is generally slight, or is characterized by a tumefac-
 tion which is confined to the inner half of the eye and to the lips of the
 wound ; and, though  it may take on the appearance of an irregular gray-
 ish and then red mammellated fungous plate at the inner commissure of
 the lids, is of little consequence, causes but little pain,  and seldom  any
 general reaction.  This projection soon disappears, and  cicatrizes under
 the proper treatment  already recommended.
   When the patient has  committed imprudences, the inflammation  may
 proceed to the formation of a complete chemosis, with cephalalgia, febrile
 reaction, intestinal disturbances, etc.   As the cornea may become impli-
 cated, bleedings, leeches, purgatives, etc., may then be required.

                § V.—Polypus in the Inner Angle.

   This is the reddish  tumor at the bottom of the wound,  as described by
 M. Verhaege, (p. 53,) and since,  by all others who have  adopted the
 method of dissection  of the tissues.  This which  at first, is a simple
 vegetation of the character of fungosities, assumes  afterwards the  ap-
 pearance  and consistence of a small mucous  polypus,  similar to those
 sometimes seen, under other circumstances, on the inner surface of the
 lids, or at the internal angle of the eye.  It is rarely observable until
 after the eighth  or twelfth day, and does not  become isolated from the
 sclerotica, and pediculated at its root, till at a later period.
   It has no other inconvenience than keeping up a slight degree of  pu-
 rulent discharge, conjunctivitis, and blepharitis, which blear the  eye and
 prevent it from assuming its natural color and  normal movements.  It
varies from the size  of a currant-seed, to that of a pea or small nut,
 and has the appearance of a cherry,  or strawberry, in the corner of the
eye.   It took place in two thirds  of  the cases upon which  M. Velpeau
had operated.  It is rare after the operation for external strabismus, or
the section  of the  superior and inferior rectus and oblique muscles.
 The  section of the internal rectus  is the only  one, almost, that pro-
 duces it.  It does  not originate from  the anterior extremity of the di-
vided muscle, nor  from  the conjunctiva, because it has  been formed in
 some, where M. Velpeau  has with the greatest care excised the conjunc-
tiva close up to the cornea; and in others, where, after  the division of
the rectus muscle, and after scraping the sclerotica as much as possible,
he has removed the tendon  of  the muscle.   In fact, the pedicle of  the
vegetation is farther back than the cut end of the  muscle in question,
 or than the conjunctiva.
   The process by which this polypous vegetation is formed, he explains
 thus :—The lamellar  cellular tissue which lines the sclerotica, vascula-
 rizes and softens a little,  at the same time that the divided  edges of the
 conjunctiva  and  aponeuroses are becoming tumefied.   The cicatrization
 proceeds from the  circumference towards  the  centre of the traumatic
 surface.   The contact of the lids,  which  makes  permanent  compression
 on a great portion  of this wound, leaves the vicinity of the  caruncula
 lachrymalist intact.   The continual  movements of the  eye thus crowd 
STRABISMUS.
527
all the vascularizable  portion of the cellular tissues behind the straight
portion of the free border of the lids, and thus forms the polypus.
   This tumor, though frequently observed in the cases operated  upon
by MM. Dieffenbach, Verhaege, Phillips, Dufresse, and  all others, who
practise the method of  dissection, is, however, a circumstance of little
importance.  Even if left to itself, it will disappear sometimes without
any treatment, only that it may then last for  several months.  It may
be arrested and destroyed even before it is pediculated, by touching it
lightly with the nitrate of silver crayon three or four times a day  for
the space of ten days.   The better way is to let it pediculate  perfectly,
and not to touch it under three weeks or a month.  It is then removed
with the greatest ease, and without pain, by a pair of blunt scissors, the
patient turning his eye outward.    Nothing more is necessary.  In
the first cases, it returned two or three times, because  they  undertook
its excision  before it was properly  pediculated.  To retard its growth,
all that is necessary in the first eight or ten days, especially where it is
in the form of a small cone, is to touch it with the lapis infernalis ; or
, with astringent collyria, if the patient is intractable or timid ; finally,
to excise it with the scissors,  from the fifteenth  to the thirtieth day.
There is no need of a hook or erigne, to raise  it up first, as  the  blade
of the scissors  sufficed  for that.  Cauterizing the root afterwards, is
also unnecessary.

          Article  VII.—Imconveniences of  the Operation.

   Besides diplopy, an abnormal separation of the  lids, exophthalmia,
and alterations in  the mobility of the eye,  as already mentioned, the
operation may also cause a shrinking or absorption of the  caruncula
lachrymalis.

                   § I.—Diplopy, (Double  Vision.)

   Double vision is readily  accounted for in those who squint, because
the axes of the globes cross each other at an angle more or less  acute,
instead of being parallel; but why this should continue to  exist,  imme-
diately and for some time after the operation, and when the eye has
been righted in its position, has not been explained.   Some inpute it to
the eye being yet unaccustomed to its new functions.  Most frequently,
it lasts during the  first eight to fifteen days, and  entirely disappears
before the end of a  month.  In one case only, of. a man aged fifty, in
whom the rectus internus and externus were divided in both eyes, and
the internus again for the return of convergent strabismus in the right
 eye, the double vision obstinately continued, though the strabismus was
 removed.

                    § II.—Separation of the Eyelids.

   Though mentioned by MM. Phillips, Lenoir, and Dufresse, this flaring
open of the lids has not been seen by M. Velpeau, in his own  cases, ex-
cept as connected  with  exophthalmia.  In those  of others, he has seen
it.  Where it exists in both eyes, where both have been operated  upon,
it is of no  consequence ; but if in one eye only, it makes a deformity, 
028
NEW ELEMENTS OF OPERATIVE SURGERY.
and the cause always is too extensive a dissection of the sub-conjunctival
aponeuroses,  and different lamellae  which  unite  the  lids  to  the eye.
M. Yelpeau suggests, that the reason why he has not  observed it in his
cases, may be because he is in the habit of incising the  conjunctiva much
nearer the cornea than the caruncula, whereas the reverse is the practice
of M. Phillips and others.  The treatment of compression on the whole
front  of the orbit, as recommended  by Dufresse, is of no  use; and the
suture, as some suggest, makes a worse deformity.

                       § III.—Exophthalmia.

  The projection of the globe is a serious  deformity.   In a young man
operated upon some months  before, by M. Baudens, it  seemed  to M.
Yelpeau as if the ball was double its natural size, and had started  out
of the head.   A sort of buphthalmia, he says, is  thus sometimes pro-
duced.
  He has seen it in his own cases, only in those where several of the mus-
cles had to be divided ; as  in a woman aged  fifty-two, with convergent
strabismus  in  both eyes from  infancy, and  in whom the internal, supe-
rior and inferior recti muscles in both eyes had to be divided, before the
eyes were restored to their position.   However, the appearance of both
eyes is uniform, which is  one thing gained over their previous condition.
So in two  other  similar  cases, in one  of which, a fat  subject,  the eyes,
naturally protuberant, were made excessively disagreeable by the opera
tion.   He never  saw it on  one side only, in two or three  cases.  In no
case of his was this exophthalmia ever perceptible, where only  one mus-
cle was divided, or the neighboring  fibro-cellular tissues  also with it,
except in a very slight degree.
  Unfortunately, it is without a remedy.  In some cases,  perhaps, early
compression, and before  the divided ends of the muscles have formed
adhesions,  might possibly  succeed.   He has  great doubts of any ad-
vantage from the kind of  palpebral  suture advised by MM. Rognetta,
Guerin, (Cunier, Premier  Suppl., Annal d' Ocul., p. 310,) and others,
or as practised  by M. Cunier, after  excision of the conjunctiva at the
angle of the eye, (Suppl., p.  311.)

              § IV.—Immobility and Fixity of the Eye.

   The eyes arc  often affected, after  the  operation, with a certain re-
 straint, irregularity, and  inequality  in  their  movements.   However
 strange, as remarked by  M. Velpeau, it might seem, a priori, yet he has
 established, that in some cases an obliquity still continues  inwards, (in
 convergent strabismus,)  even where the rectus internus, and  the fibro-
 cellular tissues uniting it to the superior and inferior recti muscles, have
 been thoroughly  divided.  This he noticed especially in very old cases,
  and he considers the cause to be this: that the  inner portions  of the su-
  perior and inferior  recti muscles, participating in the reaction  of the
  rectus internus, act  in such manner as to take  the place of the divided
  muscle, and thus keep up  the deviation.   It i3, however, rare in cases
  of but a few years standing, and in some cases it is impossible.
    In some cases, where it is not observable immediately after the  opera- 
STRABISMUS.                         529
tion, the divided muscle will ultimately regain its power upon the globe,
through the intervention of the fibro-cellular tissues, and will not fail
to establish it.   After a month or  two, he has seen almost all his pa-
tients enabled to move the eye in all  directions as before the operation,
but this complete mobility of the eye is, nevertheless, often wanting.
  Where M. Velpeau has been compelled to cut several muscles, and to
make extensive denudation of the globe, the  eye has sometimes become
steadily fixed in the middle of the orbit, without  the possibility of mak-
ing it pass within the antero-posterior line.   And in some, in  whom  he
divided the internal and external recti muscles, this  position in the cen-
tre of the orbit was immovable,  and could not be altered either inward
or outward.
  Where it is excessive in both  eyes, it gives  a haggard look to the vis-
age, and the patient has to turn his head like a statue, or image, to see
sidewise.   Though it be in one eye only, it is still a repulsive deformity
to have one ball turning freely  and naturally, while the  other is fixed.
This last deformity, to a certain degree, is almost inseparable  from the
operation ; as the new attachments must be more or less approximated
to the cornea, or deviated  more or less upward or downward, owing to
the  different degrees  of movement in the eye, the volume, force of re-
traction, and special contractility  of the divided muscle, and the degree
of relaxation or inflammation of the cellulo-fibrous lamellae which recon-
nect them with  the cornea;  all which are beyond the control of the
surgeon.
   In most cases this  deformity is not perceptible.   Where one muscle
only is  divided, it is generally slight,  and  almost always disappears  W
entirely.  After the  section of  two or three  muscles, on the  contrary,
it is in general very marked; and often complicated with exophthalmia,
flaring open of the eyelids, and new deviations of the organ.
   To attempt to reach and detach the divided muscle, in order to attach
it on another part of the sclerotica, as has been proposed, would be too
difficult and dangerous, and probably do more harm than good.
   Preventive measures, therefore, during the operation, are all that can
be relied  upon, and those M. Velpeau has been in the habit of employ-
ing, are:  1. Not to liberate or  detach the aponeurosis above and below
the  divided muscle, but to  the extent absolutely required;  2.  To allow
only slight movements to the eye during the first days, and should im-
 mobility be apprehended, to  prevent it, by covering it, from  moving in
 the direction opposite to that of the divided muscle.
   Time will 'often do much, in these  patients, in restoring the organ to
 its natural state.

            § V.—Alteration of the  Caruncula Lachrymalis.

   When the caruncula disappears after the operation the eye appears
 much larger on one side than the other, and is extensively denuded of
 the conjunctiva in one direction, and covered entirely by it in the other.
 The internal angle of one of the orbits, is thus also made much deeper
 than the  other, causing a hideous deformity.
   M. Velpeau thinks  he has noticed it at Paris, more frequently in pa-
 tients that had been operated  upon by MM. Phillips, Amussat, and L.
   Vol. I.                   67 
530
NEW ELEMENTS OF OPERATIVE SURGERY.
Boyer ; and more frequently still, in those who had been under the hands
of M. Baudens.  Having  seen  it but very seldom in his own cases, he
imputes it to the process of Strohmeyer, as adopted by MM. Phillips,
Amussat, and  others.  While  M. Simonin, and the  English  surgeona
who adopt M. Yelpeau's mode of incising the conjunctiva, at a very
considerable distance forward of the caruncula, make no mention of it.
  M.  L. Boyer proposes, as a preventive, to  incise the conjunctiva both
above and below the muscle, and  to divide this latter behind  the tegu-
mentary membrane, as under a bridge, so as  to leave this bridge or
bridle  untouched in its whole  extent, from the root of the nose to the
neighborhood of the  circumference of the cornea.
  M.  Guerin ascribes the absence of all deformity of the caruncula, in
his cases, to his process of operating.
  M.  Velpeau, in conclusion, says, that when the conjunctiva is grasped
over the tendon of the muscle by one of the forceps, while we take care
to force this membrane inwardly with the other forceps, it is divided at
a point so remote that the caruncula is not  touched by the operation,
and there remains afterwards but a very trifling depression in the angle
of the orbit.   He therefore thinks, that the  suture of M. Cunier, and
the precautions of MM. Guerin and Boyer, are alike unnecessary.

    Article VIII.—State  of the Parts after  the Operation.

  Three opinions have been entertained on  this subject: 1. That the
body of the shortened muscle being approximated to its deep attachment,
became fixed and contracted new adhesions, and was transformed, at its
free portion, into a new tendon, which  would attach itself to a part of
the sclerotica more  or less distant; 2. That  a  new tissue would be
formed  between the two ends of the division, so as to re-establish the
continuity,  at the same  time giving it a  greater length ; 3. M. Phillips,
among  others, (Tenotomie sous-cutanie, etc.,) adopting the idea of M.
Strohmeyer, maintains that after the  operation, the muscle, no longer
undergoing retraction by the spasm, is enabled, by a kind of elongation,
to become  fixed near  its former attachments.  None of these opinions
are positively  true, and that of M. Strohmeyer ( Yerhaeghe, p. 49 and
50) must be pronounced from inadvertence.
  An examination of the orbit after death, has shown that each muscle,
when once  divided, retracts more and more backward for a week or two;
that the cellulo-fibrous lamina? or aponeuroses which line its surfaces,
approximating and  hardening as they  become thicker, assume by de-
grees the form of a riband or small flattened  tendon, which, inserting
itself upon the sclerotica  near the extremity of the transverse diameter
of the eye, is continuous in front with the sub-conjunctival aponeurosis,
that  ultimately  becomes  partially re-established, and behind with the
aponeurosis of the eye, properly so called.   This kind of new tendon
does  not reach to the situation of the former one, but the lamellae which
compose it, in other  respects are arranged at a short distance from the
cornea, in the same manner as were the  aponeurotic layers of the primi-
tive  muscular  sheath.  This is what M. Velpeau saw in three subjects,
also in the cases that M. Bouvier  exhibited to the Academy, as well as
in some others whose details have been  published in England. 
strabismus.
531
  We have thus the  explanation of the variety, force, and re-establish-
ment of the  motions of the eye, where  the operation has not begn fol-
lowed by any unpleasant consequences.
  It sometimes, however, happens  otherwise.   Where the inflammation
has been very active, and the muscle has become too quickly reattached
to the globe of the eye, it is  possible that an  immediate reunion may
take place between its recently divided fleshy extremity, and the cellular
tissue which belongs to the sclerotica.   M. Velpeau had two patients, in
whom the wound completely reunited in twenty-four hours, and whom
he operated upon a second time at the end of eight days.   In a case of
M. Lenoir, dissected two months after the operation, the rectus internus
muscle  which  had  been divided,  adhered to the sclerotica by its fleshy
substance, and not by a flattened  tendon, in  the  manner the three other
recti and  the  two oblique muscles were attached to it.  There had also
been, in this  case, a return  of the disease.  The nerves, vessels, and
other connections of the eye, undergo no change.

                 Article IX«—Counter-Indications.

   Some of these appear to me not well founded.  M. Cunier, for exam-
ple, who at first approved of the operation only  in permanent strabismus,
(Myot. Ocul., etc., p. 39,) has abandoned this opinion.

                      § I.— Optical Strabismus.

   A natural,  though not a real distinction,  has been proposed, of mus-
cular and optical strabismus.   There are persons in whom the eye devi-
ates, because  the rays of light cannot any longer  reach the retina on
their natural axis ; as happens from  spots or cicatrices upon the cornea
masking the sight, and  obliging  the eye to deviate in the direction of
the blemish, in order  to bring the pupil as much as possible in a line
with the light; so also, when from disease  or  lesion of some kind, the
pupil is approximated to the circumference  of the iris.   To these forms
we may apply the title which M. Guerin  gives them, of optical strabismus.
   For  these,  it was contended, no operation should be performed—1.
Because the deviation is an advantage; 2. Because the eye would reas-
 sume this deviation after the operation.  It  is  false, that  strabismus
must necessarily bo produced by the above causes.  I have seen hun-
 dreds of persons, as all physicians can daily  attest of their own, who
 have for years had albugo, leucoma, and various kinds of opacity of the
 cornea, covering a quarter, a third, two-thirds, and even four-fifths of
 the pupil, and whose eyes, nevertheless, were perfectly straight.  So
 with those who have the pupil on one side,  whether from the operation
 of cataract, or artificial pupil, or from accident or  disease.   I have
 operated upon a considerable  number  of subjects, in whom the  cornea
 was in the  condition I have  described, and the restoration of the  eye
 has been as perfect as in others.   The  operation, in them, has been at-
 tended with no  particular  difficulty  or embarrassments, or any serious
 consequence or tendency to a return, that I  have not met with in others.
   The only question that could  arise in such  cases, is whether the im-
provement of  the sight, from the  deviation of  the eye, compensates for 
532            new elements of operative surgery.

the inconvenience of the strabismus ?  This must be  decided by the
patient.  The deviations, in fact, are but a slight advantage, while the
strabismus is a serious deformity.  Optical strabismus, therefore, should
not be considered a counter-indication.

                     § II.—Fixed Strabismus.

  In many cases, where the eye would  appear to be permanently  fixed
in its morbid position, it is found  to possess all its motions on closing
the sound eye.   There are, however, some in which the globe is stead-
fastly  maintained in its false direction, and  in which  even mechanical
means of traction cannot force it into  a central position  between the
lids.   Cases  of this kind  may arise from paralysis  of some of the mus-
cles, and unnatural  adhesions between the sclerotica and corresponding
wall of the orbit.

                § III.—Strabismus with Adhesion.
                                       •
  Strabismus complicated with adhesion, by M. Cunier  denominated
strabisme ankylosi, is not unfrequent.   M. Velpeau has seen  five  cases
of it.  It is caused, chiefly, by  former inflammations, wounds, and vari-
ous lesions of greater or  less  depth in  the  corresponding  angle of the
eye.  In one ca_e, an abscess which had been for a long time suppurat-
ing, was the cause; in another, it  was produced  by  a wound from a
ram-rod, between the eye and the caruncula lachrymalis; in a third, by
a wound from the point of a knife, in the same place ;  in a fourth case,
from shot lodged there by a musket; and in the fifth, it was ascertained
that there had been an  acute  inflammation in that part twenty  years
before.
  Although  these are the only  cases which, according to a rigid inter-
pretation  of M. Cunier's  principle, should be operated upon,  they are
precisely those which, in that  respect,  often present serious inconveni-
ences.  M. Velpeau operated upon all the above five cases, and in  three
of them the normal direction and  mobility of the eye were almost per-
fectly  restored.   In the  other  two  the deformity  was re-established.
In such cases, the muscles, fascia?, and  even conjunctiva, are sometimes
so blended  together, and so intimately  and  extensively united to the
sclerotica, that their dissection becomes very difficult, and their isolation,
in the manner it is effected in ordinary  cases, out of the question.   We
must expect, therefore, under these circumstances, great difficulties and
tedious painful  dissections, besides the tendency of the parts to become
readherent.   The cure is almost as uncertain as that of the attempt to
relieve deformities produced by cicatrices from burns  in other parts of
the body.   It is these cases that are adapted to such remedies as com-
pression in the angle of the eye, and other orthophthalmic  means.   Yet  ;  ;
fixed strabismus, by adhesion, is not absolutely a counter-indication.

                 § IV.—Strabismus with Paralysis.

   When the eyes are deviated by  defect of innervation, it would  natu-  ■  ■
rally  seem  impossible to  remedy the deformity by an operation.   But  ;  . 
strabismus.
533
there arc many kinds of paralysis.  Sometimes it is in the brain, when
nothing can be done : at other times, in one of the nerves going to the
orbit.  It may be the sixth pair, producing then convergent strabismus.
If it is the  third, or common  motive of the eye at its source, the  stra-
bismus is external, with complete immobility of the eye.  If only one of
the branches of this latter, the eye, though turned  outward, may still
move upward and downward, or inward, according to the muscles that
remain unaffected.
  For the most part, strabismus with paralysis is a counter  indication.
However, there may be established two  classes of this deformity: 1.
Complete paralysis  from some lesion of a part of the  brain, or of the
body of the nerve, and which lesion is still existing, in which case there
can be no operation.  The treatment for the paralysis is the only  indi-
cation.   2. When the paralysis is only partial, unaccompanied with any
lesion of the brain, and is ancient, and appears to be permanent, and
not to have varied for many years ; and where the eye still retains cer-
tain  movements  and oscillations in a direction opposite to that of the
deviation.   The  operation may then be performed, if the patient con-
sents ; and it is proper to inform him of the slight amcnduicnt only that
he may derive from it.   One of the first patients M. Velpeau operated
upon, (viz., in  September, 1840,)  had  a convergent strabismus  from
paralysis of the rectus-externus.   The eye was straightened, and could
perform  slight movements outward and  inward,  and  preserved  its nor-
mal power of elevation and depression.   He explains  this result by the
division  of the rectus-internus muscle, the  only one which  could givo
equilibrium to the externus, while the oblique muscles, acting in concert,
direct the eye a little outward, and the inner fibres of the superior and
inferior recti muscles come to the relief of  the divided muscle, as their
outer fibres do to the paralyzed muscle.   It was, no doubt,  M. Velpeau
says, from not taking into consideration this arrangement, that M. Cunier
(Myot. dans le Strab., etc., p. 87) censured  the operation for strabismus
in any case of paralysis.
   M. Velpeau  made trial of it again, in two patients  affected  with di-
vergent strabismus.  In one, the eye had lost its movement of adduction
only; the section of the rectus-externus restored the eye to the centre
of the orbit.  The movements on the inner  side were not  restored, and
there resulted  from this a kind of fixity in the organ.  Nevertheless,
the strabismus  was  destroyed, and the second deformity was infinitely
less repulsive than the first.
   The other case, though unfortunate in the end, was not the less con-
clusive.  The patient was fifty-nine years of age, and had been troubled
with distressing pains in the head for eight years, and with divergent
strabismus for four years, with a depression  of the upper eyelid from the
commencement, and an almost entire  paralysis of the rcctus-intcrnus,
and of the superior and inferior recti muscles, the eye, however, retain-
ing still  some slight motions upward and downward, and in the direction
of the axis of vision.  Anxious to be operated upon, M. Yelpeau, doubtful
of the result, as he told him, nevertheless assented. • On the division of
the rectus-externus, the eye regained its straight position without diffi-
culty ; but for fear of the deviation returning, the compressing bandago
already  mentioned  was applied.   This was made by a pupil of tho hos- 
534
new elements  of operative surgery.
 pital with so much force, and so directly upon the eye, that acute paina
 on the same day attacked the entire cavity of the orbit.   On the morn-
 ing after that, the upper eyelid  was found to be swollen, and affected
 with a diffused ophthalmia.  The inflamation reached the  cellular tissue,
 and a severe chemosis  supervened; a simple erysipelas  now  extended
 over the entire face, invaded the  head and neck, and in ten days return-
 ed to the face, and aggrayated the suppuration of the lid and the inflam-
 mation of the eye, which latter  also suppurated at the expiration of the
 third week.   As to the restoration of the position of the organ, it con-
 tinued perfect throughout; and  it is not probable the deviation would
 have been reproduced, if the accidents mentioned had  not supervened.
 In strabismus  with paralysis, therefore,  the operation is  not absolutely
 contra-indicated but  in certain  cases.   It allows, however, in general,
 only of a partial restoration of the position of the  eye, and a diminution
 of the deformity, but  not a perfect  re-establishment of the  motions of
 this organ.

                         § V.—Amaurosis.

   Many cases of strabismus have been mistaken for amaurosis.   In clos-
 ing the  sound eye, it is observed that the  patient sees  badly, or with
 difficulty, with the one deviated, and that the pupil of this latter is more
 or less dilated.  At  present it is well known that this is owing to de-
fective action  in the affected eye.  Nevertheless,  true  amaurosis does
 sometimes exist in cases of strabismus.   But in cases of strabismus with
amaurosis, either true or apparent, the operation is as likely to succeed
as in those who have  not lost their power of vision, because amaurosis
does not affect the muscular action of the eye.  But though  the amau-
rosis will not be  relieved, there is no reason, if one eye is sound, why
the mere deformity itself in the other should not be removed.   It would
not, however, be prudent, if the amaurosis  proceeds from disease in the
brain or optic  nerve, compromises the life of the patient,  or is  attended
 with an organic lesion still present.   Therefore, with these exceptions,
amaurosis is not a  contra-indication, but  in truth is frequently followed,
after the straightening of the eye, by an  improvement of  the faculty of
vision.
          § YI.— General Diseases—Tumors in the Orbit.

  Where there are bony, fibrous,  or cancerous tumors in the  interior of
the orbit, and the muscle is not concerned in the strabismus, the opera-
tion for this  latter is contra-indicated, or should be deferred.   So also
where there exists  acute inflammation of the brain or in the face, some
serious affection of the nose, mouth, or pharynx, erysipelas, an affection
of the respiratory  organs, or circulating  or digestive system.   So also
in pregnant women, and, in short, in every case where an accession of
febrile symptoms is apprehended.  But  an  affection  purely local, upon
the extremities, would not be a counter-indication.

                     § VII.—Age of the Patient.

  Though infants  and old persons ought, in the opinion  of some, to be 
STRABISMUS.                         535
considered exempt from the operation, it often succeeds as well in them
as in adults.   In infancy there is room to hope the disease may disap-
pear, and after sixty the  operation scarcely compensates  for the pain,
and there is also required a more extensive dissection of the tissues;
whereas, in infants, as there is less of this necessary, it succeeds  better
than in adults; and  in fact it may- be laid down as a rule, that the
younger the person is, the more successful the operation.   Convenience,
therefore, and not necessity, may induce us not to operate at ei.ther ex-
treme of life, though we should do so, even in patients far  advanced in
age, if they desire it.   In them the chance of success  would be as great
as in young subjects, if we took the  precaution of freely liberating the
connections of the retracted muscle.  M. Velpeau has operated with en-
tire  success in patients of fifty-two, fifty-five, and fifty-eight years of
age.  In  children he does  not  operate previous to the age of three or
four years.  In the first years of life, the causes of strabismus so often
appear and disappear at  intervals of  some months, that the  deformity
might, with the same facility, recur after an ope'ration.  But after the
fourth year, though the operation may be more troublesome  than at a
later  period, the child may be  then mastered, and delay would incur
the risk of giving a greater degree of permanency to the  deformity.

                     § VIII.—Double Strabismus.

   Sometimes,  both in convergent and  divergent  strabismus, both eyes
appear to squint, and the question arises whether both should  be  opera-
ted upon, and  at the same sitting ; while some contend that an  operation
on one eye is in such cases often sufficient, others, with some degree of
hardihood, advise both to  be operated upon, even  when one only is the
seat of the deformity.
   Where both eyes are affected alike, and to the same degree, M. Vel-
peau strongly recommends that both  should be operated upon  on the
same day.  The operation  then does not require so extensive a dissec-
tion  of the tissues as for one eye, and the patient recovers in half the
time.
   Where there is a marked difference in degree, and the  patieut has his
doubts if one eye is actually affected, the operation  should be confined
to the eye most deformed.   The other eye may be operated upon  imme-
diately  afterwards, if the deformity of the first is not at  all  changed ;
if it is, however,  we should wait from eight to ten or fifteen days before
operating on the other.  M. Velpeau has cured many cases of apparent-
ly double strabismus, by operating only on the most deformed eye.  The
other soon begins  to act in harmony with the  one that has been re-
stored.
   He  proscribes operating on the two eyes when one only is affected,
though that course, it would seem, is recommended by M.  Elliot, (Bri-
tish Se Foreign Med. Review, April, 1841,) M. Guerin, &c.

            Article  X.—Advantages of the Operation.

   These consist in restoring the position of the eyes, and improving the
vision. 
536            NEW elements  of operative surgery.
                 A. Restoring the Position of the Eyes.

    M. Yelpeau alludes to the heated controversy and  discourteous lan-
\ guage which characterized the schools of Paris in the first epoch of stra-
 ; bismus, inasmuch as the immediate  restoration of the eye to its normal
  position did not always ensure success, and that the deformity often re-
  turned  within a few weeks or months, (as in the twenty cases out of
  thirty operated upon  by M. Cunier.)   Those  who  were  cautious and
  prudent in making up their minds as  to the real  benefits of the  opera-
  tion, have been too often rudely denounced by its more violent and  un-
  scrupulous partisans.
    M. Burggrave mentions a case of his, in point, (Cunier, Myot.  Ocul.,
  p. 43,) of a  young girl, wherein he was warmly complimented for his
  brilliant success, for eight days after the operation, but in whom the dis-
  ease returned  on the ninth  as bad as ever!  So in a lady of rank,  six
  months  after  being operated upon (1840)  by M. Dieffenbach.  So in a
  case referred  to by M. Velpeau, who, in six months after he had been
  operated upon on both eyes by M. Guerin (January, 1841,) squinted as
  much as before.  M.  Velpeau having also observed, that in many persons
  whom he himself had operated upon in September, October, and Novem-
  ber, 1840, the strabismus, though the restoration for eight, fifteen, twenty,
  and even thirty days, appeared  perfect, returned as  before, saw the ne-
  cessity of  further experience before he could make up his mind  as to  the
  value of the operation.
   Eighteen months, and some thousands of cases, have afforded positive
 results.   The  cases  of return of  the disease are now only exceptions.
 Three explanatory circumstances may here be mentioned.

                    § I.—Illusion of the Operator.

   One cause  of deception  in strabismic cases is this:  that when the
 sound eye  is closed, the other often regains as  it were  a  perfect com-
 mand of its  functions, reassumes its normal position, and moves freely
 and correctly under the guidance of the will in all directions, and even
 sometimes as  it  were  unconsciously.  It is a mistake  to suppose that
 thep_  is any  parallelism in  strabismus in this  respect to club-foot,  for
Sample, where the retracted or  atrophied muscles and tendons present
 a physical impossibility to  extension by the will, or even  by  tractions.
 M. Velpeau  has  seen in strabismus cases  in the dead  subject where
 there had been no operation, that the deformed eye exhibited no per-
 ceptible alteration, either in the length or thickness of the fleshy or ten-
  dinous portions of the muscles,  in comparing them with  those  of other
  subjects in whom  the  eyes had  always been sound.  One of these was
  a man of thirty, who had had convergent strabismus in both eyes  from
 birth.  M.  Simonin (Du Strab., p. 10) thinks the muscles thicker, but
  others find them  thinner.   So in a case of a female  subject a°-ed  over
  eighty, who had had  strabismus  from infancy, and  in whose°orbit  as
  exhibited by M. Bouvier, it would have been impossible to have distin-
  guished the rectus-internus of the squint  eye from  the  corresponding
  muscle of the sound eye.                                      r      ° 
STRABISMUS.
537
  Many cases of apparent or supposed return of the disease, M. Velpeau
thinks, have arisen from the practice of covering the sound eye  during
the operation, when, as has been before remarked, the  deformed  eye
would, immediately after the operation, appear to have recovered all its
motions perfectly, whereas the muscle had not in reality, perhaps, been
entirely liberated.  So also the practice of covering the sound eye, after
the operation, which M. Velpeau says he himself was at first in the habit
of, for the same reason prolonged the deception ; though in fact  in this,
as in the other case, the disease had not in the beginning been effectually
operated upon.
  Taylor, the empiric, (mentioned in the first part  of this treatise,) ap-
pears to have availed himself of this, as Lecat distinctly says that oculist
was in the habit of covering the sound eye instantly after the operation,
and that the multitude thereupon cried out miracle  !

              §  II.—Incomplete Division  of the  Parts.

   An imperfect or partial section only of the  muscles, or too restricted
a liberation of the neighboring fibro-cellular lamellae, were, says M. Vel-
peau, the principal causes of the return of the disease in the  first cases
of  MM. Roux, Sedillot, Amussat, Guerin, and himself.   Confining  my-
self, says M. Velpeau, to seizing the muscle, and to stretching and divid-
ing it with the  serpette  by one stroke, I studiously  avoided  directing
the instrument to the bottom of the wound, and afterwards dividing  the
bridles which might have remained upon the  sclerotica, and enlarging,
both above  and  below the incision of the  aponeuroses, so much fear had
I of large wounds and extensive dissections in the orbit.   It is  certain,
he thinks, that in acting in this manner he must have  often left portions
of  muscle and resisting bridles, that were  quite sufficient to reproduce
the deviation.
   To  the  discovery of this error he  imputes the recommendation of
large  denudations, and the excision even of a part  of  the muscle by
MM.  Dieffenbach and Phillips.

              §  III.— Circumstances Difficult to Control.

   M. Velpeau differs from M. Bonnet in the opinion that the strabismus,
when  the eye is once fairly straightened, never returns.  M. Velpeau
 particularly specifies two  cases where it returned twice, and  even after
 he had  carefully divided  and even scraped and cleansed off from  the
 entire inner side of the sclerotica all muscular, tendinous, aponeurotic,
 or cellular bridles, from the inferior up to the superior rectus.
   In some, the  deviation has been so obstinate that, after all this dissec-
 tion, the eye was not restored but to one half  the distance from  its true
 position.  Thus, in a case of a young man aged twenty, at La Charite,
 (April, 1842,)  where M.  Velpeau  had thus in the  second operation de-
 nuded the sclerotica as far back as the optic nerve, and where the patient
 moved his eye freely in all directions; it turned  inward  again  towards
 the nose, twenty days after the operation.   M. Bonnet errs, also, in say-
 ing that the deformity will not return where the eye  has remained  straight
 for three weeks, for M. Velpeau has  seen  cases, though  rare, where it
   Vol. I.                   68 
538            NEW ELEMENTS OF OPERATIVE SURGERY.
returned, either to the inward or outward direction, two to four months
after the operation.
  If it is true that a new intermediate tissue is formed  between the di-
vided ends, it holds the place of tendon, and must consolidate, retract,
and  shorten, and  contract  more or less extensive  adhesions  with the
neighboring tissues for several months.
  M. Yelpeau sees no reason why the process of reorganization between
the eye and its connections  should  not be kept up at the  bottom of the
orbit, in some persons, a long time after the external cicatrization is com-
plete ;  although  M. Bonnet may or may not admit (p. 157, 158) that
this result can be possible.
  If one of the causes of the  return  of convergent  strabismus, that al-
ready mentioned, in very old cases, of the  short space  on the sclerotica
upon the same side as the internal rectus, even where that and its fibro-
cellular dependencies have all been divided, could be ascertained before-
hand, it would be better not to operate.
  This condition may also exist, perhaps,  where the difficulty appears
to arise from the bandelettes of the superior and inferior recti muscles,
whose  division, however, may  prevent a return.  But  such dissections
should not be undertaken without cause, as they might favor the projec-
tion  of the eye, exophthalmia, and the fixity of the organ.
  M. Velpeau says he has operated upon a number  of persons, who,
whether from primary or accidental causes, have had a singularly abnor-
mal arrangement of the muscles.  After having divided the  conjunctiva
opposite the lower edge of rectus-internus, for example, he has found that
the scissors glided with difficulty there upon the sclerotica.   Using then
the blunt hook, he has found the muscle adherent to the sclerotica as far
back as the posterior part of the eye, in place of being separated by the
usual lamellae of that region, so that it has been impossible to isolate it,
compelling him to divide the fibres, bundle by bundle, from the neighbor-
hood of the conjunctiva to as far back as the optic nerve, and  from the
inferior up to the  superior rectus.   Once he found a muscle with three
anterior divisions, as M. Phillips mentions to have seen frequently.  As
before remarked, these  close adhesions seem to have  been occasioned by
previous purulent inflammations, though in  two cases they had the char-
acters  of primitive organization.   Failure in cases  of  this kind  ought
not to surprise us.  For however free the division of the fleshy bundles,
they will recombine with the intervening tissues, readly readhere to the
sclerotica,  and re-establish the deformity.
   It may also happen, that from fear of pain, or ignorance, the eye will
be kept immovable for several days, or  the patient may persist in re-
taining it in its morbid direction.   The  divided tissues  then speedily
reunite by  first intention.
   In a young girl, aged nine years, with strongly convergent strabismus,
and  whom  M. Velpeau  operated upon with apparent perfect success, the
disease returned in three days, the reunion  of the divided tissues having
been so complete, that  there were  no visible traces in the angle of the
eye  either  of inflammation or wound.  Two days after he repeated the
operation,  kept a bandage over the  other  eye for a week, and the cure
this time was complete.
   In some cases the inflammation,  after the operation, being  too intense 
STRABISMUS.
539
produces in the tissues, which  contract new adhesions with the eye, too
great a degree of induration, then imperceptibly a retraction, which re-
produces the  primitive deformity to a greater or less extent.

                  § IV.—Return of the Deformity.

  Rigidly speaking, it is almost absolutely certain  that a return of the
disease may be prevented ; for where the surgeon is skilful and the pa-
tient resolute, a failure is  rare.  If the section of one muscle does not
suffice, we may proceed  to  the others, from one of the recti or both to
the oblique ;  or where the  division of the internal rectus causes diver-
gent strabismus,  we  can attack the external rectus,  and repeat  the
operations.  M. Velpeau, however, is adverse  to this repetition of the
operation, for such a course must favor the production of exophthalmia,
the flaring open of  the lids, the absorption of the  caruncula, the fixity
of the eye, or some other unusual alteration in its appearance.
   M. Velpeau then makes two divisions of cases : one,  of complete suc-
cess after the operation; the other, where thero is still  some defect left.

                      Cases of Complete Success.

   1. Those in which  the restoration is so perfect, that, unless they are
examined very near, no evidence is apparent that the individual has
ever had strabismus.
   2. Where  the eye preserves its mobility, and acts in harmony with the
other; where it is neither  more projecting nor flaring than the other;
and where the caruncula remains, and the look of the eye has nothing
peculiar.

                   Cases where a Defect Remains.

   1. Where the eye is usually straight, but at certain moments  slightly
deviates  in one direction or another, especially when the patient is ex-
cited.
   2. Where the eye can  only be partially turned in the direction of its
former deviation.
   3. Where  the  caruncle is flattened, the commissure of the eyelids
slightly separated, and the eye a little more prominent than  the  other,
and its look not perfectly steady.
   None  of these discordances, however, are perceptible but upon close
examination, and are nothing compared to the deformity before the ope-
ration.
   Out of three hundred cases operated upon by M. Velpeau, [by his last
computation when this brochure on strabismus was published,] half of
those who have followed the necessary precautions have been perfectly
restored in every respect.   A third part of the other  half came under
the  second class just mentioned, that is, there continued to be a slight de-
viation  above, downward,  outward, or  inward, or a slight degree of
fixity or projection, or discordance in the axis, or movements of the two
eyes, or  a perceptible alteration of the caruncle, or a certain undefinable
awkwardness in  the opening  or appearance  of the two lids.  The two 
540
NEW ELEMENTS  OF OPERATIVE  SURGERY.
other thirds  of this last half comprise the cases of actual failures—
namely, where  the  deviation  was in a direction opposite to the. first;
where the primitive deformity was completely or partially re-established ;
where the eye,  in place of turning itself outward or  inward, deviated
upward or downward; where there  was exophthalmia, or immobility,
or fixity in the  look of the eye, or irregularity  in its  movements ;  and
where all of these defects were apparent to any observer.  The defor-
mity was changed, but still unpleasant and noticeable by every person.
  Had they rigidly observed the precautions directed, the results, doubt-
less, would have been more favorable ;  but so much had been said in the
journals of the trivial nature of the  operation, and  that it was of no
more importance than a simple bleeding, that most of the patients came
to the hospital  in the morning, and  being operated upon, returned to
their homes, to  resume  their  usual occupations and mode of living, as
if the eye had not been touched.   M. Velpeau, therefore, does not wish
that the absolute  success of the operation  should be  judged of by the
cases under his care, or by others that have been related.
  It will require, he thinks, some years, to come to a definitive solution
of the question ; and when  the  operation shall no longer be attempted
but by conscientious surgeons, who will carefully weigh all the necessary
precautions.
  M. Bonnet also gives (pp. 162,163,) only fifty-four cases of complete
success out of three hundred  operations which he  had performed for
strabismus', though he says there were many of them whom ho never saw
again.   M. Velpeau doubts if he would have found in the whole  number
of three hundred more than one  hundred and fifty perfect  cures.  M.
Velpeau  justly  remarks, that it is a difficult thing  to furnish  correct
statistics in this matter, and that he should  not feel authorized to speak
with certainty of more than one hundred and fifty of his three hundred
and more cases.  Avery great number from the environs of Paris, from
a distance, or from  the  provinces, neglected to come  back, he  says, to
the hospital, either from indifference, or unwillingness to put themselves
to the trouble, or from not conceiving  any  possible utility  in doing so,
&c.
  Prepared for these difficulties, this surgeon took the precaution of ob-
taining  the  address of the out-door patients, and to keep  an eye upon
the cases during the  space  of two, three,  or four months,  in the event
of their not returning to the hospital to show him their eyes at the times
appointed.   M.  Gouraincourt, whose zeal, he  says, he  has greatly  to
praise  in this matter, visited them every eight or fifteen days, and took
a minute of all that passed.
  M. Velpeau  then proceeds to give a resume of  the details of about
one hundred and fifty cases, which, as they have been promiscuously taken,
he  thinks may be  received  as a fair  sample of a close approximation
to  the proportions of success, partial success, and failures, among those
also where no  minutes could be obtained.   He doubts if the marvellous
narrations  of the  success of others would in reality present any thing
more favorable than this list.
   There is an instructive table of the cases of M. Boinet in the Journal
des Connaissances  Medico-Chirurgicales.  Out of sixty-ei°-ht also ope-
rated upon by  M. Peyre, (Traite du Strab., 8cc, 1842,) he° admits only 
STRABISMUS.
541
eight  to ten failures.  M. Proske allows of only twelve failures in fifty-
five cases operated upon by M. Kuh.

              The Cases Operated upon by M. Velpeau

  Out of 128 cases minuted by M. Gouraincourt, there were—

       Convergent.............Ill

  Of these there were—

         Double.............17
         Right eye............67
         Left eye............27

       Divergent,..............17

   Of these there were—

         Right eye............10
         Left eye............7

                                    Totai.....128

   Out of 138 cases, as examined by M. Velpeau—

       Convergent.............123

   Of these there were—

         Double.............20
         Right eye............52
         Left eye............51

       Divergent..............15

   Of these there were—

         Double.............2
         Right eye............8
         Left eye............5

                       Total..........138

                 Cases Operated upon by M. Bouvier.

   The number was 45, and all on one eye.  The muscles divided, were the
 rectus internus and rectus externus, and in one case only the inferior ob-
 lique with the rectus externus.   In no case were the superior or inferior
 recti, or the superior oblique, divided. 
542            NEW ELEMENTS  OF OPERATIVE SURGERY.
  Of  the 45 cases, there were—

         Females.....
         Males    .  .  .  •   .

         From  8 to 10 years of age.....5
         From 11  to 20 years of age.....16
         From 21  to 30 years of age.....16
         From 31  to 47 years of age.....8

  There were in this number—

35 cases of convergent strabismus,
10 cases of divergent, (including one case which followed an operation
     for convergent strabismus.)

22 cases affected the right eye,"either exclusively or  principally.
23 the left eye.

  The definitive results of the operations, ascertained a month or seve-
ral months afterwards, were as follows :—

  1.  Convergent  Strabismus, 35 cases: the eye entirely restored in 25
cases ; the  strabismus partially remained, or appeared occasionally, in
8 ; the restoration failed entirely, or nearly so, in 2.
  Out of 25  cases of complete restoration, there were 8 in which the
position and movements of the eye were altogether normal;  16 in which
the eye was too much in the middle, between the opening of the eyelids,
and its movement of adduction more or less enfeebled, or almost entirely
abolished; 1 in which there occurred a strabismus outward, which con-
tinued in spite of the section of the rectus externus.
  Among the  16  cases (above)  where  the eye was  too much straight-
ened, is to be reckoned the case in which the operation had been already
performed without success.
  2.  Divergent Strabismus, 10 cases.   The eye was entirely  restored
in 7 cases; it preserved in all these cases its position and normal move-
ments.
  The operation failed, or nearly so, in 3;  and of  these three  cases,
one was the case of consecutive  strabismus, following an operation for
convergent strabismus performed by another surgeon, and should not in
reality be included with the other cases.  A second of these three cases
is that of a man aged 47, affected with  paralysis of the rectus internus,
from a cerebral affection; this,  therefore, is a case, also, which had
nothing in common with the others.   There were, therefore, but 8 cases
of failure.

     Section II.—Amelioration of  Vision  by the  Operation of
                            Strabismus.

  A fact, which had hitherto  almost escaped notice, has been ascertain-
ed from the operation of strabismus, viz., that almost all squint-eyed per-
29
16 
STRABISMUS.
543
sons see badly with  the deformed  eye.   With some the strabismus is
complicated with ambliopie, or a species of amaurosis; others have the
sight double, or short.   In some the eyes soon become fatigued, and  in
others  these organs  have a constant  trembling.  Not that the vision is
altered  in  all cases of strabismus; M. Velpeau has, on the contrary,
remarked  that, in  25 out of 100 cases, the patients see as far with the
distorted eye as with the sound one.
  It has been found that the defect  of  vision in question was not the
cause, but the effect of the strabismus.

                          § I.—Amblyopy.

  One of the most common defects in persons with strabismus is am-
blyopy, or a sort of  confused vision.   M. Velpeau  has noticed it in va-
rious degrees in about half his cases.   M. Phillips is in error, in saying
that the operation always removes it; for M. Velpeau has seen it in a
great number of patients as late as a month  or two after the operation.
In some it disappears immediately, but it cannot be determined before-
hand whether the operation will relieve it or not. The operator is often
deceived on this subject, from patients crying out, immediately after the
operation, that their sight is vastly improved, when, in  fact, there has
been, as yet, no  change effected in this respect.

                           § II.—Diplopy.

  Some squint-eyed  persons see double, when they attempt to use both
eyes ; which is a very natural result of the crossing of the axes of vis-
ion, and the double  image which is the result of it, as has  been before
mentioned.   There are scarcely any other strabismic patients that retain
their vision natural,  except  those who can scarcely  see with the distort-
ed eye; but these  last are most numerous; and among the others, there
are some who, in fact, make use only of the sound eye, though the vis-
ual faculty may exist unchanged in the distorted eye.  Diplopy is almost
always cured  by the operation ; but M. Yelpeau mentions a case where
it continued after the division of the rectus internus and perfect restora-
tion of the  position of  the eye.

                           § III.—Myopy.

  A considerable  number of strabismics  are short-sighted in the eye
that squints.  M.  Velpeau doubts  if this can be imputed to the com-
pression of the recti muscles, through and from  above downward  upon
the sclerotica, or to the action of the  oblique muscles from behind for-
ward and from before  backward, having the recti muscles for their an
tagonists.   The  operation, however, often removes the myopy.
  [It was, as we have  seen, (supra,) the opinion  of Dr. Hosack, that
short-sightedness  arose from the too  energetic contraction of the recti,
compressing and  thus actually elongating the  globe, and  at  the same
time giving  greater convexity to the cornea—the oblique muscles merely
serving as antagonists to  keep the eye in place.   Then a permanent
contraction of one or more of the recti  must favor the  production of 
544            NEW ELEMENTS  OF OPERATIVE SURGERY.
short-sightedness; and as this is seen  to  accompany strabismic  cases,
it  is so far, in our opinion, a striking corroboration of Dr.  Hosack'a
theory.—T.]

                         § IV.—Amaurosis.

  The alleged cure of amaurosis by  the operation  appears  to be un-
founded.  This disease is  generally the result of lesions independent of
the globe and its appendages.  No one, M. Velpeau thinks, would  hope
to  cure  amaurosis caused by remote  lesions in the digestive  passages,
interior of the mouth, or cranium, or  in the optic  nerve  or retina, by
means of the section of one or more muscles of the orbit.  Physicians
have, no doubt, erroneously diagnosed confusion of vision for amaurosis:
but the cure of the first by the operation is a very different  thing  from
that of  an idiopathic or symptomatic paralysis of the retina.  The al-
most  total abolition of  vision in the  diseased eye is, nevertheless, not a
counter-indication for the  operation.

              § V.—Kopiopy, or Fatigue  of the Eyes.

  The fatigue which the unsound eye experiences when attempted to be
used alone, has been noticed by M. Petrequin, who gives it the name of
Kopiopie, (Annal  oV Ocul., 1841,) and  by M. Bonnet and  most other
surgeons.   M. Yelpeau  rationally explains it by the diminished power
of  the diseased eye and  its  habitual  repose.  Therefore, as  he justly
remarks, when, aTter the  operation, this eye is restored to its position,
and  begins to act in concert with the  other, and to become, as it were,
disciplined and habituated to exercise, this feebleness gradually disap-
pears.   In many, however, it continues for some time.

           §  VI.—Nystagmus, or Trembling of the Eyes.

  Nystagmus, or continual oscillations  or vibrations of the eyes, is seen
in  some strabismics, and also in some persons who are not affected with
squinting.  The cause is unexplained, and the remarkable part of it is,
that the sight in such persons is sometimes as regular and perfect as in
others.  M. Selle, a physician of Paris, has it in an extreme degree.
  Whatever  others have  anticipated or related of cures of nystagmus
iu  strabismic patients by section of the muscles, from the  very natural
supposition that it must originate in some  derangement of the  motive
functions, M. Velpeau  considers it very doubtful if the operation  will
give relief.  In four or five of these cases, which he operated upon, not
one was radically cured of the nystagmus.  One was a child of seven
years, with double convergent strabismus, and perpetual oscillation in
both eyes, which was slight when he  was at  rest, but vehemently agitat-
ed, into irregular movements downward, upward, inward, and outward,
whenever any  one attempted to approach or examine his eyes, and es
pecially if one eye was, at the same time, kept shut.
   After the operation on  each eye successively,  the trembling subsided
for a few weeks, but returned in two months as strongly as ever  though
the strabismus in both eyes was  perfectly cured.  The brother of this 
STRABISMUS.
545
child, aged eleven, had, in a less degree, the same singular affection com-
plicated  with strabismus from  infancy, and the results of the operation
in both were precisely the same.
   In most  cases, however, the  operation has the effect to diminish the
oscillations.

                        § VII.— Conclusion.

   The operation for strabismus may, in general, favorably  affect, out
will not always  completely restore, all the functions of  the eye, where
the sight has undergone a certain change.
   In strabismus, the sight may  be confused, or almost abolished, uncer-
tain, short, or fatiguing, in two  ways—1. By defect of use of the organ ;
2. By some organic alteration in the tissues which  compose it.
   In the first, the eye, once  restored to its natural  position, gradually
recovers from the prolonged repose of the organ, and regains its functions.
   In the second, where the defect in the vision in  strabismus is compli-
cated with actual lesion, as of the optic or some other nerve of the orbit,
lesion of the choroid coat or  retina, the section of  the muscle, will have
little  or no  avail.  Nevertheless, even in a strabismic  patient, with
amaurosis or myopy, the operation is not to be proscribed, for the res-
toration alone of the position of the eye is a matter of some importance,
though other complications may not be remedied by it.

Article XII.—Section of Different Muscles of the  Eye to Rem-
               edy  other Diseases than Strabismus.

   The alleged results obtained in the amelioration of certain complica-
tions of strabismus,  have led to the proposition to apply  the operation
to these affections, even where there  is no strabismus.

                            § I.—Myopy.

   This has been the  first disease upon  which this  practice has been at-
tempted, and it has given birth to  three opinions as to the origin of the
disease.
   In one, it was maintained that the myopy was caused by the shorten-
ing, active or passive, of the  recti muscles.  Hence  the  proposition to
make the section of  one or more of them.
   M.  Guerin makes  two kinds  of  myopy, viz., mechanical or muscular,
and optical or  ocular, (Annal. d'Ocul., Avril, 1841, p. 31,) and gives
examples of successful treatment by the operation.
   M.  Cunier relates cures of myopy by the simultaneous  section of the
internal and external recti muscles, (Ann. d' Oe, Juin, 1841.)
   M. Kuh of Breslau, who about the  same time published  in the Journal
of Casper (1841—No. 15) a successful case of myopy, from  section of
the four recti muscles, and  one of presbyopic (Proske in Ann. d'Oe,.
t.  vii., p. 44 :  Sach's Allgemeine Zeitung]) admits that he obtained no
success from the section of the internal and external rectus in another
case.
   M. Phillips, representing the opinions  and practice of Dieffenbach,
   Vol. I.                      69 
546            NEW ELEMENTS OF OPERATIVE SURGERY.
contends  that it is the superior oblique muscle  which is the cause of
myopy, while  M. Bonnet  (Des Sect. Muse.)  maintains that it  is the
small oblique.
   M. Yelpeau  thinks, if the cause  lies in the muscles, that all may be
equally concerned in the production of myopy, the  globe, during the
retraction  of the recti muscles, finding a point  d'appui behind  by the
reaction of the oblique muscles, and  these last again, when retracting
or shortening, finding antagonists at the cornea in the recti muscles.
   M. Velpeau  says, that  having  long since maintained at his clinique,
that transparent  staphyloma of the cornea, and  staphyloma in general,
was a mechanical effect from the action of the muscles on the globe of
the eye, he was naturally  strongly  disposed  to adopt the new theories
of myopy, and even went so far as to operate on the muscles for it in
one case—a man aged about forty-six, from the provinces, who had had
myopy and nystagmus from infancy.   M. Velpeau first  divided the rec-
tus internus on one side, and, in twelve  days after, the  external  rectus
in the same eye, not  only  to relieve a divergent  strabismus  which was
beginning to form, and also an unpleasant diplopy, but in order to com-
plete the operation.
  M.  Velpeau ascertained, by careful attention to this  patient, that his
myopy was benefited to  the extent of seeing  to one half greater dis-
tance than before  the operation.   But the  double vision  still annoyed
him;  and as this might  arise from  the two  organs acting in different
fields of vision, he  operated upon  the other eye with the same precau-
tions as upon the  first.  The myopy at first appeared to subside in this
eye as it had done in the other, but  the  sight  remained uncertain and
confused, and the  diplopy, which had ceased for some time, soon became
re-established.  One  of the  eyes finally  deviated inward.   He consi-
dered that he should re-operate upon it as for  a convergent strabismus;
but the external rectus having been already divided, the eye could not
be completely  straightened but by methodical  compression in the inner
angle of the lids.
  The eyes  being now straightened, he found they could not be turned
outward or inward but imperfectly.   The double vision had diminished,
and he went home, but returned in six months to the hospital, with this
last-mentioned  disease strongly marked,  and also decided  amblyopy,
and slight convergent strabismus in both eyes.  M. Velpeau now thought
an operation for this would destroy the diplopy, and the rectus internus
of the right and left eye was again detached.   The eyes were complete-
ly straightened, but the double vision continued.   The patient now re-
solutely  proposed, as is recommended by  M. Phillips and  M. Bonnet,
that one of the oblique muscles should be cut.   M. Velpeau declined,
believing the eyes already too  restricted in their movements to justify
the section of any more of their muscular bands.
   M. Velpeau thinks that  the section of the muscles in sound eyes ex-
poses to more  unpleasant  results than after strabismus.  For who can
say that the section of the internal  and external recti muscle3 will not
be followed by a deviation inward or outward,  or  that a section of one
of the oblique muscles will not  cause any deviation of the eye ?   What
can secure us in these  sections against fixity and immobility of the eye,
in various degrees ?  With  the possibility of  such results, the remedy 
STRABISMUS.
547
would be  worse than the disease; and  as myopy itself, moreover, does
not always  yield to myotomy, the operations hitherto made trial of in
these cases will not, he conceives, be adopted in practice.

                         \ II.—Amaurosis.

  M.  Adams, an English oculist, proposed myotomy  for amaurosis.
After division of one of the recti muscles, in a girl aged 22, the vision
was partially re-established ; but, as the diplopy supervened, he cut the
rectus muscle opposite.   The diplopy ceased immediately, and the sight
continued  to improve, (Prov. Med. and Surgical Journ., April, 1841.)
But M. Fleussu remarks with justice, that this was rather a case of kopio-
py, or fatigue of the eyes, than of amaurosis, (ler Supplement aux Ann.
d'Ocul.,n. 319.)
  The two cases of M. Ruete of Gottingen, reported as cures of amau-
rosis, by myotomy, are considered by M. Fleussu to have been only par-
tial paralysis of the third pair, with strabismus and mydriasis.
  M.  Petrequin of Lyons, who contends  that certain forms of amau-
rosis may  be produced by a spasmodic state of one or several muscles
of the eye, (Revue Medicate, 1842, t. i., p. 207,) is also much in favor
of ocular  myotomy in gutta serena.  Two such cases, operated upon by
him in 1841, experienced, he says,  decided benefit, (ler Supplement,
Annates  d' Oculiste, p. 321;) but M. Yelpeau, in reference  to  these
cases, as well as to what has  been said on this subject  by  M. Kuh,  and
M. Peyre  (Traite du Strabisme, p. 174,) feels constrained to entertain
some doubts as to the amaurotic nature  of the disease in question,  and
concludes in expressing it as  his opinion, that the  operation would for
this disease be still more unjustifiable than for myopy.

                        § III.—Nystagmus.

   Among the cases of myotomy for nystagmus proper, M. Velpeau re-
marks that the patient of M. Phillips appears to have been completely
cured by this means, (Tenotomie  Sous-Cutanee, Paris, 1841, p. 317 ;)
but M. Bonnet  confesses that he failed in three cases where  he  made
trial of it, (p. 302.)   If it be true that M. Roux of Mexmieux has  cured
a person both of myopy and nystagmus, by  the division of the two infe-
rior  oblique, (Bonet,  Ouvrage  Cite  p. 305;) it is  equally  true that
M.  Bonnet himself has failed, both in dividing the inferior oblique as
well as recti muscles, (p. 303.)  Moreover, M. Velpeau says with great
candor, that his own cases are totally adverse to  the anticipations of
MM. Phillips and  Peyre (Traite du  Strab., p. 163,  1842.)   Since the
strabismics operated upon by M. Velpeau retained their trembling move-
ments of the eye, he could not rationally conclude  that the  operation
could be  depended upon for this affection, where there was no strabis-
mus.
  M. Velpeau  deems it a feeble resource in nystagmus; but believes,
with M. Bonnet, that this disease may often be complicated with, or the
effect of, various alterations in the eyes. Thus it may originate from a
myopy,  amblyopy,  diplopy, a spot on the  cornea, or  from  a cataract
from infancy.  It seems that in all these circumstances, the uncertainty 
548
NEW ELEMENTS  OF OPERATIVE SURGERY.
of vision induces the eye to carry itself instinctively and  continually in
every possible direction, as if in search of the rays of light that it required.
In these, therefore, the  cause must be first removed before thinking of
myotomy.  M. Velpeau deems it doubtful, even  where the  convulsive
trembling and strabismus are unaccompanied with any defect of vision,
(as in the two children above related,) and  has his doubts of the re-
ported success  of M. Kuh, (Sack's Allgemeine Zeilung, and  Annates
d'Oe, t. vii., p. 44.)

                         \ IV.—Artificial Pupil.

  Sometimes the spots on the cornea cover only  one half  or  two  thirds
of it.  Nature,  to accommodate the pupil, turns (as has been already
explained) the eye in such manner forward, as to bring the  transparent
part of the cornea  more directly in a line with the pupil and axis of
vision.  This is, at least, as good as an artificial pupil.
  M. Cunier, therefore, proposed making an artificial strabismus in pa-
tients with leucoma, or cicatrices of the cornea.   This, he says, he does
by dividing one or more of the muscles of the eye, (Lettre d VAcademie
des Sciences, 1841.)  M. Cunier has given one successful case, and M.
Petrequin,  in a letter to the Academy, (Bonnet, Ouv.  Cit., p. 312,) re-
lates another.   M. Proske (Ann. d'Oe, t. vii., p. 44)  has also treated
of this subject.
  M. Velpeau remarks, that this new application of myotomy  can  only
be practicable in cases where  the pupil remains sound behind  the cornea,
and that the opacity does  not go beyond the circumference of the pupil.
The operator should hold  the eye steadily with  the forceps  or erignes,
for some seconds, in the position in which the  globe should be turned,
[to enable the light to strike  through the cornea  and pupil upon the re-
tina,] so as to be assured  that this can be effected before he divides the
muscle or muscles.
  We should also weigh well  whether one of the numerous  operations  i  i  i
for artificial pupils, as these do not require division of the muscles and  '.
deviation of the eye, would not still be advisable.   This artificial stra-  ■  ■
bismus, it must be recollected, is the establishment of a permanent de-  •  ■
formity, to remedy a simple imperfection of the sight, and but  few  per-  ■  ■
sons, probably, would desire to squint for the sake  of seeing with both  .  .  .
eyes.
  The facts on  the  subject are still too limited to give a definitive opin-  ■  •
ion.
  The muscles to be divided are always those  that correspond to the  i  i  i
point of the cornea nearest to the pupil.  Thus  the internal rectus for  •  ■  ■
divergent strabismus, if the pupil, could be seen better, and the patient  ;
could see better on the nasal than any other part of the cornea, and vice  •■  •■  \
versa with the external rectus.  If the transparent point  on the  cornea  l  l  i
was below, we should divide the inferior rectus to produce a frontal stra-  •  ■
bismus and for the reverse the superior rectus.

  Article XIII.—New  Varieties of  the Operation  of Strabismus.

   Less severe means  than myotomy have been proposed for strabismus. 
STRABISMUS.
549
§ I.—Destruction of a portion (plaque) of the conjunctiva to remedy
                            Strabismus.

  Some suggestions upon  this  subject from M. Dieffenbach, are to be
found in the Journal of Casper, 1841, No. 36, and in the small volume
just published by M. Cunier, (Revue Ophthalmologique, See, ou Suppl.
aux Ann. d'Oe, p. 297.)
  When the strabismus is slight, in order to avoid an inverse strabismus
after the section of the retracted muscle, the operator of Berlin advises
an excision of a portion of the  conjunctiva and of  the tissues which line
it, near the tendon of the  corresponding muscle.   In the progress of
cicatrization, the borders of the divided conjunctiva  gradually  approxi •
mate, so as to shorten it considerably, and thus straighten the eye.
  M. Dieffenbach professes to have obtained the same result by cauteriz-
ing with nitrate of silver.  M. Velpeau, with every confidence in M.
Dieffenbach, cannot but express his doubts that  all the cures he has
spoken of were in reality cases of pure  strabismus.  The conjunctiva,
says M. Yelpeau, is too moveable and pliant, and is too easily displaced,
for an operation of this kind to restore in reality the natural position to
a deviated eye.   Moreover, if the  straightening should take place, there
would result from it a manifest impediment to the movements of the eye
in the other direction, and consequently a new deformity.
  M.  Cunier (in the  work quoted) says,  if this operation should be
adopted, it would be much  better to reunite the wound of the conjunctiva
by first intention, by means of  the  suture, than to  leave it to suppurate.
But this,  says M. Velpeau, would probably deprive M. Dieffenbach's
operation of the  only chance for success which it has  ; viz., that of form-
ing an  inodular  cicatrix, which would  slightly draw the eye  in that
direction.

        § II.—Section of the Muscles  of the Eye by a Thread.

  M. Velpeau has for a long time, he says, reflected  upon the probable
utility of operating for strabismus  by embracing the  tendon of the  re-
traced muscle, previously  raised up by the forceps,  in a noose  of silk;
then to twist the  two threads of this noose together,  and fasten  it on the
other side of the nose in external   strabismus, and on the temple in the
internal variety.  The straightening of the eye could be thus carried as
far as we judged necessary, and even beyond the central line,  and this
organ could be kept there,  until the thread had completely divided the
tissues comprised in the noose.  As I  foresee  (says M. Velpeau) the
theoretic objections which  might be advanced against this proposition,
and which I do not look upon myself with any great degree of confidence,
I have not yet made trial of it. 
550
NEW ELEMENTS  OF OPERATIVE SURGERY.
                     SECTION  THIRD.

OF ANAPLASTY OR AUTOPLASTY,  {DE L'A.VAPLASTIE OU AUTOPLAS-
              TIE,) OR RESTORATION OF DESTROYED PARTS.

   The  operations whose  object is to repair  mutilations, constitute one
of the most  brilliant triumphs  of surgery.  These  operations, known
under the name of organic restitution, animal engrafting, and transplan-
tation of parts by autoplasty, have not yet been described with precision.
If the  term autoplasty  had been sanctioned in science, I should  have
adopted it, however  incorrect it  might be ;  derived,  as it is, from the
words aviog, himself, and nXaddeiv  to create, it properly  signifies the
spontaneous creation of a part, the  creation of a part by the individual
himself, which in no  respect expresses the idea which should be formed
of the  operations  of which I am  about to  speak.   Anaplasty, being
synonymous with  the words remake, or reconstruct,  is  evidently much
more appropriate, though in itself not free from every objection.
                          PART FIRST.

                       ANAPLASTY IN GENERAL.

  Anaplasty has now been brought to such a degree of perfection, that
it is indispensable to divide it into many species, in order to treat of it
appropriately.  It comprises, in the first place, two great branches, easy
of separation :  1. The surgeon confines himself to replacing the organ
itself, or some similar parts, on the seat of the mutilation, either by res-
titution or transplantation : 2. At other times, he repairs  the  point de-
stroyed, by the transposition or elongation of parts, taken  either from
the neighborhood or from some remote regions.
                           CHAPTER I.

                     anaplasty by restitution.

  The restitution differs according as the organ to be reunited is com-
pletely separated, or  that it still holds on, by some lamella?, to the liv-
ing parts.

      Article I.—Restitution of Organs Partially Divided.

  Let  a  portion of finger, ear, nose,  or lip, be divided in such manner
as still to  hold  on by a quarter part, or half its thickness, and no one 
anaplasty by restitution.
551
will  contest the  possibility of reattaching it.   Let the same organ, a
finger, we will suppose, be cut off so as to hang, on the contrary, by only
one  of its surfaces, and to adhere only by a strip of skin, or epidermis,
and  most surgeons would consider it as lost.   If doubts may exist on
this subject for a portion of the finger still greater doubts, with stronger
reason, would exist in  respect to an entire hand, leg, arm,  or forearm.
Nevertheless, facts seem to demonstrate,  at present, that organs of con-
siderable  size, almost completely  separated from the body,  have, when
properly brought together and supported, been enabled to resume their
vitality, and to cicatrize.
  De Horn cites the case of a hand which held  only by the tendon of the
index finger, and which Jung,  (Rougemont,   Bibliot.  du Nord,  t. i.,
p. 92,) nevertheless, succeeded in reuniting perfectly.  An  observation
of Hoffman (Ibid., p.  98) is scarcely less remarkable : an arm, which
adhered  only by the vessels and a portion of the biceps, and where the
humerus and the integuments were completely divided, was, nevertheless,
preserved and perfectly cured.  Percy (Mem. de VAcad. Roy. de Med.,
t. ii., p. 14)  appears  to have been witness to  a similar fact.  The arm
was  held only by the vessels and a flap of integuments.  M. Stevenson
relates  (Gaz. Med., 1837, p. 390) something much stranger still.   An
individual had the vessels, biceps, and humerus, completely severed by
the  cut  of a  sabre ;  the arm  was retained only by  a flap of skin at its
upper part;  the surgeon, nevertheless, effected a reunion !   A case also
is related, of a great portion of the calf, which  was held only by a slight
pedicle, and which M. Groenscher succeeded in reanimating, and reunit-
ing  to the natural parts.  They have gone much farther than all that;
for Esculapius (Dujardin, Hisloire de  la Chir., Introduction, p. 15)
restored the head to a  decapitated woman ; and a soldier, who was de-
capitated by an  enemy, was cured by a peasant, (Jour. Gen. de Med.,
t. liii., p. 232—Sedillot,) who had the misfortune  of putting the head
on with the face turned backward, a mistake which Pantagruel rectified
by saying he did not wish to have a torticollis  ! while Rabelais, ( (Euv.
de Rabelais, Uy. ii.; Pantagruel, liv. ii., ch. 30, p. 286,) jesting as usual,
has preserved to us the history of Epistemon, who had had his head cut
off, but  which Panurgus  reunited  exactly, vein  with  vein, nerve  with
nerve, and vertebra with vertebra, etc.: the aforesaid Epistemon  being
perfectly  cured, except  his voice  remained  hoarse, and that he had a
dry cough, which he never was relieved of but  by the aid of liquor!
  If it is difficult  to admit as correct the observation  of Jung; if the
facts of M. Percy and M. Stevenson are equally surrounded  by improba-
bilities, it is  not the  same with those of Hoffman and Groenscher.  In
those last cases, there  remained  enough of living parts to prevent the
mortification of those which were  separated.
  Also, it is principally upon the surface of the skin, and the projecting
parts of the body, that these divisions have been observed.   The  fingers,
the nose, and the ears, have furnished the most examples of them.

                   § I.— The Fingers and Toes.

  Thompson  (De VInflammation, etc., p. 243) has  seen the fifth toe re-
unite, though  it held only by a small cutaneous flap.  The end of the 
552
NEW ELEMENTS  OF OPERATIVE SURGERY.
little  finger, which  was prevented from falling only by a slight pedicle,
was also perfectly  reunited, in a patient in whom the same auther pro-.
posed that it should be amputated.
  Two fingers, divided from behind forward, and which were held only
by a  flap of a line or two in width, were so exactly united together by
M.  Layraud, who showed  them to me, that they not only continued to
live, but  also  reacquired  all their functions.  A sausage-dealer's boy
receives the cut of a knife upon his hand ; the middle and ring fingers im-
mediately fall upon their palmar surface, and a copious hemorrhage takes
place.  Reaching the young man in about half an hour after, I find that
in the third  finger, the wound, which penetrated through the middle
joint, included the extensor tendon, the whole thickness of the bone, the
flexor tendons, the  vessels, and the nerves.  There was no other conti-
nuity  except by a small strip of the palmar integuments, which was from
two to three lines in width.  In the medius, the division was forward of
the phalangeal articulation, and did not comprise as great a width of an-
terior integuments.   The hemorrhage, which had begun to diminish, did
not prevent me from  attempting  the  immediate  reunion of these two
fingers.  A  small splint of white-wood, strips of adhesive plaster, and
a roller  bandage, constituted  all my dressing.  It was in the month of
June, 1837 ; the hand was kept constantly moistened with water, at tie
natural temperature ; the immediate reunion took place ;  and this boy,
at the present time, uses his fingers the same as before the injury.

                         § II.— The Nose.

  It is in the nose that these anaplastic unions have been more especially
noticed.  Among other facts of this kind, I will  cite that related by
Bagieu, (Examen de plus.  Quest, de Chir., etc., p. 599,) in  which  we
find  that the  nose, holding only  by a very small filament, completely
reunited in the space of eight days, in the  case of a gendarme named
Densi.  The point of a nose which held only by a slender  pedicle, was
well  restored in 1742, by Dubois.  Lombard (Thomson, Oper.  Cit.,
p. 242) succeeded in reattaching a nose, almost entirely  separated  for
several hours, though it was during winter.   A similar fact is  attributed
to Loubet, (Plaies  d'Amies d feu, p.  31.)  Thomson  (Oper.  Cit.,
p. 242) has related two similar cases: in one, the nose held only by the
skin of one of its alas: the septum only retained it in the  second.   We
owe to Boyer (Traite des MU. Chir., t. vi, p. 59, edit. 1818)  a third
observation, full as  conclusive.  The butcher of whom Dionis (Oper.
de Chir., 7e demonstr., p. 588) speaks, was not less fortunate.  Percy
(Diet, des  Se Md.,t. xii., p. 344)  relates, that he has met with many
cases of noses, which he has successfully reunited when they  held  only
by a small  flap.   Blasius (Obs. part. 5.  Obs. Ire  cite" par Percy) has
given us the history of a nose  almost entirely detached, and in which,
owing to its tardy  reunion, it was necessary to pare  the  ed<*es of  the
wound.  M. Mouline (Bull. Med. de Bordeaux, 1833, p. 21) also speaks
of a bruised nose, in great part torn off, and which he succeeded in re-
uniting, by means of a suture.  I myself have seen many similar cases •
in a young man in  whom the point of the nose held only by a smali 
ANAPLASTY BY RESTITUTION.
553
pedicle of the septum, I was enabled to reunite the  parts, by means of
simple adhesive plasters.
   Without admitting, with many  ancient authors, that the eye, in cer-
tain wounds, after hanging  down upon the face, has  been replaced in
the  orbit, and  been enabled to resume  its functions ; we cannot  now
deny that  portions of the ears, or lips, have been fully as well united
as the nose.  F. d'Arce says, that a nose even, which with a large  part
of the upper jaw had been torn down upon the chin, was raised up and
perfectly reunited.
   From these facts, and from a great number  of others which I might
have quoted, from Glandorp, Painchchriston, Ledran, Ravaton, etc., we
have these results at least: that parts of the body, partially  detached,
may in certain cases be reunited with those from which the wound had
temporarily separated them.  Only that we should be wrong in conclud-
ing, therefore, that these attempts at agglutination will be always fol-
lowed with success.  The conditions which the surgeon should  look to
for his prognosis, are the  following :—All other things being equal, the
chances of success are greater in wounds from a cutting  instrument,
than in cases of contused wounds.   In the first cases, the adhesion will
almost always take place, if the flap which is preserved, includes a cer-
tain number of vessels, or presents a thickness of several lines.  It will
also be practicable and  proper  to attempt it, in cases where the  pedicle
holds on to the rest of the  body  only in the  extent  of a line  or two,
provided it is a part of  the tegumentary  tissue, and  that there are nei-
ther bones, muscles, nerves, nor vessels, of a  large size in  the  parts
separated, as is seen in the ear, at the  point  of the  nose, and in  some
regions of the face.  If it was an arm, or forearm, as  in the observations
of Horn, Percy, and Stevenson, or what is worse, the leg, and that the
section  comprised the whole thickness of the limb,  with the  exception
of a flap of integument, we ought  not, as I conceive, to count  on the
success  of the reunion :  every thing shows, that it would be better then
to resign ourselves to the sacrifice of the  part.   In the second  case,
that is, in cases of contused wounds, the restitution is hardly possible,
except the pedicle has at least the fourth or fifth of the thickness of the
injured  organ.   If under  these dimensions, it  would be more prudent
not to attempt the anaplasty, but to complete the section of the flap.
   [There can be no harm, as we conceive, in at least making the attempt,
however small  the pedicle or flap  may be ; for, if the union does not
take place, the  decomposition in the separated  parts will soon be made
manifest, without occasioning  but very  little  delay in the subsequent
treatment, and  certainly without  producing  any mischief to the sound
parts.—T.]
   Another  circumstance which  must be kept in view, is that which re-
lates to the  nature of the divided  tissues.  Thus the organs whose in-
teguments are nourished by numerous vessels, or which are united in an
intimate manner with the subjacent tissues, such as the fingers, the sole
of the foot, the cranium, face, nose, and  ear, in a word, homogeneous
parts, offer, in this respect, the best possible conditions.   If the division
comprises, also, tendons  or bones, as is seen in the  fingers, or simple
cartilages, as in the  nose and  ear, there is still no  reason to object to
anaplasty.   The  most unfavorable conditions are those of the division
   Vol. I.                     70 
554
NEW ELEMENTS  OF OPERATIVE SURGERY.
 of the  muscles, bones, nerves,  and vessels  of a large size.  For the
 rest, the chances of success are in direct relation wdth the homogene-
 ousucss of the parts, and the  absence of large circulating trunks in the
 parts ;  that is to say, that the organs which appear to exist under the
 influence of the capillary circulation or imbibition, are more favorable
 to the success of the operation, than those which are naturally traversed
 by vessels or nerves of large size.  t
   Whenever the surgeon shall find the parts in the favorable conditions
 of which I have spoken, he will attempt  the reunion.  It is important,
 then, not to leave any foreign  body, or any clot, between the lips of the
 wound, and to place the two ends  of the divided  organ in perfect  con-
 tact.   For that  purpose, we should wait until the blood ceases to flow,
 if the divided  vessels are not of sufficient size to require  the  ligature.
 A quarter of an hour, a half an hour, or even an hour of delay, under
 such circumstances, should  not  disquiet us, but would be rather useful
 than injurious in a considerable number of cases.
   If the blood should not stop of  itself, and we can suspend its current
 between the wound and heart without too much inconvenience, we should
 call in the aid of compression; if  it were actually necessary to act upon
 the wounded vessels, torsion would be the best means to use.   We should
 not, consequently, have recourse to the ligature, unless it became indis-
 pensable.   The  parts being well cleaned, and properly brought together,
 are kept in contact  by means  of simple bandages, adhesive  plasters,
 or the  suture.   Bandages generally suffice on the cranium, trunk, aud
 limbs.   Strips of adhesive plaster are  much better for wounds of the
 fingers which do not  involve the bones, and for some similar wounds in
 the face.  When the  bones  make  a part of the section, it is almost in-
 dispensable to associate with the strips, splints of wood or pasteboard ;
 it is then that the immovable bandage would also become valuable.  But
 for the nose, ears, and around the mouth, the suture should almost al-
 ways have the preference.
   It is important, in these essays, that  we should make but very little
 pressure upon the  parts.  If their exact contact is  indispensable, a
 compression which  would interfere with the  circulation, would cause
 the whole to fail; in the place of having recourse to topical refrigerant
 applications or to antiphlogistic means, it is better  to wet the parts with
 aromatic and slightly stimulating lotions, such, for example, as  spirits
 of camphor ; it is well, also, that the  wounded region should remain in
 a dependent position during some days.  It is to be understood, also,
that the surgeon should watch  these wounds with the same care that he
would all others ; and that he should carefully prevent their lips from
being disturbed, until the reunion is complete, or become impossible.
   [Dr. Mott mentions to me the  case of a penis severed by the sweep of
 a razor, in the hands of an enraged woman, almost entirely off, close up
 to the scortum.  It  hung  by a mere thread of integuments.  Dr. Mott
 did not  dare to hope for its restoration, but it did take place in the most
perfect aud natural manner.—T.]

   Article II.—Restitution  of Organs Completely Separated.

   The restitution of organs  partially separated, has rarely been regard- 
ANAPLASTY by  restitution.
555
 ed as  impracticable, under the circumstances  which 1 have just men-
 tioned ; but those are not the  points of controversy in anaplasty, which
 are prevailing at the present time.  The point which  has found the
 greatest number of skeptics, and given rise to the most contention, is that
 relating to actual transplantations.   It would  appear difficult, in truth,
 for a part which has been  completely  isolated from the  body, and then
 put back in its place, to be capable, under such circumstances, of  reac-
 quiring its vitality.   Reflecting  persons, therefore, have  not  been dis-
 posed  to admit the fact, but upon proofs altogether conclusive.
   These transplantations, however, were  credited by certain persons in
 former times, since  Lanfranc, Guy  de Chauliac, and other surgeons of
 the middle ages, exerted themselves to prove their impossibility.  There
 are, also, two kinds of transplantation, which  it is proper not  to con-
 found  : in one, it is the detached  part  itself which is  reapplied, and
 which we endeavor to reunite—in which case we have a simple  restitu-
 tion ; while, in the second kind, it is at the expense of another individual
 that we reconstruct the mutilated  organ, by an actual transplantation.
 The idea of restoring to its  place, a part completely separated from the
 body,  prevailed also at a very remote time.

                           § I.—The  Nose.

   One of the most ancient observations of this kind, appertains to Fiora-
 venti,  (Secrets de la Chir.,  liv. ii.,) who, to convince the incredulous,
 replied to them thus: " Go  visit Signior  Andreas, who lives at Naples,
 and  where every one knows  his history  ; he will tell you that, happening
 on the spot where the accident  occurred, I took up his nose, which had
 fallen in the sand,  and washed it and replaced it in the best manner I
 could.   Examine this nose, and  listen  to the statements which  will be
 made to you, and we shall see  if you can still call in question a fact so
 clearly demonstrated."  The  point of a nose which had been  cut off,
having  been  received in a hot  loaf, was  also  reattached  byJVIolinelli,
 (Bonet, Corps de Med., t. iv., p. 59,) with complete success.^According
to Blegny, (Zodiaque Mid., Mars, 1680,) a nose  which had  been cut
off by the stroke of a sabre, was replaced with no less success by Winseult.
  An observation which acquired  for Garengeot the title of a liar, re-
lated to a soldier, whose nose, bitten off by the teeth of an adversary,
who  threw it into the mud as he escaped, was  afterwards cleaned, re-
placed in  its position, and  reunited by  the barber  Gallien.   Though
 looked upon as fabulous by De la Motte,  Dionis, and Lafaye, the trans-
 plantations of the nose are, nevertheless, reasserted in a  thousand  ways
 with circumstances  fully as  marvellous.  There  is one which is not less
 extraordinary than that of Garengeot:   A man named Loudun had
 his nose entirely bitten off by the  teeth of a smuggler.  The  patient
 had  wrapped it in his handkerchief, where the surgeon who was sent
 for found it, cold and black.  " I put the piece in camphorated spirit
 of wine," says Regnault, (Gaz. Salutaire, 1714, No. 26, p. 4,) " and
 washed it thoroughly ; I then replaced  it  in the best manner I could,
 and  kept  the whole in place by a containing bandage.   Three times a
 day, I sprinkled the upper  part of  the nose with the same camphorated
 spirit  of wine.   At the end of eight days I took off the  dressing, and 
 556            NEW ELEMENTS  OF OPERATIVE  SURGERY.

 saw that the part had become attached.   As there were large lacerations,
 a suppuration came on which lasted a month ; there finally resulted from
 it only two small  cicatrices, slightly  sunk in  on the lower part of the
 organ."  Leyser was not less fortunate  than  Fioraventi, in the case of
 a young man of respectable  family ;  and Loubet (Plaie d' Amies d feu,
 etc., ou Rev. Med., 1830, t. iv., 119) had the same success  at the battle
 of Rocroy.
   Utterly  incomprehensible as they would  appear to be, these histories
 seem, nevertheless, to have been confirmed by recent facts.   A student,
 in fighting a duel, had the point of his nose cut off by the stroke of a
 sabre ;  having sent to look for the end of the nose, which was found un-
 der a chest, M. Chelius warmed it, then  replaced it, and succeeded per-
 fectly, though an hour had intervened  between the accident and the op-
 eration !  M. Bridenback says, in the same letter, that a dog having got
 possession  of a nose  that had been cut off,  finally surrendered it to the
 surgeon, who took it from his mouth to restore it to  its place, and  that
 the operation was entirely successful.   Germany, also, offers  frequent
 examples of similar anaplasty.  M. Hoffacker (Annal. Cliniq. de Hei-
 delberg, vol. 4., cahier 2; Bullet,  de Ferussac, t.  xvii., p. 75;  Gaz.
 Mid. 1830, p. 403) alone, has  published sixteen cases of them.   Here
 is one of the examples which he gives :—M. Sch**, aged twenty,  of me-
 dium height and  strength, was wounded in  a duel, January 1, 1825.
 The stroke of a sabre carried off, 1. The end of his nose to the  extent
 of half an inch in all its  dimensions ; 2.  A piece of the upper lip; 3. A
 piece of the lower lip and chin.  All these parts fell upon the ground ;
 the last was first found, and fixed in its place by fifteen points of suture;
 the point of the nose was not found until ten to fifteen minutes after  the
 wound; as to the  piece of the  upper lip, it was  searched for in vain.
 The end of the nose reunited to two-thirds of its extent, and the wounds
 of the lips  cicatrized in six weeks.
   When consulted by M. Champion on  the authenticity of  these facts,
 M. Chelius replied, that they had taken place under  his eyes, that they
 could be received with perfect confidence, and that he possessed others
 in every respect  similar to them.  To  explain their frequency at  the
 University  of Heidelberg, it suffices to know that sabre duels are there
 extremely  frequent among the  young men, and that M. Hoffacker has
 been appointed  surgeon  of duels, by the senate.  It is next to  impossi-
 ble, therefore, to reject absolutely,  and without qualification, all the his-
 tories of this  kind that  are related  by authors.  The case of a nose
 which was entirely detached, and which  was reunited with success is
also related by M. Barthelmy (Journal Hebdomad, et Univers., t. v.'p.
15) on the  faith of Regnault, of the Gros-Caillou.   The nose 'removed
by the  bite of the teeth,  could not be replaced until at the end of five
hours, yet it reunited.

                        § II.— The Fingers.

  Similar observations, also, have been made on a great number of other
parts.   I have had a case, says Regnault, (Gaz. Salut., 1774, No. 26
p. 4,) where I replaced,  without any  unpleasant result following, the 
ANAPLASTY BY RESTITUTION.
557
 whole external ear, that had been removed by the bite of a horse; and
 if my observations required proofs, I could furnish them.
   In a long note by M. Magnen, (Bullet, de la Facult., t. vi., p. 497 et
 507,) we find also the case of a portion of the concha (the external ear)
 entirely  separated, and then reunited.   M. Manni (Filiatre  Sebezio,
 Mai, 1834;  et Arch.  Gen. de Mid., 2e serie, t. v., p. 300)  has more
 recently related the  history of an ear cut off by the stroke of a sabre,
 and which he reunited with success, by means of a suture.
   The fingers, also, for half a century past, have been the occasion of
 numerous  operations of  anaplasty, by  transplantation or restitution.
 Heister.  (lnstitui. Chirur., p. 468) cites an  example of it in the wife
 of a butcher.   Bossu d'Aras (Thomson, Trait. Chir. de Vlnfl., p. 241)
 says he succeeded  in a similar case; and Flurant  mentions, according
 to M. H. Berard, (Rev. Mid. 1830, t. iv. p.  416,)  the case of a laborer
 who had the extremity of his left forefinger removed, and in whom ana-
 plasty succeeded perfectly well, though  the division had comprised the
 articulations of the two last phalanges.
   These facts, nevertheless, were passed by unnoticed, when Balfour, in
 1814, made known two others, with all the details that could be desired.
 Since that time, there have  been  published a great number of them in
 the  periodical journals.  Thomson, says that different  persons, whose
 veracity he has no reason to suspect, have related to him a great number
 of examples, in which the phalanges of the fingers or toes had been to-
 tally separated, yet nevertheless reunited, (Thomson, p. 242.)  A sur-
 geon of d'Armentiere, M. Lespagnol, (Bull, de la Facult., t. v., p. 313,)
 published, in  1818,  through the medium of M. Percy, an observation
 similar to that of Balfour.  A similar fact was communicated, soon af-
 ter, by Agouge, (Ibid., t. vi., p. 50;) but information obtained from the
 spot, authorizes us to call in question the existence of any such physi-
 cian, as well as the authenticity of  his facts.
  More recently, M. Houston (Arch. Gen., t. xi.,p. 447) has published
 the case of a thumb completely reunited in this manner.   We find in the
 Bulletin  of Ferussac, (1830, p.  229,) an analogous observation  taken
 from the  English journals.  M. H.  Berard, (Rev. Med., 1830, t. iv., p.
 417,) on the authority of Wigorn, mentions the case of a young girl who
 had  the muscular mass of the left thumb removed, and who recovered
 exceedingly well  by anaplasty.   One of the  most  ancient histories of
this kind was published  by Regnault, (Gas-. Salut, 1714, No. 26.)
  " A youth of fifteen or sixteen years of age, finding himself crowded
by a chariot at the corner of a street, placed  his belly against the wall
 and his left hand upon the angle of  the same wall, in order to hold him-
 self  more steadily; the end of the axle-tree  grazing a little  too  near
 this angle, tore off the little finger at the articulation of the second with
 the third  phalanx.  The finger had  fallen, and the young man  took it
 up;  I was called immediately, and readjusted  the detached finger, which
 I took care to keep in its place by a containing bandage.  I made him
hold  his hand down, and  the  little finger in a glass of brandy during
 two  hours.   The finger united exceedingly  well in a few days, and so
perfectly, that  to-day he has as much strength in  this  part, says Reg-
nault, as if it had never been detached."
  It has nevertheless  been necessary, in order to draw attention defini- 
 558            NEW ELEMENTS OF  OPERATIVE SURGERY.

 tively to these facts, that many surgeons  of known  reputation should
 furnish others of a similar  character.  Somme (Traite  sur  Vlnflam.,
 p. 42) has communicated a case of reunion of the end of a finger which
 had been completely separated.  M. Piedagnelh as related a similar case,
 (Revue Med., 1830, t. iv., p. 405.)   M. Bar  thelemy (Journal Hebdom.
 Univers., t. v., p. 15) speaks of a  portion of  skin  removed  from the
 inner side of the sole of the foot, and which  reunited  perfectly; after-
 wards of two similar reunions, where fingers had been severed.  M. Beau
 (Arch. Gen. de Med., 2e serie, t. iv., p. 472) practised anaplasty  with
 success, in a woman who had lost her thumb at the  Salpetriere.  M.
 Despres, who at the Hotel-Dieu endeavored to reunite a finger by the
 same  method, says that just as Dupuytren,  (lb., p. 480,) who did not
 believe in the reunion of the  parts, was going to pull upon them under-
 neath, to detach them, it was seen that the union, by intercommunication
 (abouchement) of the vessels, had in reality begun.
  We  ought, nevertheless to add, that many of these cases not having been
 attended, in all their stages, by the same person, and being found almost
 always deficient  in  details, have continued to create a certain distrust.
 I myself hesitated to admit of their accuracy, until an observation ab-
 solutely  conclusive,  succeeded, in 1837,  in  removing all my doubts.
 A member of the Royal Academy of Medicine, M. Gorsse, cut  off the
 pulp of the left forefinger by the stroke of a razor;  the piece fell upon
 the ground; the patient hastened to pick it up, cleaned it and reapplied
 it, and held it in its place by means of a handkerchief.   Having reached
 my  study in less  than  half an  hour, he again let the end of his finger
 fall while unwrapping  his  hand.  Having picked up this fragment of
 tissue, I washed it in pure water, replaced it accurately upon the wound,
 which still bled, and fastened it there  by  means of small  compresses,
 and then a roller bandage methodically applied.  It was  agreed that
 the dressing should be  saturated with spirits  of camphor,  three or four
 times  a day.  Pains, somewhat  acute, were experienced for the space
 of a week.   I  renewed the bandage on the  the fifth day and again on
 the  tenth, and finally removed it upon  the twentieth.  No suppuration
 had taken  place ; the  cuticle alone had assumed a dark hue, and came
 off in  the form of an eschar on the  twenty-fifth  day.   The  portion of
 skin and fatty cellular tissue had reunited completely ;  and M. Gorsse,
 showing his finger a month afterwards, perfectly cicatrized, brought con-
viction to the minds of his associates, in presence of the whole Acade-
my.   A similar accident happened  to another surgeon of Paris, with
this difference, that the flap of integuments  still held on by a filament
of cuticle, and  that the size of the flap was only a fourth  part  that of
 M. Gorsse.

       [Reunion of a Completely  Separated Portion of Finger.

  The case  of M. Velpeau, in the  text, is fully confirmed  by one of
Mr. Alex. Graham, at Edinburgh, (Edinb. Monthly Journ. of Med.  Sci-
ence, April, 1841,) in which a joiner, of middle age and healthy consti-
tution, entirely severed the  left forefinger by an axe, between the  first
and second  phalanges.  He lifted  the separated part from among the
shavings, and walked a few yards to where the surgeon  happened to be. 
ANAPLASTY BY  RESTITUTION.                 559
Being asked for the  separated  portion, he took it out  of his waistcoat
pocket and laid it on the table.  Mr. Graham fixed it on by two sutures
and an adhesive strap, and on the fourth or fifth day the patient found
that  the part had recovered its sensation, as  he could distinctly  feel
when it was touched  by the point of the scissors.   Complete  union was
effected, and a perfect  restoration of the  powers and  functions of the
finger.
  Another more recent  confirmation of the above cases,  is related by
Signor Delia Fanteria.  A girl, aged fourteen, had  two of her fingers
severed below the first phalanx by a knife.  The two  pieces were soon
after found in some meal, but each piece was separated into two portions.
He replaced them together,  and kept them upon the  parts from which
they had been separated, by sutures and strips of plaster.  In few days
the adhesions was  complete.   Marvellous as this  case appears to be, its
authenticity is confirmed by Professors  Centofanti and Vacca. —(Vide
British and Foreign Med. Rev., July, 1842.)—T.]
  I do  not, therefore, see how we  can possibly call in  doubt, at the
present time, the practicability of uniting, by anaplasty, tissues that have
been completely separated from the body.  In admitting  that most of
the facts related until now, are doubtful, or that they  have been imper-
fectly detailed, it is certain that some of  them have  a  real existence.
It would be of no  avail, for the  purpose of refuting  them,  that we
should  adduce facts of a contrary  character, or the want  of success in
cases of a similar kind.
  In place of rejecting this class of observations, surgeons  consequently
will, in future examine into them, and reserve a place  for them in prac-
tice.
  We must not on that account suppose that all parts  of the body  may
be thus agglutinated.  The  favorable or  unfavorable conditions, also,
are the  same for this order of reunions as for cases  of incomplete divi-
sion.   It is, therefore, in the fingers and  toes, and  in the palm of the
hands and sole of the feet, in the nose, ears, and face, and even in the
bones of the cranium, as we had already seen by  some observations of
Ambrose Pare, M. Maunoir, and M. Walther, that we may have reason
to hope for success.
  M. Chelius, who has frequently  seen cases  of this  kind, thinks  that
if success  is an object, so far  from  being in a hurry,  we should await
the cessation of the bleeding;  that we  ought not to allow ourselves to
be misled  by  the  unpromising appearance of  the part which has been
separated; that even if it assumes the  aspect  of gangrene, there ordi-
narily results from it desquamations only of the cuticular  lamellse, and
that the important point is, to put the  wounded surfaces  into perfect
contact.
   The choice to be made between adhesive plasters, the suture  or sim-
ple bandages, will depend upon the same circumstances  as those I have
previously pointed out.  Though, at the end of five or six  days, we no-
tice the tissues to be of a blackish  hue and flabby, as  if mortified  still
we must guard ourselves against abandoning every hope.   Though there
should  even be an elevation of the cuticle in  the form  of phlyctsense
with a reddish liquid, we should be wrong, provided the flap  has con-
tracted adhesions, not to continue to use means of reunion.  The great- 
560
NEW ELEMENTS OF OPERATIVE SURGERY.
er part of the facts that are given with details, prove that after the des-
quamation of some external  layers, the rest of the flap remains not the
less adherent to, and engrafted upon, the primitive wound.
                          CHAPTER II.

          ANAPLASTY BY HETEROGENEOUS TRANSPLANTATION.

  In all the cases that we have  been speaking of, it is the  part  itself
that we agglutinate ; but in another series of facts, we see that the mu-
tilation has only been repaired by borrowing from other parts, or other
individuals.   It is in this respect that anaplasty may be compared, in
every particular, to  the engrafting of plants.  However surprising and
inconceivable this species  of organic reunion  may at first sight appear,
it is nevertheless founded, at present, upon a certain number of experi-
ments  of very great importance.   It comprises two varieties.  Some-
times, in  fact, in order to remedy a deformity, we borrow a part similar
to that which has been destroyed ; sometimes, on the contrary, we re-
pair the mutilation at the expense of parts altogether different.
  The nose and teeth have served as a point of departure for these two
kinds of  operations.

        Article 1.—Transplantation of Analogous Parts.

  Ambrose Pare had already spoken of a sound tooth, which, extract-
ed by  mistake, and  immediately reinserted, had continued to  live.   A
fact  exactly  similar, is related  by Pomarest, (Bonet, t.  iv., p.  404.)
From  thence arose  the practice of borrowing  teeth, to replace  those
that had  been lost.   Hunter says that he had ascertained an actual vas-
cular reunion between the new  tooth  and  the socket.   M. A. Cooper
possesses a specimen  similar to that which  served as the foundation for
Hunter's assertions.  Fauchard, afterwards corroborated  by  Bourbet,
maintains even that a tooth, dead in all respects, when introduced into
a living socket may be retained and remain  there for years, without the
intervention of any  mechanical means, (Thomson, p. 236 a 241.)  The
proof, says Fauchard, that these transplanted teeth actually live, is, that
we can neither plug them nor sound  them, when they are carious with-
out occasioning the  most acute pain.
   [That a human tooth that has been for  years out of the body, and
thus, in  common parlance, dead, nevertheless possesses  the  principle
of vitality to a certain extent, and in a dormant state, like those seeds
of wheat that have  been for thousands of years  hermetically sealed, as
it were, and debarred from the vivification of  their germinating proper-
ties, in Egyptian sarcophagi, is a fact  that is familiar to every dentist;
since such teeth, set in the month even upon plates of metal, and espe-
cially of seahorse bone, are well known to reacquire their vital energies
by this mere contact with  the heat and breath of a living person so as 
ANAPLASTY BY  TRANSPLANTATION.
561
actually to become  carious, and decay like a living tooth in its  socket,
though of course without any pain.  We doubt, however, if such  teeth
inserted as stated above in a living socket, could ever possibly  become
repossessed of that degree of vitality which would assimilate their func-
tions to those of the living parts in which they were located.  The me-
chanical  experiments of charlatans in these  matters, and which  are too
well known, have produced the most disastrous consequences, in their
attempts to force the  agglutination of fresh healthy teeth of another
person, transplanted into sound gums where decayed  ones had been re-
moved to give place for them.  Destruction of the alveoli, gums, and
parts of  the jaw, and  extensive ulcerations  and abscesses in the roof
of the mouth, vault of  the  palate,  etc., have been some of the fruits of
this empiricism.  And the thing is not singular, when the immense dis-
parity, and proverbially known capriciousness of form, seen  in the roots
of teeth, are considered ;  for how  is it possible that there ever can be a
coaptation of the tooth of one person to the alveolus of another ? though
we doubt  not, if by quickly shaping  the former to a mould, taken as
quickly, of the cavity of the latter, by any mechanical means, the parts
containing and  contained  could  be brought  into as  close contact as
in  the  case  of the finger related by the  author  of this  work,  that
a reunion, more or  less perfect, would take  place.  There  is  no know-
ing, in fact, whether, in the unexampled  progress of scientific  discovery
in our days, a mode may not be discovered, resuscitated even from the
destructive experiments hitherto made  by dental charlatans, which shall
establish a new and most  profitable order of anaplastic  operations, by
the insertion of fresh living teeth into the toothless gums of  those whose
alveolar processes  have not yet  been  absorbed by  age.  A series of
well-conducted, careful experiments, might  even lead to the  formation
of an artificial socket in a sound cicatrized  gum and  alveolar  border,
and the immediate  insertion there of a fresh living  tooth, whose  exact
form  and  dimensions  had served as the model for the  cavity to be ex-
cised.  Some curious facts of deep abrasions of parts ih anaplastic ope-
rations, and  that have, nevertheless, healed perfectly, might  trace the
way for such experiments.—T.]

   [Transplantation of a  Sheep's  Tooth into the Alveolar  Socket of a
                               Child.

   M. Twiss, of Kerry, (Ireland,) states that he extracted the remainder
of a broken front tooth from a young lady aged fourteen, and transplant-
ed into  its socket (April 24,1831) the front tooth of a yearling sheep,
reeking  from the jaw of a living animal, previously shortening its root
about a quarter of  an inch.  It sat rather loose, but after the  first week
it became firm and soon  enlarged, but less than it would have  done in
the animal to which it belonged.  M. Twiss recommends  the teeth of
the sheep from the cleanliness of this animal, and from the beauty and
aptitude of their form.   He  would prefer the teeth of sheep  of two or
three years  old, as at that age they are about the size of adult human
teeth, and are more likely to grow when transplanted. The  root may be
shortened  or pared to fit in its  new situation, and kept in place by waxed
   Vol.  I.                    71 
 562            NEW ELEMENTS OF OPERATIVE SURGERY.

 silk ligatures.—(Vide London and Edinburgh Monthly Journal of Med-
 ical Science, Oct., 1842.)—T.]
   The history of noses restored  in  this manner are numerous and an-
 cient.  Van  Helmont relates, (De Magnetica Vulner.  Curat., p. 459,)
 that a man thus repaired saw, at the end of thirteen months, his borrow-
 ed  nose  putrefy  and  fall, at  the  moment when the porter who had fur-
 nished it died.  Dionis was told, (Demonst. des Oper., p. 589, 7e de-
 moust.,)  that  a robber, whose nose  had been cut off, ran to a surgeon,
 who asked him for the piece, in order to replace it.  Having lost it, his
 comrades ran out, cut off the nose  of the first person they met with, and
 brought  it fresh  to  the surgeon,  who reunited it  in  the most perfect
 manner.
  But, besides that  none of these facts  of anaplasty are authentic, or
 even probable, we cannot  see how it would be possible  to find venders
 of the article,  even though it were  allowable to appropriate in this man-
 ner the nose of another person.

   Article II.—Transplantation of Parts  that are Different.

  A method which  consisted in reconstituting a nose, or any other or-
gan, by means of  integuments borrowed from the breech of another  per-
son, is one which it appears has been very anciently practised in India.
M.  Dutrochet affirms that, upon the evidence of his brother, a general-
in-chief to an Indian  prince,  a subaltern officer, who had had his nose
cut off, went to consult some of the natives, who willingly undertook the
cure.   At the  end of a certain time, these Indians selected a place upon
the breech, which they excited  into  a swelling by repeatedly striking
upon  it  with  their slippers.  Having cut out from this part a piece of
tissue of the proper form, they applied it, and successfully kept it in its
place upon the destroyed nose.  If there were  only  this fact in favor of
the animal engrafting of which I am now speaking, it would be unneces-
sary to occupy ourselves  any farther with it; but the experiments of
Duhumel, (Acad.  Roy. des. Se, 1746,) from whence it results that the
 spur (Vergot)  may be engrafted  upon the comb of  a cock; those of
 Hunter, which  confirm the  same  fact;  the case of the testicle  of the
 same  fowl, which, after being introduced into the  belly of a hen,  con-
 tinued to live ; the  experiments of Baronio, which, if we are to credit
 him, would prove that the  wing  of a canary bird, or the tail of a cat,
 can also be engrafted upon the comb of  a cock;  other facts, also, from
 which, according  to  Bartholin, it would result that  the flesh of a  sheep,
 placed upon  the  wound of a sailor, adhered to it, and soon effected a
 cure ;  and the fact  related by Olaus, of a portion  of a fowl which had
 been advantageously employed in the cure of hare-lip; all tend to prove
 that actual animal engrafting is, perhaps, not absolutely impossible.
   Supposing, however, that  this was of  easy execution, it would be dif-
 ficult, as may be seen, to derive  any advantage from it, seeing that no
 person probably  would be  willing to submit themselves to such  opera-
 tions.  There  has, nevertheless, been presented in my  division  of the
 hospital  of La Charite, a  case, in which, strictly  speaking, it  would
 have  been allowable for  me  to have undertaken this species of trans-
 plantation, and I  really regret that I did not profit of the opportunity. 
ANAPLASTY by  transposition.
563
 A patient had  two deformed toes removed from which were otherwise
 perfectly sound.  Another patient, whose fingers had all been destroyed
 by  being frozen, would  have liked nothing better than to have had a
• small hook on each of their stumps.  It might have been, in this manner,
 easy for me to have engrafted the toe of the well man upon the metacar-
 pus of the maimed one.
  In  conclusion, the  question  of animal  graftings, by transplantation
 from  one individual  to  another, does not, as yet, offer any facts which
 operative surgery can profitably occupy itself with.  With the few re-
 marks  above, therefore, I will conclude  what  I had to say on this
 subject.
                          CHAPTER III.

                    ANAPLASTY BY TRANSPOSITION.

  In place of bringing back to the mutilated part the portion which has
been  completely separated  from it, as in anaplasty by transplantation,
we  confine  ourselves in anaplasty by  transposition to cutting and dis-
secting off the tissues, without wholly detaching them, in order to draw
them suddenly, or by degrees, to the destroyed parts.   Almost the only
kind now in use, this species  comprises two varieties that are very dis-
tinct;  the one consists in seeking at a distance the tissues suitable to
repair  the mutilation, the  other, on  the contrary, borrows  them  from
neighboring regions.  Destroying but incompletely the continuity of the
flap, anaplasty  by  transposition has nothing in it repugnant to the laws
of the  organization, nor contrary to sound surgery.   The whole consists
in knowing  how to cut in a proper manner the parts of which we stand
in need, and to preserve for them  a pedicle, or proper points of ad-
hesion.

Article  I.—Anaplasty by Remote Flaps,  or the  Italian  Method.

  One  of the most  ancient modes of anaplasty consists in  cutting the
patches, which  we have need of, from a  region more or less remote, and
completely distinct from that which it is our object  to restore.   This
method seems to have had its birth  in Italy, or in India.  I shall, how-
ever, designate it under the title of  the  Italian method.
  Every thing shows that it was first put  into use by practitioners, of
whom history has not preserved the name.  The family of the Brancas
do  not seem to have originated it.  If Bojano, or Voiano, have  been
enabled to discover its  source in Calabria, without  pointing out its au-
thor, it is evident, that it was an ancient method, and one whose origin
was already lost.  Tagliacozzi, who seems to appropriate to himself the
title of its inventor, has, in strict justice, the merit only of having regu-
larized and- perfected it, and of ultimately introducing it into  practice.
In  this species of  anaplasty,  the  progress of science has established
many processes. 
564
new elements  of operative  surgery.
                      §  I.— The Italian Process.

   Tagliacozzi was in the habit of taking his flap  from the outer and
 front part of the arm.  This flap, of a tringular  form, and whose  base
 remained adherent, was  immediately fixed upon the destroyed region,
 which had been previously pared.   When it was sufficiently agglutinated
 in its new position, the surgeon cut through  its root, in order to set the
 arm at liberty.  Nothing more then remained to be done, but  to mould
 the borrowed piece upon the organ to be restored, and to shape it to its
 new uses.
   Frequently performed in Calabria in the fifteenth  and sixteenth cen-
 turies, the  Italian method has been  the object of some new trials in
 more recent  times.   M. Roux made use of it in my presence upon a
 young girl, in whom  he  wished to  close up a hole in the face;  M. Sig-
 noroni likewise employed it for a mutilation in the face.   It is, neverthe-
 less, almost entirely abandoned.  If we  still wished, however, to make
 trial of it, we should not forget that the restorative flap suits so much
 the better, in proportion as the integuments of which it  is formed are
 thicker, more homogeneous, and more vascular.
   As it is almost impossible to keep the parts in a state of perfect rest
 by means of  adhesive  bandages, stitches of suture, sufficiently  approxi-
 mated, should,  I think, merit the preference  over containing dressings,
 properly so called.   It would, furthermore, be  superfluous to dwell upon
 the necessity of not comprising in the incision any more than the teguments
 and the  sub-cutaneous tissue.  If Vesalius, Pare, and others,  in citing
 the Italian method, have  spoken of the biceps muscle, it  has  been by
 inadvertence.  The plainest reflection is sufficient to show, that the flap
 which the Brancas  and Tagliacozzi made use of was never cut at the
 expense of the muscles.   The wound which results from it ought, more-
 over, to be dressed like any other simple wound.  Before detaching the
 base or pedicle of the flap, we must assure ourselves that it is perfectly
 agglutinated, and that it has acquired vitality at its edges.  This sepa-
 ration being made, we trim its angles with the scissors,  so as to adjust
 it accurately  upon the region upon which it is to  remain.   From fifteen
 to thirty days  are in  this manner  generally required to  complete the
 operation.  Sooner  than this period the new circulation  might not be
 established ;  at a later period it would have nothing  to gain.  The
 adhesion of the borrowed flap is well advanced at the end of the second
week, or it will not have taken place at all.

                     § H.—Process of Graefe.

  Perceiving that the patch of skin,  separated in  this  manner, has a
great tendency  to become gangrenous, that it agglutinates with  diffi-
culty, and also contracts to a considerable degree, some modern surgeons
have  adopted the plan of not applying it immediately  upon the new
region, and of giving it time to contract and to cicatrize  upon its edges
while yet in its  place.  In operating upon a young man, who had already
submitted, without success,  to another  kind  of anaplasty, M.  Graefe
after having cut the  flap upon the fore-arm, left it to cicatrize separately' 
ANAPLASTY BY TRANSPOSITION.
565
 and did not make the attempt to unite  it to the nose until after the ex-
 piration of some months ;  he took thus more  than a year to complete
 the operation, which, moreover, succeeded perfectly.  It is, in fact, true,
 that in the limbs  the cutaneous  flaps are too thin,  and  are provided
 with too large a proportion of adipose cells, to agglutinate with facility
 to the teguments  of other regions, or  to  be exempt from readily be-
 coming gangrenous.   In this respect, there are, in reality, some advan-
 tages in leaving the flap free, after it has been cut.  It is then seen to
 retract upon  itself, in the direction of its two largest diameters, to be-
 come thicker and  firmer, and more and more  vascular, and to assume,
 in fact, some of  the characters of the integuments of the cranium, or of
 the face.  When it has  become so,  we may, without fear, pare its edges,
 and fasten them, either by suture or bandages, on the part which is to
 become their new residence.  We afterwards proceed for the wound
 which results from  this flap, and for the section of  its root, when the
 flap has become  adherent in its place, as we do in the process of Tagli-
 acozzi himself.
   I should, nevertheless, add, that these precautions would be unneces-
 sary for a flap cut from the  palm  of the hand, the sole of the foot, or
 from the cranium or face.  The  arteries that course  upon the  internal
 surface of the skin in those regions, keep up too active a vitality there,
 to permit us  to  have any apprehension of mortification.  Even on the
 body of the limbs, the plan of M. Graefe would not be necessary, unless
 the flap should  be of great length, and had more breadth in its free
 portion than  at its base  or root.

 Article II.—Anaplasty by Flaps from  Neighboring Parts, or the
                          Indian  Method.

  The method which consists in taking from the neighborhood, tissues to
 repair the loss of substance in a mutilated organ, comprises, in truth, a
 great number of modifications ;  all of them, however, may be reduced to
 two principal kinds :—Sometimes, in fact, we cut a true flap in the neigh-
 borhood, but beyond the  circumference of the deformity, and in such man-
 ner as to be enabled to reverse it, turn it around, and  adjust it, like a
patch upon the part that it is  to cover: it is this fundamental character
of a pediculated flap, which constitutes,  in my mind, the Indian  method.
At other times, we confine ourselves to separating the parts all around the
 ancient solution of continuity, in  order to be enabled to elongate ap-
proximate, trim, and adjust them in contact by their free border, with-
 out either reversing or twisting them.   This is  what  I shall  call the
French method.
  The anaplasty which  consists in cutting flaps completely independent
 of the mutilated organ,  but at such distance as allows of our immediately
 covering them with it, is evidently derived from the Italian method, of
which, in reality, it is nothing more than an improvement.  It comprises,
 moreover, three or four processes.

                                §1.

  The Indians of the tribe of Koomas} formed a flap sufficiently  large to 
566
NEW ELEMENTS OF OPERATIVE SURGERY.
 fill up, in a suitable manner, the voids in the organ destroyed.  Being
 turned over from above below, and twisted upon its pedicle, they after-
 wards fastened this flap to the previously pared lips of the part to be re-
 constructed.  In acting in this manner, there is generally preserved only
 a very narrow pedicle to the flap, and as this pedicle  has to be twisted
 upon itself, there are but a very few regions where the method of the
 Kooraas presents positive chances of success.  Moreover, they employed
 it only to the  nose, where the vascularity of the skin, and the homogen-
 eousness and thickness of the subjacent tissues, render  gangrene difficult
 in the parts that are separated.  It results from  this, that in the chest,
 arm, and thigh, where I  have attempted to employ it, it offers no longer
 the same chances of success.  It is on that account, that early attempts
 were  made to modify it.

                                §11.

  In cutting the flaps thicker, it has been  found practicable, 1. To  turn
 them  back from below upward, thus folding them upon themselves, with-
 out twisting them, as  I have done for fistulas ;  or, 2. To twist them, as
 Delpech did in cheiloplasty; or, 3.  To detach  them  from within  out-
 wardly, to bring down their free border in another direction, as M. Roux
 has done in  a case of  genoplasty.  In certain cases, the flap  once cut
 has admitted, 4.  Of being rolled up like a cork, and held by a large root,
 as I have frequently  done ; but  all these  modifications, and also some
 others of the  Indian  method, will be more  easily understood in their
 special applications, than under the general head of  anaplasty.

     Article  III.—Anaplasty  by Separation of  the Tissues.

  We find some expressions in Celsus, which would lead  us to believe
that at the time of this writer, the mutilation of the ears, nose, and lips
especially, was sometimes repaired by a species  of  anaplasty.  Celsus
says, in fact, (Lib. 7, cap. 9, ou  trad, de Ninnin., t.  ii., p.  275 :)  We
begin by seizing hold of the  borders of the mutilated part;  after which
we make incisions at the  inner angle of the wound, in order to separate
its flesh and skin below  from those above :  we  then take the portion
which has been detached, and bring it upon  the part we wish to repair.
If the edges do not approximate  sufficiently, says Celsus, (Ninnin., t.
ii., p. 275,) we must make, in a crescent form, two other incisions, whose
points should be turned towards the wound, and which should not pene-
trate deeper than the skin :  "Alias duas lunatas et ad plagam conversas
immittere quibus summa tantum cutis deducatur."  This text, however,
is sufficiently obscure to have allowed of discovering therein the internal
separation of Roonhuysen, Van Horn, and Pauli, and the external gashes
of Guillemeau and Thevenin.  Valentin, (Recherches  Critiques  sur la
 Chir. Moderne, p.  249,)  who severely reproaches Louis with having mis-
understood there authors, and of imputing to them a practice which they
were not chargeable with, would have  been in the wrong, if Louis  had
not confounded the precept  of Van Horn with  that  of Thevenin since
the  semilunar divisions of some,  and the internal  dissections of  others
seem both alike indicated in  Celsus.  It may also be  urged as an objec' 
anaplasty by  transposition.                507
tion, that these  different  passages, whether  of Celsus, or of Thevenin
and Guillemeau, or of Van Horn, Roonhuysen, Pauli, etc., relate rather
to hare-lip, than to legitimate anaplasty.

                      § I.—Process of Franco.

   But Franco (Traite des Hernies, chap. 122, p. 462) explains himself,
on this  subject, in a manner altogether unequivocal.   If anaplasty by
separation of the tissues were not found in the Latin authors, it would,
however, be impossible not to recognise it in an example related by him
with much detail, and in which we perceive that he succeeded, by this
means, in closing a hole which a man had had for a long time in his face.
   The anaplasty of Franco, or by the  French method, exposes to fewer
deformities than any of the  others.  It is founded upon this  principle,
that when once  separated and  detached  from the subjacent  parts, the
cutaneous and the cellulo-adipose and  musculo-cutaneous tissues, yield,
elongate themselves, and  allow of being easily drawn to a very consid-
erable distance.  In adopting it, we succeed  perfectly in putting  into
contact  the sides or borders of very deep notches, and in filling up great
losses of substance.  We should, nevertheless, be wrong in therefore
concluding, like some modern  surgeons, that by this method it is always
possible to procure a great elongation of the parts.  In all regions where
the teguments are dense, or the tissues are firm and adherent, it would
be necessary to effect a  separation of some inches to obtain  an elonga-
tion of some lines.  Persons with retractile tissues, and firm flesh, are
rather unfavorable subjects for it.  In the face, there is scarcely any
other part than the lower  portion of the cheeks, and  the chin, which
will advantageously allow of it; in the cranium, we  would succeed still
less frequently;  on the neck,  breast, and abdomen,  and on the body of
the limbs, it is, on the contrary, a species  of anaplasty which gives us
great  resources.  To sum up, it is the method which is the best safe-
guard against gangrene, and  which allows of the speediest  cure, and
exposes  to the least risk  of deformity.  At the same  time that it does
not exact the  absolute displacement  of any  flap, it does not  require
wounds  upon the skin of sound regions ; but it has the disadvantage of
not filling up, except by  means of tractions, and  often in an imperfect
manner, those voids in which there have been extensive  losses of  sub-
stance.   Compelling us to destroy  the natural adhesions of parts to a
considerable  extent, it  singularly  favors erysipelatous  inflammations,
angioleucitis, and even phlebitis and the formation of dangerous purulent
collections.
   It should not, therefore, have the preference, except, 1. In individu-
als or in regions where the integuments  have an easy play ; 2. Where our
object is to remedy losses  of substance  that are of greater breadth than
depth ;  3. Where, by adopting  the Indian method,  we should be com-
pelled to cut the flaps in those  places  where it was  important  to avoid
all cicatrices and deformities.  It will be seen, however, that the method
of separation of the  tissues, is one of  those  anaplasties that we  shall
have the most frequent occasion to apply;  it results from this,, therefore,
that it embraces many varieties. 
568
NEW ELEMENTS  OF OPERATIVE  SURGERY.
  §  II.__Anaplasty by Internal Incisions, [or scorings.— T.]  or the
                          Process of  Celsus.

\  Though  the  text of Celsus leaves much to desire, it seems however
. that some  surgeons of his time, with a view to elongate the lips, the
 nose, and the ears, separated  those parts  from the surface of the bones,
 and afterwards scored them in different  directions, upon their  internal
 face.   This process, which has the advantage  of leaving no  cicatrix
 upon the skin, and of placing all the wounds in the interior, is  not cer-
 tainly to be despised, but it procures, in fact, but a very moderate elon-
 gation, and does not answer but in a very small number of cases.

 § III.—Anaplasty by External  Incisions,  [or scorings,— _T.] or the
                         Process  of Thevenin.

   A modification of French anaplasty, might be derived  from  the lan-
 guage of Thevenin, (CEuvres, in-fol., edit. 1658, p. 28,) and of Guille-
 meau, (CEuvres, in-fol., edit.  1049, p. 682.)  In  place of cutting  the
 separated  parts perpendicularly, upon their  internal surface, it is upon
 the skin (i. e. externally) that they afterwards score them, according to
 the process of those authors.  Thus, to relax the tissues, they make on
 each side,  at some distance from  the wound, long straight or semilunar
 incisions, which go through the  entire  thickness  of the  integuments.
 There is no doubt that by this method we may, from having  a  less ex-
 tensive  internal separation, favor better  the reunion of  the  separated
 lips of the wound, than by the process  of  Franco or Van Horn ; but, on
 the other hand, we create cicatrices  upon the surface, and deformities,
 from which the other method  exempts  us.  The regions where the sub-
 cutaneous tissues are more extensible than the skin, or where a uniform-
 ity  of the  surface of the body is a matter of  little importance, are con-
 sequently the only places which occasionally allow of a preference for
 this method.
   [Dr. Mott cannot  conceive what  utility there could have been  in the
 incisions upon the inside, as it is not the sub-cutaneous tissues that
 resist.   They are  always  sufficiently extensible.  It is the incisions on
 the skin  itself, externally, therefore, which  are the important point to
 be attended to—as that is the part whose  elongation we desire.—T.]

 § IV.—Anaplasty by Simple Lateral Incisions.  Process of Diffenbach.

   These lateral incisions,  which  are only spoken of by Guillemeau  and
^ Thevenin in reference to  hare-lip, have been adopted, in our time, first
' by  M. Dieffenbach, afterwards by a great  number of other practitioners,
 who have  more or less modified them.   Thus,  without separating the
 parts upon their internal  surface,  they are abraded and then reunited by
 the lips of the division:  but in order to relax the parts, and to prevent
 all  traction of the suture, there  is  made, upon each side, an  incision
 which  comprises^  the whole thickness of the skin, and which,  in place
 of being shaped into a semicircle, is made parallel to the wound created
 by  the loss of substance.   It is an operative  method, which has already 
ANAPLASTY BY  TRANSPOSITION.
569
been put in  practice about the mouth, cheeks, and velum of the palate,
and upon the sides of most fistulas, and one which I have made trial of,
also, in certain  cases  of artificial anus, ulcers in  the limbs, and per-
forations in the vault of the palate.  I feel that I am also justified in
saying, that wherever the  cicatrices do not disfigure, as  about the
genital organs, and the anus, and in the interior of the mouth, vagina,
and rectum, that it is a process which has  not yet been sufficiently in-
troduced into general practice.

     § V.—Anaplasty by Transportation of a Cutaneous Bridge.

  It has appeared to me, that in certain cases it would be advantageous
further to modify this  kind  of anaplasty ;  that is to say, that in order
the more easily to approximate the two borders of a  great  destruction
of substance,  in the limbs, for  example, it would not only be useful to
incise  the integuments on each side of the deformity, to a great length,
but also to separate them, [the integuments,] in order to construct from
them a flap  in form of a bridge,  adherent  by its two extremities, but
capable of being stretched to a very considerable distance by its inner
border.

     §  VI.—Anaplasty by Raising an Arcade of the Integuments.

  I  have modified, in still another form, the bridle which I have just
spoken of.   After having  incised it, and separated it as in the preced-
ing case, I have thought it advisable to raise the  flap which I had thus
dissected from the recto-vaginal partition, up to the interior of the blad-
der, with the view of closing a vesico-vaginal fistula.

           § VII.—Anaplasty in the Manner of  a  Drawer.

  In order to  obtain a complete elongation, Chopart  had, as it appears
to me, the idea, not only of separating the tissues to be displaced,  but
also of forming a flap with them, by means of two  parallel  incisions.
This process, which I have many times  seen employed by M. Roux, in
1824 and 1825, which allows of our giving to the flap such shape as we
wish, and of carrying it up or drawing it across to the opposite  border
of the mutilation, is now definitively introduced into practice.  Appli-
cable especially to the lower lip, the process of Chopart is equally suita-
ble to  the forepart  of the chest, and to  some regions of the abdomen
and limbs.  I have  to say, however, that in  order to fill up in this man-
ner a wound of three inches extent, after the removal of a breast, I was
obliged to cut from below a square flap of  nearly five inches in length,
and which ultimately terminated in mortification.

                 §  VIII.—Anaplasty by Invagination.

  M. Blandin ( Tliise  de  Concours, 1836) admits,  as a species of ana-
plasty, the operation which consists  of invaginating the integuments in
certain musculo-fibrous canals, the inguinal, for example, to make a ra-
  Vol. I.                    72 
570
NEW ELEMENTS  OF OPERATIVE SURGERY.
dical cure of hernia; but I do not think that this  invagination  can be
arranged under any head in the class of anaplasties.
  As to the other different  modifications and varieties of the  processes
of anaplasty which I have been  describing, it will not be possible to
point them out and to appreciate them, but when treating of this class
of operations in the regions to which they are most easily applicable.
                         PART SECOND.

                    ANAPLASTY IN  PARTICULAR.

  Reason points out, and practice proves, that anaplasty is applicable
to almost all the regions of the body, and that the different modifica-
tions of this operation  should be estimated precisely according to the
nature of each organ that requires it.
                          CHAPTER I.

                   ANAPLASTY OF THE CRANIUM.

  There can be no doubt that we could transfer to the cranium, all the
different  kinds of anaplasty  which I have  spoken of above.  As the
mutilations of this region do not, but in a very inconsiderable degree,
compromise  the beauty of the  person, it has scarcely been thought of
for them.  The lateral slits of Thevenin, and the method of Franco, are
almost the only  ones which permit of application, in cases that relate
to the destruction of parts in  the hairy scalp.   But  anaplasty by trans-
plantation, or  animal engrafting, has more  than once been made trial
of on the bones themselves.   Some surgeons, for example, relying upon
the  experiments of Duhamel, and of Hunter, have  thought, that after
the operation for trephining, it would  be  possible  to replace and recon-
solidate the osseous disc, in the  part  from whence it had been removed,
and to reunite the soft parts over it.
  Job-a-Meckren (Gooch on the Wounds, See) had already mentioned
the case of a Russian nobleman, who, having lost a portion of  the cra-
nium, undertook to replace it with an osseous plate, taken from the head
of a  dog, and  that the operation was perfectly  successful.   Also, M.
Maunoir (Diet, des Se Mid., art. Ent. Animate) formally advises this
method, to protect the  brain  after the operation of trephining.  Some
facts, more remarkable still, have been since related.   After having laid
bare the cranium of a dog,  M. Walther removed a disc of it by the tre-
phine ; the piece, completely  denuded of  its  soft  parts, was replaced a
little while after, and the integuments having been brought over, it im- 
OTOPLASTY.
571
mediately reunited.  The dog was killed a year after, and hardly a trace
of the callus could be found; but the bony disc was paler than the rest
of the cranium.   After  having performed the operation of trephining
upon a man, M. Walther, finding no  disease existing  under the bones,
immediately returned to its place the disc which  he had just removed.
A suppuration ensued, which continued three months, and was followed
by the  separation of a scaly plate of bone;  but  this  plate comprised
only the external table of the disc, and did not prevent the other part
from consolidating perfectly.  M. Merem, therefore, thinks himself au-
thorized to conclude, that it is proper in this way to reapply the frag-
ment  removed by the trephine, as often as we wish to attempt the im-
mediate reunion of the wound.  For myself, in reflecting upon the case
of M. Meckren, the facts of M. Walther, or the experiments related by
MM. Maunoir, Dubreuil, etc., I deem it incumbent upon me to proscribe
this  kind of anaplasty, seeing that it would be a means of favoring in-
flammation, or suppuration, within the cranium, and that the fact of the
reconsolidation, spoken of by authors, is not yet absolutely demonstra-
ted.
  [Dr.  Mott remarks, that he would  deem such an attempt in the high-
est degree reprehensible.—T.]
                           CHAPTER II.

                OTOPLASTY, (ANAPLASTY OF THE EAR.)

  The art of repairing the ear, is as ancient  as  that of restoring the
no§e.  Galen, and  Paul of Egina, as well as Celsus, speak of both.
Every thing leads us to believe that the Brancas, and other surgeons of
Italy, made many improvements in this process during the course of the
fifteenth and sixteenth centuries.  In the example given by Tagliacozzi,
he says, that  after the cure the resemblance between the two ears was
so exact, that they might readily be mistaken for each other. Otoplasty,
however, had  ceased  to be spoken of when Dieffenbach attempted to
reintroduce it into  Germany.  No doubt, if the whole body of the ear
was entirely carried away, we ought to give up the idea of restoring it,
and  to decide, as in the time of Pare, to  replace it by a metallic  ear;
but when it is destroyed only in part, and that at least one  half of it is
remaining, we may endeavor  to restore  it to its natural dimensions.
The lobe, especially, could be very easily  reproduced. While the loss
of substance  does not comprise more  than the anti-helix, or though it
should even include almost the whole  of the helix, we still  should not
despair of success.   Without  ever acquiring  the firmness  of the  de-
stroyed cartilages,  the new tissues that are put in  their place, attain
sufficient consistence  to render the deformity of the ear much less re-
pulsive.
  [Dr. Mott  has seen the whole  external  ear restored, where it hung
down and was held  only by a small pedicle.—T.] 
572
NEW ELEMENTS OF OPERATIVE SURGERY.
   The Indian and the Italian methods, moreover, are the only ones ap-
 plicable  to  the  ear.  To the cases of otoplasty by restitution, which I
 have  already spoken of, it is necessary  to add the  successful case of
 this kind which has been related by M. de Renzi, (Filiatre  Sebezio, etc.,
 Gaz. Med., 1834, p. 634,) remarking, at the same time, in reference to
 myself, that I have twice made trial of it without success.

                            The Operation.

   As with the nose, it is the skin of the  neighborhood  which is to fur-
 nish  the material for reparation.
   First Stage.—We  commence by  excising, shaping, and paring  the
 mutilated border of the ear.   We afterwards separate above, below, or
 at  the posterior  part of the concha, the integuments which  cover  the
 temple, mastoid process, or subauricular fossa in the neck, a little nearer
 to the meatus auditorius  than in a line with the abraded border, but in
 a direction  parallel with this border.  Another incision, of greater or
 less length, made at each extremity of the first, allows of our giving to
 the flap the form  and extent that we wish, an extent  which ought at
 least  to be one half greater than the  loss of substance would seem to
 indicate.  In dissecting  this flap in a circular direction, that  is to say,
 from  the first wound towards its adherent border, it is important to turn
 over with it a sufficiently thick layer of the cellular tissue which lines
 its posterior surface, and  which furnishes  it nutrition and life.
   Second Stage.—The surgeon immediately adapts the free  border  of
 the flap to the bleeding wound of the external ear, and effects its reunion    '
 by means of short fine needles, and a sufficient  number of turns of the
 twisted suture, delicately adjusted.  To  finish  the operation, we have
 nothing more than to pass behind the kind of bridge which results from
 this arrangement, a small band of linen, spread with  cerate, the  object
 of which is  to prevent  the reunion of the  dissected skin.  After havino-
 enveloped the whole  with compresses, wet with tepid water of marsh-
 mallows, we replace or leave the patient in his bed.   At the end of three
 four,  or five days, if the  adhesion is accomplished,  we may remove the
 needles, those at least that correspond  to  the points the most solid.   In
 the contrary case, we should examine if it is not advisable to substitute
 new ones in the place of some of the first.   When  the cicatrix is solid
 that is to say, from the  fifteenth to the  thirtieth day, we separate from
 the cranium the tegumentary flap, which being  now liberated, requires
 additional attentions.
  Third Stage—In the  first  place, it is requisite to  remove  all the
 inequalities of this flap, to round off its angles, in a word, to adjust  its
 external border.   In the fear that it may  mortify, we renew the dress-
 ings with emollient applications, for some days ; afterwards we treat  it
 as well as the wound which is left upon the head, like any other solution
 of continuity.  In retracting, it thickens and  hardens, and takes the
form of a raised border, and  after  being  first pale, then becomes red,
and remains for a  considerable length of time more highly colored than
the  parts surrounding the external ear.   Such, at least,  were the appear-
 ances in a case reported by M. Dieffenbach.
  [Otoplasty  has  been successfully performed  by  Dr. M'Clellan   of 
RHINOPLASTY.
573
Philadelphia, (Reese's Ed.  Cooper's Surg. Diet., Loe Cit.)  The ex-
ternal ear was buried in the adhesions of the cicatrix following a wound
of the head, and the deformity was remedied by dissecting out the car-
tilage, and elevating  it to its normal position, by flaps taken from the
adjacent integument.—T.]
                          CHAPTER III.

               RHINOPLASTY, (ANAPLASTY OF THE NOSE.)

  In Italy, and also in India, it was formerly the practice to cut off the
nose of criminals.  Sextus Quintus caused it to be enforced upon thieves
and rogues ; the king of Goorka inflicted the same upon the inhabitants
of Kirtipoor, in order, he said, that he might recognise them everywhere,
and to be able to apply to them the vile epithet of Nascatapoor.  Per-
sons have been seen who have themselves cut off their own nose, to es-
cape pursuit, or who have deprived others of it from motives of vengeance.
Charles II. thought he could not inflict a more  cruel punishment upon
the fcarl of Coventry,  who had  dared to speak lightly of two actresses.
Frederick II. treated  in the same manner a certain nobleman who had
complained, in  disrespectful terms, of having been enrolled  by fraud.
On the approach of the Danes, a great  number of women and young
girls cut  off their noses, it is said, with the view of securing their chas-
tity.  An abbess, with her forty nuns, did the same, when the Saracens
presented themselves  at Marseilles.  Let us add to these unnatural mu-
tilations, those which depend upon unforeseen accidents, which are caus-
ed by  small-pox,  syphilis,  cancer, frost-bite, scrofula, burns, etc., and
it will be conceded that the occasions for restoring the nose must have
frequently presented themselves to the surgeon.

                       Article I.—History.

  The  hideous  appearance of persons who have  had the misfortune to
lose  their nose, must  have  early created a desire to remedy, as far as
possible,  so repulsive  a deformity.   Thus Celsus (Meth. Mid., lib. 14)
and  Galen (lib. 7, cap. 9)  already spoke  of the  art of restoring  the
nose.   Nevertheless, it is only from the fifteenth century that rhinoplasty
has taken rank among regular operations.   P. Ranzano (Annal. Mundi
in Sprengel, t.  viii., p. 172) says, that the Brancas, father and son, sur-
geons  of Sicily, and  who lived in 1442, practised it with great  skill.
Bojano (Eloy. Diet.,  etc.) and  Benedetti  (Anatom., lib.  iv.)  speak of
it as a common practice.
  G. Tagliacozzi, who died in 1599, had  acquired so great a celebrity
in this matter, that they caused a statue  to be  erected to him in the
Anatomical  Amphitheatre  of Bologna.   Mercurialis, Fyens, Fallopius,
Vesalius, Read, (Sprengel,  t. viii.,) and Gourmelin, have spoken of the
art of remaking the nose.  According to Fabricius, of Hildanus, ( Cent. 
574
NEW ELEMENTS OF  OPERATIVE SURGERY.
 4, Obs.  31; Bonet, p. 399,) Griffon, of Lausanne, was a skilful nose-
 maker, (nasifex;) and A. Pare (OJluvres Compl., in-fol.,liv. 23, p. 671;
 liv. 17, p. 295) says they were  astonished, at the  court of Henry III.,
 when they saw reappear there the  chevalier de Thoan, who had been to
 Italy to have a new nose made.  Nevertheless, in spite of  so much tes-
 timony,  to which we  might have added that  of  Cortesius, Molinelli,
 Dubois, Garengeot, Rosenstern, Moinichen, Leyser, and Fioraventi, and
 notwithstanding, I repeat, so many and  such numerous  proofs, no one
 scarcely, among us, would have dared to admit the possibility of restor-
 ing the nose, when the work of Doctor Carpue,  published in 1816,
 placed the subject beyond  all doubt.  A Mahratta, who served in the
 English army, was  made  prisoner by Tippo-Saib.    This prince caused
 his nose to be cut off.  Returning among his comrades, Cowajec (which
 was the name of the prisoner) excited the pity of a Hindoo, who made
 a new nose for him in the presence  of T. Cruso and M. Finley, physicians
 at Bombay.  Pennant had made known an observation of the same kind
 in 1798, and Sir Maket affirms that  this  operation is in general use in
 the East Indies, where, Lucas says, it had been practised from the time
 of Hyder-Ali.  These facts, transmitted  to London, excited the notice
 of MM. Lynn, Carpue, and  Hutchinson, who  proceeded immediately to
 investigate the origin of the  Hindoo methods, as well as the advantages
 that surgery might obtain from them.   Doctor Carpue (Account of Two
 Successful Operations, etc.,  1816)  himself twice performed rhinoplasty
 with success.  M. Graefe (Rhinoplast. sive arte  Curt., etc., 1818) also
 occupied  himself with it, and made  known, in 1818, the result of his
 essays.   Trials of the same kind were soon made in France, by Delpech,
 Dupuytren, Moulaud, MM.  Thomassin, Lisfranc, and  Blandin.   MM.
 Travers, Liston, and Green, in England, and MM. Dieffenbach and Beck,
 in Germany, have all endeavored to extend the art of repairing the nose.
  In consulting the writings  of Tagliacozzi, (De  Curtor. Chirurg. etc.,
 Venis., 1597,) and of M. Carpue and  Professor Graefe, we are compell-
 ed to admit that, in  certain  cases  at least, the newly-made nose does
 not differ as much as might be thought from a natural one.  One of the
 patients,  also, operated upon by Dupuytren, and who  was seen at Paris,
 had no reason to complain particularly of this patching.   I have seen
 the patient whose case M. Lisfranc  has  published.  In  him, the new
 nose was far from presenting all the regularity desirable.  Those of M.
 Blandin were better.  On the other  hand, we must not forget  that at
 Paris there are manufactured, out of plates of silver, leather, pasteboard,
and even wax, false noses, which are  capable of being kept on the face
by means of different  springs, or better  still, by suspending them  to
 spectacles, so as almost to entirely conceal  the deformity.   Boyer speaks
of a patient in whom, at the first glance, it was difficult to perceive that
he was wearing a nose  of this kind.  The metallic  nose, however, will
never, like a patched nose even of  the most deformed  shape, allow of
blowing, taking snuff, or the free use of the olfactory functions.

                Article II.—Operative Processes.

  As it is for the nose that anaplasty  was first invented, it is very natur-
 al that the different methods  which  I have spoken of above, should have
 been transferred to rhinoplasty. 
RHINOPLASTY.
575
               § I.—Rhinoplasty by  Transplantation.

  In the country  of the  Parias, men  who  possess  power do not, as it
appears, make any scruple of cutting off the nose of any of their sub-
jects, and putting it in the place of one that has been lost.   To believe
travellers, this  mode has succeeded so well, that, in order to prevent
criminals thus mutilated from remedying their deformities, they take the
precaution of throwing the nose into the fire, as soon as it is cut off.
  Rhinoplasty by restitution and transplantation not requiring any fur-
ther special  consideration, authorizes  me to refer, for  what  relates  to
this  subject, to what I have said  when  treating generally of anaplasty
by transplantation and restitution.

                § II.—Rhinoplasty by  Transposition.

  Anaplasty by transposition is applied to the nose, as to all other parts
of the body, whether we adopt the  Italian method, the Indian, or the
French process.

                     A.  The Italian  Method.

  There exist two  varieties of the Italian method: the  one ancient,
which preserves the name of Tagliacozzi; the other new, and of which
M.  Graefe is the  inventor.
  I.  Process of * Tagliacozzi.—Though in Sicily  and Calabria they
appear to have proceeded in various modes, there is one, however, which
has taken the preference of all others, and which is  generally adopted ;
it is that which Tagliacozzi, has made  known, and the only one which
was seriously entertained in Europe, until in these  latter  times.  The
surgeon  commences by imitating a nose  with  pasteboard or wax ; then
bringing the anterior surface of the forearm in front of the nostrils, he
immediately puts it back to its natural position, in order to spread out
upon the spot which is suitable the pasteboard nose, the point of it being
towards the shoulder ; having marked out the circumference of this nose
with ink, he by this  means circumscribes a triangular flap of skin, which
he dissects from  the point towards the  base, which  latter  is to remain
adherent.  A strip  of adhesive plaster  is placed  under it, to  approxi-
mate the lips of the wound.  After the expiration of a certain time, we
pare the edges of the deformed nose, as well as those of the tegumentary
flap of the arm.  Nothing now remains but to place  the bleeding edges
in contact with each other by means of the suture, while the arm is fas-
tened  in front of the face by means of an appropriate  bandage.   Dos-
sils of lint, also, are placed in the anterior openings of the nares.  When
the union is effected, we separate the base of the flap, and trim the lobe
of the new  nose in the best manner we can.  In certain cases, the sur-
geon confined himself to making in the forearm an incision, to which he
attached the abraded borders of the mutilated nose, until they had con-
tracted  intimate adhesions with the skin.  He had then nothing more
to do  than to cut and separate a triangular flap in the teguments  of the
arm, on each side, and  unite them  upon the median line, or dorsum of
the nose. 
576
NEW ELEMENTS  OF OPERATIVE SURGERY.
  II. Process of M.  Graefe.—In the method of M. Graefe, the patient
commences by putting on a laced waistcoat, surmounted by a hood, which
will hold the  head steady.   One of the sleeves of this  waistcoat, and
which is open  in front, has four leather straps near the elbow, and two
shorter  ones near the wrist.  The operator pares the openings of the
destroyed nose; takes the  measure, as in the process of Tagliacozzi;
marks  out and  cuts  the  flap in the same  manner; fixes the arm thus
arranged, by means of the straps  just mentioned ; and  makes use of
needles  and the twisted  suture, to maintain in contact the sides of the
mutilated  nose and the edges  of the flap of the arm.  At the end of  a
period, which  varies from four to thirty days, the union should be com-
plete.  We then remove the bandage, and  the base of the flap may be
detached.   Having brought it down upon the subseptum, [i. e., the co-
lumna, or inferior  border of the  septum  nasi.—T.,]  we  pierce it with
two openings,  which should  resemble the natural openings of the nose,
and in which  are to be inserted small pieces of gum elastic  catheter,
until the cicatrization  is complete.
  III.  Appreciation.—M. Graefe  is  almost the only one  among  the
moderns, who, in  modifying the Italian  method, has practised it with
success.  Having employed it  successfully in four cases out of five, he re-
turned to it again with no less advantage, in 1834, (Gaz. Med. de Paris,
1835, p. 168.)   M. Signoroni, (lb., 1834, p.  3,) who also attempted it
in Italy once,  failed entirely.   Here is a fact which  M.  Champion  has
communicated  to me, but which, however, must be placed  by the side of
those of M. Graefe :—A  young man, in 1823, having lost his  nose in
consequence of syphilis, consulted M. Wazel, who, after having put  him
upon a course  of mercurial treatment, restored the nose  by a flap from
the forearm.   All visiting to this patient was  interdicted, from  the  mo-
ment the operation was  performed, in order  to prevent the slightest
movement, and to exempt him from speaking.  The nose, examined some
months after, appeared thin and meager, and in strong contrast with the
rest  of  the  face, which was well  nourished ; in other respects, it  was
passable.  The young man, who said he had been punished during the
whole time of  the cure, from the restraint in which he was kept, did not,
however, at all regret having submitted himself to the operation.
  On the supposition that the Italian method should be practised in some
cases, we should take  care, mt  least in the beginning, to detach  the  flap
from the arm only by  a very limited incision, in order to preserve to it
a base of sufficient extent and vascularity to sustain its vitality perfectly.
The union of the borders, and  of the point of this flap, with the  abraded
lips of the mutilated nose, would not afford any prospect of success, un-
less it was aided by numerous stitches of suture.  Joining  the immovable
bandage to this first means of  union, the surgeon would have every pos-
sible chance of keeping the parts in the most perfect state  of immobility.
  It would, moreover, be required  not  to use  any compression, and to
prevent  every kind of  traction  upon the flap, until it should be evidently
adherent to the forepart  of the nose.  Another essential precaution
would be,  to give to it, at the first,  dimensions at least twice the size of
those which it  is ultimately to have ; dimensions,  moreover, so much the
greater, in proportion as the integuments employed in its construction are
thinner, more distensible, and more pliant. 
RHINOPLASTY.
577
  If gangrene has not taken place in the flap by the fourth or fifth day,
every thing promises  that its  vitality  will be maintained, and that the
union has actually taken place.  We should not, however, be in haste to
remove the stitches of suture, and to take  off the bandage.  It should
not be, moreover, until towards the fifteenth day,  or later, that we ought
to allow  ourselves to think of completing its section, in order to mould
it definitively upon the nose.   For this last stage  of the  operation, we
are sometimes under the necessity of reconstructing both the septum and
the alse of the organ.   We may do this in two ways :
  1. The base of the  flap, folded upon its cellular surface, and fastened
above the upper lip, is afterwards pierced on each side in such manner
as to imitate the two openings of the nose.  Two canulas, of gum elastic
or other substance, prevent the obliteration of these openings, and force
them to cicatrize  in the shape  of holes.
  2. We may cut also, upon the base of the flap, a pedicle destined to
replace  the subseptum.   The  rest of this  base, brought down on each
side to a sharp point,  is afterwards united, by other sutures, to the root
of the alae of the nose.   The canulas, of which I have just  spoken, are
here no less indispensable.
  IV. By  means of  a  Cutaneous Flap  from  the  Breech.—In some
countries, as soon as a person of rank has lost his nose, he procures a
slave, who  is struck upon his breech  with a slipper, until  the  integu-
ments in that place become  considerably  swollen.  A nose-maker, at
the expense of this part, so singularly prepared cuts a flap of the form
and width sufficient  to replace  the  lost nose, applies it and fastens it
firmly upon the  nostrils,  the openings into which  are maintained by
means of small cylinders of wood.  It is evident that this strange oper-
ation will never be practised in Europe.
  Y. By Transplantation of a Nose.—I have stated above, what value
is to be put upon rhinoplasty by tranplantation or restitution ; on the
testimony of Olaus, who says he had seen the flesh of a living fowl suc-
cessfully employed in  the cure of  hare-lip ; that  of  T. Bartholin, who
pretends that a sailor was promptly cured of a wound, with loss  of sub-
stance, on the hypochondriac region, by causing a surgeon to apply over
it some  sheep's flesh, which  soon adhered to and nourished it; on the
experiments of M. Baronio of Milan, contradicted, it is true, by those
of MM. Huzard and Gohier, but corroborated by those of Duhamel and
Hunter, from which it results that the skin from the flanks of an animal,
transplanted from right to left, or applied upon the same parts in another
animal, becomes  engrafted  upon  them,  and  continues to live;  on the
custom  of  those  youth  in the north  of Germany, who, as a pledge of
intimate friendship, each one  exchange a flap from the front surface of
their forearm; in fine, on those cases of fingers completely separated
from the hand, which so many authors mention, and which I have al-
ready related.

                     B.  The Indian Method

   The different processes of Indian anaplasty have been applied to the
nose, more than anywhere else.
   1.  With the  skin  of the  Forehead, or Process of the Koomas.—In
   Vol.  I.                     73 
578
NEW ELEMENTS OF OPERATIVE  SURGERY.
the process which has been especially followed in England and France, we
begin, as in the Italian method, by imitating a nose with pasteboard, or
wax;  wc afterwards reverse this pattern, by spreading it upon the fore-
head in such  manner  that its point may be turned downward.  Its cir-
cumference is  also touched with some coloring matter.   The flap is thus
traced  out.  The  operator, who  dissects it, taking  care to leave at its
base a small prolongation, destined to replace the nasal sub-septum, re-
verses it from  above downward to  the ossa nasi;  twists the pedicle, that
the cutaneous  surface  may remain outside; pares and smooths the con-
tour of the  nares; unites  with their bleeding borders, the edges of  the
frontal flap; maintains the whole in contact, by means of a composition
of Japanese earth, or  the  suture;  brings  down the median pedicle up-
on the  front of the upper lip, and fills up  the  openings  of this  new
nose with small  compresses,  rolled into the shape of cylinders, or with
quills, or canulas of gum elastic.
  The  Hindoos scarcely  ever employ the suture.   But M. Carpue has
thought it advisable to put it in practice, and Delpech- who says he has
performed rhinoplasty  several times, insists that it should not be neglect-
ed, and that we should give the preference to the  twisted suture.
  Among  the  modifications which this process has undergone, there  are
three which I  propose to speak of.
  II. The first trials, as we have said, of Indian rhinoplasty, were made
in  England, Germany, and France; in such manner  as that a  bridge of
sound  parts might remain intact between the pedicle of the  flap  and the
part of the nose which was to be restored.  Thus practised, the opera-
tion requires  that we should  divide this pedicle, and excise  its free por-
tion, as soon  as the adhesion  of the flap itself is effected.   It results
from  this, that the new nose, feebly sustained above, sinks down more
than is desirable, shrinks into the form of a tumor, and assumes a pal-
ish tint, which  contrasts  with the rest of the visage.  A patient  thus
operated upon  by Delpech, and whom  I saw at Paris, had a nose that
was wrinkled  and shrivelled like a potato, and which a lupus,  moreover,
finally destroyed.
  III. In order to remedy this inconvenience, M. Dieffenbach makes  a
slit at the root of the  nose, and fastens into this  cleft the pedicle of his
flap, in order  that there  may remain  no free integuments  below.  By
excising, at a  later period, the  projecting  portion  of this  pedicle, M.
Dieffenbach finds the flap blended  with the dorsum of the nose, supplied
with large-sized vessels, and  secured from  all downward tendency to-
wards the upper lip.  Many  patients, says  M.  Dieffenbach,  who were
thus treated, obtained  so much advantage from it, that their nose hardly
differed from a natural one. Jt is at least certain, that  a woman, somewhat
over thirty  years  of age, who had the point of the nose destroyed by  a
lupus, and  whom I requested M. Dieffenbach to operate upon in  1833, in
my division  of La Pitie, was tolerably well satisfied with the restoration.
I  should  add, nevertheless, that rhinoplasty, in  the the  hands of this
surgeon, becomes  a very complicated operation.   After having  engraft-
ed his flap, he cuts from it, sometimes on one point, sometimes on anoth-
er, different portions,  which  he excises or transposes according as the
 new nose has need of being  raised up, depressed, inclined,  or flattened,
 in  this or that direction, where it has the appearance of being too thick 
RHINOPLASTY.
579
or too pinched.  Each of his patients, therefore, have to undergo as many
as five or six operations, before they are cured.
  IV. In a  patient operated upon in 1825, at La  Pitie, M. Lisfranc
brought  down the incision of one of the borders  of  his flap, quite into
the mutilation ; then, in  place of twisting  this flap upon its axis, in the
manner of the Koomas, he turned it over, brought it around upon its
side,  and was enabled to attach it from one end to the other, to one
of the sides of the opening to be repaired.
  We have, in this  manner, a pedicle which forms  a kind  of pucker,
open  below, but which  is not separated by any bridge from the wounded
surfaces.  It is true, that the  nose obtained  in  this  manner remained
quite misshapen ;  but  as the flap  had been  badly united, and the sur-
geon, in the place  of sutures, had made use of simple strips of adhesive
plaster, the  failure, under such  circumstances, proves nothing  against
the process.
  V.  M. Blandin, at  a  later period, adopted a mode somewhat differ-
ent ;  having  brought down and  attached the parts in the manner of the
Hindoos, he excised the intervening cutaneous portion, in order to place
the pedicle  of his flap in immediate contact with this bleeding surface,
where he kept it fixed  by means of compression.
  VI. The  Author.—It appears to me  that authors, in  this way, are
pursuing the shadow of the difficulties, and that it is a matter of little
importance, whether we follow  one of these processes or another.   If
the immediate adhesion of the pedicle, in one respect,  has its advantages,
it  has also  the inconvenience of rendering the operation more difficult
and longer, and of requiring tractions  and  a degree of teusion, which
manifestly interfere with the integrity of the  circulation in the flap.
  To prevent the sinking down of the tip of the nose, which MM. Dief-
fenbach and Blandin appear especially desirous to avoid, I should  pre-
fer, after the principal adhesion  has been effected, to  cut off the pedicle
very high up, to trim it, and shape it into a triangle with the  point up-
ward, to excavate a notch  for  it, and to attach it, by some additional
stitches of suture,  to the root of the nose, and in a cleft  in the neigh-
borhood of the forehead.   It would be the means of obtaining every de-
sirable degree of regularity in  the new organ, without having  to  fear
the  embarrassments and the difficulties which present themselves in the
modifications of which I  have been speaking.
  If it be important to preserve  carefully, in  the pedicle of the flap, all
the  arteries of any considerable  size that may exist there, it is not be-
cause the absence here of important  arterial trunks exposes us to all
the  inconveniences that M.  Blandin has specified; but  because, what-
ever  M. Dieffenbach may say of it, the more  active  the circulation in
the  flap is, the more  are the chances of our seeing its vitality sustained,
and of our obtaining its adhesion.
  If,  on the day after, or on the following days, the new nose should
appear swollen, or livid, it may be  advisable to use some  bird-peck
punctures to it, or to cover it with leeches.  Lotions, often repeated, of
spirits of camphor, and infusion of chamomile, appeared to me to favor
the  success of the  operation, in the patient whom I confided to the  care
of M. Dieffenbach in 1833.
  It has also appeared to me, that the simple suture, with stitches very 
580
NEW ELEMENTS  OF OPERATIVE SURGERY.
 nearly approximated, as employed by this surgeon, are preferable to the
 twisted suture, or to the stitches of  suture at long intervals, as adopted
 by other practitioners.   We also take away this suture on the day after,
 from the places where the adhesion  appears evident, and afterwards, ou
 the second, third, fourth, and fifth day, from the rest of the wound.
   As to the wound  in the forehead, I do not agree in opinion  with the
 Professor  of  Berlin, who  recommends that  we should  approximate its
 borders  as much as possible by means of suture, and who, in order to
 favor this  approximation, has recourse to long vertical  incisions on the
 sides of  the  temples.   In proceeding in  this manner, we favor the de-
 velopment of erysipelas, diffused  phlegmons, or meningitis, and which
 we cannot afterwards  always control.   For, out of five or six  patients
 operated  upon in the  hospitals  of Paris,  at  the time I have mentioned,
 two of them died, and  the others experienced very serious symptoms.
 I would, therefore, content myself with a very moderate approximation,
 made  by means  of  strips  of adhesive plaster of diachylon, then  with
 simple dressing; being well convinced that  the action of  cicatrization
 itself would soon gradually close up the wound,  and finally reduce it to
 a very unimportant affair.
   To sum up all, the Hindoo rhinoplasty is a serious operation.  Of two
 patients, M. Blandin came near losing one of them ; one of those of M.
 Lisfranc died.   M. Dieffenbach lost  two out of five or  six, at Paris. If
 M. Green, (The  Lancet, 1829, vol. i., p. 24,) M.  Doubovitsky, (Gaz.
 Med de Paris, 1835, p. 748,) and M. Warren,  have  also performed it
 with success, M. Travers  (Bullet, de Firussac, t. i., p. 352)  has  seen
 the half of the flap mortify, and his patient left with a greater deformity
 after, than before the operation.
   A peculiarity sufficiently  remarkable is, that the point of the nose of
 some patients, operated upon by the Hindoo method,  becomes  covered
 with hair; and that in some of them, when it is touched, it  conveys the
 idea of pressing on the forehead.
   VII. Ala and Sub-septum.—If in the  place of the tip, the patient
 has  lost one of the alae of his nose,  it is  from the neighboring cheek,
 and not from the forehead, that we should borrow the flap ;  but it is evi-
 dent that the  French method, in such cases, would answer  better than
 the  Hindoo.
   It would be otherwise, if the sub-septum alone was wanting.  Then
 we should imitate  M. Liston, (Bulletin de  Firussac; Practical Sur-
gery, See, p. 233, London, 1837,) cut out a vertical flap of tissues from
 the  middle of the upper lip, and  raise it up in order  to fix its apex to
 the point of the nose.   Afterwards  reuniting the wound of the lip, as
 in hare-lip, we should, of course, take care to keep the small flap firmly
 supported against the  septum of the nasal  fossae.  We should, never-
 theless, succeed  better if it were  possible to unite also the  upper edge
 of this flap, with  what remained  of the septum itself.
   [If there is none of the septum  remaining, Dr. Mott thinks it useless
 to attempt this operation.—T-]

                      C.  The French Method.

  Rhinoplasty, by the French method, consists much more in the repair- 
RHINOPLASTY.
581
ing of a nose, than in the formation of a new one.  M.  Dieffenbach,
(Bull, de Firussac, t. xix., p. 273,) who, following after  M. Larrey,
(Clinique Chir., t. ii., p. 15,) has revived this operation among us, cuts,
pares, detaches, and raises up, the borders of the mutilated nose; then
adjusts between them, in order to hold them up and to fill the void that
separates them, small flaps or strips, that  he takes from the neighbor-
hood ; then unites the whole, with fine needles and the simple or twisted
suture.  The passages of Celsus,  which  seem to have reference to rhino-
plasty, had, as I think, this  manner of proceeding  in view.   It is  in
dissecting  the  circumjacent  tissues that Franco  succeeded, as we shall
see further on, in restoring the cheek of one of his patients.  We  should
add, that a rhinoplasty of this kind, performed  by M. Larrey in 1820,
was completely successful, and that  the soldier was exhibited  cured to
the faculty of medicine, where I had an opportunity of examining him.
Ajnong these cases, M. Dieffenbach insists principally on that of a young
girl, in whom  the vomer, the ossa  nasi, and the plate of the ethmoid
bone, had been destroyed by scrofula; and in whom the nose, in place
of being convex,  was found  depressed, and as if sunken  in.  Several
incisions, much more nearly approximated to each other in the direction
of the forehead, than towards the  upper lip, enabled him to bring out
the middle portion of this apology for a nose, and thus to raise up its
sides.   Other incisions,  which were transverse or semilunar, gave him
an opportunity of uniting the little strips circumscribed by the first, and
of borrowing from the lip a small flap to replace the septum.  Numerous
needles were then applied, in  different directions, and by the aid  of sev-
eral small repairings, which  some  accidents  rendered necessary, M.
Dieffenbach finally succeeded  in giving to the nose of this patient a tol-
erable shape, and  a certain degree of regularity.
  The trials which since the last  ten years  have been made,  of this
method of rhinoplasty, in France,  Germany,  England, America, and
Italy, enable us, at the present time, to lay down the steps of the oper-
ation according to  certain rules.   It  includes, moreover, two distinct
processes:
  I.  Rhinoplasty by simple Separation of the  Tissues.—After  having
separated by dissection the teguments around the deformity, to the ex-
tent of half an inch or an inch, it is generally easy to stretch the parts
and draw them towards  each other, so as to be enabled to bring them
into contact by their previously pared edges.  This process, which  ap-
pears simple and natural, has  the inconvenience of requiring a consider-
able separation of the tissues, where there exists a loss of substance to
some extent,  and of exposing to a  retraction, difficult  to  manage.   A
nose restored in this manner, and  which I have had an opportunity of
seeing at the  hospital of La Pitie, became by this means so flattened,
that it finally sunk to  a level with  the rest of the face.   In  the  suc-
cessful cases cited by M. Signoroni,  (Gaz. Mid. de Paris, 1834, p. 3,)
he  does not appear to  have been more  fortunate.  In  spite  of  the
good  opinion which M. Serre has of it, (Compte rendu de la Clin. Chir.
de Montpell., 1837,) this inconvenience will-always render French ana-
plasty painful, and of but little  advantage in its application to the mu-
tilations of  the nose.  It would be useless to rely upon it, for example,
when a portion of the bones, and of the cartilage  of the  septum, have 
582
NEW ELEMENTS OF OPERATIVE SURGERY.
been destroyed.   When the  point  alone has disappeared, it is yet still
more  frequently found to  be  unavailing.   It is for losses  of substance,
therefore, of little extent only, that  it should be reserved.
  II.  Rhinoplasty by  Combined Dissections  of the Tissues.—If, after
having dissected the tissues, as in  the preceding case we incise them,
in order that we may displace them with  more ease, we have a method
which puts it in our power to repair a great number of deformities.  In
a young man who had lost  the  whole of the right ala of his nose,  M.
Mutter (Case of Autoplasty, etc., Philadelphia, 1838) enclosed the hole
by a  V-shaped  incision reversed,  and then removed it.  A horizontal
incision, carried towards  the cheek bone, enabled him then to make an
L-shaped incision of the outer branch of his first wound.   Then dissect-
ing off the flap thus bounded, he was enabled  to bring it inward and in
front, up to near the  meridian line, where  stitches of suture fastened it
to the anterior  branch of the A.   The  operation  was  completely suc-
cessful.
  Upon the supposition that  we might find this method too difficult, it
would be necessary to call to our aid the lateral incisions of Thevenin,
or, better still, to detach completely the outer  or jugal side of  the flap,
which  could  then be transported (transporter) at the  pleasure of the
operator.

            D. Relative  Value of the Different Methods.

  Of all the methods, those of the Koomas, evidently the most painful,
have, moreover, the serious objection of only correcting one deformity,
by producing  another.  As one of  its consequences,  the  forehead be-
comes necessarily the seat  of an ineffaceable cicatrix, sometimes of great
size.  In persons whose eyebrows blend with  each  other  upon the me-
dian line, or who have their  hair very low, the base and another part
of the flap may, after the  cure, become covered with hair, and without
our having it in our  power in any way  to prevent  it.   Few persons
among us, at the  present  day, would  consent  to sell  their  nose to the
rich patient, that would like to make use of it to mend his own.  Though
what  has been said,  therefore, of this species  of animal grafting  were
true, we  could  not put in practice  the method of the Parias, unless in
those cases analogous to that  of which Garengeot speaks.   The  process
of the Mongolians, the most  outre of all, has  the same objections.   As
to the French  method, we should  do wrong,  as I  conceive, either to
adopt or reject it exclusively.  Applicable to cases of simple deformity,
to those where there  is but little  destruction of parts, it would no longer
answer where there is an almost total loss  of the organ.  A patient up-
on whom  M. Serre  performed it, and whom  I had  an opportunity of
seeing at La Pitie, derived but very little advantage  from it.  M. Mar-
jolin told me that he saw  a man who was operated upon in this manner
at Rouen, and who was not more fortunate.   Every thing,  for the first
few weeks, seems to  go on very well, but in proportion as°the cicatrices
become more firm, the  tissues retract, and the new nose becomes more
and  more  flattened  down.  The method of the Koomas is still  the one
which, in our time, has been the  most frequently attended with entire
success. 
RHINOPLASTY.
583
  So long as the bones have not disappeared, and  that the  point  and
cartilages only are destroyed, rhinoplasty may, to a great degree, reme-
dy the deformity.  In the contrary case, there is much to fear  that the
new organ will  be reduced to a sort of fungous substance, [i. e. mush-
room,] and always remain flabby, to such degree, indeed, as to shrivel
like a piece of linen  subjected to the action of atmospheric pressure.
When we make use of teguments from the forehead to construct it, pre-
serving, in the meanwhile, as much thickness  as possible to the flap, it
is important to leave  to the twisted pedicle the width only that may be
necessary to  keep up the circulation.  Before  separating it from the
root of the nose, and  cutting off as much of it  as extends  beyond the
line of the neighboring parts, we ought to wait  until the reunion of the
tissues, recently brought into contact, shall have been firmly established.
In the place of linen  rolled  in the  shape of a cylinder, dossils of lint,
and canulas of gum elastic, I should  prefer rather to keep in the open-
ings of the nares a piece of lead bent into the form of a ring, and which
might, at the same time, serve as a mould, or pattern, for the borrowed
patch with which the new organ has been formed.  In short, it appears
to me that Delpech has perfectly well combined all  the different stages
of the operation.  The modification of M. Lisfranc, or better still,  that
of M. Blandin, which is only an improvement of it, would, though never
absolutely  required, also have its advantages.   As to taking the tegu-
ments from the arm,  I do not know which would be the most advanta-
geous, whether  to follow the  directions of the surgeons of Sicily, or to
adopt the process of the professor of Berlin.
  In conclusion, rhinoplasty is as yet an operation too little practised
among physicians, not to allow of our performing it  in any manner we
please.  The circumstances, also, under which it may be required, are
so variable in their nature, that the details of the manipulations may be
left to the particular views of  the operators who may choose to under-
take it.

              [Rhinoplasty—Operation for the Columna.

  In adopting the Indian method, Mr. Liston of London, (in his Ele-
ments of Surgery,) says the hairy scalp  has in most cases to be en-
croached upon, to obtain the  slip of  tegument for the columna.  After
engrafting it on the lip, also, there is a risk of its not adhering, and if
it does, it will, as happened  in a case of  his, be difficult to  prevent its
shortening and turning inward upon  itself, and thus pulling down the
apex of the nose.  In the case to which he refers, a  columna was made
after the consolidation of the  rest of the organ, by  borrowing a thick
narrow strip, cut out  from the middle of  the upper lip.   This modifica-
tion has also been since practised by him with perfect success.   The
flap from the forehead is  made to supply only the  alas and apex, the
part for this last being only a slight but broad projection of  a few lines,
serving as well for the apex as for the attachment of the columna.  The
latter must not be cut till the forehead flap has perfectly consolidated.
This plan of M. Liston, for the columna, has been found by him  of emi-
nent service, in reparations where the columna only was wanting, and
in which the deformity is nearly as great as where the whole nose is 
584
NEW ELEMENTS OF OPERATIVE SURGERY.
  destroyed.  The inner surface of  the apex  is first pared, and the mid-
  dle portion of the upper lip, to the extent of about the eighth of an inch
  on each side of the  median  line, and of the  breadth of a quarter of an
  inch, is then quickly insulated, by two successive parallel incisions with
\  the  sharp-pointed  bistoury, piercing through  the lip  and proceeding
  from above downward to the free  border of the lip.  The frenulum is
  then divided, and the prolabium of the flap removed.  The flap is turned
  up (not twisted) and fixed  to the  apex  of the nose  by a few turns of
  suture, made with  the small  spear-pointed  hare-lip  needle.   Twisting
  the flap would incur a risk, and is  not necessary,  as the  mucous lining
  of the lip, forming  now the outer surface of the  columna,  readily  as-
  sumes the color  and appearance of integument, after exposure for some
  time, as is well known. .  The  edges of the fissure  in the lip must now
  be neatly brought  together by the  twisted suture, for  which purposo
  two  needles are  sufficient, which must perforate  to the depth of two-
  thirds of  the thickness of the lip—one  passing  close to the vermilion
  border.  Should troublesome bleeding  take place from the coronary
  artery, one  of the needles should  be made  to pass through the cut ex-
  tremities  of the vessel.   Each thread  is to  be  finally  secured by a
  double knot, and with a view to  more exact  compression,  the thread
  may then pass from one needle to  the other, but  the  pins must not be
  pulled upon, or  the  parts pucker in  healing.  The ends of the needles
  are to be  snipped off with plies, and no  further dressing is  necessary,
  as it might disturb the  wound on being removed, retain the matter,
  produce fcetor, and  retard the cure.   The needles may be removed, on
  the second or third day,  by gently  rotating them.   The crust  formed
  by the threads, and matter,  and  blood,  is not to be  disturbed, as it
  serves as a covering and  protection,  and comes off in a few days after.
  Some care is necessary in  raising and filling  up the alae with  lint, in
  order to effect, by proper compression, a repression of the cedematous
  engorgement which  is apt to ensue  in the columna.  The lower part of
  the columna, also, is to be  pushed upward, that it may come into  its
  proper situation, which is effected by a small roll of linen, supported by
  a narrow bandage passed over it, and secured behind the vertex.  The
  flap  from the lip is  of great advantage to that part, because, when the
  natural columna is  destroyed,  the  lip is apt to sag  down and tumefy,
  and  become elongated in  that very middle portion "from whence the  flap
  is taken ;  and besides, the cicatrix being in the natural fossa, is scarcely
  perceptible after the cure.
    Mr. Liston further remarks, that the alas of the nose,  and deficiencies
  in the upper, anterior, or lateral parts of the organ, in the forehead, etc.,
  may be supplied from the neighboring integument on the same  principle.
^  In many of these operations, the flap can be so  contrived and cut out,
  that  it can be  applied  without its attachment being  twisted—as by
  making a more or less acute angle in its pedicle, etc., which angle is
  effaced when the flap is  applied.  This last plan of Mr. Liston's, then,
  virtually becomes the French method, or anaplastic par decollement des
  tissues.—T.] 
BLEPHAROPLASTY.
585
                 [RHINOPLASTY IN AMERICA.

  The first successful case of the operation of rhinoplasty performed  in
America, is stated, on the authority of Dr. Reese, (Loe Cit.,) to have
been by Dr.  John Mason Warren, of Boston, in 1837.  In 1840,  he
again performed it four times ;  first on a female, by the  Indian method,
the flap being taken from the forehead, effecting in this manner the res-
toration of the entire nose.   In the  second case, he used the Italian  or
Tagliacotian method,  the flap being transplanted from the forearm, be-
ing the first successful case  of this method in America.  In the third
case, he restored the alse of  the nose, by sliding the flap  from the cheek
by the French method.   In  the fourth case, he again adopted the Ital-
ian method, for the restoration of the tip end and alae of the nose, the
flap being taken  from over the biceps  muscle.   In seventy-two hours,
the adhesion was sufficient to allow of the division of the flap; being the
shortest time on record in which that  has been done.  The patient was
well in two months.   [For the first three cases, see the Boston Medical
and Surgical Journal.]  As  remarked  by Professor Velpeau  in the
text, the sensations of the patient were generally found by Dr. Warren,
in his constructions of a new nose, to be referred to  the  place from
which the skin  was borrowed ; to the forehead,  in  those  cured  by the
Indian method, and  to  the  arm in the Tagliacotian.   The pins were
used in his first case, but afterwards the interrupted suture  was prefer-
red.  The new nose, in some of Dr. Warren's cases, was so perfect  as
not to be distinguished from a natural one.
  Dr.  George McClellan, of Philadelphia, has  performed rhinoplasty
four times, with  complete success.  Dr. Gibson, of the same city, eight
times successfully, since his first attempt in 1827, which, however, failed.
  Dr. Mutter, of Philadelphia, has performed rhinoplasty five times.
  Dr. Muzzey, of Cincinnati, (Ohio,) twice; once by the  Indian method,
successfully;  the other,  by the Italian, did not succeed.
  Dr. March, of Albany, has had complete success (Reese, Loe cit.)
in two  cases of rhinoplasty,  by the Indian method.
  Dr. Pancoast, of Philadelphia, has operated successfully with rhino-
plasty, in three cases.—T.]
                          CHAPTER IV.

           BLEPHAROPLASTY, (ANAPLASTY OF THE EYELIDS.)

  The eyelids, more than any other part  of the body, perhaps, are sub-
ject to alterations which daily make us sensible of the value of anaplasty.
Besides ectropion and entropion, which sometimes require this kind of
operation, there also occur losses of substance in the  eyelids, which can
be remedied in no other manner. 
586
NEW ELEMENTS OF OPERATIVE SURGERY.
                Article I.—History and Indications.

   The adage  of Celsus, Si palpebra tola deest, nulla id curatio resti-
 tuere  potest, (De re Medica, lib. vii., cap. 3, sect. 2, p. 391, edit.  Va-
 lart.,)  which  has  been a law in surgical  practice, has  given 'place, in ,
 our days, to an axiom totally  opposite.   It is now possible to restore i
 the  eyelids, as we restore the nose.   Moreover, blepharoplasty, or ble- \
 pharopoesis, which  some  surgeons of Paris, in 1833, viewed  as a  new
 operation, although  I had  pointed it out in the first edition of this book,
 is a process which was long since known.  M. Graefe employed it  suc-
 cessfully  in 1816 or 1817, since he refers  to a case of it in his treatise
 upon rhinoplasty, (Rhinoplastik, etc., Berlin, 1818.)  Another German
 surgeon, Dzondi, (Journ. de Hufeland, 1818,) makes mention of it about
 the same  time.  Nevertheless, the facts set forth by these practitioners
 were almost entirely forgotten when M. Fricke (Journ. des Progres, 2e
 serie, p. 56—80)  made  a decisive trial of it in  May, 1829.  At  the
 same time, almost, M. Jungken  (Journ. d'Ammon, t. i., p. 262 ;  Arch.
 Gin. de Med.,t. xxvii., p.  257)  published two cases of similar attempts,
 but  where it had  completely  failed.   From  that  time, blepharoplasty
 was omitted neither by M. Langenbeck, (Nosologie und Therap., etc.,
 t. iv., p. 188,)  M. Rust, (Handbuch  der  Chir., 1830, p.  97,)  nor M.
 Blasius, (Handbuch der Akiurgie, t. ii., p. 14,) in  their treatises.   It
 has since  been the subject of  interesting dissertations from the pen of
 M. Dreyer, (Dissert. Inaug.  etc., Yienne, 1831,)  M. Staub, (Dissert.
 Inaug.  etc., Berlin, 1830,)  and  M. Peters, (De  Blepharoplasiice, etc.,
 Leipsick,  1836,) besides the articles which MM. Dieffenbach  and Am-
 mon, in Germany, have devoted  to it.
   In France, MM. Blandin, (Journ. Heb.,  t. viii., p. 95 ;  Gaz. Med. de
 Paris, 1835, p. 406,) Jobert, (Gaz. Mid.  de Paris, 1835, p. 404,)  and
 Carron  du Villards, (Guid. Prat, des Malad. des Yeux, t. i., p. 364,)
 also soon directed attention to it.  We must add to their  observations
 those which have been  published by M. Robert, (Barbier, These, No. 6,
 Paris, 1837,)  and the  cases  which  belong to myself.  It results from
 these facts, that blepharoplasty has  now  been performed a sufficient
 number of times to enable us to  appreciate its value.
   The circumstances under which  this operation may be required, are :
 l.The  destruction of a greater  or less portion of the eyelids;  2. Cer-
 tain cases of shortening of the palpebral integuments; 3. Many of  the
 deformities ranged under the head of ectropion, entropion, and trichiasis.
 Nevertheless, the principal purpose of anaplasty to the eyelids, as else-
 where, should be to supply losses of substance in the skin.
   Blepharoplasty comprises many varieties, which, however, all belong
 to anaplasty by transposition.  No one has advised to apply to the eye-
lids anaplasty by transplantation, nor even the Italian method.   I will
 add, that blepharoplasty, though  it had already been performed in three
 different modes, that is to say,  by the method of the Koomas, or torsion
 of the  flap, that of Chopart, by drawing or sliding down of the flap,
 and by the method of Franco,  or stretching of the parts, has neverthe-
less  continued to be  almost exclusively  restricted to the processes  of
Indian anaplasty. 
BLEPHAROPLASTY.
587
       Whatever may be the process adopted, blepharoplasty will afford no
     positive chances of success, except  where the skin and the cellulo-adi-
     pose or fibrous tissues only are destroyed.  Nothing, in fact, can replace
     the muscles of the eyelids, if  they are found involved in the mutilation.
     It is through inadvertence that a surgeon of Paris (Gaz. Mid. de Paris,
     1835, p. 405)  has  said that he had  restored the entire thickness of an
     eyelid by means of blepharoplasty.   It is nevertheless true, that in the
     lower eyelid, and  in some  cases of  the upper  eyelid, where its levator
     muscle is preserved, we may  construct, with the skin  of the  neighbor-
     hood, something analogous to  the  tutamina  oculi, and thus  partially
     mask the deformity.   The destruction of the eyelids, by leaving the eye
     in perpetual contact  with the atmosphere, exposes the  patient to oph-
     thalmias of every kind, and to the destruction  of the cornea, and makes
     him sensibly feel how fortunate it would be, if he could  count upon the
     efficacy of blepharoplasty.

                     Article II.—Operative  Methods.

       The  different modes of performing blepharoplasty, have  almost  all
     been borrowed from  anaplasty  to  the nose.  The three principal pro-
     cesses for this purpose, which  science should  preserve, belong, one to M.
     Fricke, if not to M. Graefe, the second to M. Dieffenbach, and the third
     to M. Jones.   The figures  annexed to the  articles already cited from
     MM. Fricke, Peters,  and Carron, give a very  exact representation  of
     them.

           ,   § I.—Process of M. Fricke, or the Indian Method.

       M. Graefe and Dzondi, having scarcely alluded to their mode of ope-
     rating, have in some  sort left  to MM. Fricke and Jungken,  all the honor
     of  blepharoplasty by  the  Indian method  of anaplasty.   In  this method,
     which I have twice employed for the upper eyelid, and which MM. Blan-
     din, Gerdy, Jobert, and Carron  du Villards,  have also  made trial of at
     Paris, we begin by excising the tissue of the  cicatrices which deform
     the eyelid, in order to make in that  part a regular wound.  If there is
     no inodular tissue there, we cut  through  the skin transversely, in order
     to be enabled to elongate the retracted part, or that we may create there
     a void in order to lengthen the  part by transferring a piece to this space.
     This being done, we cut in the neighborhood a flap which, turned  round
     by one of its borders, is brought forward and fixed by a sufficient num-
     ber of stitches of suture, upon the part of the eyelid where  its  substance
     has been destroyed.  If it is the upper eyelid, M. Fricke takes the flap
     from the forepart of  the  temple, above the outer extremity of the eye-
     brow.  This flap, which he detaches from above downward, preserving a
     large pedicle to it, is immediately brought,  by its  front border, to the
     lower border of the lid, while its posterior  border is attached by de-
     grees  to  the upper border of the lid.  For the lower eyelid, M. Fricke
i  •  takes his flap from the outer side of the cheek bone, and conducts it also,
     by the same mode, to the vacancy to be  supplied. M. Ammon (Peters,
     Opir. Citat., fig. 11,12,13,14) has modified this process  in such man-
     ner that  the wound of the flap, and the wound of the eyelid, are made 
 588            NEW ELEMENTS OF OPERATIVE SU^CEIiY.

 continuous with each other in the form of a capital L; so that the hori-
 zontal branch of the L ultimately becomes filled up by means of the flap,
 while its vertical branch remains void.   M. Ammon, moreover, proceeds
 in  all the different steps after the method of M. Fricke, or that of M.
 Jungken.
   If MM. Gerdy, Blandin, and Jobert, have pursued a somewhat differ-
 ent method  in  the construction and adjustment of the  flap, it is, doubt-
 less, because  they were unacquainted with what had been done, in this
 respect,  in Germany ; for  their process is evidently less favorable to
 the complete success of the operation, than  those of which I have just
 spoken.

                                 §11.

   In the first patient upon whom I operated, I felt myself obliged to con-
 form, in  every point, to the rules of Indian anaplasty; the flap which I had
 cut upon the forehead was reversed, twisted, and brought down, like the
 arch of  a bridge, upon  the wound of the eye-lid.  In the second case,
 I borrowed the flap from the upper part of the cheek bone, and I imitat-
 ed, in some  measure, the process of M. Fricke ; but it has appeared to
 me that  this process requires modification.
  The rules which I would desire to lay down upon this subject are the
 following: 1.  That for the lower eyelid, the flap should be cut from the
 temporal region, rather  than upon the cheek, in order that its root and
 the  wound it leaves may tend, by their natural retraction, to draw the
 lid  rather upward than downward: 2. That this flap should, at the first,
 have twice the  dimensions that it  is  to  retain afterwards; 3. That it
 should be  fastened by numerous stitches of suture, rather than by com-
 pression  ; 4. That  it  shall  have a pedicle as large and thick as the con-
 dition of the  parts will permit; 5. Finally, that we should approximate
 its upper side  as much as possible to the free border of the eyelid.
  In  one of the patients treated at the hospital of San Louis, the ope-
 ration was unsuccessful, because the flap  which had been cut from the
 cheek had agglutinated  too far from the ciliary border of the eyelid.
 In one of mine, the deformity disappeared only in part, because the flap,
 which was a  third larger than  the space it was to supply, contracted
 finally to more than one half its size. In the second case, the flap seemed
to mortify in  part, because I  had diminished the pedicle too much, or
because  I  had not fastened it by a sufficient number of stitches in the
 suture.   It is evident, that if the root of the flap for the upper eyelid, Is
 situated upon the cheek, it will be a means  of preventing all consecutive
ectropion;  and that,  for the  same reason, where we are  treating the
lower eyelid, it is important that its root should be turned towards the
temple.

           § III.—Blepharoplasty  by Sloping of the Flap.

  Chopart's method of anaplasty is'applicable to the eyelids, as to other ,
 parts of  the face.  M. Dieffenbach, also, has  applied it  in such manner
 as to obtain from it  a process of blepharoplasty  altogether  peculiar.
 To  follow this method, we begin by excising all the cicatrices, in order 
BLEPHAROPLASTY.
589
to transform  them into a regular wound.  We  afterwards cut a flap of
sufficient width, at the expense of the integuments on one of these sides
of the new wound, so that this flap shall have the shape of a trapezium,
the inner border of which corresponds to the outer lip of the wound,
whilst its upper or lower border, according  to  the eyelid which it is to
be applied upon, must be detached upon a line  which should extend be-
yond the outer palpebral commissure.  To form this flap, therefore, we
must make a horizontal incision, which should be prolonged to a greater
or less  distance  from the outer extremity of  the eyelids towards the
temple ;  then an oblique incision, from above downward, or from below
upward,  and from  within  outward, according as it is for the upper or
lower eyelid, an incision which ought to have nearly  twice the length of
that of the horizontal incision.   By means of  these two incisions, and
those  wdiieh  we have made to remove the inodular  tissues, we form a
flap of the figure of a trapezoid, or parallelogram, which is to be dissect-
ed from  below upward on the temple or forehead, for the upper eyelid,
and from above downward on the cheek, for the lower eyelid.   Nothing
is afterwards easier, than to  draw this flap inward, without  twisting or
turning it, so as to be enabled to sew its inner border  upon the inner
lip of the previous excision,  and the free border to the teguments adja-
cent to the ciliary border of the corresponding eyelid.   In  conclusion,
this flap  then takes the place  of the parts which it has  been thought ad-
visable to remove, and the situation which the  flap itself did occupy, is
that in which the wound in fact is now located.   By this process  ble-
pharoplasty is, in reality, an operation easy enough for any one to per-
form.  Many cases successfully treated in this manner, have been related
by M. Peters, and I have  been convinced, in examining at Paris one of
the patients  operated upon by M. Dieffenbach, that it is a process that
should be  preserved.  Its principal  inconvenience  is  that of obliging
us to make a considerable dissection of  the tissues, of requiring so long
a flap  that we have to apprehend its mortification, and of not being per-
fectly  applicable but to losses of substance that have greater length than
breadth.

                    § IV.—Process of M. Jones.

  An  operation more simple  than  the  preceding, and which is, never-
theless, a kind of blepharoplasty, is that which  M. W. Jones states that
he has performed,  (Encyclographie  des Sciences Medicates, 1836, p.
91.)  In this process we begin by making two incisions, which, setting
out from the extremities of the diseased eyelid, proceed to unite under
a more or less acute angle, in the form of a Y, more or less elongated
either  towards the cheek or  the forehead, according to the eyelid for
which the operation is to be performed.  We then dissect this triangle
from its  point towards its base, to nearly one half of its length ; we then
draw upon it, as if to stretch it, by  pulling upon the free border of the
eyelid itself.  Then immediately reclosing, by  means of the suture, the
wound which it leaves behind it, we succeed in pressing it towards the
eye, by actually elongating the eyelid to the extent  to which  it is defi-
cient.  As this flap is neither twisted, reversed, nor  inclined, we at the
same operation reunite its borders, by some additional stitches of suture, 
"90
NEW ELEMENTS  OF OPERATIVE SURGERY.
to the  tissues from which they have  been momentarily  separated.  I
have many times made trial of this method upon the dead body.  I had
become so satisfied with it, that I would have performed it upon a young
girl, had I not recollected that M.  A. Berard, in making trial of it some
months before, had failed completely.  It nevertheless appears to me to
be a modification of blepharoplasty which deserves to be tested.  Sinco
it has  reference to a  shortening of the tissues, a double incision  will
permit of our drawing, in this manner, one  of the eyelids towards the
other as much as we may desire.  In order  to secure  the  lid, and to
prevent it from shortening again,  it suffices  to reunite  immediately the
new wound;  we have thus a simple  rapid  operation, giving but little
pain, which  does not  require the  extensive  dissections of the Indian
method, and rarely exposes to a mortification of the tissues.

                    Article III.—Appreciation.

  We  must not, however, deceive  ourselves with any illusion in respect
to the  resources which blepharoplasty may supply.   Whatever mode we
adopt,  the eyelid which has been  repaired in the best manner possible,
rarely  fails to become again deformed; sometimes the borrowed  flap
contracts  so  much  that  it assumes the form of a small tumor, or of a
prominence of more or less irregular shape;  sometimes  it  terminates by
reproducing  the ectropion, by drawing the repaired eyelid in one direc-
tion or another, in the manner of an inodular bridle.  On the other hand,
it would be folly to suppose that a flap, purely tegumentary, could ever
replace an  eyelid whose  orbicular muscle,  or tarsal cartilage, had been
destroyed.   We may also readily conceive, that the eyelashes could not
be reproduced by this kind of operation.
  It results from this, therefore, that for all cases where  the deformity
of the  lids is caused solely by a disease of the skin, blepharoplasty me-
thodically performed offers a remedy which is truly valuable ; that even
where  the  orbicular muscle  is gone, it may  be of great benefit, if the
eyelashes and the cartilage of the  tarsus have been preserved.   If the
destruction should be deeper, still blepharoplasty should not be rejected,
provided it would allow us to furnish to the eye a protecting  covering
against the action of the atmosphere, and the inflammation or destruc-
tion of the cornea; but we should do  wrong, in  such cases, to count
upon procuring perfect eyelids, or  to promise the patient that we would
wholly relieve him of his deformity.
              [BLEPHAROPLASTY IN AMERICA.

  Dr. George McClellan of Philadelphia has, according to the authority
of Dr. Reese, in his  last and valuable  American edition (New York,
1842) of Cooper's Surgical Dictionary,  [frequently cited by us,] (see
also North Am. Med. and Surg. Jour.,) performed this operation fifteen
times, and with most satisfactory  results.  Drs. Mutter and Horner, of 
KERATOPLASTY.
591
Philadelphia, Drs. Mott  and A. C. Post, of New York, and  Dr. J. M.
Warren, of Boston, have also frequently succeeded in this delicate pro-
cess —T.]
                          CHAPTER V.

                           KERATOPLASTY.

   It has, doubtless, never entered the mind ot  any one  to  graft on a
 cornea, in cases of atrophy, or disorganization of the eye ; but it often
 happens, that this tissue only is changed, and that by its  opacity vision
 is rendered impossible.  It is in  such cases that certain oculists have
 suggested to substitute a sound cornea, in the place of the diseased one.
 Keratoplasty, considered in this point of view, had  already  passed, in
 the last century, from theory to practice,  if we are to believe Pellier,
 who gives  himself out as its  inventor.  The character of this oculist,
 and  the few details he furnishes, have  prevented surgeons from giving
 attention to his  assertions.   Since  Pellier,  keratoplasty has been sub-
 jected to legitimate experiments  by many authors of character.   M.
 Moesner attempted it in 1823, M. Reisinger in 1824, M. Drolshagen in
 1834; MM.  Himly and Bigger (The Lancet, Aug.  1837, p.  750) have
 also submitted it to various trials upon  animals.  These experiments,
 resumed by M. Dieffenbach, and M. Stilling  (Encyclographie  Midicale,
 1836, p. 73,) have induced some German practitioners  to make trial of
 it also upon man.  Two processes, even, have  been proposed for this
 purpose.  In one, which is  that which experimenters  have  most fre-
 quently employed upon animals, the diseased cornea  is cut out, and  re-
 placed by  a cornea taken from  a calf or sheep.   I should, as it  seems
 to me, abuse the patience of the reader, to describe  such  an  operation,
 and I should censure that surgeon who would have the  hardihood seri-
 ously to propose  it to a patient.   In the second  process,  which  M.
 Dieffenbach has told me he  performed successfully upon a young girl,
we pass, by  means of a fine needle, three threads through  the cornea on
the sides of the opacity,  afterwards  circumscribing the spot  by two  in-
cisions, we remove it from the  cornea  in  the shape of an ellipse, the
wound of which is immediately after closed by tying the threads previ-
ously passed through its entire thickness.  Since a man  high  in rank in
our profession, has said that he has been successful in operating in this
manner, we are bound to believe him;  but I should'scarcely credit it if
I had done it myself, and I doubt very  much  if M. Dieffenbach will find
any imitators among discreet surgeons. Of two things, one must  hap-
pen ;  either the transparent cornea is  opaque  in  its whole  extent, in
which case there could be no other than keratoplasty by transplantation
that  could in reality be employed; or there is but a  spot in the middle
of this membrane, when it is clear that keratoplasty is not as servicea-
ble as the operation for artificial pupil.
  Pupil.—It  might have seemed  that the  experiments which I  have 
 592            NEW  ELEMENTS OF OPERATIVE SURGERY.

 been speaking of, relatively to the cornea, would have  formed the last
 limits  to these kinds of essays ; this, however, is far from being the
 truth.   In the article above cited, M. Stilling speaks also of experiments
 having for their object to create a pupil upon the  sclerotica, by  trans-
 porting to it a flap from the cornea.   MM. Moesner (De Conformation
 Papilla de Artif, etc.,  1823) and Dieffenbach, and M. Ammon himself,
 have however proved, by their reiterated failures, that the success of
 keratoplasty  by  transplantation  is  utterly  impossible.  Nor have  I
 learned that  the experiments which  M. Stilling instituted, during his
 sojourn at Paris, have confirmed  those which he made in Germany.  To
express myself with all  sincerity, I  must  say that such trials, in  my
opinion, only  seem calculated to consume the time of the experimenters,
and  to impede the legitimate march of operative surgery.
                          CHAPTER  VI.

                 ANAPLASTY OF THE LACHRYMAL SAC.

   Some surgeons, particularly M.  Dieffenbach, have  had recourse to
anaplasty for certain  cases  of fistula lachrymalis.   We  may  indeed
conceive that the integuments of the neighborhood, separated by one of
the processes of blepharoplasty, might possibly be  applied and  secured
by strips of adhesive  plaster, or  appropriate bandages, upon  losses of
substance at the  great angle of the eye.  But  I do  not believe that
anaplasty can be  of any great value  in these cases, even though we
should substitute  for the other processes  the tegumentary cork which
in 1833 I proposed (Gaz.  Mid.  de Paris, 1833,  p. 317) to apply to
them.  The cutaneous  opening, in such cases, is but a trivial  circum-
stance in the disease.  I therefore do not see any reason for directing
our attention to this, when we wish to relieve a fistula lachrymalis.  In
order that anaplasty in the great angle of the eye should  be indicated,
it  would be  necessary that there should  have  been gangrene, ulcera-
tion, or some wound that had caused there a loss of substance, in which
the front part of the lachrymal sac has been involved.  Then,  in truth,
the borrowed flap would have the same object to effect as on any other
part of the body.   It remains to be seen, if such  conditions shall pre-
sent themselves in practice.
                         CHAPTER  VII.

                           CHEILOPLASTY.

  The art of repairing and  restoring  the  lips, when mutilated or de-
stroyed, has in our day made the most  astonishing progress.  Until re- 
CHEILOPLASTY.
593
cently, a loss of substance sufficiently extensive to render simple chcilo-
raphy  impracticable, seemed  to be  beyond the  resources of surgery;
now, on  the  contrary, the  most hideous  deformities do not appal the
skilful operator.   Whether a lip be wanting on one side or the other,
whether it be deficient in whole or in part, alone or with a  portion of
the cheek, it is almost always  in our power to reproduce it, by borrow-
ing what we stand in need of  from the surrounding parts.   Therefore
the surgeon is rather to  plan out, than  to learn  cheiloplasty.  It is an
operation which can scarcely be submitted to detailed rules, and which we
have to modify almost as often as we practice it.  Every process of ana-
plasty has been  applied to  it.  Tagliacozzi  says he succeeded by the
Italian method, that  is, by borrowing from the arm the materials for the
new lip.   Delpech, M. Lallemand, Dupuytren, M.  Dieffenbach, and M.
Textor, have used the Indian method.   Finally, the French method now
counts a great number of trials.   There are none of these methods, not
excepting that of Celsus, in which the incisions  were made  either ver-
tical, horizontal, internal, or external, outside the  deformity, that have
not found their advocates.  Having for their object to  remedy lesions
of various form and character, it was to be presumed that each one of
those methods would soon include a number of distinct  processes.

                 Article  I.—The French Method.

  The method of detaching the tissues, is in these cases applicable in
all its processes.

              §  I.—Process of Horn, or of Roonhuysen.

  If there is only a notch in one of the lips, provdded its breadth trans-
versely is of no great extent, even if it should be very deep, the cheilo-
plasty differs but very little from  the  operation  of hare-lip.  The first
thing to  be done, is to transform  the abnormal notch into  a fresh
wound, and to give it the form of a V, by excising its borders and every
thing about it which is diseased, with a scissors or a bistoury.   In  the
second place, the  surgeon dissects  in succession, down to beyond  the
point of  the bleeding triangle, and in a space  proportioned to the  width
of the void to be filled, the two flaps of soft parts, separates them from
the maxillary bone, and turns them outward.   Nothing afterwards is
more easy than to elongate them, and to put them in contact, by draw-
ing them towards each other.  The suture is applied, as in the hare-lip,
and with the same precautions.   The  posterior  surface of the  new lip
unites to the subjacent parts at the same time that its two halves become
agglutinated together; and its  free border,  after the cure, differs in
reality from what it was before  the disease, only in having a little less
length.  Nevertheless, this  process has the disadvantage of narrowing
the mouth to a very considerable degree, and of sometimes giving to its
aperture a very disagreeable deformity.

                     § II.— The Ancient  Process.

   Celsus, it is very  probable, had something analogous in view, when
     Vol. I.                    75 
594            NEW elements  of operative surgery.

he advised to make a transverse incision, then a  semilunar one, upon
the internal surface of each cheek, between the cheek bone and the com-
missure of the lips, in order to admit of the elongation of the two halves
of the  divided lip.  Every thing, in short, induces us  to believe that
this kind of cheiloplasty, of which Galen and  Paul of Egina  also say
a few words, had been already  reflected upon in those times.

                 §  III.—Process of Guillemeau.

  After having freely dissected off the parts, M. Dieffenbach often finds
it useful to relax them, by means of the lateral  incisions of Guillemeau,
or of Thevenin.

                    § IV.—Process of Chopart.

  The preceding operations may suffice very well, when the  loss of sub-
stance has  not been very considerable in breadth ;  in the  other cases,
however, we must renounce it and give the preference to one of the pro-
cesses  which  I am about to describe.  That which appears  to have ori-
ginated with  Chopart, and which I  have seen succeed  completely in
many cases, is one of the most valuable.  If the case is one of cancer,
the surgeon commences by  making, external to and upon each side of
the disease, an incision which descends vertically from the  free border
of the lip to beneath the lower jaw;  afterwards dissecting the quadran-
gular flap  traced  out by these two incisions, he detaches it from above
downward,  preserves to it all the thickness possible, and taking care not
to graze too near the periosteum, prolongs his dissection to a greater or less
distance below the chin, according to the greater or less quantity of dis-
eased  parts he thinks  he  shall have to  remove.  This being done, he
cuts out, in a square shape, every thing which  is  changed,  trenching a
little, at the same time, upon the sound tissues ; removing  thus with a
single  cut the whole of the cancer, he immediately seizes the flap that
he has just dissected, adjusts it in front of the chin, and by  gentle trac-
tions raises its upper  border  to a line  with  the upper lip,  or with
what remains  of the border of the  lower  lip outside; three  or four
stitches of twisted  suture on each side, serve afterwards to  secure it to
the lateral  parts of the face, beginning always with the upper needle ;
nothing more  remains to be done, than to recommend the patient to
keep his  head  inclined forward, in order to prevent  all traction or
tearing.   To understand with what facility these flaps yield  and become
elongated, we must have been witness to it.   In one  of the  cases which
I had an opportunity of seeing, the operator being compelled to remove
the whole extent of the tissues, up to the  limits of the orbicularis mus-
cle, did not terminate the root of his flap  until  he had  reached towards
the middle of the supra-hyoidean  region.  Nothing, however, was easier
than  to  bring up  its  border to a level with the line which the lip for-
merly  occupied.  In four  days the  reunion appeared to be completed,
and  all  the needles could  be  removed.  No suppuration came on,
neither at the lateral borders nor upon the posterior surface of the flap,
while its upper margin soon became covered with a reddish pellicle, to a
great degree resembling that which naturally covers the vermilion bor-
der of the lips; on the  fifteenth  day, the patient, who was forty-eight 
CHEILOPLASTY.
595
 years of ago, exhibited scarcely any trace of the  operation.  Another
 case was  not less  fortunate, and I have not learned that any accident
 has since  happened to them.  This  new lip, however, having no con-
 strictor muscle, ordinarily remains without motion, resting against the
 teeth, and as if drawn backwards ; but such trifling inconveniences can-
 not enter into comparison with those that are caused by the necessity of
 wearing a silver lip, and  patients are fortunate  indeed, when they can
 be relieved at such a price as this.

     § V.— Process  of 31. Serre,  (Rev. Mid., 1835, t. ii., p. 134.)

   If the mucous  membrane is not degenerated, M. Serre dissects  and
 preserves it, in  order to bring it  forward and sew it, as a covering, to
 the skin of the  free border of the flap, or new lip, as he terminates the
 operation.  We thus obtain a more regular conformation, and one more
 in correspondence with the original  condition of the  parts, than by a
 pure and  simple excision.  The  only difficulty in this modification is,
 that it is not practicable but in a very small number of cases.

  § VI.—Process of M.  Viguerie, (Journ. Hebd., 1834, t.  i., p.  186.)

   Upon the  supposition that the  disease  has not involved the  mouth,
 but extended rather in the direction of the chin, we might, while cut-
 ting and  dissecting the flap as in the preceding  cases, leave a bridle
 above.  After having romoved from  it  the  diseased  tissues, the  flap
 should  be raised up towards the mouth, and fastened by means  of the
 suture by its upper border, to the  preserved bridle of the lip.  The pa-
 tient thus treated by M. Viguerie, recovered perfectly.

                  §  VII.—Process  of J.  N. Roux.

   M. J. N. Roux  (Revue Med., 1828, t. i., p.  30)  has several times
 employed  cheiloplasty by a process which  he considers as his own, and
 from which he has obtained remarkable results.  In the place of cut-
 ting a flap which is to be raised up after the diseased parts  have been
 excised from it, this practitioner  begins  by circumscribing, by  means
 of incisions made in proper directions,  every thing which it is important
 to destroy, and  thus removes  the  cancer.  By a careful dissection, he
 then detaches the surrounding soft parts  from the maxillary bone, and
 from the  anterior region of the neck ; he thus forms, out  of the  skin
 and cellular  tissue, a kind of apron, which he raises up  to a level with
 the upper lip, and with  which he encloses the front part of the jaw ;
 he  secures it  there  either with strips of adhesive plaster, or, when it
 has been necessary previously to prolong the commissures by a transverse
 incision, he fastens and  suspends it, by some stitches of suture on each
 side, to the  upper border of the wound.   The  patient, assistants, and
 surgeon place themselves as in the operation for harelip.
   If the disease extends somewhat beyond the transverse limits  of the
lower lip, M. Roux  makes, with the scissors, a nrst incision of a semi-
lunar shape, an incision which dilates each commissure in the same pro-
portion, by prolonging them towards the  masseters ; he then, with  the 
596
NEW ELEMENTS  OF OPERATIVE SURGERY.
  bistourv, makes another incision on each side, commencing  with them
  at the "outer extremity of the first, and carrying them  down to below
  the cancer,  so as to unite them in front  of the chin;  in removing all the
  diseased parts, he proceeds sometimes  to the extent of laying bare the
  entire body of the jaw ; he then  dissects upon their inner surface what
  remains of the cheeks, returns  to the chin, descends to the sub-maxillary
  border, and to the supra-hyoidean  region, preserves as much thickness
  as possible to the integuments, draws  them  upward, attaches  their ex-
  tremities to the extended  wound  of the commissures in such manner as
  to leave a sufficient length of flap free, to represent  the border of the
  lower lip ;  finally, he supports the whole with some  strips of adhesive
  plaster, and a sling and containing bandage.  When, on the contrary,
  one side of the lip is sound, and the  disease extends to a certain distance
  upon the cheek of the opposite side, there are three incisions  required
  to circumscribe the cancer; one somewhat short  and transverse, above
  the affected commissure ;  the  second, straight or  curved, it is of no im-
  portance which, is equal in  length to the first, is  made continuous  with
  it, and descends obliquely in front towards the chin  ; the third, finally,
  which commences near the sound commissure, and terminates by uniting
  with the second.  After dissecting the border cut by this last, we bring
  it towards the first  incision,  and the suture  is applied, to maintain the
  whole in contact.  By  this transportation, the last  wound  ascends to
  the position of the free border of the lip destroyed,  which it represents
  sufficiently well, and the form of  the mouth is preserved.
   Operating upon  these principles, or those of Chopart, M. Cambrelin,
  (Arch. Gen. de Mid., t. xxvi., p. 263,) M. Thomas, (Journ. des Conn.
  Med.  Chir., t. iii., p. 269,)  and  M. Nichet,  (Bouchacourt, Rev. Mid.,
'•■  1838,  t. iii., p. 242,)  have each had a fortunate result.   I have myself,
  in conforming to the precepts of M. J. N. Roux, succeeded in repairing,
  in part, a deformity in an old man, in whom I  had to extirpate the whole
  contour of the mouth; and also in a young girl, who had lost her lower
  lip  in infancy, in  consequence of a gangrenous  affection.   It is never-
  theless true, that the simple process  of Chopart, when it is applicable,
  merits the  preference, and that it answers the purpose where the lower
  lip alone requires to be repaired.  If we have also to fill up some  void
  near the commissures, or upon the upper lip,  the  process of dissections,
  either simple or associated  with  the  incisions either of Chopart, or of
  Dieffenbach, are evidently to be preferred.   I should add, also, that in
  regard to  transverse elongations, we should  do wrong  to count much
  upon  the method of  dissections  practised  at the lips; and  that young
  subjects, well made and of firm flesh, are the least favorable to this  kind
  of anaplasty.

                   §  VIII.—Process of Ph.  Roux.

   In a young girl, who had  nothing remaining but a very small portion
  of the lower lip, and who had  also lost, from  her  infancy, more than the
  half of her  upper  lip, the  maxillary  bones  were so  deviated  outward
  that they projected to a considerable extent, through the loss  of  sub-
  stance.  To remedy this horrible deformity,  M. Ph.  Roux (Rev. Med.,
  1830, t. i., p. 5) concluded  to make  the operation  in  two stages, and 
CHEILOPLASTY.
597
 proceeded in the following manner:—After having transformed the lower
 half of the wound into a triangle, by the excision  of its borders,  and
 after having detached its two halves to the extent of several^ inches, he
 had recourse to two cuts .of the saw, and  removed  about an inch of the
 jaw.   Then  having approximated  the two portions of the bone, he
 brought the two flaps of the fresh wound together,  kept them united by
 the twisted suture, and succeeded thus in  restoring  the lower lip, and in
 more than half curing  the young patient, without much difficulty.   The
 success  of this first stage  was complete; but M. Roux, who wished to
 proceed in the same manner with the second, and to destroy also a por-
 tion of the upper  jaw, found an insurmountable obstacle in the opposi-
 tion of his patient.  It is evident, however, that the excision of bpne
 would have  presented  much more difficulty there than below,  and  that
 to  effect it, he would have been obliged to make much  more use of the
 gouge and mallet, or of the cutting nippers, than of the saw.
   By the exsection of bone, the  surgeon  hoped  to  diminish sufficiently
 the transverse dimensions of the face, to be enabled to bring into coap-
 tation the opposite sides of  the wound.

 §  IX.—Modification by M. Morgan, (The Lancet, July 1829, vol. ii.,
                              p. 537.)

   In 1829, M. Morgan  had a case of an old  man, whose lower lip  was
 entirely destroyed by a cancer.   A semilunar incision, with its concavity
 above, enabled him to detach and excise all the diseased tissues.  From
 the middle of this incision he made another, which he directed  perpen-
 dicularly  towards the os hyoides; dissected  off successively  the /two
 flaps thus traced out, as in the T incision,  from the median line  towards
 the  sides, and  from above  downward; and  thus was enabled  to bring
 them up in front of the lower jaw, and make use of  them to replace the
 lip  which  he had  just  removed.  Some stitches of twisted suture held
 them in contact, and sufficed, together with the sling bandage and plu-
 masseaux  of lint, to prevent  them from descending to their natural po-
 sition.   The success appears to  have been complete; but another  old
 man, operated upon in the same manner at a little later period, October,
 1829, by M. Lisfranc, was less  fortunate.  Towards the fifth or sixth
 day, the  patient suddenly died.   The operation  is assuredly more easy
 by this process than by that of M. J. N. Roux; but it is doubtful if we
 can by this means  give as much regularity  to the free border of  the new
 lip, as by  the original process of M. Chopart.   It is, however, a modifi-
 cation which may have its value, and may in part be admitted  into  the
 French method, of which, in fact, the process of M.  J. N. Roux itself is
 nothing more than a slight variety.
  The great point here is the dissection of the  tissues which  envelop
 the bones about  the circumference of the wound; all the rest has refer-
 ence to the modifications required by  the  nature  of the lesion to be
 remedied.  Guided by this  principle, M. Nichet  (Gaz. Med.  de Paris,
 1836, p. 454) was enabled, by merely dissecting a  flap of integuments
rolled up under  the chin, and by paring the contour of the wound, to
 cure a large fistula in  the supra-hyoidean region,  produced  by a dis-
charge of fire-arms.  It is for  the surgeon to multiply or diminish  the 
598
NEW ELEMENTS  OF OPERATIVE SURGERY.
 number of incisions, and to determine their form, direction, and depth,
 as often as he is called upon to put  in practice  the  French method of
 cheiloplasty.
                    Article II.—Indian  Method.

   Delpech is the first, I believe, who  applied the Indian method of ana-
 plasty to  the lips.  After  having cut and dissected  his  flap upon the
 supra-hyoidean  region, ho raised it, twisted it upon itself, and  doubled
 it upon its cellular face, before attaching  it, by numerous points of su-
 ture, to the two sides of the deformity which had been previously pared.
 This folding  of  the flap, suggested by Delpech, had for its object to give
 to the new lip  two cutaneous  surfaces, instead of one, and  to  prevent
 the adhesions of its free  border to the alveolar arch.  The operation
 thus  performed, was not  successful.   Gangrene ultimately  destroyed
 nearly the whole of the flap.
   Appreciation.—Delpech was not more  fortunate in a second case of
 Indian  cheiloplasty.  M. Lynn had, in the year 1817, performed it, ac-
 cording to M. Brodie, with better results, and M. Textor (Bull, de Fir-
 ussac, t. xv., p.  326 ; Journ. de Progres. t. xiv., p. 246) takes to himself
 the  credit of having once performed it in 1827.  M. Dieffenbach also
 appears to have cured some  cases by it, (Gaz. Med. de Paris,  1831,
 No. 2;) but  these practitioners took very good care not to follow the
 example of Delpech, by doubling the flap which they had borrowed  from
 the  neck. In a case where a large trapezoidal flap was taken from be-
 low, raised up but not doubled, and then fixed by  means of suture to the
 contour of the  part where the  loss of substance was, M. Voisin  (lb.,
 1836, p. 366) of Limoges, was enabled to reconstruct for his patient all
 the parts  of a lower lip and chin.
  The  advantages  of the method of dissecting the  tissues, which M.
 Roland (Serre, de la Riun. lmmid., p. 514)  of Toulouse, once put in
 practice with success, which M. Blandin (These  de Concours.,  p. 151)
 has  also  made  trial of, and which  I  myself tested in 1830, (Romand.
 These, p.  24,) at the hospital of St. Antoine, at La Pitie in 1831, after
 the removal  of  the  inferior  maxillary bone, and since then on four or
 five  patients  at La Charite, are not less indisputable.   The two unsuc-
 cessful  trials  of Delpech  (Clin. Chir. de Montpellier, t. i.) with the
 Indian method, prove, that  it is but of secondary importance, and then
 only when the loss of substance is too deep or too extensive to allow of
 remedying it by stretching the tissues over it.   The processes of Celsus,
 (lib.  vii., cap.  3, sect.  4,)  and  of Franco, (Traite des Hernies, 1561,
 p. 462, ch. 122,) are in reality nothing more than varieties of this me-
 thod, a  variety  which ought only to be called to  our aid in certain par-
ticular cases.  As to the  Italian method, it is no more suitable at the
present  day, to  the  restoration of lips, than it is to  rhinoplasty.   The
following  article will enable us still  better to appreciate the force of
these remarks.

 Article III.—Cheiloplasty by a  Hem of the Mucous Membrane.

  In  consequence of cutaneous  affections, burns, ulcerations, etc., the
anterior orifice  of the mouth sometimes becomes so contracted and in- 
CHEILOPLASTY.
599
durated  as  to disfigure the patient, and interfero with the functions of
the lips.  [These abnormal  contractions of the mouth are sometimes
congenital.—T.]

                                §1.

   In  view  of such an evil, the first remedy which presents itself to the
mind is, mechanical dilatation.  Unfortunately, this means can give only
temporary relief, and has rarely effected any permanent cures.

                                §11.

   After dilatation, comes incision of the labial commissures, which we
should take care  to prolong a little beyond what would be really requir-
ed, since the  wound, in cicatrizing, never fails  to contract itself more
than  we desire.   If we  could without difficulty cause the two borders
of the  solution  of continuity to cicatrize separately, this first operation
would effect,  as  well as we could wish, the object we have in view; but
it is not so.    In spite of compresses spread with cerate, pieces of sheet-
lead, and the small hooks that  are  made to draw constantly upon the
angles of the  wound, it nevertheless finally becomes reagglutinated, and
places matters in the  same  condition in which they were before, if in
truth the deformity does not thereby ultimately become considerably ag-
gravated.

                               § III.

   Some  practitioners have thought that they could more effectually over-
come the difficulty by  treating the contraction of the lips by means of
lead wires.   A trochar plunged through the skin near the mouth, at the
place where the commissure on each side should be, drills a hole for the
wire,  one extremity of which in the mouth, brought through the natural
opening, should be united to the other, in order that the surgeon may
twist  them  as in fistula in ano, and gradually cut through the included
tissues.   This process, though less alarming to the patient, is much longer
than  the  preceding, and  can  scarcely be considered more certain.  In
proportion as  the wire cuts the parts, they reunite outside  of it, so that
in reality the ligature is not more effectual than the incision.

  § IV.—Process of M. Serre, (Gaz. Mid. de Paris, 1835,p. 317.)

   This  difficulty  now, however, seems  no longer to exist.   The incision
being made, Serre, by  means of the suture, puts in contact the mucous
border with the cutaneous border of each lip, and thus prevents all new
agglutination.  Operating in this  manner on a young girl, I have obtain-
ed the same successful result  as the professor of Montpellier.

                     §  Y.— The Hem, (Ourlet.)

   Reflecting upon these difficulties, and the insufficiency of the known
means, M. Dieffenbach (Journ. des Progres, t. ix., p. 268') supposed that 
gOO            NEW ELEMENTS  OF OPERATIVE SUiWERY.
 by excising a portion from the tissues of each labial  angle, to the ex-
 tent for example, of an inch, and leaving the mucous membrane wholly
 intact  we should probably obtain complete success.   Facts have justi-
 fied his theory, and already it has been attended with successful results,
\ that leave nothing to desire.  His process, which  is more easy to under-
 stand than to perform, is nevertheless available to every one.  The sur-
 geon  introduces into the mouth of the  patient the point of his finger,
 to support and protect the organic layer which it is his intention to pre-
 serve.   With the other hand, he directs the blade of his scissors upon
 the border of the  contracted  opening, a little above  the  commissure,
 and introduces it with caution from  before backward, between the mu-
 cous membrane  and  the other  tissues, and  horizontally to the point
 where he wishes to place the corresponding angle of the lips ; having
 cut with a single stroke, and square through, every thing which is found
 included between  the branches of his instrument, he makes, a little
 lower down, another incision parallel with, and in every respect similar
 to, the first, including as much of the tissues in the lower lip as he had
 in the upper; then reuniting  the two wounds by a small  semilunar sec-
 tion at the outer extremity, he isolates the little strip thus circumscribed,
 and excises it, without touching the  mucous  membrane, which he also
 afterwards lays bare all around the wound ; after having done the same
 on the opposite side, he gently separates the jaws of the patient, as if
 to stretch the membrane which  forms the bottom  of the wound, and di-
 vides it transversely into two equal  portions, and to within three  lines
 of its genial extremity, [i. e., the  extremity towards the cheek.—T.,]
 draws it out and turns it over upon the labial  commissure which he has
 just made, first on the lower and then on the upper border of the  divi-
 sion, in both which places he  fastens it,  and  also to the vermilion pel-
 licle of each border of the lips, by means of a sufficient number of fine
 short  needles, or by twisted suture, either alone or combined  with  the
 interrupted suture.  The operator here makes use of the mucous mem-
 brane as a lining, which he unites to  the integuments by a sort of hem-
 ming  operation, as the shoemaker unites to the leather of his  shoes the
 last side of the riband which is to cover its borders.
   Operating in this manner upon a young girl, whose mouth was strongly
 contracted in consequence of a phagedenic eruptive disease, I  made use
 of a bistoury in lieu of a scissors, and it appeared  to me that by this
 means the section of the tissues was  accomplished with greater ease.
   Another modification, which would also have its advantages, would
 be the following :—The excision of the tissues is  completed ; the mu-
 cous layer gently thinned  down, and stretched  like a piece  of linen,
 alone remains at the bottom of the wound.  Before slitting this mem-
 brane, we insert all the threads, one after the other, from the mouth
 into the wound, after which we carry them outward  from the wound
 through the cutaneous border of the division, commencing with the low-
 er range  and finishing with the superior range of each commissure.
 Then  dividing the membrane between the two lines of threads, the sur-
 geon has  only to take  hold of the  ends of these latter and  tie them, to
 complete the operation.  I have found that I have in this manner been
 enabled to give great regularity  to the suture, while rendering the
 operation evidently more easy. 
GENOPLASTY.
601
                               § VI.

  M. Campbell, (Gaz. Med. de Paris, 1833,p. 153,) who has repeated
the operation of M. Dieffenbach with success, also used the bistoury in-
stead of the scissors ; but the scissors were preferred in the young lady
whom  M. Mutter  (Cases of Autoplasty,  See, Philadelphia, 1838)  re-
cently operated upon in America, with  complete success.
  If the mucous membrane, which should not be too much thinned down,
is well  stretched, and well  hemmed upon the bleeding  borders of this
wound, it agglutinates to it with the greatest facility, and in the  space
of a few days.  The artificial portion  of the lips afterwards acquiring
the same  state of organization  as  the natural  portion, their  reunion is
hardly any more to be apprehended at the sides than at the middle.
  There is nothing more  ingenious than this process, and  every  thing
induces to the  belief that it will  be generally  adopted.  Applicable to
every modification and degree of the disease, whether acquired or con-
genital, and whatever be the age of the patient, the only objection to it
is, that it requires great delicacy in its execution.   It is an operation
that should be made trial of wherever the  contraction is not surrounded
with too extensive an alteration of the mucous membrane of the lips.
  [Dr. Eve,  of Georgia,  (U. States,) has recently, says Dr. Reese,
(Loe  Cit.,)  successfully removed a cancerous lip  by the method  of
Yelpeau, (see North Am. Med. and  Surg. Jour.,) separating the  lip
by the French method of anaplasty, and terminating with the continued
suture.—T.]
                         CHAPTER  VIII.

                            GENOPLASTY.

  The cheeks, also, are  of a nature to admit, to a greater or less  ex-
tent, of a perfect  restoration.  Their  loss of substance, also, almost
always includes at the same time a portion of the lips, and renders the
face truly hideous.  And there is scarcely any description  of means,
that within the last twenty years  have not been resorted to, to remedy
this difficulty.  Delpech, and M.  Lallemand, (Archiv. Gen.  de Med.,
t. iv., p.  242,)  appear to have been the  first who have paid  particular
attention to it among the moderns.

                 Article I.—The Indian Method.

  A young girl, ten years of age, had at the lower  part of the  left
cheek, in consequence of gangrene, a wound of  an irregularly circular
shape, two inches in extent in both its diameters, involving half an inch
nearly of the lower lip, but only some lines in extent of the  upper lip.
To fill up this void, M. Lallemand commenced by trimming off its whole
  Vol. I.                     76 
602
NEW ELEMENTS OF OPERATIVE SURGERY.
circumference, giving it the form of an ellipse rather more curved above
than below, and the outer extremity of the longer diameter  of  which
reached to the space between the masseter and triangular muscle of the
lips, while the other rested upon the upper and outer side of the tuft of
the chin.   He then proceeded to cut upon the  side of the neck, under
the angle  of the jaw, and in front of the sterno-mastoid muscle, a flap of
the same form, but full one third larger.   This flap, oblique from above
downward, and  from behind  forward, and  no farther  attached to the
living parts than by a kind of root of about an inch in width, and  the
upper border of  which flap, moreover, made  part  of  the  wound, was
brought gradually and without torsion, by drawing the whole of it from
below upward,  on  to the wound,  where  the  operator  fastened  it by
several stitches of interrupted  suture, strips  of adhesive plaster, layers
of lint, and some turns of  bandage.  The elliptical form was  preferred,
with the view of facilitating the  reunion of the wound  in the neck, and
the torsion avoided, because the surgeon apprehended it  might tend to a
gangrene of the borrowed parts, as  had happened in the case of Delpech.
  The operation of M. Lallemand  did not  succeed  without being  at-
tended with some accidents.  The wound was torn apart several times,
in consequence of the cries  and restlessness of the  child, and  perhaps
still more  owing to the presence of a  canine tooth, which projected
outwardly, and which it  became necessary  to  extract.  Nevertheless,
the cure was ultimately effected.
  Since then, Dupuytren  (Journ. Hebd., t. v., p.  110) has made an at-
tempt of the same  kind, but in  a  case much  more  complicated.  His
operation  came  under  the  head both of cheiloplasty and  genoplasty.
The patient was  a child nine years  of age, who, in consequence of gan-
grene, had lost the left half of  the  lower lip, as well as of the corres- •
ponding cheek, under the labial  commissure, and to within three lines
of the masseter muscle.  The  flap was taken in front of the sterno-
mastoid muscle, twisted upon  itself, and fastened to the  abraded bor-
ders of the wound  by five  stitches of suture.  The  anterior needle at
first, and then the one next to it below, having cut through the tissues,
were detaehed.   The lower border alone mortified and suppurated.   A
notch of an inch long, having its base upon the free border of the lip,
was the result.   Everywhere else, the union took place.  To make this
new void disappear, Dupuytren treated it  as a  simple hare-lip ; but  the
tongue, which had  for  a  long time contracted morbid adhesions upon
this side, was an obstacle to the ultimate completion of  an agglutination
which at first seemed to have  promised entire  success.  The fact nev-
ertheless proves, that torsion, so  much dreaded by M. Lallemand, does
not necessarily involve the  mortification of the flap which has been sub-
mitted to it, and  that, in a case of necessity, we may  with great propri-
ety take from the neck the integuments that we may require, to fill up
Wounds of the face  that are attended with loss of substance.

                Article II.—The French Method.

                   § I.—Process  of J. N.  Roux.

  In a  similar  case to that of  M. Lallemand, M. J. N.  Roux (Rev. 
GENOPLASTY.
603
Mid.,  1828, t.  i.,  p. 30)  adopted another mode.   The cancer, which
had destroyed the left cheek, and trenched upon the lips, represented at
this point an ulcer,  two inches in width from above  downward, and an
inch and a half transversely.   By  means of two semilunar incisions,
which commenced at the lips and united  in  front of the masseter mus-
cle, the surgeon effected the excision of the carcinoma, and  obtained in
its place a fresh elliptical  wound, a little  longer transversely than from
above downward, (un peu  plus  large que haute,*) in order to be able
to bring its lips together.   He dissected the whole lower lip to near the
masseters, and to below the chin.  The  sides of  the  wound were then
easily brought into  contact.  The twisted suture, the strips of adhesive
plaster, and the containing bandage, applied as  usual, prevented all dis-
placement, and the  cure was completed in a very short time.

                    § II.—Process of  Gensoul.

  A woman, aged fifty  years, had, when  nine  years old, her left cheek
destroyed by gangrene.  When  admitted into  the hospital of Lyon, in
the month of June, 1829,  she presented on the left  side  of her mouth
an enormous loss of substance, which  left bare a great portion of the
tvvo  jaws, the two lateral  incisor teeth,  the  two canine, and the first
three molars upon that side, all of them projecting very much outwardly.
The circumference  of the ulcer, which had  cicatrized a long time be-
fore, was closely adherent  to the bones, and  had caused  an anchylosis
of the  lower jaw.  After  having  separated it  from the  bones,  and
abraded it, M. Gensoul  (Journ.  des. Hopit. de Lyon, t. i., p. 16) then
detached from the  subjacent tissues,  from above  downward, and  then
backward, both the remainder of the cheek, as  well as the correspond-
ing extremity of the lips, as far as the neck in one direction, and to the
masseter in the other.   Compelled  to resort to the gouge and mallet to
remove the projecting portion of the prominent  jaw, as well as the teeth
that were implanted in it, he was afterwards enabled  to approximate the
two borders of the  wound, and  to apply the  suture.   A small  salivary
fistula,  scarcely visible, was all  that remained  in this woman, after so
vast a  destruction  of parts.

                   § III.—Process of Ph. Roux.

  Here is a case to which I  have been witness, and  which, while it
blends  with the preceding  cases, nevertheless,  in some  respects differs
from them.  A young girl about twenty years of age, endowed with de-
termined courage, and of remarkable docility, had  had, two years before,
the  ala of the nose, and  the half of the upper  lip  and of the cheek,
situated above the horizontal line of the mouth, destroyed by gangrene.
A portion of the maxillary bone  having also been necrosed, there result-
ed from it a communication  from the wound to the nasal fossae, as well
as the  sinus maxillaris  and the tongue constantly hung out of the mouth.
Admitted into La Charite in the summer of 1826, M. Roux  yielded to
her  entreaties, and undertook  the cure.  To effect  this object he per-

     *  [To avoid mistake, we have translated this phrase by a  circumlocution.—T.] 
604            NEW ELEMENTS OF OPERATIVE SURGERY.

formed seven different operations, which extended through a whole year.
A first attempt permitted him to dissect the left side of the  lower lip,
and to displace it, by carrying it  upward to make use of it for supplying
the destroyed  portion of the upper lip.  Every thing, in this  trial, suc-
ceeded to the  satisfaction of the operator.  The buccal opening was
then found completely separated  from the wound, which latter was itself
reduced to a large ulcer of a rounded shape, and which M. Roux in vain
endeavored to close by abrading  its  borders, and by attempting to ap-
proximate them by means of a suture.  A flap, detached  from the pos-
terior surface of the lip by dissecting off  its mucous lining, and  then
reversing and  bringing it out, was followed by no better result.   It was
the same with  an attempt by means of integuments  from the palm of
the hand.   It was then determined to  draw from above and outward, in
order to unite it to the ala of  the nose, and  to  the corresponding  half
of the wound, the flap which  the upper lip had at first borrowed  from
the lower.   A triangular fissure at the left commissure  of the mouth,
and of the shape of a hare-lip  of considerable  width, was the  conse-
quence of this new  displacement.  The surgeon did not hesitate  to
abrade its edges, at a little later period ; then brought them together with
ease, and applied the suture to them,  this trial  being the least difficult
of all.  There remains in this patient no other traces of her ancient de-
formity, than a certain narrowness of the mouth, and on the cheek some
scars, as if produced by a burn.

                         §  IY.—Remarks.

   Almost  all  the attempts at genoplasty  since 1831, have been made
upon  the French method of  anaplasty, or that of dissection of the tis-
sues ; a patient thus operated upon  by M. Serre ( Compte rendu de la
Clin,  de  Montpellier, Sfe, 1837) was  completely cured.   M. Dieffen-
bach, who also often joins the remote incisions of Thevenin to the dis-
sections of Franco, likewise mentions  many successful operations upon
the same method, and I may now add  to those which science already
possesses, three new cases taken  from my own practice.
   Since all the modes of perfomting genoplasty  have been devised for
so many specific and dissimilar cases, it would be superfluous to compare
them in order to point out their   differences.   It is for the  skilful sur-
geon to determine what answers best  for the case immediately  before
him.  It is nearly the same with  cheiloplasty.   Therefore, I feel that I
ought to leave the decision of this matter to the sagacity of the reader.
Franco also had  already looked upon it in the same light, and his ob-
servation demonstrates indisputably that he understood cheiloplasty, and
especially genoplasty, almost as well  as modern operators: " A man
named Jacques Janot," says  he, " had a  defluxion which descended up-
on the cheek, which or the greatest part of it was destroyed, and also
portions of the jaws with several of the  teeth, whence there remained
an opening of about  the size  of a goose egg .... To  effect the cure,
I took a small  razor and cut the border or skin all  around it.   After-
wards I slit the skin opposite the ear, and towards the eye  and  lower
jaw; then I cut within and  lengthwise, and crosswise to elongate the
flaps taking care not to cut through outwardly, for it was not necessary 
GENOPLASTY.
601
to cut through the  skin.   I [then] immediately applied seven  sharp
needles,  three of which at the end of four or five  days fell out,  in the
place of  which it became necessary to insert  others.  In short, he was
cured within fourteen days."*  But we must read in the  author himself
the quaint narrative  of this long case, and bear in mind that the dissec-
tion of the parts is attended  with much more difficulty, and  procures
much less elongation to the cheeks than the lower lip.   In conclusion, I
do not think that  the Italian method, which has been attempted  in one
case, as  we have seen, by M. Roux,  answers better for genoplasty than
cheiloplasty.  It is to the Indian method that we  have recourse, if it
should in reality be impracticable to adopt the French process.   [Geno-
plasty has been successfully performed by Dr. M'Clellan of  Philadel-
phia, (see Reese's Cooper.)—T.]
   [An interesting operation in Cheiloplasty I recently saw performed by
Dr.  Mott, upon  a  patient aged about 62, (Judge E., from the state of
Missouri.)   The whole of the  lower lip down to the chin was  removed,
together with the cancer which occupied it, by means of a free semilu-
nar incision, which was prolonged on the right side to a little beyond the
commissure, in consequence of the disease extending in  that direction.
The soft parts covering the extreme point of the chin, and on  each side
of it and below it upon the neck, were separated to some extent to with-
in an inch from the os hyoides.   The  sound margin of soft parts was
now brought up from the chin  and neck to meet the  upper lip.   To
prevent  the puckering  which this elevation of parts  must  necessarily
have occasioned, a horizontal incision  of an inch  or more in extent was
made through the cheek, close to each  commissure.   A stitch was intro-
duced into each angle of the mouth, and a second  one  outside of that,
through  the cheek  on each side.   These nicely approximated the parts,
and perfectly sustained the newly-formed under lip.  Adhesive plasters,
and a double-headed roller  were used to assist  in firmly supporting
and keeping in place the newly-elevated parts and the lower jaw.  The
stitches were removed on the seventh day,  and adhesions having taken
place, the  cure was soon after readily  accomplished.   During the first
ten days the patient was supplied by liquid nourishment, passed into his
mouth by a quill inserted into the mouth of a teapot.  For some time af-
ter the stitches had been removed, the chin and soft parts continued to be
supported by a double-headed roller.   The cure was rapid and  complete,
without  the slightest unpleasant  symptom.  The mouth looked exceed-
ingly natural, and he conversed with ease.   The  carcinomatous ulcera-
tion had  existed twenty years, having been  unusually  slow in its pro-
gress.   The patient, as may be supposed, went home delighted.  Being

  * [As this quotation is from one of the most ancient authors in Surgery, and the style there-
fore now obsolete, I will give it here in the original, that it may be seen whether in the judg-
ment of others I have caught the true meaning : " Un Jacques Janot eust une defluxion qui
lui descendit en la joue, et tomba la dite joue ou la plus grande partie d'icelle, et pareillement
des mandibules dont il perdit plusieurs dents, et demeura un pertuis par lequel un ceuf d'oye
 pu passer.....Pour -venir a la cure, je prins un petit rasoir, et coppay le bord ou cuir tout a
 l'environ   Apres je fendoys la peau contre l'oreille et vers l'oeil, et vers la mandibule  infe'-
 rieur; puis je coppay au-dedans en long et a travers pour allonger les labis, me gardant toute-
 fois de venir jusques au dehors, car il ne fallait pas copper le cuir.  J'appliquay incontinent
 sept aiguilles eufilees, desquelles, au bout de quatres ou cinq jours, en tomberent trois, dont il
 fallut en remettre d'autres.  Bref, il fat guei-y dedans quatorze jours."—T.] 
606
NEW ELEMENTS OP OPERATIVE SURGERY.
corpulent, and the parts soft and pliant, transverse incisions below were
rendered unnecessary.
  Making an entire new mouth.  Should a case present where  there
was  necessity of making an entire new mouth, Dr. Mott suggests the
measuring out a flap of the  proper oval shape and  size, transversely
upon the supra-hyoid and sub-hyoid regions, with a long broad connect-
ing pedicle. .During  the first  days, and until adhesion of the edges
of the flap to the excised edges  of the corresponding opening to receive
it should have perfectly taken  place, breathing might be kept up by a
small aperture of sufficient size, made in the  centre of its longest diame-
ter,  and kept pervious  by a  curved  piece of gum-elastic catheter.
Dr. Mott  has  performed this operation  on  the dead subject, and  it ap-
peared to answer exceedingly well.—T.]
                         CHAPTER IX.

STAPHYLOPLASTY, (ANAPLASTY OF THE UVULA AND OF THE VELUM PALATI.)

  Since  staphyloraphy came into use, surgeons  have had it in their
power to demonstrate that anaplasty to the velum  of the  palate  might
also have its  advantages.   M. Roux and  M. Dieffenbach, (Bulletin de
Firussac, t. x., p. 261; t. xv., p. 61,) who  appear  to have practised
staphyloraphy most frequently, have also had recourse to staphyloplasty ;
one in conforming himself to the rules of the anaplastic method of Cho-
part, the other in following the  principles of Celsus or of Thevenin.
After having pared the borders of the primitive fissure, and united them
by suture, M.  Dieffenbach makes a long incision  on each side to relax
the tissues.   M. Roux, proceeding  at first in  the same manner, after-
ward divides  transversely  each  half  of the  velum of the palate near
its bony  vault.  It is then easy to draw the two sides of this velum to-
gether, whatever may have been the distance of their separation.
  The two processes we are speaking of deserve to be retained in prac-
tice.  That of M.  Dieffenbach (Arch. Gin. de Mid., t. xviii., p. 436)
suffices when we have merely to guard against the tractions of the su-
ture.  A young man  whom I treated in this manner  recovered perfectly
well.  If the  separation of  the cleft is of considerable extent, the pro-
cess of M. Roux should be preferred.
  Indian anaplasty itself has been proposed to  remedy the losses of
substance in the velum of the palate.  In a case of this kind, a surgeon
of Nancy,  M.  Bonfils, (Transactions Medicates, t.  ii., p. 293 a 308,)
dissected upon the posterior  part  of the bottom of the mouth a flap,
which he detached from before backwards, and which he then proceeded
to attach by stitches  of sutures in the cleft in the pharynx.  This opera-
tion succeeded but very imperfectly, and ought not, in my opinion, to be
repeated ;  not that the hemorrhage which  seems to alarm M. Burdin,
(Ibid. p. 294,) or necrosis of which  M. Jacquemin (Ibid, ib.) speaks,
are really sources of apprehension, but because of the gangrene, or al-
most unavoidable retraction of the flap.   I shall have occasion to speak 
PALATOPLASTY.
607
again of the utility of staphyloplasty, in treating of staphyloraphy it-
SOU*
   [Dr. J. M. Warren of Boston, (Reese, Loe Cit.,) in a case of con-
genital fissures of the soft and hard parts of the roof of the  mouth and
palate, proceeded in this manner: The soft palate having been prepared
for staphyloraphy by the usual abrasion  of its edges, and the introduc-
tion of the  necessary  points of suture, the mucous membrane  covering
the roof of  the  mouth was carefully raised on each side of  the fissure
in the hard  palate, and when thus  detached  they  were brought across
the fissure, and united like the soft palate by the interrupted  suture, the
flaps formed by the the mucous membrane of the mouth being continu-
ous with the denuded edges of the  soft palate.  This difficult and deli-
cate operation was completely successful, and is by no means  diminished
in value from having  been first devised,  and successfully  performed,
(as  we shall see below,) many years before by  a German  surgeon,
M. Krimer.   Failure after  failure, however,  so  often  baffles  the most
elaborate  processes  hitherto contrived to remedy  this  disease, even in
the hands of the most accomplished surgeons, that we can scarcely hope
for success with  all the  the  aid  of anaplasty, except in some rare in-
stances and  most favorable subjects.—T.]
                           CHAPTER X.

       PALATOPLASTY, (ANAPLASTY OP THE VAULT OF THE PALATE.)

  Anaplasty of the palate is an operation frequently indicated ;  three
different conditions may require it.  Surgeons have  remarked  that sta-
phyloraphy  often leaves at the  root of the velum a hole which is very
difficult to close up.   It is also known, on the other hand, that  the per-
foration of the vault of the  palate may be congenital;  it is not rare, in
fact, to find holes produced in the palate by accidents or wounds.   Even
if it were true  that, by means of obturators properly  constructed, like
those that M. Toirac has contrived, we may succeed in perfectly closing
up these holes, it is nevertheless also true, that their effectual obliteration
by the living tissues would still be preferable.   It is very natural, there-
fore, that in such cases the aid of anaplasty should have been called in-
to requisition.

                         Process of Krimer.

  The first case of palatoplasty that has been published, belongs  to M.
Krimer, (Journal de Graefe  et Walther, t.  x., p. 625.)  This surgeon
made an incision at the distance of some lines outside a cleft which  re-
mained in the vault of the palate after a staphyloraphy.  He  was thus
enabled to dissect from the sides towards the middle  two flaps, which he
reversed upon themselves, and then united by some  stitches of suture.
The patient recovered perfectly.   In the place of these two flaps, M. Bon- 
608
NEW ELEMENTS  OF OPERATIVE SURGERY.
His (Transact. Mid., 1830, t. ii., p. 307) proposes to cut one only behind,
and to bring it afterwards into the hole, of which the two anterior thirds
only are to be abraided.
  MM. Xelaton and Blandin (Bulletin de  Therapeutique, t. xi., p. 379)
have, as it appears, modified the palatoplasty of M. Krimer, by changing
the form of the flap proposed by this author; but, as they have  not ap-
plied it on the living subject, it is scarcely possible at  the present time
to appreciate the actual utility of their process.
  If the hole in the vault of the palate is not merely  the remains of a
fissure of the velum, it scarcely ever closes up spontaneously.  We should
do wrong to count  on cauterization in such cases ; the successful results
obtained by M. Henry of Lisieux, (Bulletin de VAcad. Roy. de Mid., t.
i., p. 291,) those that are attributed to Dupuytren and Delpech, (Bull.
de Thirapeul., t. xi., p. 379,) and those which belong to myself, all
have reference to perforations in the velum  of the palate, and not to holes
in the vault of the palate.  It is then to palatoplasty that we must actu-
ally have recourse in these last  cases.

                       Process  of the Author.

   One important circumstance to be observed is, that the fibro-mucous
membrane of the palate, with its firmness and  little vascularity, admits
but imperfectly of  the formation of largo flaps, and  that, if it is requir-
ed to give to these flaps  more than half an inch in length, they almost
inevitably mortify in whole or in part.  Having tried it in that manner,
and  observed that the flap became  gangrenous  to one half its  extent,
though it had a large base, and  had been borrowed from the root of the
velum  of the palate,  I determined upon the following process.
  Two strips of tissue, from six to ten lines  long, and  having the form
of a somewhat elongated triangle, are cut,  the  one  in front, the other
behind the perforation.   Dissected and brought down towards each other,
and united by means of  a stitch of suture at their apex, these flaps each
leave a wound the approximation of the borders of  which  gradually
closes  up the fistula in every direction.   We may also, in order to aid
in the cure, make from time to time a longitudinal incision upon the two
sides of the hole to be closed.   We  may  make transverse ones,  also,
upon the root of each flap when they are sufficiently revivified.   It was in
this  manner I proceeded in the  case of a young man who has become
unfortunately celebrated, and who in consequence of  a  discharge from a
pistol, had a  hole  eight  lines long  aud six broad in the vault of the
palate.  This subject also will be recurred to again  under the head of
staphyloraphy.

[Anaplasty applied to great loss of Substance in removing  Cicatrices
                           from Burns.

   If America owes to Europe the first-improved processes of anaplasty,
there is one remarkable and recent  case on record in which one of 'our
surgeons, Dr. Mutter of Philadelphia, may  lay  claim  to  have  carried
the art to  a higher perfection than  elsewhere known.  In an adult fe-
male, who had been shockingly burned when aged 5 years, and who, from 
                       AMERICAN ANAPLASTY.                   609

the chin being drawn down by the cicatrix on the neck to an inch and a
half from the sternum, had not  been able to close her mouth but for a
few seconds at a time during the space of 23 years, who could neither
throw her head back or to the left side, and whose clavicle on the right
side was imbedded in the lower part of an enormous cicatrix which fill-
ed up the space between the chin and the sternum ; Dr. Mutter made a
transverse incision across the middle of the cicatrix about three quarters
of an inch above the sternum, commencing on sound skin near one side
of the cicatrix, and terminating the incision  in the sound skin on the
other side.  This was to get at the attachments  of the  sterno-cleido
muscles, which muscles were not over three inches in length.  Carefully
dissecting down over this vital part, through the fascia  superficialis colli,
he exposed the sterno-cleido-mastoid muscle on the right side, and pass-
ing a director under it as low down as possible, divided both its attach-
ments.  He could  thus  raise the head  an inch or two, but perceiving
the retraction of the muscle on the  other side unyielding, he  divided
its sternal attachment only, and was  delighted to find he could replace
the head completely in its natural position.  The clavicular attachment
offering little or no resistance, was not divided.  A shocking wound of
six inches in length by five and a half in width now presented itself,
yet almost without hemorrhage,  only three or four vessels requiring the
ligature.  He next detached an oval flap of sound skin six inches and
a half in length by six in width, by continuing  the  first incision down-
ward and outward over the deltoid  muscle, leaving a  pedicle at the up-
per part of the neck.  This dissection was painful but not  bloody, only
one small vessel  being opened.  Making a half turn of the flap on its
pedicle, it was brought over the chasm and carefully attached by several
twisted sutures to the edges  of the  primary  wound, the  whole being
supported by adhesive straps.  The edges of the wound on  the shoulder
were completely  brought together by straps and sutures, except its up-
per third only, on which raw  surface was applied a pledget of lint wet
with warm water, after which  the patient was put to bed with the head
maintained backward by a bandage.  No unfavorable  symptoms occur-
red, and union took place by the first intention.  Twelve  months after
no contraction of  the flap had taken place.   Dr. Mutter has succeeded
by this process in several other  cases.  Oleaginous frictions to the new
parts are useful to give them  flexibility and softness.   He recommends
this  process in cicatrices from burns in the neck, cheek, eyelids, nose,
lip, &c.  In the three latter he has effected complete  restoration of the
organs.  (Vide American Journal of the Medical  Sciences, July, 1842;
see also figures of the above extraordinary case in Dr. Norris's  Ameri-
can Edition of Fergusson's  Surgery,  and in the more  recent work
(Philadelphia, 1844) on  Operative  Surgery, by  Professor Pancoast;
also, Professor Mutter's own late work on Cases of Deformities from
Burns.)—T.]
  Vol. I.                   77 
610            NEW ELEMENTS  OF OPERATIVE SURGERY.
                          CHAPTER XI.

  BRONCHOPLASTY, (ANAPLASTY OF THE LARYNX AND OF THE TRACHEA.)

  Wounds in the anterior region of the neck, always so  dangerous
from the large vessels that they may include, are still  more so by their
tendency to become fistulous when they  involve the respiratory  canal.
It is  important, nevertheless,  to  arrange  them, in  this respect,  under
distinct heads.  Those  of  the trachea, unless  the  canal  is completely
divided through, in general cicatrize with facility.   Over the cricoid
and thyroid cartilages,  also, art triumphs without much difficulty;  but
it is no longer so in the thyro-hyoidean space.   Here position, bandages,
and even the suture, do  not always suffice to keep the lips of the wound
properly approximated.

                       Article I.—Anatomy.

  The cause of these aifferences lies in the anatomical arrangement of
the parts.  Under the laryngeal prominence, in fact, the skin and  the
subjacent tissues possess a thickness, and enjoy a mobility, almost every-
where  equal.  The trachea is sufficiently pliant, and  endowed  with a
sufficient degree of vitality, for the process of cicatrization, when pro-
erly  conducted, to close up its openings without difficulty.  Nothing
would  prevent our applying the suture to them if we judged it proper,
and the movements of the head have  but  little influence upon the pro-
gress of such wounds.   In the thyro-hyoidean  groove,  it is entirely the
reverse.  There, the parts  lose their parallelism as soon as they have
been divided.  The angle of the cartilage draws  the  lower  lip of the
wound forward  and downward, while the os hyoides draws the  upper
one backward, and upward.   The  first presents a complex  structure.
We remark there, at the same time, a solid cartilage, a very delicate
skin, very irregular cellulo-fibrous tissues, and the attachment of some
muscles.   If, in the second, the tissues are more homogeneous, the os
hyoides gives it such mobility that surgical remedies have but little hold
upon it, when our object is to maintain it  in connection with the other.
The least movement of the chin, also, immediately deranges the coapta-
tion.   Mastication and  deglutition, whether of solids or liquids,  or  of
simple saliva,  do the  same  every  moment.  If the epiglottis is  below
the wound, which is rare, the matters coming  from the mouth almost
always become entangled in the accidental opening.  If, on the contrary,
as generally happens, this part is found detached from the glottis, the
air and mucous matters  repelled by its postero-inferior surface are still
more easily driven into  the wound.  Thus, on  the one side we have the
tongue, and epiglottis, and  fleshy, vascular, pliant and  movable tissues;
and on the other, the thyroid cartilage solid  and fixed, and  but little
vascularity in the tissues.  Is there any thing more wanting, connecting
these with  the other peculiarities just mentioned, to explain the fistulas
produced by transverse  wounds in this part of  the neck ?
  Anatomy, moreover, explains why  divisions by cutting instruments
more frequently take  place in  this place  than elsewhere; as it is  to at- 
BRONCHOPLASTY.
611
tempts at assassination and suicide that they are most generally to be at-
tributed.   The projection of the chin, and the top of the larynx, thus
in some degree  strongly invite the arm of the murderer to this spot.
In other respects, the upper border of the thyroid cartilage on each side
terminating behind  in a kind of horn of considerable  length, it is rare
that the  instrument  penetrates beyond that part.  The carotids are by
this means protected.   The  superior thyroid artery, and some other
branches of still less volume, being alone accessible, the wounded person
almost always survives, and the fistula has, in this manner, full time to
establish itself.

                     Article II.—Indications.

  Most authors  have pointed out the dangers of wounds of the throat,
and the difficulty of curing their fistulous openings.  We may on this
subject  consult  Pare,  (Liv. x., ch. 30, p. 292,) Richter, (Bibliotheque
du  Nord,  t. i., p. 167) Bousquet, (Theses de Paris, 1775,) the Memoirs
of the Academy of Surgery,  (torn, iv., p. 429,) J. Bell, (Traiti Des
Plaies,  Traduction  d'Estor,  p.  474,) and the  fourth volume of the
Clinque of M. Larrey.  Only that, inasmuch as these practitioners have,
with the exception of a very small number of their cases, confined them-
selves merely to saying  that the respiratory passage had been  opened,
without designating specifically the  part wounded, their observations
cannot be of any great  assistance in such matters.
  For the same reason that wounds of the thyro-hyoid space are, from
the very first, difficult to cure, the fistulous openings which are produced
by them must be still more difficult  to close.  Sabatier was so convinced
of this, that he hardly deigns to devote a page to them in  his excellent
work.  MM. Roche  and  Sanson, (Element, de Pathol., t. v., p. 280,)
who have  not  thought it  necessary to treat of  them at greater  length,
admit they are almost  always  incurable.  To such extent, in fact, has
this opinion been carried, that to judge of these wounds  by the silence
of writers, they have not, up to the present time,  been  the object of any
attempt at surgical  relief.  Our latest dictionaries, and treatises, give
no more details on this subject, than the works  of  past ages, and there
is no scientific work which makes particular  mention of  them.   The
cause of such an omission can only be explained,  as I conceive, in three
ways.  Finding that it sufficed to pare the borders of these thyro-hyoid
fistulas, to cause them to agglutinate by means of sutures and  bandages,
has it not  been that surgeons have deemed  the treatment too simple and
easy to be worthy of being made the  object of special  consideration ?
The assertions of Sabatier, however,  and the  facts  that I am about to
state, prove that such a version is not admissible.
  May we not, on the contrary, be permitted to think,  that, having fail-
ed in their efforts, practitioners have deemed it unnecessary to make the
same known to the public ?  As they do not jeopardize life, and may be
covered over by the cravat, or completely shut  up by a tent of linen,
lint, etc.,  is it not therefore still more probable, that patients making up
their minds to take care of their fistulas  themselves to an indefinite  pe-
riod, having thus thought proper to exclude surgery from an opportunity
of interfering with them ?  The future will reveal to us if it is not these 
612
NEW ELEMENTS  OF OPERATIVE  SURGERY.
two  last motives, as I think it is, to which  more  especially  the  blame
must be imputed.  Whatever, however, may be the cause, it is sufficient
for me, at the present moment, to prove the difficulty of curing some of
these fistulas by the methods now known.
   [The presumption is, that in many instances this apparently most sin-
gular omission may be as satisfactorily explained, by the facility wdth
which these fistulous openings sometimes rapidly close up spontaneously,
(as in children especially,) as by the obstinacy with  which, in  other
cases, they resist  all  remedial measures.    Thus, remarks Dr. Mott, as
recently  happened to him in a successful  case of tracheotomy which I
had  the  satisfaction of seeing performed by him upon a child of three
years of age ; the clean incised wound, notwithstanding the great num-
ber of arteries and veins which necessarily had to be tied, (owing to the
engorgement of all the vessels of the part,  through  the violent and
strangulating efforts of the patient to relieve itself,) rapidly granulated,
while the fistulous opening  gradually contracted  itself as the neighbor-
ing parts neatly cicatrized, and finally spontaneously closed up, leaving
scarcely a trace behind, and  without  the slightest dressing whatever
having  been used. Dr. Mott, indeed, is of opinion, that it is  better in
such cases to leave open the  artificial  incision into the trachea to its
own curative action, as  the air passing a part of the time  through this
aperture, saves the portions of the trachea and larynx  above, from the
fatigue of the respiratory  functions, and which exemption, partial as  it
is, they require, from  the extent to which  irritation  has been produced
there previously by the foreign body—in this case above, a large  black
straight  pin, two  and a half inches to three inches in extent, with  the
the head of the size of  a large pea, and lying downwards.
   In adults, on the other hand, as is familiarly known, artificial fistulous
openings between the  ribs, and penetrating into the cavity of the thorax,
are often exceedingly  difficult to close up.   But even in  the greater part
of these, also, the cure  is readily  effected, and the  silence of authors,
therefore, is upon the  whole to be imputed to the  fact, that such wounds
in the  trachea,'at least, are, by the facility  with which  they  are  healed
up, a matter of very  little  importance.   From the  rapid and healthy
curative process which took  place in the  case  above mentioned, and
which will be given in detail in the appropriate part of this work, ought
not much of this  result to be  imputed to the  clean incised and fresh
wound made by the operation ?  And does not  this therefore suggest
that, in all cases of fistulous openings into  the trachea, whether  conge-
nital or from ulceration, or lacerated wounds, it would  be advisable  to
excise the edges  completely, so as to make as straight  an aperture  as
possible ?  And then, if aid were  required to assist nature, as in cases
of long  standing, what more would  be necessary than to approximate
the lips together, either by strips of adhesive plaster, or the  suture ?
   In making this excision,  however, the utmost care is required, because
of the extreme danger of suffocation from the  introduction even of a
single drop of blood into the air passages.   To do it properly, therefore,
we do not know of a better mode than to do it in the manner, and with
the  precautions, which  Professor Velpeau very ingeniously proposes bo-
low in his own process.—T.] 
BRONCHOPLASTY.
613
                 Article III.—Operative Process.

  If it be true that all the modes of anaplasty may be applied to fistulas
of the larynx, the French or the Indian method, however, have hitherto
been the only ones had recourse to for their cure.

                    § I.—Process of the  Author.

  One of the patients whom I cured of a fistula, had been already ope-
rated upon unsuccessfully, in  a large hospital;  another case belonged
to M. P. Denis, ancient laureate  of  the  school  of Paris, who, fearing
that he  would not  be sufficiently well attended to in the establishment
which he has the  management of, in one of  the provinces, sent him to
me, in the month of December, 1832.  These facts of themselves show-
ing^ that their disease was not easy of cure, I mention the circumstance
to justify myself  for having made  use  of a new method of anaplasty.
This  method consists, essentially, in  the construction of a fold, or tent,
of sound tissues, which is introduced into and kept in the fistula.  Here
is the process:
  First  Stage.—The patient being laid upon his back, as in bronchoto-
my, is held down in a proper manner by assistants.  The surgeon, placed
on  the right, cuts on the front part of the larynx, below the ulcer, with
a straight or convex bistoury, a flap of integuments, an inch in width and
two inches in length, more or less, according to the breadth or  depth  of
the aperture to be closed, shapes this  flap into a cushion, or square form
below, gives it a little less width above than at its under  part, dissects
it and raises it from its free border towards its root, reversing with it as
much cellular tissue as possible, but without denuding the cartilage, and
stops then to proceed to the second stage of the operation.
  Second  Stage.—This second stage includes the paring of the  edges
of the fistula.  As  it fatigues the patient by the cough that it excites,
and  the  repeated movements of deglutition which it causes, it requires
some  precautions  and patience.   In. place of doing  this by removing
layer after  layer  horizontally, which would  seem  to  be the most easy
mode of performing it, I would remark,  that it would be better to force
in at first the point of the bistoury outside of and upon a part of the
circle  to be excised, in order afterwards to go round its whole circum-
ference, before dividing, in any part of it, the continuity of the pellicle
that we  wish to  detach.  We thus excise an annular band of tissues,
which is held successively, at its different points, by the forceps, in pro-
portion as the instrument separates it from before backward, until the
operation is completed.   As its deep border [i. e., the bottom of the
incision—T.] is not to be detached until the last step, the blood escapes
on the side of the wound.  Not entering, unless in very minute  quantity,
into the laryngo-pharyngeal cavity, this fluid cannot, therefore, excite in
the patient a violent desire to cough, or expose to any risk of suffocation.
It is, moreover, better to excise in such manner that the wound may be
made  a  little wider superficially, than  at its bottom, [i. e.,  flare out-
ward.—T.,] and that it may present,  in some degree, the form  of a cone
or funnel. 
614            NEW ELEMENTS OF  OPERATIVE SURGERY.

  Third Stage.—After allowing a minute or two to the patient to repose,
which  is  required  also to suspend  the oozing of blood from the wound,
we  proceed to the third  stage, that is, to the adjustment of the flap.
This part of  the  operation  presents two modifications, sufficiently dis-
tinct.
  First  Process.—If the  fistula has  more extent crosswise, than from
above  below, we begin by folding the flap double, taking care, however,
in making this  fold, not to carry up its point quite as high as the root.
We reverse it  in this state, without twisting it.  Its cellulo-adipose sur-
face  only being free, the surgeon then adjusts its heel,  that is, its mid-
dle part, into the fistula.  There is nothing more  to be done than to in-
sert, from left to right, a long needle, which perforates at the same time
the lips of the wound, and the whole thickness of the  body which fills
it up.   A few turns of twisted suture, a perforated  linen spread with
cerate,  some lint, one  or two  compresses, and  some turns of bandage,
support the whole.   The flap requires here a certain degree of attention.
Its  point being free, opposite to the internal or cutaneous surface of the
pedicle, would easily escape by slipping backwards, if the needle, by be-
ing badly adjusted, should pass between its two folded  halves, in place
of actually perforating them.
  This  accident  happened to my second  patient, and made me fear, for
a moment, that  I should be obliged to begin again.  It  may be avoided
with certainty, by previously fastening together,  with one stitch of suture
the apex and root of the tegumentary fold.  Then the deep-seated needle
and  the twisted suture would not be indispensable.  A strip of diachy-
lon plaster from before backwards, and sufficiently long  to surround the
neck, could be readily substituted for them.
   Second Process.—When the fistula  has  its greatest  diameter  in the
vertical direction, or takes on the circular form, it is sufficient to roll
up the flap, cut as we have described it, upon its cutaneous  surface, and
parallel with its  length, in order  to  form with  it a cylinder or tent.
The  operator,  then  reversing it, inserts its  free extremity  to  a certain
depth into the abnormal opening, fastens  it as  in the  preceding case,
and is  careful  to leave no void between  the pared surfaces.
  If any circumstance, moreover, should require it, this flap could just
as well  be taken from the side, or above, as  in front of the  thyroid car-
tilage.   It is  for the  practitioner  to determine in what direction  the
tissues are best adapted for this purpose.  It is important only, that he
should give to it one half more length and breadth, than the size of the
opening to be  closed would at first  sight  appear to require, seeing that
its natural contraction necessarily diminishes its  size considerably, as
soon as it is in its place.
  As to the wound which results from its dissection, we might, in the
greatest number of cases, reunite it immediately by two or three stitches
of twisted suture ;  but the difficulty of establishing a uniform compres-
sion in  the neighborhood, would expose to the risk of an erysipelas, or
suppuration throughout the entire neck.  Prudence therefore suggests,
that we should confine ourselves to  approximating its edges gradually,
in place of attempting a perfect contact.
   I have yet  had,  it  is true, but two occasions to put  this method in
practice ; but in both the success was complete. 
BRONCHOPLASTY.
615
  First Case.—One of the patients, twenty-eight years  of  age, and in
other respects in good health, had had his throat  cut  four months be-
fore, between the os hyoides and thyroid cartilage, and from one sterno-
mastoid  muscle to the other.   Stitches of  suture,  a bandage, and the
flexed position of the  head, had  recourse to  on the spot by M. Denis,
physician of the Hospital  of  Commercy, procured  only an imperfect
union of the wound.   When he came  under  my care,  December 15th,
1832, the borders of the wound had cicatrized apart, to the distance of
about six lines.  When his head was  raised  up, it  was easy to insert
into the fistula the point of the little finger.   In this state he could
scarcely make himself heard.   In depressing  the chin, on the contrary,
he regained his voice and speech.   A curved sound, introduced into the
bottom of the wound, and the left forefinger inserted deep into the back
part of the mouth, enabled me  to ascertain that  the division penetrated
directly above the glottis, and under the epiglottis.  The deglutition of
liquids caused  more cough than that of solids.  Mucous  matters es-
caped in abundance by the fistula.  Much  caution, also, was  required,
to prevent the ingesta from also  becoming entangled in it.  The least
contact  with these bodies,  or of  any foreign  body whatever, with the
interior of the wound, produced immediately a paroxysm of coughing
so violent as to render it impossible  to  make  any continued  approx-
imation  of the borders of the wound.  I operated on the twenty-second
of the same month, after the first process above described. The  flap,
after being dissected,  was  doubled, reversed  from  below upward, and
then introduced, thus folded, into the excised fistula, and finally attached
by a single pin.   I did not remove the dressing until on the fourth  day.
The point of the flap being a little too short, or badly  fastened against
its root, had slipped off and got into the larynx.  The swelling, in  fact,
of the tissues, made me think, for an instant,  that the whole cutaneous
fold had succeeded  in getting  into the  passage.   A violent  spasm of
coughing, which had come on  the day before, still more confirmed this
opinion ; but the event showed that there  was no  such  thing.  In  fact,
it was by retracting itself from behind  forward,  that this flap succeeded
in stopping up the fistula, and its pedicle was found so to speak, distinct,
before the cicatrization was completed.  A hole, which  scarcely admit-
ted the head of a pin, and which was  with  difficulty cicatrized by  cau-
terization with  nitrate of mercury, the  red-hot iron,  and nitrate of
silver, did not become entirely obliterated  until after the  beginning of
March, 1833.   The strangulation  caused by  a  long strip  of adhesive
plaster,  placed above to depress its upper lip, prevented also the wound
of the flap from cicatrizing till very late, and caused an abscess which
had formed on  the outer side,  to re-appear  several times  afterwards,
but not  in any  manner, however, to endanger the success  of the  first
operation, the cure of which had  been completed a long time  previous.
   Second  Case.—In the other patient,  the  wound was in the  same
place, and was  produced by the same  cause  as  in  the  preceding case.
Its size  was rather larger, at least in the vertical direction;  its borders,
also, were a little thicker,  and  the epiglottis was not separated from the
back  part of the larynx, but to the extent of two thirds of  its breadth.
When the  patient obtained admission into the Hotel-Dieu, in the month
of  October, 1831, his fistula had existed  six  months.  The publications 
616
NEW ELEMENTS OF OPERATIVE  SURGERY.
 at the  time (Lancette  Francaise, t. v.,  p. 240,  310—315)  state  that
 Dupuytren dissected laterally the lips of the wound, to a certain extent,
 in order afterwards to  approximate them, and to  unite them  in this po-
 sition by some turns of twisted suture.   Doubting the success  of his
\ essay, the skilful professor had, as it also appears, (Ibid., t. v., p. 315,)
■ formed the project of making trial of another method, that is, " of bor-
 rowing from the neighboring parts, and  of plugging up the fistula with
 the detached flap;" but the  patient  left the hospital  and came to La
 Pitie, in January, 1832.  A flap, borrowed from  the anterior surface of
 the larynx, dissected, raised up, and rolled upon  its  axis, was inserted
 into the fistula, which had been  previously excised, and  was fastened
 in its place by means of pins.   The two fissures which were at first left
 upon the sides, yielded, at a later period, to  the  application of the ac-
 tual cautery, and another point of suture.
    The patient did not leave the hospital until a long time after the com
 pletion  of his cure.

                       § II.—Ancient Processes.

    The method which I propose, is not the only one that may be applied
 to fistulas in the air passages.   I know,like M. Larrey, (Clinique Chir.,
 t. iv., p. 290,) that to  cure a number of these fistulas, it suffices to pro-
 long their angles above and below, then to excise  their borders, and to
 keep  them approximated, either by means of a bandage or suture.  A
 cut of the bistoury crosswise on each lip of the wound, to detach its low-
 er extremity, would also favor its coaptation.   The  lateral incisions of
 Thevenin  would have  the same  effect.
    When the perforation is larger, the method employed by Dupuytren,
 or anaplasty by dissection of the  tissues, is also  of  a nature to procure
 some advantages.   We might also imitate the first  processes of rhino-
 plasty, and confine ourselves to sewing the borders of the borrowed flap by
 the Indian method to the excised borders of the fistula.   But even cauter-
 ization and simple bandages alone, are sometimes quite sufficient.  I even
 think that these two last means, which have since succeeded  with me in
 two different cases, and the simple suture, will be preferred to the bron-
 choplasty which I have made use of, provided their  efficacy  should not
 appear  to be  questionable.  But the  process,  nevertheless,  which  I
 have suggested, appears to me of a more  certain efficacy,  more easy in
 its application, and better adapted to the ability of all surgeons, than the
 other methods hitherto  employed, and which, moreover, certain fistulas
 obstinately resist.
    When it has been decided upon to separate, transversely, the thyroid
 angle from the perforation, in order more effectually to  bring the lips of
 the latter into contact, there remains, most frequently, a transverse fis-
 tula underneath the vertical division which has been cured.  The solidity
 of the cartilage, and the projection which it makes in front, explain this
 fact.   The lateral dissection  of the  tissues, presents an inconvenience
 much more serious still; the mucous  discharges  which come from the
 trachea, even the saliva, gliding between the approximated flaps and the  '
 subjacent  tissues,  almost  inevitably  produce an erysipelatous inflamma-
 tion, which may  speedily involve a  great part of the neck.   Then, in 
BR0NCH0PLASTY.
617
fact, it becomes an ulcer, whose orifice we close before having cleansed
its  bottom. ^ The  state of the  parts, moreover,  scarcely ever admit of
giving sufficient thickness  or regularity to the flaps, to remove all fear
of gangrene or suppuration.
  The skin in  the neighborhood is too thin  and pliant to  enable us to
form a suitable  covering by the mode of  the Koomas, or of Chopart, and
to apply  it after  the  rules laid down by MM. Roux, (Arch. Gin. de
Mid., t. xv., p. 468,) Lallemand, (Ibid., t. iv., p.  242,)  and Dupuytren,
(Lancette  Frangaise,  iii., p.  273,)  for cheiloplasty.  The  numerous
stitches of suture that it would require, and the tendency of the laryngo-
pharyngeal fluids to escape by the fistula, would, in  most cases, prevent
its agglutination from succeeding.  This last method, in fact, has all the
inconveniences  of  that which I brought  into  practice,  without affording
any of  its advantages.  In reality, it merits the preference only in fistulas
too large to admit  of being closed by a tent,  or simple  cutaneous  fold.
                          CHAPTER XIx.

                     ANAPLASTY OF THE THORAX.

  It is scarcely other than large wounds in the chest, with great loss of
substance, that can require the assistance of anaplasty ; and among these
wounds, those which result from the removal of the breast, are the only
ones to which it has hitherto been applied.   When the adhesions of the
skin, or the extent of the tumor, require a wound  whose edges it is im-
possible to  place in immediate contact, we may in reality ask  ourselves
if there would not be an advantage  in filling  the void  by some one of
the processes of anaplasty.  Various  reasons  may be advanced in sup-
port of this  proposition.   If after the amputation  of  the breast,  the
borders of  the wound remain at a great  distance from  one another, we
have to wait a long time for the cicatrix, and it is not  effected but by
the intervention of a new tissue, whose retraction produces a constant
tendency to the return of the disease.   The suppuration which such solu-
tions of continuity involve,  and  the tractions which such cicatrices ex-
ercise, fatigue and torment  the patient, and render the radical cure of
such wounds  a difficult matter.   If, then, the surgeon could at the com-
mencement fill up the whole of the wound, the patient operated upon
would find  great  advantage and  security from it.  For these reasons,
various kinds of anaplasty have been made trial of after amputations of
the  mammae.

                            Article I.

  The anaplasty known as that  of Chopart,  or that  by drawing, has
been made  trial of by myself.  I had been obliged to  remove the integu-
ments with an encephaloid tumor, which extended from the right clavi-
cle  to below the breast.   The woman was thin, and her skin very adher-
  Vol.  I.                     78 
618
NEW ELEMENTS OF OPERATIVE SURGERY.
ent.   It  was impossible  to leave  a space of less than three inches be-
tween the borders of the wound; prolonging the sides of this wound to
the extent of four inches below, I circumscribed in this manner a quad-
rilateral  flap, which I dissected to  the  same extent, and which I en-
deavored  then  to raise upward, in  order to sew its free border to the
upper lip of the primitive wound.  I hefe experienced serious difficulties;
for, owing  to the density  of the dermoid tissue, the flap elongated but
very little under my tractions.  Having, however, united it by a great
many stitches of suture, to  the entire circumferense of the wound of the
breast, I  succeeded in fastening it in a suitable manner;  but the opera-
tion  was long and painful,  and  the borrowed flap finally mortified, after
having given me, during the space of a week, some hopes that it would
agglutinate to the neighboring parts.

                  Article II.—Indian Anaplastf.

  A surgeon of La  Creuze, M. Martinet,  speaks  of several women  op-
erated upon by him, and who did very  well  under the Indian  method
of anaplasty.  After cutting a large flap,  either from without and near
the axilla, or from below and near  the flank, M. Martinet says that he
then isolated, twisted, and  reversed it, as is done with the flap  of the
forehead  in Indian rhinoplasty.  He adds that patients operated upon
in this manner, and in whom the disease had  already reappeared twice,
were ultimately cured,  and  that  it is a means which may protect the pa-
tient from a return of cancer.
  For myself, I fear that anaplasty, whatever may be the process, has
hardly fewer inconveniences  than  advantages in the mammary region.
Whether the wound, resulting from  amputation of the breast, be closed
immediately, or left to  cicatrize  by  second intention, the surgeon is not
on that account either more or less secure against the return of the dis-
ease.  Even though he should succeed in closing this wound by anaplas-
ty, either by the drawing method, or by a reversed flap, the cure, to be
complete, will require not less than  fifteen days,  or a month.  We  can-
not fill up a great loss of substance in this region without producing a
wound in the neighborhood  still  larger.  The teguments thus dissected,
also, are  very much disposed to become gangrenous, in consequence of
the manner in which the vessels penetrate  into or are  distributed to
them.  The accessory  operation, sometimes worse  than the  principal
one, scarcely therefore merits being preserved  here, under the form in
which I have described it.

               Article IH.*-Anaplasty of Franco.

  All that it  would  be proper to do, if, in order to obtain a complete
union, a slight elongation only was necessary, would be to separate the
tissues of the  circumference  of the  wound  to  a certain  extent, after
the manner of Franco, or to incise the integuments upon the sides, after
the method of Thevenin.  We would thus cause a relaxation, which
would effect, without  much difficulty, an elongation of an inch or two
in the lips  of the wound.  In  fine, anaplasty in the mammary region,
does not  appear to me destined to occupy a high rank in surgery. 
ANAPLASTY OF stercoral fistulas, and artificial  anus.  619
                         CHAPTER XIII.

       anaplasty of stercoral fistulas, and artificial anus.

  Fistulas of different kinds may be  established in the  abdomen, and
in the inguinal regions.  When  these fistulas are not kept up except by
an exudation from the peritoneum, the cure is generally  easy.  Those
that are  connected with a wound of the liver, also disappear without
difficulty.  When caused by a disease of the kidneys, or a  perforation
of the gall bladder, they ordinarily resist every remedy.   Those  of
the stomach would yield, probably, to  some of  the processes of ana-
plasty ;  but they are  so rare,  that they  have  not hitherto  occupied
the serious  attention  of practitioners.  Those  which  are caused by a
perforation of the intestines, alone merit  consideration.  Whatever, then,
may be the  part  of the belly where the fistula exists, it takes  the name
of artificial anus.  Nevertheless, this last  name is applied more parti-
cularly to fistulas that  remain divided at the bottom  by a kind of parti-
tion or spur.  While this eperon exists, the intestinal fistula requires^
treatment foreign to  that of anaplasty, and  which I shall recur to in
treating  of artificial anus.
  If the two ends  of  the  intestine,  on the  contrary, communicate
sufficiently freely with  each other, and in such manner that the digestive
canal is in some sort divided only on one of its sides, or on its convexi-
ty,  there  is an opportunity of calling  in  the assistance  of anaplasty.
When reduced to the state of stercoral  fistulas, artificial  anus, in other
respects  difficult  to close by the other  modes known, has already been
treated by several processes of anaplasty.

       Article I.—Anaplasty by Dissection of the Tissues.

  Having to treat a case of this  kind, M.  Collier detached the integu-
ments on the contour of the fistula, then pared its borders, and immedi-
ately proceeded to their reunion.  The  patient recovered.  Dupuytren,
(Diet,  de Med., et de Chir. Prat.,t. iii., p. 157,)  however, who attempt-
ed this method, states  that it proved unsuccessful.  It is moreover evi-
dent, that it would incur the risk of an infiltration of stercoral fluids
into the  tissues of the  prarietes of the  abdomen, and that it might then
be difficult to prevent gangrene, or erysipelas of  a bad character.   The
process of M. Collier,  therefore, has  found but a very small number of
partisans.
                 Article II.—The Indian Process. .

  Very recently, in  1838, M.  Blandin, (Bull, de VAcad. Royale de
Med., t. ii.,) having cut a tegumentary flap in the inguinal region, suc-
ceeded in twisting this flap,  and in attaching it to the circumference of
a large artificial anus.   The agglutination of the parts was  effected,
and the borrowed operculum, though thin and flabby, effectually closed 
 620            NEW  ELEMENTS OF OPERATIVE SURGERY.

 all exit to the matters.   It resulted, however, in this, that the intestine,
 with  the  constant  tendency to produce a hernia, pushed it out like a
 valve, and obliged the patient to wear a bandage.   This case of success,
 however, to which I have alluded, will not be  sufficient  to  bring  into
 general use the  anaplasty of the  Koomas.  This  method, at the most,
 could only  in  fact be adapted to  large  fistulas, and to cases where the
 parts admit of  cutting from the neighborhood a flap of sufficient thick-
 ness.

             Article III.—Processes  of the Author.

                          § I.—The Plug.

  Desirous of transferring to stercoral fistulas the method which I had
 tried to the larynx, I endeavored, in 1832 and 1833, by means  of a tent
 of integuments, to shut up a fistula of this  kind  in a boy aged about fif-
 teen years.   The anus, about an inch in width, was  entirely  free of an
 eperon.  Many operations had already  been attempted  for it in vain.
 It had its seat in the right iliac region.  I cut on  its outside a triangu-
 lar flap, three inches long, and  twelve lines in breadth.  This flap, re-
 versed upon its cutaneous  surface, then  rolled in the form of a plug,
 was introduced by its cellular surface into the fistula, which had been
 previously abraded.   I fastened it  there by means of several stitches of
 suture, and  kept it in its place by  the aid of a  slightly compressing
 bandage.  Violent  colics supervened on the third day, which were soon
 succeeded by a stercoral exudation at the circumference of the flap,
 which soon mortified and fell out in a state of putridity.
  The acrid  penetrating  humors which pass under the fistula, insinuate
 themselves so readily  between the parts, and render the  agglutination
 of the tissues so difficult afterwards, that to succeed in such cases would
require a concurrence of  circumstances which we could scarcely be per-
mitted to hope  for.

                      § II.—French Anaplasty.

  In other cases I have proceeded differently.   After having pared the
fistula, in  order to transform it into a sort of a slit, and  to unite it by
three or four stitches of  simple suture, I made, at the distance of an
inch on each  side, an  incision which extended  beyond its two extremi-
ties, and which went  through the whole thickness of the integuments
 and  penetrated down to  the aponeurosis.  I in this  manner obtained a
 considerable degree of relaxation, and the patient was completely cured,
 (Jour. Hebdomad., 1836, t. iii., p. 5, 33, 65, 70.)   But,  as I shall  re-
 turn to these different  methods in  treating of artificial anus, I have no
 occasion of alluding further  to this subject at the present moment. 
ANAPLASTY OF THE  SCROTUM AND PENIS.
621
                         CHAPTER  XIV.

               ANAPLASTY OF THE SCROTUxM AND PENIS.

Article  I.—Prepuce.  Different Causes  may produce the Partial
              or Total Destruction  of the Prepuce.

  Gangrene, chancres, and certain  operations, as circumcision for ex-
ample, all tend to this  morbid conformation.  The desire to remedy it
has been felt  from the earliest antiquity.   Galen, in quoting Antylus,
had already described the kind of anaplasty which was formerly used
for  it, viz.: by dissecting off the surrounding tissues.  After having
separated from the corpora cavernosa  the integuments of the penis  in
their whole  circumference, and to the extent of about an inch, Antylus,
drawing  upon this sheath, brought it  forward so as to cover the glans
penis  with it.  The operation in  itself presents neither  difficulty nor
danger;  but by the effect of their contractility alone, the integuments
gradually retract  backward, and soon  reassume  their former position.
In becoming agglutinated  to the  circumference of the glans, they  pro-
duce a more serious deformity than the first.  I,  therefore, am of opin-
ion that anaplasty  of the penis, such as we understand it up to the pres-
ent  time, is not worthy of being preserved.  Composed  as it is  of a
mere  fold of the  integuments, the prepuce  is not an organ of sufficient
importance in the animal economy to justify operations of this kind.

          Article II.—The  Penis, Properly so  Called.

  It happens sometimes that the surgeon is obliged to deprive the penis,
either wholly or partially, of its cutaneous covering.  We may conceive
that in a  case of this kind it would be practicable to borrow, either from
the scrotum  if it was sound, or from  the fold of the groin, or the hypo-
gastrium, flaps capable of subserving the uses of the penis.   It is  very
doubtful also if Indian anaplasty would succeed  here, and I  do not be-
lieve that it  has ever yet been tried  for this purpose.  It might, how-
ever, possibly become  necessary after the removal of certain  tumors  of
the scrotum.

                      Article III.—Scrotum.

  The scrotum is very often the seat of tumors, which, notwithstanding
their very great volume, include nothing more  than the  integuments,
and leave uninvolved  both the body of the  penis and the testicles.   In
such cases,  surgeons have conceived that it might be possible to  save
these  last-mentioned  organs, though the  entire  diseased  tissues were
removed. It is what Delpech (Clin.  Chirurg. de Montpellier, t. i.)—
[See the first  account of this case, published soon after its occurrence,
in the New  York Medical  and Physical Journal for the year 1822,  as
the same was communicated to m%  at the house of the lamented Delpech
at Montpellier that year, together with his original manuscript in French, 
622           new elements of operative surgery.

and the  original  colored plates, all of which I treasure as a precious
relic of that truly accomplished surgeon.—T.]—appears to have been
the first to do with success, in a man from whom he had removed a scro-
tal  tumor of the weight of sixteen pounds ; it is what I also did in 1835,
(Lancette Frangaise, 1835, t. ix., p. 177,) in the removal of a similar tu-
mor, but infinitely less voluminous. In these cases we circumscribe exactly
all the parts to be removed, taking care to avoid the testicles and penis.
After having dissected the integuments in the direction of the perineum,
thighs, and hypogastrium, we reverse them, and  trim them to make the
flaps out of them.  All the  flaps are then  brought together, a portion
of them  below  and  inward to reconstruct the scrotum, the  others upon
the body of the penis, in  order to remake a sheath and prepuce for this
organ.  Numerous stitches of suture, and a bandage making moderate
compression, maintain the whole in its place, and promote the  agglutin^
tion of the parts.
                         CHAPTER XV.

                          URETROPLASTY.

  The great losses of substance in the urethra, ordinarily lead to the
formation of incurable urinary fistulas.  Various practitioners, however,
have, in these cases and some  other  obstinate fistulas, made trial of
different modes of anaplasty.

                Article I.—Indian Uretroplasty.

  To cut a flap of integuments on the upper part of the thigh, and after-
wards to transport it and fasten it by means of the suture to a urethral
fistula  previously pared, is a method  which M. Earle appears to have
been the first to have essayed with  success, (Archiv.  Gen. de Med.,
t. i., p. 102.)  M. A.  Cooper (Surgical Essays, vol. ii., p. 221; Journ.
Hebd., t. v., p. 108) has not  been less fortunate in one out of two of
his cases ; but Delpech, operating in the same manner, completely failed
at two different times on the same patient. (Lancette, Fran., t. iv., p. 264,
278, 285, 288, 295.)  Attempted  afterwards by other  practitioners,
this kind of anaplasty has been equally  unsuccessful.   The objections
I have  made to Indian anaplasty, in speaking of stercoral  fistulas, exist
in all their force in reference to urethral fistulas.   In order to succeed,
two things are required:—1. That for  four or five days no urinary dis-
charge should infiltrate  into the contours of the fistula; 2. That  the
borrowed flap should be thicker and more vascular, and  less  disposed
to mortify in fact, than it necessarily is in  those regions.

           Article II.—Uretroplasty by Drawing.

  Desirous of avoiding this double inconvenience, M. Alliot ( Gaz. Med. 
URETROPLASTY.
623
de Paris, 1834, p. 348) has proposed to  pare the fistula  freely upon
one side of the urethra, in the direction of its tegumentary tissues, then
to dissect and draw over to that  side, by  a sort of slipping  motion, the
same tissues from  the opposite side, so'that the  convex border of the
flap may be compelled to cross and go several  lines beyond the opening
in the urethra, in order to rejoin the excised border of the integuments.
The  fistula, resting then upon tissues perfectly  sound, is reduced to the
state of a simple ulcer opening into the  urethra.   The patient of M.
Alliot  was  completely restored,  and I doubt  not that  in  transporting
thus the integuments from one side  of the fistula to the other, we may
succeed in establishing a process of uretroplasty of great efficacy.

         Article III.—Uretroplasty by Lateral  Incisions.

   Desirous  of avoiding all dissection or detachment of  the surrounding
parts, M. Dieffenbach  conceived that in order to  cure urethral fistulas,
it would suffice to pare their  edges, to unite  them  together by suture,
and  then to make a deep and long incision on each side.

      Article IV.—Uretroplasty by Dissecting the Tissues.

   I would say the same of the process which I have already spoken of
in treating  of bronchoplasty; since, from not having yet tested  it in
cases of urinary fistulas, I cannot regard its success  as  any thing more
than very probable.
   In the place of seeking for a flap near the rectum,  or upon the lateral
parts of the penis, as the English surgeons have done ; of borrowing
it from  the  groin, or the inner surface of the  thigh, as is preferred by
the Professor of Montpellier; it  would, probably, be better to proceed
by dissection and approximation.  In this mode, the fistula being arrang-
ed as for an ordinary suture, we should successively dissect off the two
sides from  within outward, so as to form two flaps, which we should
preserve as thick as possible.   The border  of these flaps being afterwards
pared, either by the  bistoury or a pair of  good scissors, allows, in fact,
of our effecting the coaptation with the  simple  or twisted suture.  A
methodical compression made upon these lateral parts, would keep them
in exact contact with the subjacent tissues, and would  serve to prevent
the urinary infiltration.   But experience not  having  yet  pronounced
upon this operation, I do not think it necessary to say  any more  upon
the subject.

                      Article V.—Appreciation.

   We cannot  deny that all these varieties of anoplasty may sometimes
be useful in these cases, and that each one of them may have its indica-
tions ;  but we should, nevertheless, do wrong to repose any great degree
of confidence  in any of them, or  to  have  recourse to them before  as-
suring ourselves of the inefficacy  of  other therapeutic means.   It is evi-
dent, also, that the details of the manipulating process would be super-
fluous, and  that  these are  operations  that the surgeon ought in  some
measure to devise for  each  particular case.   The important point is to 
621
new elements  of operative surgery.
know that the stitches of suture cannot be too numerous ; that we ought
not, if the  attempt is practicable, to  leave any void, or any separation
of tissue, (decollement,) in the  neighborhood of the fistula; that the
integuments and the flaps ought not to be detached but to such extent as
is absolutely necessary ; that it is requisite to leave a gum-elastic cathe-
ter in  the urethra, or  to use  the catheter every time the bladder has
need of being emptied, in  order  that the urine in passing out cannot
possibly touch the walls of the canal.   (See Operations which are per-
formed on the Urethra.)
                         CHAPTER XVI

               VAGINAL ANAPLASTY, OR EUrTROPLASTY.

  Of the three kinds of fistulas which may  be formed in the vagina,
vesico-vaginal, recto-vaginal, and entero-vaginal, there are two at least
in which anaplasty may be proposed, and which have, in fact, been sub-
mitted to some trials of this operation.

               Article I.—Vesico-Vaginal Fistulas.

  Whether the fistula which opens a communication between the urinary
passage  and  the  vagina, commences at the urethra  or bladder, it  is,
nevertheless,  always very  difficult  of cure.  Having ascertained that
neither cauterization, the suture, hooks, (erignes,) nor other operative
processes, have ever hardly succeeded  in  these  cases, surgeons very
naturally welcomed the suggestion of any thing like a new operation.

                               §1-

  Nevertheless, it is  scarcely any  other than  Indian anaplasty which
has been employed to remedy fistulas in the vagina.  No one had spoken
of it previous to my having suggested, in 1832, the shutting up of laryn-
geal fistulas, by means of a plug of integuments.  I  added at that time :
" If analogy  does not deceive  me, this method would answer equally
well for other fistulas, and for the closing up of a  great number of other
openings.  Deep narrow fistulas with loss of  substance in the urethra,
thoracic  and abdominal fistulas, artificial anus when  the  obstruction to
the course of matters no longer exists, and  certain salivary and lachry-
mal fistulas, would probably derive more advantage from  it  than from
the different anaplastic methods hitherto used."
  It is,  nevertheless, proper to say, that in expressing myself thus, I
was guided only by analogy, and  that my  assertions were not yet sus-
tained upon any known  fact in practice.   We  have seen above that my
predictions were in part realized, in respect to artificial anus and fistula
lachrymalis.  A  surgeon of the hospitals of  Paris, M. Jobert, (Bullet.
de  VAcad.  Roy. de Mid., t. ii.,) has taken advantage of this idea, and 
VAGINAL ANAPLASTY, OR ELYTROPLASTY.           625
appears to have made  up to the present time numerous applications of
it  to vaginal fistulas, whether of the  bladder  or urethra.   It appears
also to have been demonstrated that one of the patients, operated upou
by him for a fistula at the bas-fond of the bladder, has now been radi-
cally cured of it for more than two years past.  It is true that this pro-
cess proved unsuocessful in most  of the women he tried  it upon, and
that M. Roux on his part Journ. des  Conn. (Mid. Chirurg., t. iv., p. 107)
has completely failed with it.  It is  even to be feared that by this method
we must often  anticipate a failure.  Nevertheless, as it is an easy pro-
cess, and one which any  one may perform, it deserves, as I think, to be
retained, at least for  cases where  the fistula is  of little  extent, and
where its edges are neither too much thinned nor too indurated.
   The operative  process of M. Jobert is  copied precisely after that
which  I  have  described in treating  of bronchoplasty.   The  fistula is
abraded  by means of  caustic, or a  cutting instrument; a flap of much
greater length than width and also of greater or less length or breadth
according as the fistula itself is of greater  or less  size, or more or less
deeply situated, is then cut  upon  one of the sides of the vulva, so that
its point  shall be turned towards the sub-ischiatic groove, and that its
root may be continuous with  the vulvar opening  of the vagina.  Dis-
sected and separated from its apex towards its  base, this  flap should be
sufficiently long to be drawn without difficulty through the fistula into the
bladder  or urethra.  Having folded it upon its cutaneous face, we pierce
the fold  with a double thread ; this thread, which is to serve as its con-
ductor, being attached  to the head of Bellocque's sound, previously intro-
duced  into  the urethra  through the vagina, easily draws the  tegumen-
tary plug towards the fistula, and  prevents it afterwards from falling
hack into the vagina.  As  the presence of the thread  in  the urethra
might cause an ulceration, there would be some advantage, perhaps, in
passing it through a female  catheter, which would serve as a support, at
the same time that it would give egress to the urine.   It is evident, also,
that the  flap may be taken almost indifferently  from the tissue of one of
the labia majora, or from the inner surface of the thigh, or from near
the breech.   The  important point is, that it may have a  certain degree
of thickness, especially on  the side of its  pedicle;  otherwise, with the
length we are obliged  to give to it, it would be next to impossible to
prevent  its  mortification.   Perhaps it would be well, also, after having
doubled  it, to keep it thus folded at its point  by means of one stitch of
suture, and to let it contract  itself and become vascularized, before in-
troducing it into the fistula.   It would also be advantageous, as I think,
to draw it by its larger  extremity, and to use  some force to make it en-
ter, in order that its largest portion, being in the bladder, might in some
measure be retained underneath by the fistula  itself, which would then
perform the office of a constricting ring.  What is also necessary is, that
the flap  should  be placed in contact with the fistula  by its cellular, and
not by its cutaneous surface, and that the edge of the fistula  should bo
in a state of complete abrasion.
   In this manner no stitches of suture are necessary, and the parts may
remain in their place of themselves.  Moreover, we should not think of
 dividing the pedicle of  the flap till at the end of some weeks, and after
 having positivelv ascertained  that a solid agglutination has taken place
    Vol.  I.                      79 
626            NEW ELEMENTS OF OPERATIVE SURGERY.

between the new substance and the periphery of the  fistulous opening.
This section, also, should be made towards the middle of the length of
the flap, in order that in retracting by its new extremity, it may ultimate-
ly form a sort  of button with two heads, one in the vagina, the other in
the bladder.   As to the external  wound, it should  be treated by suture
and  other uniting means, to its outer  half, and with the view of pre-
venting all  constriction of the pedicle of the flap, it  would be advanta-
geous not to approximate its edges too near to the base of the flap.   In
the case  mentioned above, the obturator  flap consolidated so perfectly,
that it remained covered with a tuft of hair in the interior of the vagina.
   I have no occasion to remark, that  in regard  to attention to cleanli-
ness, and the precautions which the excretion of the  urine requires, we
must, when  elytroplasty is decided upon, proceed according to the rules
laid down in treating of vesico-vaginal fistulas in general.
   M.  Roux, having to close a vesico-vaginal fistula, of two to three
lines in breadth, concluded to cut  his flap upon the  wall of the vagina
itself.  Having reversed this flap upon its mucous face, he introduced it
into the  fistula in the manner we have described, but the apex of the
plug soon mortified,  and the operation proved  unsuccessful.

       § II.—Elytroplasty by Raising up a Tegumentary  Arcade.

   Having met with many women who had  been unsuccessfully operated
upon by elytroplasty with the process of the plug, [literally a cork.—T.,]
I determined  to make trial, in these cases, of another  mode of anaplasty.
Grasping, by  means  of an erigne with a double  hook, the posterior wall
of the vagina opposite the fistula, and  drawing  towards  the vulva this
part, which the  forefinger introduced  into the rectum pushes forward,
and raises up in front, I give the erigne to an assistant, in order to have
my hand free.  I then use a straight bistoury, held  as a pen, to  incise
the vaginal wall to  the extent of an inch, or an inch and a half, above
and then  below the point raised up by the erigne, taking care  not to
penetrate to the interior of the rectum.  The limits of the arcade to be
formed being  thus defined, I glide the point of the bistoury flatwise from
the lower to the upper incision, and through the tissue of the partition,
so as to detach the middle part of this patch of the vagina from right to
left, and to the extent of about an inch, without opening  into  the rec-
tum, and also without  detaching its two extremities.  The fistula, pre-
viously pared, is  immediately treated by suture.  Each  thread, armed
with its curved needle, is first passed from before backward, or from be-
low upward, under the vaginal bridge, then  from the bladder  into the
vagina, through the  posterior lip of the fistula, and afterwards brought
under the bridge, and  then outside.  A second stage of the operation
consists in traversing, from behind forward, and from the  bladder into
the  vagina, the anterior lip of  the hole with the other extremity of each
thread, each of which is alike  armed  with a  needle.   Desiring now, as
 the last step,  to tie these threads, we force up the dissected arcade into
 the fistula, to be placed in the  bladder at the same time that the lips of
 the fistula have  been brought into contact underneath.   The flap thus
 borrowed from the  vagina, projects  into the bladder, and  is in reality
 placed astride upon the suture. 
VAGINAL ANAPLASTY,  OR ELYTROPLASTY.            627
   I his process, which appeared to me to present  some chances of suc-
cess, nevertheless failed, in  the only case in which 1 tried it; but it is
to be remarked, that  the fistula had more than an inch diameter and
that all ^ the parts of the vagina had been for a long time changed,
by all  kinds of attempts at operations.   My intention was, in the sup-
position  that the agglutination could have been made, to divide,  at
the end  of ten or  fifteen  days, first one  of the extremities of the flap,
and at a little later period, the other extremity, then to let  the wound
gradually cicatrize.

                    § III.—Direct  Agglutination.

  Another method which I have wished to apply in two cases, but which
the women would not consent to undergo, would consist in actively cauter-
izing the edges of the fistula, and the corresponding wall of the recto-
vaginal partition, then to keep this partition raised up by means of plugs
of lint, and dilated bodies introduced into the rectum.   An  agglutina-
tion obtained in this manner would, at a later period, allow of re-es-
tablishing  the  continuity of the vagina, and of leaving, as  an  opercu-
lum on the fistula, the portion of  tissue which would  have been thus
dissected.  To what extent do these processes deserve to be  employed ?
It is what I  do not  venture to say, having myself failed when I have
wished to put them in practice.

               § IV.—Excisions in the Neighborhood.

  Would  we perhaps  succeed better by excising, at each extremity of
the fistula, an  elongated  triangle to half the thickness  of  the vesico-
vaginal wall ?   The cicatrization of these new wounds are of a nature,
it seems to  me,  to retract, and perhaps  completely to shut up the old
one.

                   §  V.—Depresssng the  Uterus.

  Another process which might be  borrowed from anaplasty, when the
fistula  is  very high up, would consist in actively cauterizing its vaginal
region, then in hooking the neck of the uterus with an erigne, or a noose
of thread, in order to pull it down  and cause it to slide as a drawer to
below  the  vesical opening.   But I  repeat,  all these suggestions want a
foundation to rest upon;  none of them can yet adduce any success in
their favor.

     Article II.—Recto-Vaginal Anaplasty, or  Elytroplasty.

   All  that I have said of vesical elytroplasty, is applicable  to those fis-
tulas  by  which  the rectum communicates  with the vagina.  It is true,
however, that  the  attempts in respect to  these have been less numerous
than for the other, either because this kind of fistula yields better to or-
dinary means, or that it  is less freqnent, or  because females  are  less an-
noyed  by it.   The suture to the perineum, however, is an operation which
will perhaps  draw attention  to this subject, since  when that has been 
628           NEW ELEMENTS OF operative surgery.

performed, it is not unfrequent to find a hole remain above, in the low-
er part of the  recto-vaginal partition.  A lady who was in this state,
in consequence of a suture in  the perineum, which M. Roux had intro-
duced, was operated upon by me in 1837, by means of the Indian mode
of anaplasty.  I cut a flap in the tissue of the left labium majus, two
inches long, and eight to ten lines in breadth at its root. A thread, affix-
ed to the  upper  extremity of  this flap, enabled me to draw it from the
vagina into the fistula in the rectum, and to hold it fastened in this man-
ner near the anus.   It mortified to two-thirds of its extent, and contract-
ed adhesions only on one of its sides; so that the fistula, in fact was di-
minished only by  one  third of its size.  It is  nevertheless true, that in
patients more tractable, and by taking every possible precaution not to
weaken the vitality of the flap, elytroplasty by the tegumentary plug will
offer some  prospect of success in this kind of fistula.
                        CHAPTER XVII.

                    ANAPLASTY OF THE PERINEUM.

  Clefts (fentes) and fistulas of  the perineum in women, might, in fact,
allow of many kinds of anaplasty.  From  the  pliancy of the tissues,
however, and  the ability to bring  the lips of the  division in contact, the
incisions of Celsus only have been applied to them.  Thus, after having
pared and united  these fissures,  we may, if the  parts seem too tense,
make on each  side a long incision, and one of sufficient depth to prevent
the elasticity of the tissues  exercising  any further resistance to the ac-
tion of the suture.  Only it would be necessary then, in order not to
lose the advantage of these incisions, to fill  them with dilating bodies,
for example, with rolls of lint, covered with cerate.  I shall have  occa-
sion to refer to all these chapters, in  treating of  the genital organs and
the anus.
              PLASTIC SURGERY IN AMERICA.

CASES OF GENO-CHEILOPLASTY (ANAPLASTY OF  THE CHEEK AND LIPS) BY
                             DR. MOTT.

  It will  be seen by the following  cases of restoration of the com-
missure of the mouth, and portions  of the  cheek, performed  at New
York by Dr. Mott, the one as  early as about the year 1825, (the pre-
cise date of the year being lost,)  at the New  York  Hospital, the other
in 1831, that the French  anaplastic method,  so called, the  ruling prin-
ciple of which is diplacement, was adopted in the practice of that sur-
geon at a very early date for the history of this department of surgery. 
GENO-CHEILOPLASTY.
629
                     Case I.—By Displacement.

   This was a middle-aged man, (see plate A.)  in  whom the left com-
 missure, and  several inches of the cheek on that  side  in a horizontal
 direction, were totally destroyed, together with a corresponding portion
 of the alveolar processes  and teeth  of the lower jaw, by necrosis, and
 all the result  of vdolent mercurial action.
   Upon removing the  necrosis, and allowing a few days to elapse for
 the jaw to heal, I performed (says Dr. Mott) the following operation :—
 The hardened edges of the cic- (Dr. Mott's case of Geno-Cheiloplasty, about 1825.
 atrized margin of the  chasm,                (Plate A.)
 were pared off, the  cheek was
 then freely detached above and
 below, and as  far back as the
 edge of the masseter muscle.
 The fresh surfaces  were now
 readily, by  distension of the
 parts, brought into  contact by
 several stitches  of  the  inter-
 rupted suture, one stitch being
 applied to the neat adjustment
 of the angle of the mouth.  The
 stitches were  then supported
 by strips of adhesive plaster.
 The wound readily united  by
 the adhesive process.
   The  yielding nature of the
 tissues involved, enabled me to
 effect so complete and natural
 a restoration of the parts, that
 the little deformity  that re-
gained was truly surprising.
 Nothing but a mere seam of cicatrix  was left.   This result seemed then
 the more remarkable, as but few or no operations  of geno-cheiloplasty,
 by the  French method  at least, had then been performed  anywhere.
 This case has  never been published until  in the present work.

               Case II.—By  Displacement and Flaps.

   This case of geno-cheiloplasty was involved also with immobility of
 the lower jaw, and comprised  the  double  operation of flaps  and de-
placement.  We  annex Dr. Mott's own  published  account of this case,
 from Dr. Hayes'  American Journal of the Medical Sciences for Novem-
 ber, 1831:  "
   " On the  7th of April, 1831,  I was  consulted  in the case  of Miss
 Mary Park, aged seventeen, of Southbridge, Massachusetts.
   " Her attending physician,  Dr. Samuel Hartwell, gave the follow-
 ing relation of the case.   ' In the autumn of 1822, she  had an attack
 of typhus fever :  the symptoms were  mild in the commencement of the
 disease, and  nothing unusual  occurred  until the  middle of the third
 
630            NEW  ELEMENTS OF  OPERATIVE SURGERY.
week, when tumefaction and redness were discovered on the left cheek,
accompanied with slight delirium and general aggravation of fever.
   " ' At the end of the third week, a dark  vesicle,  about the  size of a
pea, appeared at the angle  of the  mouth, announcing the existence of
sphacelus, and in a few days extended to about two inches  in  diameter
upon the side of the face.   A crisis of fever now supervened, which was
followed by sloughing of the  whole gangrenous  portion, leaving  the
teeth and gums exposed.   Upon its cicatrization the jaws remained im-
movably fixed, being  apparently  tied together by  a ligamentous band
within and about the cicatrix.   Her food was introduced into the mouth
through a space formed by  the  removal of a tooth on the right side.
The first set of teeth and the alveolar process of the diseased side, were
detached by caries.   Most of the second teeth were developed in a few
years afterward.
   "' No mercjiry was used in the treatment of the  fever.  Her general
health is now very good.'
   " Her countenance was much disfigured,  and presented  the appear-
ance represented.   [See Plate B. fig.  1.]
   " As the only means of permanently  overcoming the closure of the
jaw was the removal  of the cicatrix,  I  determined upon excising  and
replacing it by sound integument from the face and neck."
   The operation was performed by Dr. Mott  on the 8th  of  April, as
follows:—
   " It was commenced by carrying an incision from a little within the
upper angle of the mouth, around the outer margin of the cicatrix, to a
little within the  lower angle of the under lip, and by the immediate
removal of the newly-formed parts included within it.  The adhesions
between the jaws were next divided, which  enabled  me, in consequence
of the relaxation thus produced, to insinuate  between  the  teeth of the
opposite side, the point of the lever used in my former cases, with which
I finally succeeded in opening the mouth.
   " This point accomplished, the  lips  were  brought together at the  an-
gle of the mouth by a  suture, and I  proceeded to detach  a portion of
integument sufficiently large  and of corresponding shape to replace the
part removed.   [See dotted lines, Plate  B.  fig. 1.]  It was turned into
the space it was  intended to  fill, leaving a tongue three quarters  of an
inch in breadth connected with the adjacent part, and sufficient for all
the purposes of circulation.   The cut edges were  adjusted with extreme
accuracy,  by means  of interrupted sutures and adhesive  straps :  the
lower wound was contracted as much as possible by adhesive  plasters,
and the  whole covered with  lint, compress, and bandage.
  " Previous to the  operation  she  took sol. sulp. morphine, double
strength of Majendie's formula, gtt. xiv.  The operation occupied  about
an hour, and was sustained with a firmness peculiar to the female sex.
  " Evening.—Had been sick at her stomach, and vomited  some  coag-
ulated blood, which had no doubt been swallowed during the operation.
  " April 9th.  Found her sitting up at the side  of the bed.   She felt,
she said, very comfortable, and had passed  a  good night.   Hardly any
perceptible  swelling of the face.  As far as the parts can be  seen, all
looks  favorable.   Ordered  her a dose  of sulph.  magnesiae.  She can
depress the lower jaw, by the  effort of the will, to the extent of about 
GENO-CHEILOPLASTY.
631
 half the width of the finger.  I advised her to continue the motion of
 the jaw, from time to time, as much as the  soreness at the angle of the
 mouth would permit.
   " 10th and 11th. Continues to do well.
   " 12th. Some little tumefaction under the eye, but sne  makes no com-
 plaint.   Directed an emollient poultice to the hard  dressings upon the
 wounds on the neck.
   " 13th. Several poultices have been applied to the neck, which have
 softened the lint; upon  carefully removing it and the plasters, the wound
 was again dressed in the same manner.
  _" llth. Complains of a little  headache from  not  sleeping well last
 night.  Felt great comfort  from the removal of the stiff dressings yes-
 terday.  Bowels are in a good state.   Cannot say to what the headache
 is to be attributed ; she thinks it owing to the loss of sleep  last night.
 The swelling of the cheek has subsided.  Changed the lint again to-day.
   " 15th. Found her in bed this  morning, with pains in her limbs gene-
 rally, and with some swelling of the right knee, and tenderness to the
 touch ; passed  a bad night; her  pulse is much more  frequent than na-
 tural.  Is not aware  that she ever had rheumatism before.   Directed
 general and local treatment for her disease.  She makes no complaint of
 her face, which in all respects is very  promising.  I removed three  of
 the stitches from around the angle of the mouth, and reapplied  lint and
 plasters.
   " 16//i. Still in  bed.  Has  less pain and swelling  in the knee, but
 more  in the foot and  ankle ; generally she feels  better.  Removed
 another stitch  from the lower part of the  patch.   The  wound of the
 neck looks well; dressed it with  ungt.  resinae and plasters.
   " 11th.  To-day she is generally better, but feels most  pain and ten-
 derness in the  knee and ankle of the  other leg.   Says  her  face  feels
 very comfortable.   I removed three stitches from the upper part of the
 patch, and for the first time all the plasters,  and washed  the whole sur-
 face.  Adhesion seems to have taken  place  at every point of the  flap.
 Dressed the face as yesterday.
   " 18th. Every part of the flap  appears to have united.   Dressed the '
 wounds  with dry lint.  Advised her  to move  the lower jaw a little
 downward, every day, several times.  The rheumatic affection is seated
in the right wrist and fingers.  Ordered the  use of tinct.  colchici.
   " 19th.. Passed a better night;  but both arms are now nearly useless.
 Consented to-day to be bled.   Repeated the  infus. sennas as a  cathartic ;
 dressed the face, which  looks very well.
   " 20th. Feels generally better.   Both arms still much affected.  Drew
 the edges of  the wound in the neck together with adhesive straps.  Di-
 rected the tinct. colchici to be increased.
   " 21st. In  all respects better;  a slight rheumatism  yet continues in
 the left band and arm. The colchicum has produced some cathartic
 action on the bowels.   I dressed  the face and  wound as yesterday ; di-
 rected her to open the jaw more frequently; and to continue the colchicum.
   « 22r/. Found her sitting up, and says she is more comfortable.  The
 left hand and wrist still a little tumefied and painful.  Face and wound
 continue  to improve ;  dressed  them as  yesterday.   Has more  motion in
 the lower jaw. 
632           NEW ELEMENTS OF  OPERATIVE SURGERY.

  " 23c?. Is free from all pain to-day, and feels quite well again.  Or-
dered the colchicum to be discontinued.   Dressed the wound as before.
  " 25./.. Continues free from rheumatism.  The wound  improves, and
was dressed as yesterday.   The jaw moves more freely.
  " May 12th.  Patch in  the cheek entirely healed, [see Plate B. fig. 2.]
The wound in the neck is nearly closed.   She can open the jaws suffi-
ciently wide to admit solid food.
  " l<lth. She  leaves town  to-day  in good spirits, and delighted with
the result of  the operation.
  " Although I have before often operated for immobility of  the jaw,
and with the  happiest results, and have once removed a deformity occa-
sioned by a hole in the cheek, by the  Tagliacotian  method, in  the New
York Hospital, with perfect success, [see Case I., above,] I have never
before seen it necessary  to combine both operations in one individual;
and the gratifying termination of this long and arduous case,  is a con-
vincing proof of the  excellence of the  means employed,  and  of the
power of art in repairing the ravages of disease, and in relieving its
distressing consequences.
  " 25 Park Place, New York.

  " N. B. A letter was received  from Miss P. by the  lady with whom
she resided here, in which she stated her  health to be excellent, the jaw
to have acquired increased motion,  and her friends much  pleased with
her improved appearance.—July."
(Dr. Mott's case of Geno-Cheiloplasty, New York, 1831.)
                (Plate B.)
  Since the date of the last operation, Dr. Mott has performed various
operations of a similar kind, as well as blepharoplasty, rhinoplasty, and
uretroplasty,—of  which last more particular mention will be made un-
der the head of Injuries and Diseases of  the Urethra. 
MET0P0PLASTY.
633
      INTERESTING CASE OF METOPOPLASTY, BY DR. JNO. WATSON OF
                             NEW YORK.

       [Communicated by Dr. Watson for this work, and never before published.]

                 Metopoplasty, or Forehead- Mending.

   An anaplastic operation on the forehead, probably the first of the kind,
was recently  performed, with marked advantage to the patient, at the
New York Hospital, by Dr. John  Watson, one of the surgeons of that
institution.
   Hugh McCabe, a native of Ireland, a carpenter,  aged  forty-two, was
admitted into the Hospital on the 19th of April, 1844, with necrosis of
the os frontis of six years standing, probably the result of syphilis, which
he contracted some twenty years ago, but  of which  for many years past
he had supposed himself entirely cured.   According to his own account,
the disease on the forehead was the result of local injury.
   At the date of admission a large ulcer, exposing a considerable por-
tion of the os frontis, existed on the forehead.  The greater part of the
external table of the bone had already exfoliated, and was held in place
merely by the overlapping of the soft parts.   A fistulous opening existed
at the upper  border  of each orbit, and another in  the left temple, and
through  these there  was a considerable flow of purulent matter.   The
upper eyelids were somewhat elevated and deformed by adventitious ad-
hesions around these fistulae.
   A few days after admission, the  exfoliated portion of the bone was re-
moved by Dr. J.  K.  Rodgers, who, in order to effect this removal, was
obliged to increase the  size  of the opening by a short  incision on the
scalp, at the upper and left angle of the ulcer.  The undermined integ-
uments, now deprived of  support, rolled  in upon themselves, turning a
portion of the hair of the scalp inwards upon the face of the sore, and
adhering in this folded form along  the left border of the  ulcer.
   On the first of  June, the date at which Dr.  Watson took charge of the
case, the central portion  of  the  ulcer appeared to  be covered by a sort
of cuticular cicatrix.   The whole aspect of the forehead was exceedingly
disgusting.  The cavity was about two inches and a half wide in its
shortest diameter; its borders were rugged,  abrupt, and irregular.  A
portion of diseased bone lay still exposed  and  adherent  near the upper
and right angle of the opening, another under the  fold  of integuments
along the left border.   A deep sulcus, exposing some points  of the dis-
eased bone, existed above the root of the  nose.  The left frontal sinus
was exposed to view, and the rim of bone along its outer and lower bound-
ary was carious.  From these several points of diseased  bone there was
a free discharge of purulent matter.
   The patient's general health was good.  After  deliberating for some
time on the case, finding the internal table unaffected, and all the carious
portions  apparently within reach, Dr. W.  advised the patient to submit
to an operation, with a view of removing the  diseased bone, and of clos-
ing the cavity in the  forehead.  To  this  he readily acceded, and the
operation was accordingly undertaken on the 27th of July of the present
year, 1844.
   Yol. I.                    80 
 634            NEW  ELEMENTS OF  OPERATIVE SURGERY.

   After shaving the scalp, and removing the cuticle from the centre of
 the ulcer by washing it with concentrated aqua ammoniae, the operation
 was commenced by unfolding the integuments along the  left border of
 the ulcer.   This required the free use of the scalpel.  A small fragment
 of bone,  which lay buried in this fold  of skin, was removed during this
 first step of the operation.
   The next step was to carry the point of the knife completely  around
 the circumference  of the  opening, and  through the whole  thickness of
 soft parts; and to remove a strip of integument, varying from an eighth
 to a quarter of an inch in width, throughout  the whole  of this  extent,
 thus making a smooth and fresh border for the subsequent adjustment
 of the flaps.
   The third step consisted in raising two large quadrilateral flaps the
 one on the left, and the other on the right side of the opening in the fore-
 head.  This was effected by four incisions running somewhat horizontally
 backward, nearly parallel with each other, two on each  side, one from
 each upper, the other  from each lower angle of the opening; and after-
 wards detaching the flaps from the periosteum.
   The fourth step  consisted in the removal  of the  diseased portions of
 bone, as  far as they could be detected.   This was effected mostly by the
 cutting pliers.  The largest of these portions was the  projecting rim of
 bone at the left frontal sinus, the removal of which caused a slight  depres-
 sion over the left orbit.   The hemorrhage, which hitherto had been rather
 free, was now checked by the application of ligatures  to such vessels as
 required them.  The most obstinate point of issue was from the  minute
 vessels of the glabella, where ligatures  were out of the question.
   The fifth step was  an  attempt to  approximate the lateral flaps, so as
 to cover  the opening.  This however,  could only be partially effected.
 They  could be made to meet  only to the extent of an inch from their
 lower edges, even after considerable stretching.   The parts  thus approx-
 imated were secured by two sutures.   A large V-like gap still existed
 on the upper part of the forehead.
  The next step consisted in an attempt to fill this by a flap from  the
 top of the scalp.  For this  purpose a free incision was carried from
 near the  upper and  right angle of the ulcer,  in a  curved direction,
 towards the crown of  the head.  The flap thus made  was  dissected up
 and then partially  rotated, so as to bring its lower and right  angle down-
ward on the centre of the forehead.   In this way the remaining  de-
 ficiency of integument  was effectually supplied.  The approximated edges
were now brought  into exact coaptation along the whole of  the lines of
incision by numerous points of suture.   No part of the wound was  left
gaping.   The sutures  were strengthened by strips  of adhesive plaster,
and the forehead was covered with a compress and bandage.
  The patient suffered comparatively little subsequent to the operation.
 During the greater part of the first week he was kept on a restricted
 diet.  The dressings  on the forehead were kept wet  with cold water.
 This had no effect in detaching the adhesive straps, and was exceedingly
 grateful to the patient.   The first dressings were  removed on the sixth
 day.  About three fourths of the  lines of incision had united by the
 first intention.  A few of the sutures were removed, and the wound  was
 dressed as before.   At the second dressing, on the ninth or tenth day, 
                           METOPOPLASTY.                       635

cicatrization had progressed somewhat further.   The lower angle of the
upper flap had not adhered, and it had receded somewhat, so as to leave
a small gap  about the size of a  shilling in the middle of the  forehead.
All the remaining sutures  and  ligatures  were now removed, and re-
placed by simple adhesive straps.

                   (Fig. 1.)                     (Fig-2.)
  Subsequent to this period, although the central gap increased slightly
in size, the  integuments around it  became  attenuated  and cicatrized
firmly to the parts beneath, so as to leave very  little depression.   The
patient left the hospital about five weeks after the operation ;  at which
period the wound had entirely cicatrized, with the exception of a papil-
lary opening which  communicated with a small point of carious bono
that had escaped notice during the  operation, and that had not yet ex-
foliated.  This opening was at the upper and right angle of the original
cavity, and was seated on the hairy scalp, so that as  the hair  grows it
will become entirely  hidden, provided it is not soon allowed to cicatrize
by the exfoliation of the point of bone beneath it.
  Figure first, in the accompanying plate, is a representation of the pa-
tient's features just before the  operation.  Figure second illustrates the
lines of suture subsequent to the operation ; and  Figure  third is a re-
presentation of the face at the date of the patient's dismissal.
  Keratoplasty, or  transplantation  of a new  cornea,  which, though
touched upon by our author, (vid. text, Yol. I.) is deemed of  an expe-
rimental character too hazardous and empirical  almost to be spoken
of, otherwise than as an operation to be absolutely proscribed, we per
ceive, nevertheless, continues to engage the  attention of some practi
tioners in France as well as in Germany.  M. Desmarres, (Archiv. Gin.
de Med., 4e  ser., Paris, Nov., 1843, t. III., p. 363,) at the sitting of the
Paris Academy of Sciences, Oct. 2, 1843, states that he has ascertained
that the cornea of a rabbit may  with much facility be  engrafted upon 
636            NEW ELEMENTS OF OPERATIVE SURGERY.
that of another animal of the  same species; but that the transparency
of the new graft is generally deficient, at least in the greater part of its
extent.   The new cornea first  swells, then becomes  gradually flattened,
and contracts so as  to become diminished in all its diameter to tiro-
thirds of its primitive dimensions, though preserving the exact form of
its  original periphery.   In  its retraction, it draws to it concentrically
the border  of the former cornea, which  latter, singular as it may ap-
pear,  becomes elongated  sometimes to six times the breadth of what
was pared off.   Hence if, in  transplanting, we take care to remove a
flap of the iris, the  icidening  of  the  remains of the  old cornea gives
free passage through it, and through the aperture in the iris to the reti-
na, whereby vision is established,  but not through the  transplanted cor-
nea.
   [Dr. Richard S. Kissam has reported in the  New-York Journal  of
Medicine, for March, 1&44, a case of Keratoplasty, in which the cornea
was obtained from a pig six months old, and engrafted on a man thirty-
five years  of age.  Adhesion  took place, and the vision was improved
immediately after the operation, but as the humors themselves were dis-
eased, it was still imperfect.   In the course of a month the transplanted
cornea was absorbed.   G. C. B.]
                         BLEPHAROPLASTY.

  Among those German  surgeons who were the earliest  after Dieffen-
bach in the successful treatment of loss of substance in the  eyelids, by
plastic operations, we have to mention MM. Beck, Schwcerer, and Burow,
of each of whom a successful  case is given, in Yon Ammon's Monat-
schrift, Bd. 1, Heft. 1.  (See  also  Archiv.  Gin. de  Mid., nouv. ser.,
tome v., Nov., 1839, Paris, pp. 363, 369, 370.)
  Case I. That of Professor  Beck.   The patient, a robust man, aged
thirty  years, had a cancerous  ulceration in the inner angle of the eye,
with ectropion, and ending in total destruction of the lower lid.   Prof.
Beck, following the method of Dieffenbach,  mado two incisions from
the commissures of the lids, one above and outwardly, the other  above
and inward, so as to include in the lower flaps all the  parts  degenerat-
ed towards the temple and nose.   The upper lid, on a line with those
two incisions, was dissected to a small extent.   Two new incisions, set-
ting out from the  external and internal extremities of the first, and unit-
ing below upon the cheek, at an acute angle, so as to form  with  the
palpebral border  of the lower lid a triangular flap, allowed the oppor-
tunity  of removing the altered  tissues, one  portion  of which,  deeply
seated in the inner angle of the eye, had to be dissected with  care.  A
new incision was then made horizontally from the outer angle of the eye
towards the  temple, and prolonged  to an extent equal  to that of the
base  of the bleeding triangle ; the  flap  included by this and another
incision, directed downward and inward towards the cheek, was dissect-
ed with caution, and  placed  upon the triangular space  formed by the
loss of substance, which it exactly filled.  This  flap was first attached
at the inner  angle of the eye by means  of a suture,  the needle being 
BLEPHAROPLASTY.
637
directed downward and outward, upward and  inward ; afterwards it
was attached at the outer angle and  base.  A complete union and cic-
atrization of the  wound of the cheek were effected at the expiration
of some weeks.   Perceiving then that the external palpebral commissure
had too much extent, an incision was made at the outer angle of the
eye, and the conjunctiva drawn and attached by suture, upon the upper
border  of the solution of continuity, making a continuation with the
upper lid, while a layer of  cellular tissue was applied to the lower bor-
der.  The separate cicatrization of those two borders, and their adhe-
sion to the parts with which they had  been placed in contact, fully car-
ried out the objects of the  surgeon and  effected a complete cure.   The
lids now had their normal  extent and direction; the  lower was not in-
verted by entropion, its free border was pliable, and in no way impeded
the ball by its contact.  The cicatrix  on  the cheek was scarcely visible.
   Case II.   That of Prof. Schwcerer.   A scrofulous tumor on the free
border of the upper lid of the right eye of a child aged nine years, pro-
duced  excessive  pain and severe inflammation of the. conjunctiva.  The
tumor attained the size  of a nut, and was accompanied with an ichorous
bloody  discharge of a cancerous character.   The base and inner fourth
of the  lid  were  sound, while outwardly the degeneration extended to
the palpebral commissure.   The Professor made an incision above the
free border of the lid, to  the extent of the  three outer fourths of its
length.   The two extremities were  united  by a second incision which
was curvilinear, with its concavity downward, and  comprising all the
degenerated  portion, which was  completely removed.  To supply this
deficiency, a flap, setting out at the  outer  angle of the eye, was  cut
above the  eyebrow, and placed between the lips of the wound.  The
union was effected by second  intention, and the cure was complete.  The
new eyelid was well formed and moveable.
   Case III.  That of Dr. Burow, of Koenigsberg.  A venereal affection
of ten  years' standing,  in a  man  aged  fifty-four  years, had destroyed
many of the bones of the face, and caused obstinate ulcerations, which
produced  much mischief to  the left  eye, and  total  destruction of its
lower lid, with the exception of a small  portion, which remained undis-
eased, at the inner angle, but which was in a state of ectropion, and so
much drawn down  that the  conjunctiva was completely everted.  The
upper lid at the  outer angle  was also drawn downward by cicatrices in
the same  manner.  The globe of the eye was the seat of a permanent
inflammation.  Dr.  Burow, adopting  the method  of  Dieffenbach, with
some modifications, first excised a great portion of the conjunctiva which
was altered, leaving  thus a  bleeding surface extending from one angle
of the  eye to the other, then cut upon the cheek a flap, whose pedicle
was towards the nose, and,  having adjusted it in its place, fastened it
by three twisted sutures.  The cure was  complete on the fourteenth day,
and the new eyelid perfectly  fulfilled its functions.
   A new  and  rather ingenious process in blepharoplasty for ectropion
was proposed by M. Berard, jeune, at the sitting of the Paris Academy
of Medicine, Nov. 2, 1841.  (Yid. Archiv. Gin. de Med., 3e ser., tome
xii., Nov., 1841, p.  387.)  In the  removal of a cancer from the cheek
of a female patient, two years before, he was obliged  to destroy the ca-
nal of  Stenon.   Cicatrization, however,  took place without  a  salivary 
638            NEW ELEMENTS OF OPERATIVE  SURGERY.
fistula. The retraction of the cicatrix, ho »>-ever, produced a traction and
eversion  of the outer part of the eyelid on that side.   M. Berard made
a vertical incision at a centimetre from the outer angle of the lids, and
three to  four centimetres  in  length; the  inner lid was detached from
the cheek-bone, and the lids thus liberated assumed their normal state.
He took his flap from the temple, and reversed it upon the vertical wound.
The  operation was successful, and the ectropion disappeared almost en-
tirely.  The  woman having afterwards died of a visceral affection, the
autopsy showed the union of the flap to the tissues to have been complete.
The  absence of a salivary fistula after the section of the canal of Ste-
non, was  explained  by the transformation which the parotid gland was
found  to  have undergone into adipose tissue.  This may have taken
place after the section, or before, in consequence of the cicatrix of the
cancer.

                  New Suggestions for Rhinoplasty.

   Mr.  William Keith, one of the surgeons of the Royal Infirmary, Edin-
burgh, dissatisfied with the  shrivelled, unnatural, and bloodless charac-
ter of most new  noses, proposes, as practised by him in a recent opera-
tion, (See Cormack's Lond. and Edinb. Month. Journ. of Med. Science,
Feb., 1844,) to make the pedicle of the flap not  only unusually broad
and thick, (say fully one-third of an inch wide,) but also to leave it un-
divided, and to agglutinate  permanently to the cutaneous tissues beneath
it, in order to  have a better circulation  and more  nourishment  to the
flap.  This latter result was  effected, as had been  previously recom-
mended by others, (vid. text,  supra,) by causing the  pedicle to adhere
to the  root of the nose  by rawing, (i. e., abrading,)  by means of can-
tharides  plaster,  the two opposing surfaces.  This plan of bringing the
cutaneous abraded surfaces of the pedicle and root of the nose together
does not, to us, appear  as well  calculated to effect extensive vascular
inosculation as that which has been  proposed, of cutting out for it a
suitable groove on the root  of the nose under the pedicle, and fastening
it or imbedding it there in the bloody tissues.  , (Yid. our author in the
text, supra.)  This nose, however,  of Mr.  Keith's construction was, he
says, full, plump, and prominent  several weeks after the cicatrization
and attachment were complete.
   It came near being frozen one cold night, as the operation was impru-
dently performed in winter.

                   Cheiloplasty in  Cancerous Lips.

   Should the degeneration of parts  be so great  on  the lower lip,  for
example,  as  to involve  the muco-buccal membrane, and prevent  our
adopting  the new method of M.  Serre, of  Montpellier, (vid. our notice
of his  recent  excellent  work, infra,) viz., dissecting off that membrane
to cover  the border of the  new lip, we think it might be advisable in
some cases to follow a mode practised in 1841, (April 5,) by Professor
Andrew  Buchanan, of the  University of Glasgow, (see Lond. Lancet,
1841-42, p. 79-82.)  The carcinoma being removed  from the lower lip
by an  elliptical incision convex downward, and extending from commis- 
BLEPHAROPLASTY.
639
sure to commissure, the loss of substance  was restored by taking two
flaps from the chin, each bounded by a curvilinear incision, which began
at the median point on the border of the cut lip, and slightly curved as
it  proceeded  downward to near the outer side of the indentation on the
chin.   From this last point a longer and straight incision, being the ex-
act radius  to the curvilinear, extended outward and upward to near an
inch from the angle of the mouth.  These flaps, dissected off and rotat-
ed  on their radii, exactly filled up the  space left, and formed  an excel-
lent lip, so  that " a perfect  mucous membrane," says Prof. B., " lined
the upper margin and inner surface of the flaps forming the lip."  The
flaps were secured by the twisted suture, adhesive plaster, and bandage.
Two narrow triangular spaces, pointing outward, were left on  each side
the depression of the chin, in place of the flaps removed.

   Early  and successful Operation for Geno-Cheiloplasty, by Mr.
                            Lisfranc.

  In the ingenious and highly important plastic operations  undertaken
at an early period for the reparation of the lips, we mention with pleas-
ure those of M. Lisfranc.  As early  as the  summer of 1840, we have a
case, aged fifty-five, of this eminent surgeon, wherein the destroyed parts,
including  the whole of the lower lip and part of the cheek,  (from, as it
appears, a papulous  eruption treated by arsenical  preparations,) were
complete^ restored by a flap from the neck.   The  operation  was per-
formed June 28, 1840, by commencing  with a semilunar and  two hori-
zontal incisions, which removed the  whole of the  diseased edges, the
vascularity of the  cut  surfaces requiring torsion for ten small arteries.
The next incision  was along  the median line of the neck to the thyroid
cartilage, and dissected back a flap at either side.   Diseased  portions
of the alveolar process were removed by the bone nippers, and  several
of the teeth  also  extracted.   The projecting  angle of the symphysis
was removed by a saw, to prevent its protruding between the flaps. The
flaps were perfectly adjusted  by fourteen pins with twisted sutures.  In
three days all  the pins were removed,  except at  the angles  of the wound.
A slight erysipelas on the neck, small  abscesses at the  angles of the
mouth, and one below the chin, especially the  latter, from the purulent
sub-cutaneous infiltration it  caused  in the neck, gave some trouble;
counter openings  to  the outer side  of each jugular  vein  were found
useful; after the removal of some dead  cellular tissue from one of  these
openings, the  erysipelas immediately  subsided, and  the purulent  exca-
vations became filled up with  granulations.   The  cure was  complete,
(vid.  Gazette des Hopitaux,  Aug. 20, 1840, Paris; also Lond. Lancet,
1839-40, p. 879.)
   [The geno-cheiloplastic operations, however, of Dr. Mott given above,
with plates, (performed in  1825 and  1831,)  so far as priority is con-
cerned, were  probably among the first ever  performed  anywhere, espe-
cially that at the New York Hospital by this  surgeon, about  the year
1825.  Though the flap operations in all reparations of the face, how-
ever great the loss of substance, (as will  be seen farther on,) are now
entirely superseded by the French method  of  diplacement,  it is, never-
theless, proper to chronicle  these early and bold  successes of eminent 
640            NEW ELEMENTS OF OPERATIVE SURGERY.
surgeons, in what now already may be called the rude  period  of ana-
plasty.—T.]

          Anaplasty applied to the Operation for Hare-Lip.

  M. Malgaigne, (vdd. Journal de  Chirurgie ; also Lond. Lancet, Aug.
31,1844,) to remedy  the  disagreeable depression which generally re-
mains on the free border at the median line, after the operation of hare-
lip, proposes that the paring should be commenced from above, and car-
ried downward, the operator stopping when  he has arrived so low that
but a small  pedicle remains.  This is to  be  done on both sides.  By
this means we obtain two small flaps, which merely adhere to the lip by
their  pedicle.  After  uniting with  pins the two sides of the labial divi-
sion in its entire length, except at the lower extremity, the small flaps
are turned downward, and  placed  in juxtaposition.   The surgeon, hav-
ing formed his opinion as to the length which they ought to retain, in
order to form a substitute  for  the  natural median prominence, then
shapes them as he thinks fit,  preserving a greater or less portion, ac-
cording to the extent of the deficiency which he has to supply.   He then
completes the reunion by uniting  the two flaps by means of a suture or
two, or a very fine insect pin.  If the pin or suture is placed very near
the free edge of the lip, the cicatrix subsequently appears scarcely visi-
ble.  The operation has been twice  performed—once by the author, a
second time by M. Guersant.  M. Malgaigne  states  that  in his  case the
operation was perfectly successful, but in M. Guersant's the median tu-
bercle appears to have been rather too large.  M. Huguier  proposes to
use the scalpel instead of the scissors.
   [In relation to the above, Dr.  Mott remarks : " That  the object pro-
posed by M. Malgaigne appears to be to remedy a small notch or  deficien-
cy, which often is, but never should be found to exist, when the ordinary
mode of operating for this  deformity is  properly and judiciously per-
formed ; which mode is:  1. To remove, by a smooth cut with  the scis-
sors, a sufficient amount of  the  lip on each  side, in order to take away
all the flare ;  2.  To make the lowest stitch pass close to the vermilion
border, and entirely  through the lip, and always to tie the  knot on the
vermilion  border, so as to adjust with great accuracy the coaptation of
the lower edges;  in fact, the making of the knot  there keeps  them ad-
 justed.  It may be asked how it is possible to unite the outer edge of
the peduncular flaps, proposed by M. Malgaigne,  so as to fill up the flare
of the lip, inasmuch as it is bringing a natural surface to a natural sur-
face ;  and if pared, they would  render, we fear, the lip much  more ir-
regular than by the usual method."—T.]
   The  editor of the Gazette Medicale  of Paris, (June 8, 1844, torn.
xii., p. 872,) in noticing this  operation of M. Malgaigne, (as published
in the Journal de  Chirurgie of Paris, Jan., Fev. et Mars, 1844.) does
 not seem  to attach much  value to it.  The  difficulty  is, he  thinks, in
givino- the normal thickness to the vermilion border, and the danger of
makino- the lip too long.  He suggests this modification of the hare-lip
operation, viz.: to pare the edges in  a curved manner, so that their con-
cavities may face  each other. 
BLEPHAROPLASTY.
641
                      Anaplasty for Ranula.

 # M. Jobert (vid. his first memoir to the Paris Acad,  of Sciences; also
his second  memoir  to the  same, Aug.  28, 1843, in the Gaz. Med.,
Sept. 2, 1843, tome xi., p. 562)  has applied anaplasty, in  two cases,
with complete success  for the radical cure  of ranula, (grenouillette.)
He confines this disease exclusively to the tumor formed by a collection
(amas) of  saliva from engorgement, caused  by obliteration  or obstruc-
tion of the canal or duct of Wharton.   Much difficulty has  arisen, and
many failures in the treatment been produced, from the carelessness of
surgeons confounding with this disease other tumors which may  form in
the same place.  Yet these last, he also thinks, will have most  chances
of cure by his anaplastic method.

     Anaplastic Operation for the Cure of a Cicatrix from  Burn.

  In according  to our countryman, Professor Mutter of Philadelphia,
the honor of having first ingeniously and happily applied the principles
of anaplasty for the  cure of cicatrices from  burns, we have unknow-
ingly, but, as it will  appear, innocently done injustice  to  Mr. H.  D.
Carden, surgeon to the Worcester Infirmary, England, who,  by a paper
of his inserted in the  Transactions of the  Provincial Medical  Se  Sur-
gical Association, vol. xii., London, 1844, p. 585 et seq., but, as far as
we can learn, never  before  published or announced, appears to be en-
titled to all the  honors of priority in  this new treatment, having  per-
formed the operation on a case very similar to those of Prof. Mutter's,
as early as November  1, 1839;  while the first case  of Prof. Mutter's
was  not performed until Jan. 12, 1841, (see  The American Journal of
the  Medical  Sciences, by  Dr.  Hayes,  new series,  vol.  iv.,  Philad.,
1842, p. 66 et seq.)
  The case of Mr. Carden, was  a girl  by the name of Mary Ann Bar-
nett,  aged fourteen, who was admitted, says Mr. C, into the Worces-
ter Infirmary, Sept. 9, 1839.  The burn which occasioned  the deform-
ity, occurred on the anterior and upper  portion of the neck  about seven
years previous.  " The movements of the head (by  the large cicatrix
formed) are (says the surgeon) greatly restricted, the  mouth  remains
permanently open, the tongue protrudes, the lower incisors  project hor-
izontally,  and there is constant salivation.  On attempting  to raise the
head, the eyelids are drawn considerably downward. The patient, as
well as her friends, being most anxious to have something done for her
relief, a consultation  was held upon  the case, when it was admitted
that the experience of modern surgical  authorities was not in  favor of
such attempts ;  and that where excision of the cicatrix had been  prac-
tised, the deformity had generally been  increased rather  than  other-
wise.  Under these circumstances, a new mode of proceeding was  sug-
gested, which,  on  explanation, was sanctioned by my colleagues, and
performed November 1, 1839, in the presence of, and assisted by Messrs.
 Sheppard  and  Pierpoint, surgeons  to  the hospital, Mr. Cole, house-
 surgeon,  and the pupils.   A contrivance for keeping tho  head  erect
 during the after treatment of the case, had previously been  provided.
   Yol. I.                     81 
642
NEW ELEMENTS  OF OPERATIVE SURGERY.
        " The patient being placed on  a well-cushioned table, with her head
,  ,   and shoulders somewhat elevated, I commenced the operation by  care-
     fully gathering up the cicatrix from below the left ear to the top of the
     sternum, between the fingers and thumb of the left hand, which enabled
     me to transfix and divide the whole of that  side at a stroke ; the same
     was repeated on  the  right  side, and a  short  cut  over the top of the
     sternum connected the two incisions.  In this manner the whole trans-
     verse extent of the cicatrix wras  rapidly divided, the wound terminating
     in sound skin on each side.   The chin was  then drawn upward  by an
     assistant, and every tense band of cicatrix  successfully divided by re-
     peated strokes of the scalpel, until the head was released into nearly its
     natural position.   By this mode of dissection,  although  nothing had
     been removed, the hiatus produced was  very great, and extended from
     above the chin and edge  of the  lower jaw, to below the  upper border
     of the  sternum, exposing the greater part  of both sterno-mastoid mus-
     cles, and external jugular and thyroid veins, the  latter being particu-
     larly large and prominent.  The  quantity of  blood  lost was very tri-
     fling, scarcely requiring the torsion forceps.   As  soon  as all bleeding
     had ceased, I proceeded to select a portion of  sound skin on each side,
     about three inches  long and two and  a half wide; these were raised
     and detached,  except  at  their junction with  the outer edges of the
     wound, and brought together across  the  centre of the  neck, and there
     united by  hare-lip  needles.  The side-wounds  left by  the flaps were
     then brought together, and the exposed  parts  covered  with lint.  The
     flaps were carefully supported by adhesive  plaster,  leaving apertures
     for the points of the needles, and the whole of the wound and surround-
     ing integuments were well supported by long plasters and bandages.
        " She  bore  the  operation,  which was severe  and  necessarily pro-
     tracted, with great fortitude, and without fainting,  and  went on favora-
     bly.  The needles were withdrawn two days  after the operation; the
     dressings were not  removed until the  sixth  day, when the flaps were
     found to  have retained their position ; but  the upper  border of each,
     being  composed of old cicatrix, had perished, diminishing the breadth
     of each to less than two inches.   The  complete healing of the wound
     occupied nearly twelve months, during which time various contrivances,
     in addition to that first used, were had recourse to for keeping the
     head in the  erect position; but  the bodily  and  mental suffering was
     so great, each  lime  the wound was  dressed,  from  these repeated
     stretchings, that 1 discontinued  them  altogether.
        " She was  made an  out-patient in May, 1840, and in November fol-
     lowing she presented the following appearances ;—Wound healed ; posi-
     tion and movements of the head greatly improved ;  can  close the mouth,
      retain the saliva, and articulate  distinctly ;  teeth  regaining their natu-
      ral position.   A narrow cord has sprung up between the flaps,  which
      threatens to draw down the centre of the lower lip, and also to  prevent
      the farther expansion of the flaps, which has hitherto been steadily going
      on, and forming the most satisfactory feature of the case.
        " I passed a curved bistoury under this and divided it, enjoining pres-
      sure and farther extension ; but from that time she avoided attendance
      at the  hospital, and neglected all directions, and I saw no more of her
      until October 23d, 1843,  when  I sent for her and made the sketch 
BLEPHAROPLASTY.
643
figure 4, [in the work cited.]   She has become stout in person, has en-
joyed good health, and is very grateful  for  the  improvement gained.
The teeth are quite upright, and I regret that one was extracted before
the  operation, although at that time it appeared  hopelessly displaced.
The flaps  now measure  three inches on the right side, and two inches
and three  quarters on the left, from  above downward ; but there is an
increased  contraction in  the  central cord, which is strongly marked in
the  sketch.   This she has consented  to have  divided and separated
from the flaps, which may then, I trust, be permanently united, and her
appearance considerably  improved.
   " Four years having elapsed since  the operation, a fair estimate may
now be formed of its  merits.   I should however, have considered it pre-
mature to submit it to the notice of the profession, until further  trials
in my own practice had rendered the subject more complete, had not my
attention been called to an interesting paper by Dr. Mutter, of Philadel-
phia, in the American Journal of Medical Science, the  result of whose
operations, undertaken at a subsequent period to that above detailed,
appears fully  to establish the  value of the flap method,  or,  as Dr. Mut-
ter calls it, the ' autoplastic operation,' in these very  distressing defor-
mities."
   We have given the above in detail, because it is related with a degree
of candor  becoming the dignity of the profession, and the  courtesy
which should never  be forgotten in the emulous and honorable rivalry
for distinction.
   M. Carden, in the concluding portion of his  paper, fully concedes to
Dr Mutter the superiority of his method in completely excising the cica-
trix, dividing one or both the sterno-mastoid tendons, and making use
of a sufficiently large flap in the beginning.
   The  very diminutive flaps,  not making allowance for  subsequent con-
tractions, was the principal  defect  of Mr.  Carden's  operation, and the
cause of the difficulties which ensued ; others were the leaving a portion
of the cicatrix on the borders of his two small flaps.   Hence the gap,
the new cord, &c. ; all of which he has very ingenuously admitted.
   Remarking on Dr. Mutter's proposed  modification, by taking, if ne-
cessary, two flaps instead of  one, as Mr. Carden did, the latter says he
finds, by a curious coincidence, that  he also, in his notes of his own
case, (Nov.,  1840,)  had also, without then knowing of Dr. Mutter's
case, suggested the large single flap which that surgeon used in his first
case, thus:—" In a future operation, I should endeavor to procure more
complete union between the flaps  in  the  centre, or (which, perhaps,
would be better) should, if possible, cover the whole  hiatus with a sin-
gle flap."   On this point he prefers the operation of Dr. Mutter.   " In
future,  (says  Mr.  Carden,) I should  avoid the  inconvenience experi-
enced in my case, and which is  very apparent on looking at figure 4
of a cord  springing up  in the centre, by making the flap, or flaps, if
taken from each side, sufficiently long to reach across the neck."
   Mr. Carden also, form what he  has related  in this case, properlv
condemns, in unqualified terms, the  use of extension apparatus   and
which (as  is seen  supra,  in the  text) Mr.  James, of Exeter, much en-
larges upon the advantage of  in these cases, even after the Mutter oper-
ation has been performed.                                       ^ 
644            NEW ELEMENTS OF OPERATIVE SURGERY.
  It appears, therefore, that there can be no  difficulty in adjusting the
respective claims of the English and American surgeon on this subject.
Inasmuch as the merit of priority in first suggesting and  partial carry-
ing out this now most invaluable improvement in autoplastic surgery, in
a large class  of distressing deformities that  have for centuries baffled
the greatest minds in our profession, belongs unquestionably to Mr. Car-
den.  While the full and entire honor  of establishing, by a most skilful
and successful process, the value of this operation, is to be as unhesitat-
ingly accorded to Prof. Mutter.
  To both surgeons the profession owe much ; and but for the perfection
of the processes by Dr. Mutter, we should, from the creditable modesty
of the gentleman who first originated the idea of this operation, not have
had an  opportunity, probably, of chronicling this  present  record in be-
half of  the priority which belongs to his share in the matter.

                             Uretroplasty.

   The  new process  proposed by  M. Segalas, in a letter to M. Dieffen-
bach, 1840, and which was brought before the notice of the Paris Aca-
demyof Sciences July 26,1841, (vid. Journal des  Connais. Med.-Chir.,
Sept., 1841,)  does not,  nevertheless,  appear to  have been  generally
adopted.  M. Segalas had considered, very  properly, that the  chief
cause of  failure,  and of non-union in reparations  of loss of substance
in urethral fistulas, &c, was the difficulty of preventing  the infiltration
of urine through them.  This  he imagined he could obviate, by " tempo-
rarily diverting the urine from its natural course, by opening for it a free
exit in the peringeum, and in conducting off  the  urine through  this pas-
sage by means of a catheter."  In 1841, M. Segalas furnished, for the con-
sideration of the Academy, a case  in  support  of his method.   The pa-
tient had all the intermediate  portion  of the urethra between  the scro-
tum and  glans  destroyed  by  gangrene.  The process of the surgeon
named was completely successful.   M. le Docteur Ricord  had  also suc-
ceeded  equally  well  in  another case.  In a third case  of M. Segalas,
the fistula was in the  anterior part of the  urethra, with  great los3 of
substance ; and  it  was for the  purpose of inspecting the process of M.  S.
in this case, that he solicited a commission  of the Academy, which was
granted.  Their report on the subject (if ever made) we have not been
enabled to find.

                    Episcoraphy,  or Episcoplasty.

   This  operation, which  consists in dissecting  off each  labium  with a
 small portion of its mucous surface, and then uniting  the raw edges  of
 the tissues by strong sutures, as recommended by Dr. Fricke,  of Ham-
 burg, and which,  in fact, virtually  sews up the  passage, excepting for
 the mouth of the  urethra, was performed in 1841 by Mr. Lightfoot,  of
 Newcastle-on-Tyne, (Eng.,) for prolapsus of the bladder with the an-
 terior wall of the  vagina, producing a tumor protruding through the vul-
 va, (Lond. Lancet, 1841-2, pp. 322, 323.)   It  is  unnecessary  to say
 that the remedy must, from moral considerations, and the physical ob-
 stacles it creates to the functions of the parts, be worse than the disease, 
BLEPHAROPLASTY.
645
 and can only be justified  in such extreme cases as that of Mr. Lisrht-
 foot, and in which the success was complete.

 Penoplasty, or Exsection of a portion of Hypertrophied Penis, and
         Transplantation of the  Glans Penis on the  Stump.

   An American surgeon, Dr.  Mettauer,  of  Yirginia,  (see  American
 Journal of the Medical Sciences, July, 1842,)  has the credit, we be-
 lieve, of being the first who  has ever performed the operation of  patch-
 ing and repairing a deformed  useless penis by exsection, so as to make
 a new organ thereof, for all the functions required of it, and which pro-
 cess may be called penoplasty.
   A  young man, aged nineteen,  came under Dr. M.'s care in  1841.
 His penis  was eight inches in length from the scrotum  to the  extremity
 of  the  glans, in a non-erected state ; the  anterior three fifths  dilated
 laterally, flaccid and non-erectile, with great expansion of the corres-
 ponding portion of the urethra—the latter being capable of containing
 two ounces of fluid, the cavity which it formed being bounded  anteriorly
 by the  concave glans.  The  other two fifths, or pubic portion, constitut-
 ed the stump of the organ, and was well formed and capable of erection.
 The orifice of  the urethra opened upon this, forming a  sort of os tinea,
 looking into  the  cavity  above described.  There was also a fistulous
 opening in the perinseum, from which most of the  urine escaped, anterior
 to which the urethra  for eight lines was nearly impervious. There was
 an  artificial fistulous opening, also, in the central portion of the pouch-
 like portion of the urethra above described.  The testes were  large,
 and strong sensual desire existed.
   Dr. Mettauer laid  open the pouch by an incision along the raphe.   A
 belt was then  removed  from the interior of the cavity, seven lines  in
 width, entirely  round the base of the glans, and quite to that  organ,
 so as to leave that part of the wall of the pouch to consist only of in-
 tegument  and  cellular  membrane.  A like belt  was removed from the
 inferior portion of the  pouch, quite  down to the circumference  of the
 face of  the erectile stump, which  was  then carefully denuded in  every
 part of  it.   The glans was placed with great care upon the face of the
 stump, taking  care that the  denuded margin  at  its base should exactly
 correspond with the circumference of the opposed surface of the stump.
 A short bougie was passed in the meatus and carried to near the contract-
 ed  portion  above mentioned.  This  holding  the glans in position, the
 latter was fastened to the stump by eight points of the Glover's sutures.
  The loop-like tegumentary intermedium on the dorsum was reduced
 one half, leaving the other to nourish the glans.  On  the twelfth day,
 the glans had firmly united to the stump.  The superfluous tegument was
 excised a few months after.  The  new penis was  full two inches  long,
 and comely in shape  ; and the glans, which  after the operation lost its
 sensibility, had  now  recovered it, so that the organ could perform its
 proper  functions,  being, when erected, four and a half  inches long.
The interruptions in the urethral passage were removed by a  lono- tro-
char, and the passage then kept open by a bougie, and the fistula healed
by suture.   The success was  complete.
 " The application of  anaplasty for the cure of ranula, by M. Jobert of 
646
NEW ELEMENTS  OF OPERATIVE SURGERY.
 Paris, which  we have  alluded to in our Concluding Appendix, Vol. I.,
 but could  not at the time find the details of, consists in the adaptation
 of this remedy to this  disease upon the same principles upon which it
 is used for the cure of  contractions  of natural  orifices.   In the first
 stage, the  surgeon  carefully dissects off from the tumor, without pene-
 trating the latter, its mucous  membrane or external  envelope, the dis-
 section being made to an extent proportionable to the volume of the
 ranula.  He then excises a flap, so as to obtain a bleeding surface of a
 certain extent.   The second  stage consists in opening  and evacuating
 the pouch, (or sac,) by incising the internal membrane  which remains.
 Finally, he reverses this  internal membrane on each of the lips of the
 incision, and  doubles it upon itself so as to fill up the bleeding surface,
 and keeps it in this position by means of a point of suture acting as a
 hem.   (Yid. Dieffenbach's  Ingenious  Process for Atresia or Contrac-
 tion of the Mouth: text, Vol. I.)  M. Jobert proposes thus to create
 a permanent  opening, as in the processes of Dupuytren, Boyer, &c.;
 the obliteration, however, here  being, in  his mode of operating, less
 to fear, because the borders of the orifice  are, by the very fact of the
 operation, made to consist of non-bleeding  surfaces, which can neither
 approximate  nor  unite, (Annates de  la  Chirurg.  Frang. et  Etrang.,
 Juin, 1843 ; also Arch.  Gin. de Mid., Paris, 4e ser., Sept., 1843, p. 100,
 101.)   M. Jobert proposes to extend  this process to imperforate passa-
 ges or cavities, as the vulva, mouth, &c, by first laying  them open, and
 then bringing out the mucous  membrane and hemming it by pin sutures
 to the cutaneous border of the external wound, (Archiv.  Gin. de Mid.,
 4e  ser., t.  IL, Juin, 1843, p. 238.)

                            ANAPLASTY

  In the  formation  of  a  double  undetached flap over  fistulous open-
 ings, by the ingenious bridge-like process of M. Velpeau, (see the text
 of this work, supra,—Anaplasty,) and auxiliary means of sustaining the
 proximate  sutured edges of the longitudinal flaps in coaptation, has been
 suggested and successfully practised by Dr. Dettauer, of Virginia, and
 Prof. Mutter,  of Philadelphia.  It consists in inserting a slender roll of
 some soft substance like buckskin, in the new sulcus on each side the flaps,
 so as to raise a growth of granulations from their bottom, and thus con-
 tribute [on the principle of the action of a quilled suture.—T.] to sus-
 tain the flaps and promote their union.   (Yid. Pancoast's Oper. Surg.,
 Phil., 1844, p. 344.)
  Professor Pancoast, of Philadelphia, has, since the new impulse given
to anaplasty, performed (we should judge by the  accounts he gives  in
his late  work on  Operative Surgery) more difficult operations, and with
eminent success, in the restoration of the nose, lips, &c, than perhaps
any other American surgeon.
 ,. In rhinoplasty, he recommends  the  pedicle of  the  flap  at the  root of
trie nose to be  left from half an inch to five-eighths of an inch in width,
 so as to preserve, for its nourishment, one or both  the  angular arteries
of the nose, (lb., 345.)   He approves of Lisfranc's recommendation, to
bring the incision down between the eyebrows, a little lower upon the
side opposite to that upon  which we intend to make the twist, as it facil- 
ANAPLASTY.
647
itates this manoeuvre.  He disapproves of the practice of M. Liston,
and Dieffenbach, of lodging the pedicle in a groove cut into the integu-
ments upward from the chasm of the nose ; as the shaving_ down  the
bulky prominence  which afterwards forms by  cicatrization, is attended
with difficulties, or leaves a deformity.  Prof. Pancoast proposes some
ingenious, and,  as it appears to us, valuable modifications, to the usual
Indian process of  the  flap from  the  forehead.   He has, he states,  met
with entire success by this  mode, in six cases of rhinoplasty ;  and, in
Ins work on Operative Surgery, just published, (1844.) and so frequently
cited by us in this  appendix, he enters minutely, and with the aid of nu-
merous well-delineated sketches, into the mode he adopts.  The first case,
and which he published first in the American Journal of Medical Scien-
ces of Philadelphia, for October, 1842, is exceedingly instructive  from
its formidable character, as involving, not only the soft parts of the nose,
and septum narium and turbinated bones, but also the total destruction
of the upper lip; all of which losses of substance were happily restored
by the Professor, who  thus did as much honor to  himself, professionally,
as he conferred  happiness and comfort upon the individual  whose afflic-
tions had  rendered him a spectacle of revolting deformity.
  The patient, Jno. Glover, an Englishman, aged fifty-three, according
to his own statement had, some  eight years  before, received a violent
contusion in the face, which resulted in the destruction of parts mention-
ed.  His  healthy florid look, as described, and the rapid recovery,  and
firm granulations in one of his age, seem indeed to imply that there could
not have been any  syphilitic or mercurial taint in his system.   The cav-
ities of  the antra laid bare, and now shallow by the destruction of bone,
exposed to view also the sphenoidal  sinuses.   The  teeth, and  alveolar
processes  of each jaw, were entirely gone—all that was left of the upper
jaw being a thin plate two lines thick.  The free margin of the lower
lip, when  closed, thus covered the edge of the upper gum, and reached
the nasal  cavern.  The mouth was  diminished by the previous  disease,
and ulceration, having been followed by union of the lower lip for about
half an  inch from each corner, to the  flesh of the cheek  above.   So  that
the mouth, in fact, when opened, formed a  rigid circular  orifice, three
quarters of an inch in  diameter.
  The operation consisted of two stages :—In  the  first, the  contracted
mouth was widened, by the beautiful operation of Dieffenbach, at the com-
missures,  [see text of this edition of Yelpeau.—T.,] and  the upper Up not
less adroitly restored, by Professor Pancoast taking two right-angled flaps
(their angles pointing upward and outward)  from either side of the
cheek, near the  ala of  the nose.  These cutaneous  flaps, each about an
inch  and a quarter in length and breadth, were, together with their sub-
jacent adipose tissue,  dissected off from the muscles of the cheeks, while
these latter were loosened from the malar bones and gums, and the  sur-
face of  the upper gum made raw.  The flaps were so ingeniously shaped
and disposed by the Professor, that,  when stretched  down, their inner
edges came into perfect coaptation, forming a  perpendicular line where
the groove of the upper lip formerly existed.   The general integuments
of the cheek, which, as we have said, had been loosened, were also ad-
vanced  forward by this adjustment, so as greatly to diminish  the space
from whence the flaps  were removed—the whole of the space remaining 
648            NEW ELEMENTS  OF OPERATIVE SURGERY.
being now effectually closed by pins.  " The integument by the side of
the nasal cavern, was loosened with the knife on each side, and fastened
with a cross-pin, so as  to give a cuticular covering to the raw margin of
the new upper lip.  The face was covered wdth lint, kept wet with  lead
water, and the two operations, performed in presence of the class at Jeffer-
son College, consumed an hour and a half.   In two months, the upper lip
being firm and solidly united to the gum, the second stage of the operation,
that of making  a new nose, was also performed before his class."
   The value of the Professor's process, or modification, as differing from
others, seems to consist,/?r_2: in bevelling the edge  of the  flap while
dissecting it from the forehead, which he does by  inclining the blade of
the knife outwardly.  By this means, he found the lips of the wound in
the forehead could be much more  approximated by the four hare-lip su-
tures used.  The surface of the new lip and gums were now made raw.
But, secondly, the most important part of Professor Pancoast's process,
and the one upon which he appears to rest (as far as we are acquainted
with what has been done in this part of anaplasty) a just claim to origin-
ality, and for sound pathological reasoning, is that which we shall now
describe in his own words.   After abrading the new  lip  and gums, he
" carried an incision down to the bone, just at the outer side of the mar-
gin of the nasal chasm.  The  integuments were then dissected each way
from this incision, so as to leave a groove between them for the lodg-
ment of the edges of the new nose.   The inner margin was raised up so
as to form a vertical wall, far the purpose  of bringing the raw  surface
into contact with the raw side of  the flap, and  thus give  an increased
probability to the adhesion of the graft; to render the union  still  more
certain, the  triangular piece of skin enclosed by two grooves at the end
of the ossa nasi, was cut away, and the cuticle pared off from the edges
of the flap, with which the new nose was to be formed.   Three waxed silk-
en ligatures, with a needle at each end, were placed at each side, by pass-
ing one needle from without inward through the inner wall of the groove,
and again in the opposite direction, about an eighth of  an inch above the
first puncture, so as to  leave the two needles of each ligature  resting on
the cheek, with a loop through the inner wall of the groove."  The flap
from  the forehead  was then  rotated to the right upon its root, and in
such way as not to make tension on  the  pedicle.   " The two  needles at
the end of each  ligature were then  passed  through  the margin of the
flap, from within outward,  and again through  the integuments on the
outer side of the groove, so that when they were drawn tight, they ne-
cessarily sunk  the  edge of the flap to the bottom of the groove, and
brought four raw surfaces  into contact.  The  threads  were tied over
small rolls of adhesive plaster, after the manner  of Graefe and Labat,
so as not to strangulate the  parts included in the loop.  The middle of
the three ligatures were placed a little  farthest from  the free margin,
and knotted  over a roll  of adhesive plaster three quarters of an  inch
long, which  rested against the flap, and sunk it in so as to support the
side of the nose, and give  the depression  naturally existing above the
oval cartilage.   The left  margin of the new nose was  secured before
the right, in order to give greater facility in  the nice  adjustment of the
ligatures.  A small ligature was then passed through each edge of the
integuments of  the new  column  (of the flap)  near  its root, and  tied 
ANAPLASTY.
649
upon one side, so as to  give a rounded form to the column, by bringing
the two lateral surfaces  together posteriorly, as well as prevent its ad-
hering to the margins of the new alas.   The  cuticle was removed from
the lower end of the column by a bevelled cut;  the  column was then
pushed in upon the gum, and secured upon the new upper lip by two
pins, one  of which  was semicircular.  A piece  of lint, dipped in oil,
was passed  on each  side up the  new  nostril;  another  was laid on each
side of the nose over the ligatures.  Lint spread with cerate was placed
upon  the  sides  of  the  nose, and  over the wound between  the  eye
brows—the  whole secured with a split  adhesive strap  brought down
from  the  forehead."  The operation was performed in the space of an
hour.  Prof. Pancoast says his process  of attaching the graft has been
since  successfully employed by Dr. W. P. Johnson, of Philadelphia,  and
Professor Baxley,  of Baltimore, union taking place  in each of these
instances by first intention.
  The loss  of blood, in the above  described case, was not over six
ounces.  This  novel and  certainly very ingenious mode of Prof. P.,
of  grafting  by  a  species of bevelling  and dove-tailing of the parts,
seems, indeed, well calculated to promote cicatrization and solidity, the
two great points or desiderata  chiefly to be attained, and which  have
so long baffled  most  nose-makers, giving them, for the fruits of their
dexterous manipulations, most  frequently little else than pug-shaped,
flabby, and movable knobs, that  looked more like small shrivelled po-
tatoes, than bona fide human noses.   Professor Pancoast says, however,
that his process was no sooner completed than the  patient (who at no
time made any complaint)  immediately presented a new nose which  had
much of the natural appearance, " and was held  so firm in its place as
to be incapable of being moved by the respiratory efforts," which latter
inconvenience is a very serious one in the ordinary modes  of  fastening,
which consists of only two  bevelled edges  in  contact, viz., that of the
flap and nostril.  The flap retained its sensibility  and  color, and on the
fourth day  was  found  united,  throughout its whole insertion in the
grooves, by  first intention,  and after the  second dressing, preserved its
position so perfectly as to require no stuffing of the cavity.   The wound
of the forehead healed up finely,  leaving a very small  cicatrix  only,  not-
withstanding the flap had been  made  so large (near three  inches at its
base) to allow for retraction.  In five weeks, the pedicle which con-
tained the angular arteries was divided  obliquely  upward, from  the left
to the right  side,  leaving thus a  loose triangular lamina attached to the
new nose.   The arteries were stopped by pinching.   " The triangular
piece was diminished by paring off the  sides, and shaving away a por-
tion of its inner surface;  it was then smoothly  fitted down over the
root of the ossa nasi, into a cavity made  by the excision of a portion of
the subjacent integument for the purpose.   A few stitches of the inter-
rupted suture, and  a compress  and  bandage, completed  the  dressing
On  the third day, the sutures were  removed.  Some suppuration  had
taken place  along the left line of the junction, and there was considera-
ble tumefaction of  both canthi.  By the  twelfth day the union was
smooth and  perfect."
  The drawings which  the Professor gives, (figures 1, 2, 3, 4 5 6  7
plate  71, page 348,  of his recent work on Operative Surgery, Phil.'
   Vol. I.                      82                                '* 
650            NEW ELEMENTS OF OPERATIVE  SURGERY.
1844, and especially figs. 1, 2, 6, and 7,) seem "ully  to corroborate his
assertion, that the nose was, as  it must have been from these represen-
tations, so good a one and so natural and symmetrical, as to attract the
particular observation of no one.  There was, it  appears on  inspection,
" a slight drooping at the apex, and a  sort  of abruptness at its line  of
connection with the cheeks,"  which, however, was scarcely distinguish-
able.   These, undoubtedly, were produced  by bracing down the nose
on the sides, and by its new  columna, so firmly; but it  was better  to
make this trifling sacrifice, when the great paramount object  of resistant
firmness and solidity in this projecting organ  was, it would seem,  so
admirably attained.  Fig. 7 represents the patient  sixteen months after
the operation, with a  very  decent mouth and upper lip,  and a nose
(according to the plate) of really elegant contour, presenting altogether
a physiognomy so passable, if not comely, as  to render it inconceivable
how the same face could  have exhibited the hideous aspect it  does  in
fig. 1, a few months before.
  The last of his six  rhinoplastic operations, which the  Professor says
took place during the past  winter, (1843  and 1844,) was  performed,
and the dressing completed,  in little  else than half an  hour,  (Oper.
Surg.,  Loe Cit., pp. 345-9.)
  Professor Pancoast was equally successful in an ingenious  application
of anaplasty, where the entire middle portion of the nose was destroyed,
in a young man, by scrofulous ulceration.   This operation was perform-
ed at the Philadelphia Hospital, January 9,1841. (see his Oper. Surg.,
1844, pp. 349—52; also, Amer. Journ. of Med. Se, 1842.)  The de-
struction of parts was as follows:—A great portion of the hard palate,
the sockets  of all the upper incisor  teeth, all the cartilaginous  portion
of the septum  narium, the inferior  turbinated bones, the whole of the
superior lateral cartilages of the nose, and a considerable  part of the
inferior oval cartilages, as well as the integuments of the nose;  leaving
an open cavity, three quarters of an inch  long, between the ends of the
ossa nasi and the tip of the nose, which  latter, with  the columna nasi
and the anterior  margin of the  nostrils, were uninjured.   This cavity,
on  the cicatrization  and closure of the  ulcer, drew up  the tip of the
nose half an inch, and at the same time depressed it to nearly on a level
with the cheek, while the left  ala, which had suffered  most  destruction
by the ulceration, was retracted most.  The soft  palate was uninjured,
but  the hard palate was destroyed by a fissure which extended back-
ward an inch and a quarter from the  upper lip, and  had, in its widest
part, three quarters of an inch in diameter.  The gums, uniting across,
had formed a fleshy band in front of this opening, while  the upper  lip
was flattened and  depressed.   The tegumentary  covering of the cica-
trix was first dissected off, and the tip of the nose separated from the
ossa nasi—leaving a triangular space with an abraded bevelled margin.
The normal position  of  the tip of the nose was  still more effectually
obtained, by extending the incision of the cheek outward  and down-
ward through the root of the oval cartilage, and by nicking the inner
margin of the same with a probe-pointed  bistoury, introduced  through
the nostril  on each side.  It was  also found  necessary  to  divide some
adventitious bridles within the nasal passages.  The cheeks being  full
and fleshy,  as thick a triangular flap as possible, and of proper dimen- 
ANAPLASTY.
651
sions, was then dissected out from below the malar protuberances, by an
incision which was made to bevel inward  towards the centre, in order
to adjust correctly with the bevelled raw edges of the cavity of the nose.
The base of these Y-shaped flaps, and which faced outward, was round-
ed so as to give  a prominence to the ridge of the  new nose.   The pedi-
cle  of each flap  was left opposite the attachment of the oval cartilage
upon the cheeks, and  the flaps then twisted around and brought into co-
aptation, so as to make that which was the lower margin on the cheek
become the upper margin on the nose, while the bases  formed the ridge
of the nose.   The effect of the  twisting, as had  been anticipated and
desired, was that the pedicle on each side respectively  hitched up the
root of each ala, and thus kept  the tip properly  depressed.  The flaps
were now neatly fastened and adjusted on the dorsum by palladium pins
and twisted sutures.  No stitches were used.  Before the pins were ad-
justed, the fragment of cartilage left upon the ossa nasi having a dispo-
sition to curve, was divided vertically on either side of it, which brought
it up to a proper level.  The sides  of the  two wounds on the cheeks
were united  by  hare-lip sutures, the stress being made to act  upward
towards the canthi, and not on the  middle of the lower eyelids, which
might have caused ectropion.   The oblique direction of the  pins at the
same time prevented  any distortion of the  upper lip.  Mr.  Liston's
dressing of wet lint  over the nose, covered  with oiled  silk to prevent
evaporation, was the one preferred.   The eyes were covered and kept
shut, and the patient  directed not to speak.  The whole process occupi-
ed an hour, and  though painful, was borne well.  The flaps, immediately
after the dressing, were cold, blue, and  insensible; but soon  regained
their natural temperature, but not their color  till  four hours subsequent-
ly.   Complete union by first intention had  taken place, and all the loose
ligatures were removed, on the tenth day.   Some suppuration, however,
had taken place at the median line of the ridge of the nose, at the junc-
tion of the flaps, from a pin which had been overlooked having ulcerated
through.  The nose was somewhat flabby for want of  cartilage, but the
patient breathed through it freely.   Adhesive straps were applied over
the ulcerated portion, which  soon closed, leaving, however, a depression
at this point, though the tip preserved its natural position.   Owing ap-
parently to the  traction of the cicatrix, the  pedicles  projected on the
cheeks, and the  flaps  themselves rose upon the sides of the nose a little
above the general level.  This defect was removed by the following in-
genious operation:—" I divided (says the Professor)  the pedicle trans-
versely on a level with  the cheek; cut out  a V-shaped piece of integu-
ment, with the point  downward upon the cheek, and closed the edges
with hare-lip suture;  cut out a similar piece from the new flap, with the
point upward upon the side of  the nose, and closed  the wound in like
manner.  This  double  operation was performed on  both sides of the
nose.   Its object was to diminish the bulge of the  flap, and  render the
junction between the nose and cheek smooth  and even.  To  restore the
natural sharpness of the ridge, and remove the sudden depression at the
front part of the new structure, which gave a pug-like rising to the tip,
I cut out at the  same time, in front of the graft, a small triangular piece,
the base of which was  upward  and  included the  depressed parts.   I
then made raw the edges  of the flaps ou the ridge of the nose;  dissect- 
652            NEW ELEMENTS OF  OPERATIVE SURGERY.
ed up the margin of the grafted pieces on either  side, stretched them
forward and fastened the parts together with  hare-lip pins.   The pins
were  removed  on the third day.   Every step of the second operation
succeeded  perfectly, except  the  attempt to stretch  the grafts  on  the
ridge of  the nose.   The texture of these were [was] so altered that it
would not bear extension like a fresh piece of skin, and a small portion
of the margin on each side ulcerated.   Simple dressings were first ap-
plied.  In  the course of a week, the ulcerated  edges  of the flaps on the
ridge of  the nose, being left  too high for the general level of the nose,
were rounded off by being lightly touched with caustic.  Stimulant oint-
ments were subsequently  applied  to  encourage granulation.  In  this
way, the deformity on the  ridge of the nose was entirely removed, and
the new  organ was left presenting an appearance nearly natural.  There
was still some tendency in the roots of the new alas to be drawn out on
the cheek.   In order to counteract  this, I directed two pieces of sheet-
zinc, moulded to the shape of the cheek and nose, to be worn, fastened
together with strings over the bridge, and secured with a riband around
the neck.  This effected the object  completely, but the patient was di-
rected to wear it for two or  three months at least, during the night, in
order to preserve  the shape of the nose."....."In the fastening
of the flaps in their new position, I followed (says  Professor P.) in this
case the plan of Dieffenbach as described by Zeis—the  introduction of
a great  number of pins close together, which were  surrounded with cir-
cular ligatures and  cut short.   In subsequent  operations,  (however, he
adds,) I have given a preference to the interrupted suture, as I have not
found the nice adjustment of parts accomplished by  means of the pins,
to compensate for the  greater irritation and  liability to ulceration, to
which these give rise."
   The  profile  appearance of the patient's  nose, ten  months after  the
operation, as given by the Professor in fig. 4, plate 72, (p.  378 of his
work on Oper.  Surg.,) presenting, in  fact, a graceful outline  and con-
tour to the new organ,  is well calculated to impress the reader with the
inappreciable advantages of anaplastic operations, conducted with the
tact and skill which  appear to be possessed by the  Professor in this de-
partment of operative surgery.
   In partial  losses of the nose, as of one entire ala, and  especially
where the upper lateral  part of the nose, and a portion of the cheek,
are also destroyed with the ala, Prof.  Pancoast prefers to take his  flap
from the  forehead, as that from the  cheek, which has been the usual
method, constantly tends, by its cicatrization, to  draw down and distort
the organ. He thus obtained complete success in a case (see figs. 5 and
6, of pi. 72, of his  Op. Surg., p. 348—351,)  in which, from a morbid
o-anodionic enlargement, and neuralgic  affection of the infra-orbitar nerve
in consequence of a lupus, he excised, also, the diseased portion of this
nerve.   When the defect is small, and the  nose sunken, as in a  case
which resulted from ozasna, (see  his  Op. Surg., p. 352; also, Amer.
Journ. of  Med. Se for  1842,) he has succeeded, to a great extent, in
restoring  the organ by cutting out an oval-shaped  piece, and raising
 (i. e., stretching) and uniting the margins with  the hare-lip suture.
When the  deformity  consists merely of the shrinking of the ala on one
side, Dieffenbach  has proposed to reduce the other to the same dimen- 
ANAPLASTY.
653
sions, by removing from that also, an oval piece.  Where the margin of
one  ala  is  deficient, Dieffenbach splits the back and tip of the  nose
through the cartilaginous septum, loosening the defective side from the
nasal bone so that it may be drawn  down, and taking out a piece  from
the  opposite side, and from the septum, by  two transverse  incisions.
The two halves are  then to be placed  upon the same level, and united
along the back by hare-lip sutures.
  In angular, or crescent-shaped losses of substance, at the margin of
one of the alae, which  have been found so difficult to repair, Professor
Pancoast has exhibited his usual tact in anaplastic  arrangements, and
completely succeeded by the following sub-cutaneous process :—" Hav-
ing  pared off the edges of the  fissure, a delicate scalpel was  carried
just below the skin upward  and backward, from the angle of the fissure
to the nasal process of the  upper maxillary bone, and then turned with
its edge  inward, so  as to cut into the cavity  of the  nose, dividing the
cartilage  across.  Another  incision  was then made, from the junction
of the stump of the  ala with the upper lip, so as  to divide the skin, and
the curved border of the alar cartilage below it, by a semilunar incision,
concave  downward  and outward.  The cartilaginous portion included
between these two incisions was next divided from within  outward, so
as to separate with the cartilage the soft parts for a little distance from
the  bone, but without  cutting  through the skin.  The lower segment
of the ala was now  left attached by little more than  the  integument,
and by advancing the  soft  structures of the  cheek, was readily  drawn
forward  to the upper raw margin of the nose, to which it was attached
by suture, restoring the organ at once to its proper  shape, and  without
leaving any obvious  wound.  Some attention was required in  filling the
nostril with lint, in order to keep it sufficiently patulous.   By this means
the new margin of the nose is left cartilaginous, and retains its natural
thickness and elasticity—a result which the author  has not  been able
to attain by any other process."—(Op.  Surg., p. 352.)
  This surgeon doubts the possibility of ever succeeding in Dieffenbach's
proposed process for elevating  a depressed nose, by  slitting the sunken
nose into a middle  and two lateral  strips, and then  bevelling off the
edges in such manner as to make the organ, in cicatrizing, assume the
proper  curvature as in the construction  of  an arch.  Prof. Pancoast
apprehends that the new nose would  shrink   again,  from the slow con-
traction  of the  cicatrices.   The flap  from the forehead is, he thinks, to
be  preferred.   The  following  process, however, again  happily calling
into service the principle of sub-cutaneous sections, was adopted  in the
winter of 1842-3, by Prof. Pancoast,  with the most  perfect  and  grati-
fying success.  The patient had nearly  the entire septum destroyed, by
an  ulceration of several years in both nasal  cavities, leaving only the
columna nasi.   The two ossa nasi, up to their junction with the os fron-
tis, and  all the turbinated  bones, were also  destroyed.  The case was
one of hideous  deformity, presenting no appearance of nose  except the
two apertures on either side respectively of the twisted  and deformed
columna, retracted  upward  and into the face beyond the  level of the
anterior margin of  the nasal processes of the maxillary bones__all of
which was rendered yet more disgusting, by the prominence of the fore-
head, cheeks, and alveolar processes,  and the protuberance of the upper 
654            NEW ELEMENTS OF OPERATIVE SURGERY.
lip, which was also retracted upward by the cicatrization of the ancient
ulcer:
  " A  narrow long-bladed  tenotomy knife [tenotome] was introduced
on either side, by puncture through the skin, over the edge of the nasal
process of the upper maxillary bone.  The knife was pushed up under the
skin to the top of the nasal cavity, and then brought down, shaving the
inside  of the bony wall, so as to detach the adherent and inverted nose
upon either side.   The point of the nose could now be  drawn out.  The
nose, however, still remained adherent  to the top of the nasal  chasm.
The knife was a third time introduced under the skin in a direction cor-
responding nearly with the long diameter of the orbits of the eyes, and the
adhesions separated from the nasal spine and internal angular processes
of the os frontis.  This incision was exquisitely painful.   The nose was
now attached merely by the integuments, and  was so completely  loosen-
ed  that  the patient forced it out at once by a  strong expiration through
the  passage, redeveloping, (continues the  Professor,)  to my surprise,
an organ of good size and of the natural form.   It was incapable, however,
of retaining its position, as it moved with every respiratory effort.  To in-
crease the dimensions of the  nose—which remained less  than  had been
natural  to  the  patient—and [to]  diminish its tendency to fall a  second
time, the knife  was again introduced through the lateral punctures, and
the soft parts separated from the whole length of the outer surface of the
nasal  processes  of maxillary bones  for the space of about five eighths
of an  inch on each side.  This involved the division of the branches of
the  two infra-orbital nerves and arteries.   The portions thus loosened
on each  side were pushed over towards the  nasal cavity, so as to increase
the prominence of the nose.  In this position they were held by a  quilled
suture, made  with two ligatures passed across the cavity of the  nose
from one cheek to the other.  Though there was considerable bleeding,
no  vessels  needed to be tied.   The  sutures were removed on  the third
day, and the  nose was found firm and well-shaped.  In the course  of a
couple of weeks the  skin at the root of the nose, having no bones  to  sup-
port it, became flattened out,  so as to impair the form of the organ. This
I  proposed to relieve by cutting out an  elliptical piece from its middle,
and then turning down, in the space thus made, a small  flap of skin from
the forehead, with the cuticle shaved off so as to gain a raw surface for
adhesion on both sides; which flap, when united vertically in the open-
ing, should serve as a new  septum, and by its tendency to contraction,
keep the loose integument in its proper bridge-like shape.  The patient,
however, was  so well satisfied with the organ  as it was, as to be  unwill-
ing to  submit to any thing more than the removal of the elliptical piece."—
(Oper.  Surg, of Pancoast, Phil., 1844,  p. 352-3, and plate 72,  figs.  7,
8,9.)
   The chief difficulty in the above very ingenious application of sub-
cutaneous  surgery, undoubtedly is, in contriving some  substitute  for the
cartilaginous supports of the nose, and we know of none that  could act
as a better substitute than that which was  suggested by the  operator,
and which  would have  proved more effectual, doubtless, could some
mode be devised of giving greater condensation, or a semi-cartilaginous
texture, to its tissues during the  process  of  their granulation.  As to
the  transplantation of a  cartilage, the inherent low degree of organic 
ANAPLASTY.
655
vitality in such  tissues,  and their  tendency,  therefore,  to  gangrene,
would perhaps render such an attempt quite  chimerical; though from
what has taken place in all these new departments of surgery, (anaplas-
ty and tenotomy,)—born  and  sprung up to a  ripe maturity, it may be
said, in the incredible short space of four years—it is certainly impossi-
ble to predict what human invention may not discover, in giving to them
still greater perfection, and in disclosing curative processes that are now
not even dreamed of.  The  extensive sub-cutaneous  sections required,
and the pain  necessarily attendant upon them, would probably deter
most persons from submitting to  Prof. Pancoast's  process, unless previ-
ously well assured that something could effectually be done to give pro-
minence to the raised teguments.

                            Cheiloplasty.

   In a case of cancer, in which it was found necessary to remove nearly
the whole of the  free border of the  lower lip, Professor  Pancoast, of
Philadelphia,  adopted the following process, with, however, only par-
tial success.   It is certainly worthy of consideration, although the semi-
lunar incision downward, excising the  cancer, as adopted by Prof. Mott,
(as in the case of that surgeon already described, supra,)  and then dis-
secting and loosening the teguments  within freely down to  the chin or
further, and effecting the  union of the incised  semilunar  border by su-
tures at the commissures to  the lip above,  and placing the  new lip, in
situ by traction upward, steadily maintained by adhesive straps and ban-
dages, is, it seems to us, much to be  preferred, as the most simple as
well as the most easy and natural method:—
   Professor Pancoast excised  the diseased structure also by a semicir-
cular section through the  lip.   " A vertical incision was then run down
over the symphysis of the  chin nearly to the top of the os hyoides.  This
was converted into a crucial  incision by a sweep of the knife along the up-
per edge of the base of the jaw.    The two upper flaps were then dissected
loose from the bone, and  a triangular  piece, with  the base  downward,
removed from the free end of each, with a sharp pair of scissors. The
two lower flaps of integument  were in like manner loosened, and a tri-
angular piece  removed from the end of each, but with the base present-
ing in the  opposite  direction, so as to form a vacant space of a lozenge
shape.  The two  upper flaps were then closed at their lower border by a
hare-lip  suture.  The effect of the traction necessary "to bring these
together, carried  the upper margin at once nearly to the  proper level
of the lip.  A second pin  was then introduced above the first. The two
lower flaps were then raised and similarly closed,  with a pin  which was
made to rest on the mental protuberance, the effect of which was to <dve
some additional  elevation to the new lip, though to a less extent than
was expected, and nearly [to] efface  the whole  of the vacant  space.
The parts were covered with a  light compress, secured with a few turns
of a  roller, and the head retained, for three days, lightly flexed on the
chest.  The saliva escaped for some time through the opening at the chin
rendering  the cure  tedious, but in the end of the operation was in a
good degree  successful."—(See his  Oper. Surg., 1844, p. 355 • also
ib., figs. 3  and 4, of plate 73.)                          y 
656            NEW ELEMENTS OF OPERATIVE SURGERY.

  To this, as to the  greater part of the anaplastic suggestions of this
surgeon, already noticed, we cannot  deny much ingenuity; but the ex-
cision  of the  angles of the flap must have caused a counter-traction
downward, a result  which is, in such  cases, especially to be overcome
if possible. ^  We confess we cannot  discover what  the intention of the
author was in that part of his  process, except to obtain the natural de-
pression above the chin.
  The principle which we  have expressed  a preference for, as the one
upon which cheiloplastic  operations  should be guided, to wit, that of
Dieffenbach, of separating and making traction upon the entire tissues
of the face, and which  has been adopted  successfully  by M. Meyer of
Bruges, was also recently  followed by Prof.  Pancoast  of Philadelphia,
with most gratifying results, in a young lady of Virginia, (see his Op.
Surg.,  p. 355 ; also Am.  Journ.  of  Med.  Se, Jan. 1843.)  This case
is so important that we must claim, in  behalf of American surgery, the
right of the author to be  heard in his own  words.  The whole  of the
soft parts between the upper lip and  the lower edge of the chin, and all
the lower alveolar  processes, had in  early life been destroyed by gan-
grene.   " The patient was seated upright  in  a chair.   The cicatrized
edges, which extended  from the angles of  the upper  lip down  to the
chin, were pared off so as to present a large triangle, with the apex
upon the chin.  The corners  of the  mouth  were  next thrown widely
open by an incision on each side, three fourths of  an inch  long, in the
direction of the auditory  meatus.   This was  made by  a  sharp-pointed
curved bistoury, passed from the cavity of the mouth through the cheek,
the whole thickness of which was divided on  each side at one cut, to the
commissure.   From  the distal ends of these incisions, a descending cut
was  made on either side, with a single sweep of the bistoury, obliquely
downward and inward to the top of the  lower jaw-bone.  Two flaps
were thus detached from the whole thickness of the cheeks,  lined with
skin on one surface,  and mucous membrane  on the other, and attached
to the chin by  a pedicle five eighths  of an  inch  broad.   The flow of
blood was arrested,  in  a  measure, on each side  as  the  division was
made, by the  thumb and  finger of an  assistant.   In order to diminish
the hemorrhage, the  horizontal  and descending incisions were made oh
one side before the other was touched, and the divided vessels immedi-
ately secured  by  torsion and  ligature.  The flaps were  then  rapidly
loosened from the gum on  the  inside, by a few strokes with  the knife,
and some few small arteries, which gave out blood, pinched and twisted.
The  loosened  portions were then rocked over [i. e., slided by traction
obliquely inward.—T.] upon  their  pedicles  towards  each  other, till
their inner margins  met on the middle line, where  they were  secured
with hare-lip sutures.  The traction  of the  flaps caused the  portion of
the cheek in connection with the outer margin of the pedicle to advance
forward, so as to supply, in part, the place occupied by the flaps previ-
ous to their change  of position.  An  irregular triangular opening was
still left  at the corners of the mouth.   This was  filled  up by drawing
the cheek from above downward and forward, and passing on each side
two hare-lip  pins, to connect the three  sides  of the triangle together.
Though as much stress was put on the ligatures as was thought at all
prudent, the opening could  not be completely closed, a small triangular 
ANAPLASTY.
657
 fistulous orifice remaining.  The immediate effect in regard to the im-
 provement of the  features was magical.  The flaps of the new lip, which,
 as they were rocked inward, moved forward in the direction of the line
 of their pedicular attachment,  gave all the natural fulness  and promi-
 nence  to  the  lower  lip.  The descent of the protuberant cheeks re-
 stored, in a  great degree, the natural roundness of the lower part of the
 face ; and from a disagreeable,  the patient presented, at once, a comely
 countenance.  The result  of the  treatment of this  case,  which was
 necessarily somewhat protracted, was the restoration of the face to a
 form nearly  perfectly natural.   The new lip remained to a considerable
 degree movable, and fulfilled completely its natural offices, of retain-
 ing the salivary fluid, and giving distinctness to the articulation."

                            Palatoplasty.

   Prof. Pancoast partially succeeded, by  an operation performed  four
 years since,  (see  his  Op. Surg.,  p. 357, and plate 54, fig. 5, p. 258;
 also, Dr.  McPheeter's account of the case in the  Philadelphia Medical
 Examiner, Jan., 1844 ;  also, Amer. Journ.  of Med.  Se, Jan., 1843,)
 in filling up, by flaps of  mucous  membrane from the roof of the mouth,
 an opening in the centre of the bony palate three quarters of an inch in
 diameter.  The flaps were secured by stitches over  the  aperture, and
 their loops held up by a piece of bougie placed  in the nasal  passage,
 and crossing the opening.  By this means, aided also by  a curved pin
 fitting to the roof of the   mouth, and  passing through the edges of the
 flaps, the  flaps were brought in close contact to the pared  edges of the
 fissure.  A violent  spasmodic  cough  prevented the completion of the
 granulations.

                            Posthioplasty.

  Prof. Pancoast (Op. Surg., p. 358) gives this  name to  the restora-
 tion of the prepuce, if required, and which at one time was practised by   '
 the Jews to avoid  persecution.   He recommends the process of Galen,
 by drawing the skin of the penis over the glans, and dividing the same
 merely by an annular  incision posterior to the corona—the skin thus
 loosened being retained in  front  of  the  glans  by being secured to a
 catheter introduced  through the  urethral  passage, till the  raw surface
 left behind the glans has become cicatrized.

                            Chalinoplasty.

  From x«hvos,  frenum, is a name  given  by Professor Pancoast, of
 Philadelphia, (Oper. Surg., p. 358-9,) to an operation which, to gratify
 the morbid sensibility of patients, he has twice successfully performed
 with very satisfactory results, for  restoring the frenum of the prepuce
when destroyed by disease.  " Reversing the  glans, and grasping it
laterally between the thumb and  finger, a couching  needle is passed in
the middle line under the mucous membrane, so as to elevate this at the
natural place for  the  attachment of the  prepuce.   An  assistant  then
steadies the organ, while the surgeon, with a delicate scalpel, makes an 
658
NEW ELEMENTS OF  OPERATIVE SURGERY.
incision on either side of the needle, in order to mark out a small tri-
angular space, with the apex towards the orifice of the  urethra   The
??? Jani? iS n6Xt to be dissected off from this sPace-  ^ longitudinal
told of the prepuce is then raised on the lower surface  of the organ ;
through the base of this a  sharp-pointed bistoury is passed, cutting out
at its place of anterior attachment, so as to detach a small, thin, tri-
angular flap, with its apex  in front.   This flap is then to be drawn for
ward, and secured by three delicate  sutures  on either side to the mar-
gins of the raw surface on the glans.   Union readily takes place by
first intention."
 PLASTIC OPERATIONS FOR THE REPARATION OF DEFORMITIES FROM BURNS.


   Since  the remarkaoie  and successful case of Professor Mutter,  of
Philadelphia, and which has been briefly described in our text, (supra,)
that gentleman has repeated  his  admirable process in several similar
cases, and has  published a distinct  work on the subject, ( Cases of De-
formity from  Burns, treated by Plastic  Operations.  By Thomas  D.
Mutter, M. D., Professor of Surgery in Jefferson Medical College, Phil-
adelphia, 1843,) of which we gladly avail ourselves to make some valu-
able additions in a  most important department of anaplasty, which Prof.
Mutter, by his  surgical tact and eminent success, has almost made exclu-
sively his own—having through  means of anaplasty substituted, in lieu
of the clumsy and ancient operations of excision of cicatrices, a method
which in his hands has effected results which had been  scarcely anticipat-
ed by any one.
  The dense laminated substance found in  cicatrices from burns beneath
the inodular tissue  of Delpech, is composed, says Prof. Mutter, of origi-
nal cellular substance, and that it binds the cicatrix down, and offers in
many cases the chief obstacle to the success of our  operations—espe-
cially in  severe burns, exacting on that account, if we operate, most ex-
tensive dissections.
   Another, but only occasional difficulty, is the vascularity of the cica-
trix.   It is then red, sensitive,  soft, and movable, and we have to fear
hemorrhage, presenting therein a more  unfavorable prognosis than when
 the parts are pale, firm, inelastic, and adherent.
   The prognosis of course is also far more favorable when the cicatrix is
 only cutaneous and movable, than when  thick and deep, involving also the
 superficial fascia, cellular tissue and muscles—throwing the inodular tis-
 sue into hard and nearly immovable ridges—requiring severe and extensive
 ooerations.  This  condition must not be confounded, he says, with  that
 contraction of the  fascia superficialis sometimes accompanying cutaneous
burns but often the result of other causes, many of which are  inappre-
  '  ble'   Thus Prof. Mutter has seen this fascia in the palm of the hand,
without any apparent cause, gradually become thick and  contract, while
the skin over it remained pliable and soft.
   Deen cicatrices over important organs, will add to  the difficulty  and
danger of the prognosis  and operation,  though there is less  hemorrhage
than one would imagine, since many of the smaller  blood-vessels are
found to have been obliterated. 
PLASTTIC OPERATIONS.
659
   It is an important point, in a wide and extensive cicatrix, t^j-t the rep-
 aration does not make one of still greater deformity.  Prof.  Mutter ap-
 proves of Dupuytren's directions in such cicatrices, as in adhesions ot
 the arm and thorax, or thigh and pelvis, to proceed  by fractions, and let
 the wound of one operation heal before we undertake another;  as one
 operation would make too large and dangerous a wound—which  rule is
 applicable to extensive callous prominences.
   Prof. Mutter also accords, in  general, with Dupuytren's remark that
 the older the cicatrix, the greater the success in operating, especially
 where the inodular tissue is superficial, and the cure requires only exten-
 sion and pressure to keep the incisions apart.
   The peculiar deformity of a cicatrix may arise from their extraordi-
 nary power to contract;  thus, in a case of Mr. Earle, approximating the
 shoulders by causing partial  absorption  of the  clavicles, and in a case
 of Cruveilhier, and  another of Prof.  Pancoast, where  the cicatrix  was
 on the back  of the hand, luxating the carpus from the radius.  Profes-
 sor Mutter alludes, also, to his own remarkable case, (already described
 in this work, supra,) as a sample of  curvature of the lower jaw down-
 ward.
   It is always desirable, if possible, not only to remove  the  deformity,
 but to restore the functions of the part.
   In recent  superficial nsrrow cicatrices, transverse incisions at several
 points, followed by slow,  gradual, and  permanent extension, continued
 for some time after the wounds  have cicatrized, will  generally effect a
 cure.
  In  prominent  cicatrices, which  are often  accompanied with severe
 neuralgic pains, and which generally involve  only the skin, without any
 contraction beneath, the  diseased parts are as recommended by Dupuy-
 tren, to be sliced off on a level with the skin, the wound  kept apart by
 machinery, and the excrescent growths repressed by nitrate of silver.
  In extensive  adhesions,  complicated with  abnormal  contraction or
 separation of natural parts, Prof. Mutter is of opinion that the process
 of Dupuytren, of dividing the adhesions and  dissecting them freely be-
yond  their origin, will very often  fail.  That  of Hildanus, revived by
Earle and Delpech, and much approved of by Brodie, James of Exeter,
Hodgson, &c, which consists in excising the cicatrix completely, and
then bringing the edges of the  wound together, and using extension
and splints, thus effecting a lateral  instead of the previous longitudinal
contraction,  Professor Mutter  deems  altogether improper  where  the
 cicatrix is broad, or irregular, and  situated  on the neck or different
 parts of the face.  In a case where the arm and forearm  were rendered
useless by a cicatrix, Prof. Mutter found, after excising the  tissue, that
 it was  impossible to  bring  the edges of the wound over the raw surface
until he had made lateral incisions  as in the  process  of urethroplasty
by Dieffenbach.   He could  then  cover the raw surface  perfectly, and
 causing the two lateral wounds to granulate by dressing them with warm
water, the operation, he says, succeeded  beautifully.  These lateral in-
 cisions lfe has  found  equally advantageous in the  operation for cleft
palate.
  The process of Drs. J. Rhea Barton and Gr. W. Norris of Philadel- 
660            NEW ELEMENTS OF OPERATIVE SURGERY.
 phia, derived from that of Celsus, viz., dissecting loose the integuments
 and cicatrix, is, he thinks, severe, and not much to be relied upon.
   The operation which he prefers above all others, is his own anaplastic
 method, which we have already detailed  at  length,  supra.   It is espe-
 cially valuable  in cicatrices of the neck, cheek, eyelids, nose, and lips.
   In his recent work, from which we make  the  above abrege, he lays
 down the following rules, or principles, for this new, ingenious, and ad-
 mirable triumph obtained for plastic surgery by the eminent practitioner
 in question:
   " 1.  Dividing tfce cicatrix so as to produce a raw surface in some part
 of its extent, or cutting it out  entirely as proposed  by Hildanus.
   "2.  In  applying  to this  raw  surface a piece of healthy  skin, taken
 from the neighboring parts.
   " 3.  In attaching this skin  by  suture to the margins of the wound in
 which it is inserted.
   " 4.  In approximating the edges of the wound from  which  the skin
 has been removed.
   " 5.  In  separating, by appropriate  agents, the parts too closely ap-
 proximated, and keeping them in  this  condition some time after the flap
 has united.
   " 6.  In  applying oleaginous frictions and motion to the new made
 parts, to give them flexibility and  softness.   [The almost extraordinary
 suppleness and elongation of tendinous parts which such frictions, as of
 camphorated oil, for example, steadily maintained  effect, is remarkably
 seen in those contractions of the flexor tendons of the leg particularly,
 which are caused by confinement during fractures.—T.]
   " Many shocking deformities from burns  (he adds) have been relieved
 by the  performance of operations  conducted on  these  principles; for
 example, the eyelid, the cheek, the nose, and  the  lip, have all been re-
 stored : but I believe (he modestly continues) I may claim the  merit
 (if merit there  be in  adapting an old  principle to a new operation)  of
 having first performed an operation of  the kind, for the relief of exten-
 sive cicatrices of the throat."
   How true and just it is, however, that there is  unqualified and pre-
 eminent merit in this most ingenious and happy application, by an Amer-
 ican surgeon, even of a well-known plastic  principle, is made strikingly
manifest by the paragraph in Professor Mutter's work, which immedi-
 ately follows the above:
   " Mr. Liston, whose surgical acumen and boldness  no one will deny,
 distinctly states, in his last edition of the Elements of Surgery, p. 263,
 that ' SUCH  DEFECTS ARE BEYOND  THE  REACH OF SURGERY,' and gives a
 drawing illustrative of the appearance of a person  so afflicted;  which
 drawing is almost a fac simile of my case No. I.  I  have also  carefully
 examined nearly all the modern works on the subject, and find no men-
 tion of such an operation having ever  been  performed.  Yelpeau, in his
 Medecine  Operatoire, [vid. this  present  work, supra.—T.,]  article
 Cicatrices vicieuses, merely hints at the possibility of such an operation,
 but this is all.   [In our opinion, however, this is much,  considering the
 desponding  tone of cotemporaneous surgeons on this subject, up to the
 time of Professor Mutter's discovery.—T.]
   " In very extensive  cicatrices of the neck, (says  Prof. Mutter,) it 
PLASTIC OPERATIONS.
661
 may be well to modify the operation so as to take a flap from each side,
 by which means we shall avoid the risk of a very large single flap.
   " In  cicatrices  complicated with obliteration of cavities, where the
 cicatrix produces  partial or complete  obliteration of a natural opening,
 as the mouth, &c, incision of the angles, and introduction of tents larger
 than the natural opening, will occasionally do  good; but for the most
 part all such attempts fail, and it becomes necessary to perform the oper-
 ation of Dieffenbach, (vid. text, supra, and also this appendix, supra.)  .
   " In cicatrices complicated  with the loss of organs, where organs are
 entirely destroyed, nothing short of a plastic operation, the aim of which
 will be the construction  of an organ as much like the original as possi-
 ble, offers the slightest prospect of benefit to the patient."
   Mr. H. James,  surgeon to the Devon  and Exeter  Hospital, (Eng.,)
 in a recent  paper on this subject remarks, that in the limbs, from there
 being but one joint concerned, there is no difficulty after the remwal of
 the cicatrix, in maintaining the parts in proper  position.   But in the
 neck it is different, from the peculiar mobility of that part, arising from
 the numerous joints  in the cervical spine, so that  the chin and sternum
 gradually reapproximate as the  wound continues to cicatrize, shortening
 the cervical spine  and incurvating it sidewise or backward.  In one case
 of severe burn, (and most of the cases are in children and  females,) he
 has seen the orbit on the contracted side much depressed, and the lower
 incisors pushed horizontally  by the  pressure of the tongue, from  the
 counter-pressure of the muscles of the lower lip being wholly wanting.
 To effect steady,  firm, and permanent extension, Mr. James proposes,
 in burns of  the neck, after excising the cicatrix  only, or adopting also
 Prof. Mutter's anaplastic process, to apply an apparatus which he calls
the screw collar, and which he  has found, he says, exceedingly useful.
It is to  be applied as soon as suppuration of the wound is established,
and the screw is to be lengthened as greater  extension of the head up-
ward and backward is obtained.   In reference to Prof. Mutter's opera-
tion, he says  the  degeneration  of the neighboring integuments, in the
greater number of cases, will prevent the possibility of procuring flaps.
He thinks the screw collar will be found  always  requisite, also, after
that process.  In small  cicatrices he  has sometimes found it useful to
destroy them with caustic potash, as the ulcer  left opposes no obstacle
to necessary extension, and the  cicatrix is of a very different character
from that of burns, (Provincial  Medical Journal, Aug. 19, 1843 ; also,
Braithwaitc's Retrospect of Practical Medicine and Surgery, part viii.,
p. 120—New York edition, 1844.)   In respect to the objection of de-
generation of the  skin, that can rarely much involve, as we  think, the
shoulder,  whence  Prof.  Mutter  took  his flap in his great operation, and
from whence, or from some other neighboring undegenerated  part, it
would probably be practicable in most cases to take the necessary sup-
ply of tegumentary tissues.
  In  vesico-vaginoplasly, as  we  shall take  the liberty of designating
those plastic operations which  are proposed for the closure of fistulous
openings  communicating between the  vagina and bladder, (as those  bo
tween the rectum and vagina, or between the rectum and bladder might
perhaps with equal propriety be termed, respectively, recto-vaginoplasty
and  recto-vesicoplasty,)   M. Leroy D'Etiolles of Paris has, as we per- 
662
NEW ELEMENTS OF OPERATIVE SURGERY.
ceive, recently  suggested the following process:  He raises a flap from
the posterior  wall of the vagina, penetrating with the knife only into
the cellular space between the vagina and rectum, and stopping where
the point of union between these passages becomes more intimate at the
recto-vaginal septum.   A short  thick flap may thus be obtained, which
is to be  applied, by its  raw surface, to the edges of the fistula, which
should be made raw  and bleeding.  The  flap is to be fastened by a
double quilled suture, (vid. Pancoast's Operative Surgery, Philadelphia,
1844, p.  342, plate 70, figs.  7 and 8.)   This is virtually the same as
M. Velpeau's process, (see text supra.)
   To prevent the inconvenience arising from the constant flow of urine,
M. Leroy D'Etiolles tampons the vagina with caoutchouc, in leaves or
in  paste—a substance which is elastic and unalterable, and, as he says,
freer from the  objections  which to this day have rendered all permanent
pluggi^ of the vagina nearly impracticable, (lb.)
   Mr. Barnes of Exeter, (Eng.,) employs an elongated caoutchouc bot-
tle, which, when placed in the vagina, presents an opening correspond-
ing to  the  fissure.   Prof. Pancoast of Philadelphia, however, says he
has had  better success with a boot-shaped silver or silver-gilt trough,
devised by M. Feburier of  Paris, which  when accurately fitted to the
vulva, is  easily held in position, and effectually prevents the escape of
urine by any other channel, (Op.  Surg., loe. cit.,  p. 342.)
                   SECTION FOURTH.

        OPERATIONS WHICH ARE PERFORMED UPON THE ARTERIES.

  The principal operations that surgery employs upon the arteries, are
compression, cauterization and crushing, torsion and acupuncture, suture
and the ligature.   Before examining these operations themselves, it is
important to recall in a few words the  structure, the anatomical peculi-
arities, and  the resources which nature makes use of to cure the diseases
of the arterial system.
                            CHAPTER I.

                     ANATOMICAL REMARKS.

    Every artery is formed of three coats or three concentric cylinders,
• which are very distinct in the large trunks, but imperceptibly blended
 and incapable of being any longer separated when we come to the capil-
 laries.
                                  §1.

    The middle coat, called also the muscular coat, or tunica albuginca, 
ANATOMICAL REMARKS.
663
is  a yellow membrane  composed not of longitudinal fibres, but of in-
complete  fibrous circles which are united together by lamella? of the
same nature ;  no vessel is seen there whether sanguineous or lymphatic,
though  certain  observers  have  asserted  the contrary.  It is a layer
which is almost inert, and which is broken like glass if strangulated by
a thread ; and is torn instead of being stretched when the least degree
of force is exerted upon it.  On the outside it is united to the external
coat by an amorphus layer  only of lamellar material scarcely organized ;
within,  the internal membrane adheres to it in the same manner.   As it
is destitute of  sensibility,  and  of almost all the other properties of
living tissues, it is not astonishing that the diseases of which it may be
the seat, should for the most part at least be  independent  of vital phe-
nomena, and that they  should seem to be  developed under the influence
of the  laws which belong  to inert matter.   It is  this tunic which dis-
tinguishes the arteries from the  veins,  causes  them to remain open when
they are divided transversely, gives them their form and color, renders
their diffused  and spontaneous inflammation so difficult and so rare, pre-
vents their wounds or  incomplete divisions from cicatrizing by aggluti-
nation,  and enables them  to make such  successful  resistance  to  the
lateral  pressure of the blood.   As this  coat  increases  in  thickness as
the arterial trunk is nearer to  the heart or  of greater size, or destined
to receive a greater degree of  impulsion from the  blood, so is it also
somewhat thicker upon the convexity of the  arterial curvatures than on
the opposite side.  When we come to the  branches  of the fourth or fifth
order,  in approaching in   fact   the last  ramifications  of the vascular
system, we see it becomes  thinner by  degrees and that  it loses itself in
the common tissue of the two other coats ;  from whence it follows that
the arteries are so much the more pliant  and distensible, and so much
the less liable  to break, all other things being equal, in proportion  as
they are smaller or more remote from  their origin.

                                § II.

   The  internal coat, which some have wished to  compare to a mucous
membrane, and which others assimilate to  a serous membrane,  is smooth
and generally unctuous  on its  free surface.  Externally it adheres to
the preceding coat only by thin plates  of lamellai tissue ; it contains
no perceptible fibres or vascular canals; it  is in fact  only a homoge-
neous  lamellar substance, a kind of varnish in some respects  similar
to the  transparent cornea, or  to the substance of the nails  or  horny
tissue in general, and which protects the  current of the blood through
out  the whole extent of the  arterial  system.   In the small branches
and in  the capillaries, this  coat  being no  longer separate  from the cel-
lular coat by the middle membrane, assumes  properties which approxi-
mate it much nearer  to an actual organization, in permitting its  ex-
ternal surface to receive fluids by direct transmission; elsewhere it is
thicker and more  distinct  but  extremely fragile;  isolated  throughout
the whole vascular system by  the yellow coat, (i. e., the middle—see
above,) it exists there  only as a simple  inorganic tissue, like the carti-
lages,  endowed with   very little  elasticity  and very easily ruptured.
From these characters it follows that  the internal membrane of arteries 
664             NEW  ELEMENTS OF OPERATIVE SURGERY.
is still less liable than their middle coat to become affected primitively
with diffused spontaneous inflammation, that it  cannot become the seat
of this morbid  phenomenon unless it is transmitted to  it by the sur-
rounding tissues ; in a word, that it only becomes altered mechanically,
unless it receives by its contiguity to  the other coats the diseases with
which they may  be  affected.   In that  respect I compare  the  internal
coat of arteries  to  the cuticle, to serous membranes in general, and to
cartilages  of incrustation in  particular, which do  not inflame at first
except by their adherent surface or cellulo-vascular lining.

                                § III.

  The external or cellular coat of the  arteries, is the only one  which
presents all the characters of a true tissue.   It is formed of small fibres
and lamellae, crossing each other in various  directions  and  felted, like
all cellular sheaths ; very small arterial and venous vessels traverse  it
in all directions ; these vessels  known  under the name of the vasa va-
sorum, nourish the whole substance of the arteries, yet do not as I have
said  penetrate  either into the middle coat, or much less therefore into
the internal coat; so that the cellular coat of the arterial  system is the
only one  where  there exists a real  circulation, while  the others  are
scarcely  nourished or preserved  in their natural or vital  state but by
imbibition or the simple  deposition of molecules.   This texture gives
it great distensibility, and permits it to yield,  without  being ruptured,
to  all the  forces that are  exerted upon  it, allows it to become inflamed,
to  cicatrize, to  contract adhesions with  what surrounds it, and to impart
to  the subjacent lamellae not only its appropriate diseases, but also its
 organization ; from whence it follows  that in the capillary system, where
 it forms almost the entire thickness of the vascular walls, life is there
 more active, and the diseases which are connected  with it infinitely
 more common.

                                §  IV.

    The arteries are every  where covered also with a sheath of a uniform
  character, but much less  solid than their cellular coat; this sheath which
  is  called the common sheath, similar to  that which  exists around all the
  cords and fasciculi of the organization, increases and sustains the pliancy
  of the preceding coat, unites it to  the circumjacent tissues, and  princi-
  pally to the accompanying veins.                                    m
    [In the museum at Chatham there  is a preparation which Mr. Guthrie
'  believes to be unique.   It was taken  from a man who died of gangrene
  of the leg caused by the passage of a ball  between the femoral  artery
  and vein.  The coats of the vein were  but  little injured, and those  of
  the  artery, though bruised, were not  destroyed in substance.   At the
  point of injury it was much contracted in size, and filled above and be-
  low by coagula, as was the vein, thus obstructing the passage of blood
  through both vessels.   Mr. Guthrie thinks this is the only case in exist-
  ence proving the elasticity which vessels possess, and their capability  of
  avoiding  to a certain extent an injury  about to be inflicted upon them.
  (Commentaries in Surgery, p. 199.)  G. C. B.] 
ANATOMICAL REMARKS.
665
                                §  V.

  The arteries  receive  their nerves only from the piexus of the great
sympathetic, and like  the vessels these nerves are observed only in the
cellular coat.  Externally, however, they are  accompanied by some
nerves of the cerebro-spinal system.  On this subject it is well to call
to mind a law noticed by M. Fouilhoux, (These No 35.   Paris, 1836,)
namely, that  for the arteries of considerable size in the upper half of
the trunk, the accompanying  nerve is  always  situated  at the outside,
that is  to  say, not so near to  the axis of the part, while in the lower
limbs it is generally the contrary.   But that is not the case either with
the median in the fore-arm, the crural in the iliac fossa, nor with the
popliteal, &c.   Others have asserted without  more foundation, that in
the upper  half  of the body the veins  cover the arteries; while in the
lower half the arteries cover the veins.   The jugular is outside the car-
otid, and does not cover it.   It is the same with the subclavian vein as
it enters  the  axilla.  If the  law  of M. Serres is true for the  external
iliac  and for the femoral vessels, it is not so for the hypogastric and
those in the  popliteal space.   In saying that for the upper half of the
body the venae comites are in  front and outside, and that in the lower
half they  are  behind and  within, M. Malgaigne (Anat. Chir., t.  I.,
p.  240) commits a similar error.   The axillary vein is on the inside,
then  behind, but not outside.   The popliteal vein is found outside, and
not inside.  What I have found more exact in this respect is the follow-
ing  arrangement.  The nerve, vein and artery, as we proceed'from the
skin towards the bone, the  artery, vein and nerve, as  we go from  the
bone towards  the skin.  The fore-arm, arm, shoulder,  neck, leg, ham,
and the thigh itself, justifying  this law, I cannot see what authorizes
M. Malgaigne (Anat. Chir., t.  I., p. 266) to reject it.  It is neverthe-
less true, that the relations of the nerves and veins with the arteries,
cannot  be  given with nrecision but under the head of each limb or each
organ in particular.
                           CHAPTER II.

   SPONTANEOUS TERMINATIONS OF LESIONS OF THE ARTERIAL SYSTEM.

  This  chapter, without which it  would be difficult to comprehend the
operations to be performed upon the arteries, comprises aneurisms, pro-
perly so called, and traumatic haemorrhages.

                      Article I.—Aneurisms

  Every aneurism is a dangerous disease ; it is rare, when left to itself,
that  it does not cause the loss of life to the person who is affected with
it.   The walls of the sac grow thinner as they  dilate, and, by decrees
change,  and become  perforated, gangrenous;  the  blood and clots'
  Vol. I.                    84 
666            NEW ELEMENTS  OF OPERATIVE SURGERY.

contained in the tumor escape outside ; an abundant haemorrhage is the
consequence, and this  haemorrhage ceases only with the extinction of
life.   It is true, that in certain  persons, a long  time may elapse before
such a termination  takes  place ;  that  patients have managed  to  live
many years, even for eighteen or twenty  years, with one or more aneu-
risms, without  being thereby seriously incommoded ; of which M. de
Renzi (See Italian translation of this work, p. 67,) and Saviard (Observ.
61, p. 272, Jour, des Sav., Janvier, 1691.  See also, Observ. de  Sen-
nert and  Prcuss, 30 years in the Mem.  de Ribes, 28 years, 50 years,
Gaz. Med. de Paris, 1835, p. 161) each give an example.
  Authors mention also a great  many spontaneous cures of this disease.
  M. A.  Severin (Bonet, Corps de Mid., etc. p. 96) has seen gangrene
threaten to invade the whole of  a  femoral aneurism, and yet the patient
recover perfectly, after a ligature  upon the artery.   E. Ford (Ephemc-
rides <yr., par  Lassus  et  Pelletan, 1790, t. I.) gives the  case of an
aneurism in the  thigh,  which, after having attained a considerable vol-
ume, gradually diminished, and ultimately disappeared entirely.  Reinig
published in  1741, (These de Haller,  extr. t. III., p. 382 ; in  8vo., p.
115,) the case of a traumatic aneurism of the femoral artery, which got
well without an operation, and without gangrene.  Guattani, Moinichen,
(Bonet, t. IV., p. 56,)  Pomarest,  (Ibid., t. 4, p. 104,) and  Albert, also
each give a case of aneurism terminating in  gangrene or suppuration,
and  spontaneously  cured.   In  the  body of a  young woman, M. Freer
found a  tumor as large as a  small apple, entirely composed of solid
tissues and which had once communicated with the interior of the aorta.
M. Darrach  (Journal des Progres t. III., p. 230) says  he has seen the
same thing at the arch of this vessel.  Portal (Mim. sur plus. t.  I., p.
303)  relates, on the authority of Lower,  a case of aneurism of the
carotid cured without any remedy.  Two cases of spontaneous cure of
aneurism in the ham have been carefully described by E. Ford.  (Lon-
don Med. Journal, 1788, part 2, p. 242.)  M. H. Martin (Revue Mid.
1835, t.  III., p. 408)  mentions a patient who got well of a popliteal
aneurism in  the course of a putrid fever.  M.  Marjolin also speak3 of
an aneurism  of the  femoral artery, which terminated  in  an immense
abscess, and ultimately got well.   The observations of this kind, how-
ever, are so well known at the present time, that it will be  sufficient to
refer to them while  treating of each artery in particular.

                               §1.

  To arrive at  this fortunate result, nature employs different processes.
The whole aneurismal  sac may be  attacked  with gangrene; then the
fluid which it contains  is decomposed; the blood  or  the lymph coagu-
lating above and below, acquires sometimes sufficient solidity completely
to arrest the circulation in this  part, also to permit the  tumor to open
and empty itself without danger, the wound which results  from this to
become cleansed, the suppuration  to be established, and cicatrization to
be effected, without the least hemorrhage supervening. 
LESIONS OF THE ARTERIAL SYSTEM.              667
                               § n.

  Acute inflammation may attack the walls of the  sac, and the sur-
rounding tissues, be propagated to the arterial trunk itself, give place
to a true abscess  or gangrene, cause  an effusion of coagulable lymph
above and below the part of the  artery which communicates with the
aneurism, and produce  there  adhesions  sufficiently solid to resist the
force of the blood, and allow  the purulent collection to open and empty
itself without exposing to greater dangers than  an ordinary abscess.
M.  Guthrie, (Diseases of the  Arteries, p.  97,)  who  speaks  of two
patients who died in  consequence of  gangrene attacking the  aneurism,
mentions also a third, who recovered  by means of the  same accident,
though  the tumor occupied the fold of the groin.
   [Within a few  years past, the  attention  of the profession has been
called to a peculiar form of arterial lesion, of the true nature of which
by  some, doubts are still entertained.  We  allude to the opening of an
artery into the cavity of an unopened abscess, so as  to  give rise to the
formation of a false aneurism.  Mr. Liston was among the first to bring
this matter before the profession, in a  paper  read before the Royal Medi-
cal  and Chirurgical Society of London, in 1842.   Having mistaken the
nature  of a  tumor beneath the  angle of the jaw, he opened it, and a
profuse discharge  of arterial  blood followed.   To suppress  the he-
morrhage, a ligature was  placed low on the carotid artery.  The boy
died from secondary  hemorrhage, and, on examination, a direct commu-
nication was found to  exist  between the canal  of  the  artery and the
cavity of the abscess.  Mr. Liston came to  the conclusion that as the
trunk of the carotid formed part of the walls of the abscess, the arterial
coats at a certain  point had  given way  by  ulceration, thus  converting
the cyst of the abscess into a false aneurism.  The aneurism therefore
was of  secondary formation.   Owing to the  excitement produced by this
paper  and  the  opposition made to his view of the subject, Mr. Liston
endeavored  to find analogous cases,  and succeeded in collecting eight,
but two of  which,  however, were precisely  like his own.  Mr. .Mack-
enzie of Edinburgh, met with a case of aneurism of the upper part of the
axillary artery, attended by  certain peculiarities.  The subclavian was
tied, but the patient  sank, on the 21st  day, exhausted by repeated he-
morrhages.   From the appearance of the  par.ts, Mr.  M. decided  that
the case was analogous to that reported  by Mr. Liston.   In the Monthly
Journal, for February, 1852, the reader  may find full details of this
important case, accompanied with valuable practical  remarks on  the
nature  and treatment of this peculiar form of arterial lesion.  G. C. B.]

                                § III.

   The  tumor  supported by  muscles,  aponeurotic  sheaths,  and thick
lamella, of cellular tissue, by becoming filled with  concentric layers^ of
fibrine, acquires sometimes, according to Hunter and E. Home, sufficient
 solidity and size to re-act with force, in its upper portion, against the
 arterial trunk which  gave origin to it, to obliterate it if it rests against
 some solid point d'appui, and to suspend in  this  manner the circulation
 through this part of  the artery.  From  that time all the blood contained 
668
NEW ELEMENTS OF OPERATIVE SURGERY.
in the  sac  coagulates, the most fluid  portion of it  is  re-absorbed ;  tho
molecular action by  degrees  diminishes the more solid portion of its
elements, and thus ultimately  accomplishes the resolution of the aneu-
rism.

                             § IV.

  In other  cases, and which are much more rare, the  different concrete
layers which are successively formed upon the interior of the sac, finally
succeed in  filling it up, in occupying the arterial opening itself, and in
acquiring so great a consistence that the blood  can no longer displace
them ;  so that they become gradually thicker and thicker, and little by
little approach nearer and nearer to  the axis of the vessel, until they
entirely shut it up, and permanently arrest the  circulation in that part.

                              §  V.

   [Numerous cases  of the spontaneous occlusions of aneurisms have
been observed.  Mr. Porter, in his work, refers  to three  instances of the
kind ; in one, absorption of the sternum had taken place and the tumor
seemed ready to burst; the pulsation ceased and patient recovered.  In
another instance  of subclavian aneurism, it  was  proposed to  tie  the
innominata, but during the delay, the disease disappeared.   The other,
is that in which Mr. Porter attempted to tie the innominata, but  finding
it diseased, desisted ; the patient  perfectly  recovered.  Dr.  Joseph
Parish has  reported in the Eclectic Repository, (vol. 1st, p. 506) a case
of spontaneous  cure of  femoral  aneurism.   A  case  of  spontaneous
occlusion of femoral aneurism  came under the care of Mr. Avery at the
Charing Cross Hospital, but the patient died from gangrene of the leg.
Lond. Lancet, Am. Reprint, July, 1851, p. 46.)
   Mr. Kirby has  reported another  case of spontaneous obliteration of
femoral aneurism,   (Dub. Med. Press, Dec. 10, 1845)  in  which gan-
grene attacked the two principal toes of the right foot.  This, however,
became arrested, and the patient perfectly recovered.  In the dissection
 of a body  at the school  of Montpellier, the remains of an aneurismal
 tumor of the internal iliac were found, and in this  case a spontaneous
 cure had taken place.  (Gaz. des fDpitaitx, Jan. 1846, p. 64.)  Spon-
 taneous cures of aneurisms of the gluteal and ischiatic arteries have been
 reported by M. Bouisson in  the  Gazette  Medicate, for March, 1845.
                                                        G. C. B.]
                               § VI.

    Finally, in other cases, still  more rare, these concretions, after bav-
 ins; completely filled up the sac, arrange themselves  in  such manner as
 to close up neatly the lateral opening of the artery, which preserves  its
  calibre  without preventing the resolution  of  the  aneurism from taking
  effect   This is what took place in the case  that M. Freer speaks  of,
  M  A.  Cooper (Hodgson, Mai. des  Art, et des  Veines,  See)  has met
  with an arrangement which was yet  much  more remarkable.  » The
  femoral artery "  says he " had been tho seat of a true  aneurism, whose
  interior lined with very firm  fibrinous layers, preserved in its  centre a 
LESIONS OF THE ARTERIAL  SYSTEM.
669
cylindrical canal, having the same dimensions as the rest of the artery.
This arrangement Guattani  also appears to have  met with; and Roe,
(Guthrie, Op. Cit., p. 100,) a  naval  surgeon, also thinks he has  seen
an example of it in the iliac artery.   M.  J. Cloquet  (These de Con-
cours, 1831, p. 91) has seen the same arrangement  in the aorta ; but is
it certain that there was a true aneurism there ?   Here is a fact of the
same kind, and not less remarkable, taken  from  the practice of MM.
Bouchut and Viricel: it was a case  of popliteal aneurism.  The femo-
ral artery was compressed ;  the pulsations  in the tumor  ceased at the
end of  six months.  The patient died at a later period.  A small cen-
tral canal had permitted the circulation to  be  carried  on through the
ancient sac.   (Floret, These No. 14, Paris, 1828, p. 14.)
   [The experience of Dr. Mott is directly at variance with that of Prof.
Gibson who asserts  that aneurisms  are   not common in  the United
States, and that the disease in  New York is almost exclusively con-
fined to foreigners, particularly the English.  Our city being the great
emporium of commerce, presents a greater proportion of  hard working
population than  her excess  of  inhabitants  over  that of any other city
would seem to denote.  Aneurisms, therefore, as  well as other surgical
accidents are of necessary  consequence among  such a  people.   Few
surgeons,  perhaps, of the  present day, or of the  past  century,  have
treated so many cases of aneurism as Dr. Mott, and in the cases that
have come under  his observation, the  great majority,  if not all, were
our own countrymen.  He does not recollect a solitary case of a for-
eigner, and nearly all belonged to that class accustomed to severe me
chanical labor.    T.]
    [In connection  with the allusion, in the  above note,to  the vast expe-
rience  of Dr.  Mott in the  treatment of aneurisms, the following sum-
mary of his principal operations is of interest.  Contrasted  with that of
the celebrated surgeon of the Hotel Dieu, M. Roux. ( Vid.  Union  Med-
icate,  No. 124,  1852, or  Brit,  and For. Med.  Chir.  Rev.  Am. Ed.
Jan. 1853, p. 224,) it will be seen, that in the  number and magnitude
of his operations,  he is far in advance of the French Surgeon.
	Mott.	Rous.
Innominata	1	
Sub Clavian	8	3
Carotid, (Primitive) " (External) Common Iliac	36 2 1	6
External Iliac	6	2
Internal Iliac	1	
Femoral	52	46
Popliteal Axillary Brachial	7	1 4 20
Total          107           82   G. C. B.] 
670            NEW ELEMENTS OF  OPERATIVE SURGERY.
                               § VI.

  So long as aneurism was  regarded  as being most usually formed by
the simultaneous dilatation of all the coats of the artery, the hope was
indulged of  curing it, and of preserving  the calibre of the vessel in its
natural  state.   It was  believed, tdiat  by a proper course of treatment,
the aneurismal sac could be forced to recede upon itself, and by degrees,
re-assume the place that it occupied in its natural state, so as to restore
to the artery its primitive calibre, and all its attributes  in the normal
condition.   Scarpa, on the contrary, endeavored to establish as an axi-
om, that we  cannot effect the radical cure of an aneurism, whatever may
be  its  situation, unless  the eroded, lacerated, or wounded artery, has
been to a certain extent, above  and below the place of its alteration,
converted into  a solid and  ligamentous  substance, whether this change
has been effected  by nature or  brought about by  the  process of art.
Confined to  aneurisms, properly so  called, this proposition is true, and
does not in reality appear to allow of any exceptions.  The  observations
of MM. Darrach, Cloquet and A. Cooper, which  have just been cited,
and some others that are  found in the  work of M. Hodgson, do not in
any manner  refute it; for,  in the cases related, the diseased artery had
in no respect reacquired its natural  condition.
  In respect to arterial wounds, the proposition of Scarpa seems, on
the contrary, to be  invalidated by certain facts.  The  author  himself
relates one which is opposed to it.   A patient mentioned by Monteggia,
died twenty months after  having had the brachial  artery wounded by
the point of a lancet.  The aneurism had been cured for a long time,
and the artery had  preserved its calibre ;  notwithstanding  which, there
was seen in  the interior of this vessel, a cicatrix, which  was supported
externally by a blackish-colored, very hard  clot, corresponding  to the
ancient wound.  Observations more or less analogous, have been related
by  Saviard,  Petit and Foubert.  I have in my possession some that are
still more remarkable under this point of view.  In a patient, whose ar-
tery had been wounded during venesection, and who was brought to La
Charite, where  the existence of the  aneurism was ascertained by a great
number of persons, the tumor ultimately disappeared  without the circu-
lation in the wounded vessel having  ceased for an instant.  In a young
man, in  whom  a knife  had pierced through  one of the  veins, and the
artery in the bend of the arm, the tumor and all the other characters of
varicose aneurism  disappeared in the same manner, without the pulsa-
tions having ceased to be perceptible a single  day, throughout the whole
course of the radial and  ulnar  arteries.  It may be that  the wound of
the artery in these two cases, was closed by a simple solid clot, and was
only therefore  a temporary cure; but perhaps, also, the general question
requires to  be examined anew.  Nevertheless, it is true that these two
cases, cured since three years past, exhibit at  present not the least  trace
of aneurism at the  bend of the arm.   It is also true, according to the
statement of  M.  South, (Medico- Chirurgieal Review, April, 1836, p.
550,) that five cases similar to those  of mine, and one of which was ex-
amined after death, have been seen in the practice of M. Tyrrel at Lon-
don.  We should do wrong however, to count  on  such a termination, 
LESIONS OF THE  ARTERIAL SYSTEM.
671
though M. Neil (Arch Gin. de Med., 1838, t. IL, p. 108) says he has
seen a wound of the thoracic aorta cicatrized in the dead body of a man
who had  been wounded a year  before ; this however occurs too seldom
to authorize us to hope for success by this mode.  It is only an excep-
tion, which cannot destroy the principle established by Scarpa.
   [Dr. Mott sees no reason, from  experience  and observation and  the
records of surgery, to doubt the possibility of such a wound, even in a
large arterial  trunk, being healed, without the trunk  itself being oblit-
erated, or its calibre sensibly diminished.   He has treated a case, which
will be noticed under  the head of compression, in which a little  flap or
nick is supposed to have been made in  the  subclavian, and which he
thinks, was firmly secured in its place by the  pressure of sponge, so as
to reunite its lips to the parent trunk by the first intention.   T.]

               Article II.—Traumatic Hemorrhages.

   There are no portions of the circulating system whose wounds do not
 sometimes close up spontaneously.

                          § I.— The Heart.

   The heart itself is an example of this ; here are two instances in proof
 of it.  A multitude of observations collected  by  M. Sanson ( These No.
 159.  Paris,  1827) and others, prove, in fact, that wounds  penetrating
 into this organ are not in all cases immediately  fatal.  In  forty exam-
 ples I have collected,  of cases  of wounds penetrating into the heart, I
 found two of them in whom death did not take place until the third day;
 two where it  happened  on  the fourth ;  seven where it occurred on the
 fifth; one on the sixth ; two on the seventh;  one on the eighth ; one on
 the ninth; one on the eleventh; one on the  eighteenth; one on the
 nineteenth, and one on the twentieth.  It is also to  be remarked, that
 in a case noticed by M. Champion, death was caused by a cardo-peri-
 carditis.   [In the two cases only that Dr.  Mott has seen, death occurred
 immediately.   T.]                                               .
    A patient mentioned by M. Alquie, (De Montegre,  These No 6. Paris,
 1836, p. 7,) who had  a wound penetrating the right auricle, also sur-
 vived for twenty days.  The young Gaspard Hauser, (Ibid.,)  who after
 receiving a stab, went more than a league on foot, and who did not die
 till the third  day, had the apex of his heart wounded.  The  clerk of
 whom M. De  Montegre (De Montegre, These No. 6. Paris, 1836) speaks,
 had the heart pierced  by a dresser knife, six days before he died.
    Other facts show that some  of these wounds may  recover  perfectly.
 The cicatrices  in  fact, prove  it,  as in the case  of Senac, and  another
 related in the  Gazette de  Santi; (No. 6, p. 2, 1761;)  Chastenet the
 father and  Chastenet  the son,  (Journal  de Horn, c.  II., p. 386—387,)
 have each  reported a similar  case.  De Laserre (Bibliot de Planque,
 c. XXVII., p. 180) speaks of  a living dog whom he had  made  use of,
 to demonstrate the thoracic viscera, and who,  though he had leaden balls
 in the heart,  pericardium, mediastinum and intercostal  muscles, was ro-
 bust and fat.  I opened at  the hospital of the Faculty, in the service of
 Bougon, the  dead body of a coalman, who died in 1825, in consequence 
672
NEW ELEMENTS OF OPERATIVE SURGERY.
of a pneumonia.  This  man, who had  received a thrust  from a knife
many years before, and who after a scries of dangerous symptoms finally
recovered from the wound, had a distinctly marked cicatrix in the right
ventricle of his heart, and a large hole with thin edges in the corres-
ponding region of the pericardium.
  [Dr. Trugein of Virginia, has reported in the American Journ. Med.
Science ; July, 1850, p.  99, a case of wound of the left ventricle of the
heart, in which  the  patient  survived five days.   He  had been  stabbed
with a knife.  Dr. T. quotes the statistics  collected  by M. Ollivier, to
show that instantaneous  death from wounds of the heart are much less
frequent  than is  generally supposed, as in 29 of these cases, only 2
proved fatal within 48 hours, and the others in from 4 to 28 days.  Dr.
Ramsay of Tennessee, reported in the Western Journal of Med. and Phys.
Sciences, Vol. I.,  p. 359, a case in which a negro boy survived  a wound
of the  heart  67  days, and was at one time able to  walk about.  Dr.
Bowling, of the Bengal  Medical service, reported in the  Lond.  Lancet,
Feb. 18°53,  p. 156, a  case of gun-shot wound  of the heart, which ter-
minated fatally at the end of 11 weeks, when the ball was found in the
left ventricle lying wedged in its apex.  Dr. Bowen has given the details
of a case of wound of the heart, in which patient lived  10 days (New
York Journal of  Med., Sept. 1849) and in the Lond.  Med.  Gazette,
Vol. XVII., p. 82, a case of recovery is recorded.  In the instance re-
ported  by Dr Trugein, the wound through the  pericardium had com-
pletely cicatrized  as well as that through the heart, for two-thirds of its
extent, and Dr.  T. thought it highly probable, that, but for his impru-
dent exertions, his patient would  have  recovered.   In Beck's Medical
Jurisprudence, an interesting collection of cases of wounds of the heart
may be found.  G. C. B.]

                         § IL— The Aorta.

  If it were advanced that the muscular structure and natural  consoli-
dation of the fibres of the heart readily account  for these results, I would
remark that  the  largest sized arteries  have also sometimes  exhibited
similar effects.  A person who had a wound of two lines in the  thoracic
aorta, did not die till the third day.  (Gaz. de Sante, 1787,^  p. 191.)
In another,  mentioned by Chastenet, (Jour, de Horn, t. IL, p. 360 et 375,)
life was sustained for six days ; in a third example, related by  the same
author, death did  not occur until the seventh day.  Lerouge, in Saviard,
relates that an individual thus wounded  survived till  the eleventh  day.
Pelletan (Clin. Chirurg., t. I., p. 92) even speaks  of a  patient  who,
having had the aorta pierced by a foil, nevertheless lived for  the space
of two months.    But I am not aware that any one has ever substantiated
the radical  cure of any  wound  of the aorta.  The patient of  M.  Niel
(of Bamberg, was cured, but died of pneumonia at the expiration  of a
year;  the cicatrix however, a quarter of a line, and  the small  thrombus
which were found upon  the aorta, were not incontestable evidence that
this artery  had actually been wounded.  We find in Guattani, (Lauth,
 Coll. d'aut. lat., See,) the singular case of a man who had lived several
years after having had the aorta wounded, and in whom  there  existed a
varicose aneurism between this artery  and the vena cava.  M. Syme, 
LESIONS OF THE  ARTERIAL SYSTEM.
673
 (Gaz. Med. de Paris, 1833, p. 51.  Arch. Gen. de Mid., t. XXVIII.,
 p. 403,) has given a similar  fact.   Animals whose heart or aorta I have
 pierced with long needles, have perfectly recovered.   If from this artery
 we pass to those of the limbs, facts are abundant to show  that nature
 often possesses the power to obliterate them when they have been wound-
 ed, and effectually to arrest the hemorrhage resulting from their wounds.

                                §  III.

   Having collected with another object in view, about fifty examples of
 this kind, (Jour. Hebdom.  et Universal, t. I., p. 144 et 488,) I have
 satisfied myself that  the largest arteries, notwithstanding positive evi-
 dence of  their having been  divided by crushing, tearing, or amputation
 of the part, do not always give rise  to hemorrhage, or that they  often
 admit of  the hemorrhage being effectually arrested ; although we have
 applied to them  neither compression nor the ligature.  Among  these
 cases there were found thirteen for the arteries of the fingers, hand, or
 foot, four for those of the fore-arm, seven for those of the arm, eight for
 the leg, and seventeen for the thigh.  More than half the patients were
 cases of amputation.   In the case cited by M. Fern, and that of M. Mus-
 sey, it is seen that the arm and entire shoulder had been torn off.

                                §IV.

   It is then at present an indisputable fact, that the arteries of the limbs,
 when once either opened, either by laceration, or by actual division, and
 left alone, may in reality become obliterated.   I had therefore  come to
 the conclusion, in the treatise above referred to, that this result, so com-
 mon in animals, would often  also be observed in man, if, after operations
 or wounds, prudence  permitted us to  wait for it.  M. Guthrie, who had
 been struck with the same peculiarity, came to a similar conclusion ; but
 it must not here be forgotten, that we have not yet had it in our power
 to submit to any law  or rule, the spontaneous  cessation of arterial he-
 morrhages, and that it would be dangerous to depend upon it in the human
 species in arteries of  any considerable size.
   As to the process it is still enveloped in a great degree of  obscurity.
 The experiments of  Jones and Beclard have shown that longitudinal
 wounds in arteries more easily allow of the suspension of the hemor-
 rhage than transverse wounds ;  and that in these latter, the bleeding is
 more difficult to arrest when they are partially divided than when their
 division is complete.   The section of the whole calibre  of this vessel
 augments  the chances  of its obliteration, either in consequence of the
 retraction of its  two axes, or by means  of the  species of compression
 that the other soft parts  soon exert upon it.   This fact well known to
 the ancients, inasmuch as Celsus and also Galen, (De Curand. ration.
per Venesect, chart, t. X., p. 45,) who  could  not arrest  a hemorrhage
 at the ankle-bone without completely  dividing the artery,  and Avicenna
 and  Guy  de Chauliac  had  already noticed it, has been  demonstrated
 anew by a great number of the moderns, so clearly, that in order to ar-
 rest certain obstinate  hemorrhages, there are many who after the exam-
 ple of M. Larrey, (Mem. de Chir.  Mil. t.  III., p. 29,) recommend mak-
   Vol. I.                    85 
674            NEW ELEMENTS OF OPERATIVE SURGERY.

ing a complete  division of the artery at the line where it is wounded.
As to knowing whether the artery thus divided,  closes in consequence
of the contractility of its coats, as Morand, Briot, Taxil, Bonfils, M. Lar-
rey,  and M. Guthrie have maintained; or as Poutea suggests, by means
of a compression  of the  sanguineous concretions  which  are formed
around it, or by the formation of a clot in its interior, or by the elonga-
tion  and  thickening of its  cellular  sheath, as  other moderns  have
thought; it is a question which I cannot  discuss in  this place, and the
facts  and  details of which  may  be  found in the memoir, which I have
already cited, also  in the  Treatise upon  wounds  by J. Bell, and in
the Articles, Aneurism, Artery, and Ligature, in the second edition of
the Dictionary of Medicine.
                          CHAPTER III.

                  TREATMENT OF ARTERIAL LESIONS.

  The principal  object in view  with Surgeons at the present  time in
healing diseases  of the arteries, is to effect as promptly and  with as
little pain as possible, the obliteration, either temporary or permanent,
of the injured vessel, or  that which carries  the  arterial  blood to the
organs whose circulation we wish to control.
  To arrive at this end certain operative methods have  been  devised,
independent of internal means, regimen, and certain topical applications.

                 Article I.—Medical Treatment.

  Two kinds of means have  been employed under this title : The De-
pleting treatment, or that  of Valsalva, and cold topical applications or
astringents.

                     § I.—Method of  Valsalva.

  Valsalva and Albertini, (Comment, sur  les Mini, de VAcad. de  Bo-
logne, t. II.,) while they were yet  only students of medicine, resolved
to treat the  first case  of aneurism they  met with, by bleeding and  the
depleting  regimen.  This  was their manner of proceeding: They per-
formed one or two bleedings upon  the  patient, who was then made to
lie in bed  for about forty days, and not to take any more food than  was
barely necessary  to support life, with the  intention of adding to his
nourishment afterwards, as soon as the debilitating treatment had been
carried far  enough to render it impossible  for him to raise his arm, or
to move in bed !   Hippocrates had  already said, that in order to cure
a hemorrhage produced by a rupture of  the swollen veins of the lungs,
the best remedy was to perform copious bleedings upon the patient until
he was nearly  exsanguined, and to reduce him by diet to a state of  ex-
treme emaciation.  Lancisi, Guattani,  Corvisart,  Pelletan, Hodgson, 
TREATMENT OF ARTIFICIAL LESIONS.              675
Sabatier, Boyer, M. Andreini, (Arch. Gin. de Mid., 2me serie, t. VI.,
p. 575,) and others, obtained by the employment of this treatment,
some advantageous  results and even cures, if we are to believe the An-
nals of Hecker, (Rev. M d. 1828, t. IV., p. 103.)  It must neverthe-
less be confessed, that it is difficult to comprehend its efficacy.  There
can be no doubt, that by bleedings frequently repeated, and by a severe
diet, we may reduce the impulsive force of the heart and the pulsations
of the tumor ; the size of this tumor  will in most of the cases diminish ;
but is it not to  be feared that  in  debilitating  the patient we increase
the fluidity  of his  blood, and  that  instead of favoring  the concretion
and solidification of the  aneurism, and the obliteration  of the  artery,
we may ou the contrary render those different phenomena more difficult
to be accomplished ?  When we recollect with  what  facility the least
emotion, or the slightest  movement, produce violent  pulsations of the
heart, and  that in thus reducing  our patients to extreme debility, we
put them in a condition in which it is impossible for them to support the
least operation : in  fact, that the slightest malady may then prove fatal;
when we remark  moreover that up to the present time the cures effect-
ed by  the  method  of Valsalva, are  extremely  limited in number, if in
fact it can in reality claim any that exclusively belong to  it, may we not
be allowed to question  its  importance ?  Though M. Renzi,  (Italian
 Transl. of this book, p. 71,) says, all  the  patients in the Hospital of
Incurables at  Naples, are submitted to  this course,  M.  Zaviziano  has
assured me that these patients are not cured of their internal aneurisms.
   Nevertheless, the sanguineous depletions and the debilitating regimen
ought  not to be proscribed in our treatment of aneurisms.  When  the
disease has its seat in the aorta, out  of the reach of surgical remedies,
it is proper to  have recourse to it, and to join with it the preparations
of digitalis  so much  extolled  by M. Yatmann, M.  Brook, and other
English surgeons.  Some facts related by Pelletan, (Clin.  Chir., t. I.,
p. 77,) Sabatier, Delpech, M.  Roux, &c, lead  to the belief  that this
combined treatment is not entirely destitute of efficacy, and that it should
not be neglected, when we have nothing better to make  trial of.  The
retardation of the circulation,  and a perceptible but moderate diminu-
tion of the mass of the blood,  might, it may be conceived, allow of the
fluids  in the  aneurism to become  solidified, and the  tumor to become
completely indurated, especially if the lateral orifice, by which it com-
municates with the  artery, is irregular and very narrow.   We may also
understand how such a tumor resting against the artery might cause its
obliteration, since the compression  it exercises, though  insufficient in
the natural state of the  tumor, is then great enough to resist  the im-
pulsion of the heart.
   [Mr. Yeatman has cured an aneurism of the left subclavian by means
of pressure and Valsalva's  method.   (Lond. Med. and  Phys. Journal,
vol. xvii.)   Dr. Uglow has  reported in  the New York Journ. of Med.
See March, 1853, a case of aneurism of the anterior tibial artery, which
was cured by copious blood-letting practised for another object, by one
who, at the time, was not  aware that the  patient was  the subject of
aneurism.  Mr. Luke, of the London Hospital, has cured an aneurism
of the innominata, by small and repeated bleedings, together with  the
use of digitalis.  Dr. Dudley, of Lexington, Ky., attaches great import- 
 676           NEW ELEMENTS  OF OPERATIVE SURGERY.

 ance to diet and regimen in the treatment of aneurism, and thinks that
 by these means he has cured an aneurism of the left subclavian near the
 sternal end of the clavicle.  (Trans. Am. Med.  Assoc, vol. 3d, 1850.)
 Mr. Ellsworth has reported  a case of femoral aneurism cured by  Val-
 salva's  method.  (Lond.  Med.  Times, 1844.)   Dr.  Stokes in  his
 recently published work " On the Diseases of the Heart  and Aorta,"
 p. 592,  states that both Dr. Graves and  himself,  as long ago  as 1830,
 had remarked that a plan of treatment the opposite to that of  Valsalva
 had given great relief in two cases of abdominal aneurism, as  recorded
 by Dr. Proudfoot  and Dr.  Beatty, and they  then  suggested that the ex-
tension of the disease would be better prevented by the use of a generous
 diet so as to form  a more coagulable blood.  Since that period, he asserts
that he has had abundant  proofs of the utility of supplying aneurismal
patients not only with nutritious  food, but even  with diffusible stimuli.
 Dr. Kirby,  also in his " Cases  and Observations " published  in 1819,
 strongly condemned the use of antiphlogistic measures in the treatment
of external aneurism.   Sir Astley Cooper after trying Valsalva's method
 without success, remarks that whatever is lost by this treatment in the
momentum of the  circulating fluid, is gained in velocity.   The  instances
of cure, however, which  we  have cited, certainly speak somewhat in
favor  of Valsalva's  method.   G. C. B.]

                 § II.—Refrigerants and  Styptics.

  Almost all the  ancient  authors pretend to have cured aneurisms  by
the  employment of compresses, saturated with  liquids or other  sub-
stances of an astringent nature, or by different kinds of plasters or bags
filled  with tan-bark, or by means of decoctions of bistorte, bark of the
oak or willow, the leaves of the walnut, spirits of camphor, vinegar, hot
wine,  potter's slay, (Kanelski, Bullet, de Firussac, t.  XVI., p. 450,)
 sea salt, and ashes, (Pelletan, Clin. Chir., t. I., p. 121.)  They  sup-
 posed, by acting in this manner, they could oblige the artery  to recede
 and retract  upon  itself.   Others made use of cold compositions.   T.]
 Bartholin, for example, says  he has  cured an aneurism in the arm by
 applications of snow, frequently repeated.  But it is  to  Guerin,  of
 Bordeaux, that we are indebted for hav ing made  known the importance
 of refrigerating applications  in such cases.  In 1790, there was ad-
 mitted into the hospital  of Saint Andre  a carter  having an aneurismal
 tumor, which ultimately occupied the entire supra-clavicular region and
 a part of the neck.  A few bleedings, a tisan of eau de Rabcl, and the
 application to the tumor itself of compresses saturated with  oxycrate,
 succeeded in effecting the cure  of the patient  in the  space  of a few
 months.  In 1795,  N. Treyheran treated an  enormous  aneurism of the
 femoral artery  by  the same means  and with  the same  success.   M.
 Guerin, the son,  has since reported several similar  cases.   In  1799,
 Sabatier cured, in the space of four months, a patient with an aneurism
 in the ham, by soup and bouillon as his only nourishment,  or acidulated
 tisan, and ice applied to the tumor.  Pelletan also had recourse to cold
 applications, together with  the method of Valsalva.   A  patient whom
 M. Faucon (Gaz. Med. de Paris, 1837, p. 313) treated by the method
 of Pelletan, was cured of an aneurism after all other  attempts to bring 
TREATMENT OF ARTERIAL LESIONS.
677
about this result  had been abandoned.  Since that time, M. Hodgson,
M. Larrey, M. H.  Martin, (Rev. Med. 1835, t. III., p. 408,) M. Ribes,
(Bullet, de la Facuile, le annee, p. 87,) M. Bacqua, (Ibid. 6e annie,n.
133, 140,) M. Gintrac, {Ibid. t.  IV., p. 301,) and some others, have re-
lated facts which go to the support of the method of Guerin, the efficacy
of which, however, is called in question by another surgeon of Bordeaux,
M. Moulinie, (Bullet. Medical de Bordeaux, 1833,  p. 6.)
  [Dr. Geo. McLellan states that the  principal reason why styptics so
often fail, is, that  they are applied while the blood  is still flowing from
the  orifice.   Previous to  their  use,  the main trunk should be  com-
pressed for at least half  an hour, at the end of which time  coagulation
and contraction will have become so perfected as to resist the returning
impetus  of  the  circulation.   (Principles of Surgery, p.  190.)  Dr.
Ruschenberger of  the TJ. S. Navy, has highly recommended  the  use  of
the Peruvian plant, matico, as  a hemastotic  remedy.  With it he has ar-
rested a profuse hemorrhage  supposed to  proceed from a  divided in-
ternal maxillary artery, and from the arteria ad cutem abdominis, which
was wounded in dilating  the sinuous passage of a bubo.   The powdered
leaf is formed into  a  paste by the addition of a little water, and  then
applied to the wound.  M. Velpeau has arrested secondary hemorrhage
after ligature of the brachial artery, by means of lint soaked in a  solu-
tion of the perchloride  of iron.  Mr. Solly, of St. Thomas' Hospital,
London,  employed an  injection of  this  substance into  the  sac  of a
carotid aneurism, from which secondary hemorrhage occurred after the
application  of a ligature  to this artery.  This together with pressure,
succeeded in producing a temporary arrest  of the bleeding, which, how-
ever, returning,  soon destroyed the patient.   Gallic acid; in some  cases
of hemorrhage, has proved of service.   Creosote, turpentine, &c, may
be used for  the  same purpose.   The serres-fines, invented by M. Vidal,
and represented in the following diagrams,  are now much used, particu-
larly in arresting  hemorrhage from leech bites, and to secure arteries
divided during an operation.

                     Fig. 1.      Fig. 2.       Fig. 3.
            Fig. 1st, branches open.   Fig. 2d, closed.  Fig. 3rd, open.
                                                         G.  C.  B.]

  M. Zaviziano, who has not seen a single example of the successful treat-
ment of internal aneurism at Naples by the method of Valsalva, informs
me that many aneurisms of the limbs, however, have been cured there
by associating topical applications with this method.  Topical applica-
tions, then, and refrigerants, whether we employ them alone or combine
them with the method of Valsalva, or indirect compression, constitute a
means which we may be  allowed  to  have  recourse  to when  the more
certain methods  that we possess are  not applicable,  or that patients do
not wish to submit to them.  Their action also  is easily explained. 
678            NEW ELEMENTS OF  OPERATIVE SURGERY.
Under the influence of such topical applications, the heat sensibly dimin-
ishes in the part; the circulation there becomes less active ;  the  effused
blood loses its fluidity, and strongly tends to coagulate; and if the sys-
tem should be already in  a condition to favor such a  termination, tho
result is that the artery closes and becomes  obliterated, aud  a  perfect
cure is accomplished.
   The injection of a solution of the  pcrchloride of iron  has recently
been recommended in the  treatment  of aneurisms, by Pravaz,  (lately
deceased) of Lyons.  M.  Barrier, of that  city, has even ventured upon
its use, in an aneurism of  the innominata.   Judging from  the report of
this case, in the  Moniteur des Hopitaux, Dec. 3, 1853, we do not think
that  this surgeon will find many imitators.   Indeed, this  method  of
treatment has been  unanimously  condemned by the Academy  of Medi-
cine, and in the Memoir presented to that  body, by M. Malgaigne, Nov.
8th, 1853, we find that of 11 operations of the kind, there have been 4
deaths, 5 dangerous accidents, and 2 cures.  The following is a summary
of the conclusions deduced by M. Malgaigne : " Although the possibility
of cure has been established, the cures have been so few, and the dan-
gers attending them  so great, while the number of unsuccessful cases,
even of deaths, has been  such, that in my opinion, no  prudent surgeon
would be justified in exposing his patients to such a dangerous mode of
treatment.   In the discussion which followed, M. Velpeau mentioned an
additional objection, viz. the clot formed being insoluble, must act as a
foreign body, and when large, might be the cause of inflammation.  This
occurred in  a patient of M. Dufour, after two  injections were made, in
the case of a carotid aneurism, inflammation ensued, the tumor  sloughed,
and the hemorrhage proved fatal.
  Dr. Brainard, of Chicago, is actively engaged in experimenting  with
injections of lactate of iron, in the treatment of erectile tumors, varicose
veins, and aneurisms.  This substance, in his opinion, is to be preferred
to the perchloride of iron, as, unlike the latter, its components already
exist in the blood, and it does  not produce  a sudden coagulation, but a
thickening of the coats, with deposition of coagulable lymph from  the
sub-acute  inflammation which it induces.   With it he  has successfully
treated an erectile tumor  of the orbit, a solution of eight grains of the
lactate of iron to  one drachm of distilled water  having been injected
into the centre of the tumor.   Violent pain in the head  and  vomiting
followed, but these  symptoms gradually subsided, and the recovery was
perfect.  The ligature of  the carotid, in this case, had  failed to effect a
cure.   A full report of this case may  be found  in Braithwaite's  Retro-
spect, Part xxviii, p. 174.  Some cases  of cures, in  cases  of erectile
tumors, not of great extent, have recently been reported in the London
Journals.   G. C. B.]

                Article  II.—Surgical Treatment.

  We shall now take into  consideration the compression,  cauterization,
suture, torsion, crushing, acupuncturation,  and ligature of arteries. 
TREATMENT OF ARTERIAL LESIONS.
679
                         §  I.— Compression.

   We have already spoken of compression as a hemostatic means during
or after operations, (vide supra,) and I shall return to it again in speak-
ing of amputations.   I  shall consequently  only  treat of it here  under
the character of a special operation, and in reference to the morbid con-
ditions which  require it, or for which it is used.   Possessing as it does
the power  to  arrest  the course of the vital fluids, compression of the
arteries is naturally calculated  to produce a marked alteration, whether
for good or for evil, in  all the vital functions  of the system, and in the
greater number of diseases.   Until the present time, however, it has
scarcely been  spoken of but as a remedy for hemorrhages or aneurisms.
But under whatever point of view it is considered, this method of treat-
ing the  arteries is divided into two kinds, viz., permanent  and tempo-
rary compression.  Permanent  compression  cannot  be  examined except
in its connection with wounds  of arteries, aneurisms,  amputations, and
operations in  general.  As to  temporary  compression, I have already
described the manner in which  it is to be made during  the  progress of
operations.  It is necessary now to say a word of it in reference to its
control  over certain diseases.

A.— Compression in cases of Neuralgia, Congestions, and Inflammation.

   As compression of  the arteries, moderates and even arrests the circu-
lation in the organs situated underneath, it seems at first sight to con-
stitute an excellent remedy in  congestions, engorgements, and acute in-
flammations of all kinds.  It  is, therefore, somewhat surprising that
physicians  should, for so many ages, have  omitted to  make use of it,
under this point of view.  At  the  present time the  mind  appears to
take  another direction, and compression of the  arteries, if we are to
believe its partisans, should become the sovereign remedy in convulsions,
epilepsy, inflammations, congestions of the  brain, cerebral  fever, neu-
ralgias,  inflammations of the limbs, wounds of the articulations, com-
pound fractures, gout, rheumatism, &c.
   Parry (Medical Society of  London, vol.  III.) had  already said in
1792, after Parisot and Eniet, of whom I shall speak  farther on, that
temporary compression of the arteries was an excellent means of curing
various  diseases, particularly those  of the head.   Autenrieth had had
recourse to it in convulsions, and M. Trousseau (Jour,  des Conn.  Mid.
Chir., Octobre, 1837) has published facts which fully confirm the asser-
tions of the German physician.   M. Liston (Edinburg  Med.  and Surg.
Journal, vol. XVI., p. 73) thought he had experienced good  effects from
it  in maxillary neuralgia.  M.  Dezeimeris,  (Expirience t.  I., 66,) in
giving the history of this operation, says he has seen its efficacy many times
demonstrated in the same  malady.   M. Earle, (Dezeimeris, J. Cooke,
&c, on  Exper., t. L, p.  74,) who says he has used it with advantage in
certain cases  of epilepsy, and  who  in that  finds himself in accordance
with Parry himself, and sustained by a more conclusive observation made
by M. Boileau, has been outdone by M. Preston, (Calcutta  Med. and
Phys. Transactions, t. Y.— Gaz. Med. de Paris, 1833, p. 76,) since this 
680           NEW ELEMENTS  OF OPERATIVE SURGERY.

practitioner went to the extent of tying the carotid artery to cure a pa
tient of epilepsy.   Other practitioners, as Livingston and Kellic,  (Dez-
eimeris, Experience, t. L, p. 66,) have, like Parry, employed it in rheu-
matism ; while Ludlow made trial of it principally as a remedy against
gout.   M. Onderdonk (The American Med. Reg., Exper.,_t I., p. 67)
asserts that he found it useful in extensive wounds of the  joints,  and in
fractures complicated with inflammation.   [These are precisely the cases
now in which modern conservative surgery has  proved that a treatment
directly the revrese of compression is to be adopted.   See note on the
cases of M. Prior, &c, infra.   T.]  Parry recommends it also in ophthal-
mia, and M. Watson states that  he has employed it with  success  in this
disease.  All the results which I have just related, and some of which
had already been published bv me in 1830 (Jour. Hebdom, Univ.,t. IL,
p. 59) and 1833, (Anat. Chir.,  t. I., 2d ed., p. 444,) had nevertheless
remained unnoticed in France, until M. Trousseau on the one hand, and
M. Malapert (Acad, des Sciene, Novembre, 1837) on the other, under
the belief that they had made a new discovery, have again revived  among
us the treatment of Parry.   It is proper, however to say, that a French
physician, M. Blaud, (Bibliot. Mid., t. LXIL,  p. 145,) had already de-
monstrated, as the  observations  of M. Linne  (Bibliot. Mid.  1818,  t.
LXIL, p.  157,) M. Trousseau, and M. Allier  (Exper.,  t.  I., p. 254)
have since done, the advantages of compressing the arteries in cerebral
fever, or in convulsions.  If we add.to these facts a case of sciatica, and
also a severe  case of complicated fracture, cured by a ligature upon the
femoral artery, a case of paralysis treated by a  ligature upon the carotid,
and the cases of M. Sestier and M. Rayer, as related by M. Dezeimeris,
Exper., t. I., p. 66,) we shall have a sufficient amount of proofs to war-
rant the recommendation of compression of the arteries in certain cases
of disease.
  The  idea of this treatment  also goes  much farther  back than M.
Dezeimeris supposes.
  The  placing  of  a ligature on  the carotid  had  in  fact been  recom-
mended for diseases of the head, by Robert Emet, (Essais de Midecine,
p. 191-194,)  who applied it upon a dog without any inconvenience, and
describes how it should  be performed  on man.   Parisot, (Reflexions
sur une pratique propose  pour  le  traitement des maladies  internes,
occasionnees par plethore.  Journal Economique, Janvier, 1756, p. 140,)
who recommends it for plethora, tied the carotid in three dogs without
creating any  disturbance in their functions.   We find  also in  Bressy
(Recherches sur les  Vapeurs, &c.)  a suggestion to tie the carotid for
nervous affections.
  I do not, however, mean  to be understood  by this, to  say that upon
the authority of the observations of MM. Swan, Preston, Gerdy and
others, it  is my intention to advise the ligature upon  the  large arteries
as a remedy  either for inflammations, neuralgias, or cerebral  conges-
tions ;  but inasmuch as we may have it in our  power, by temporarily or
momentarily compressing those  arteries  which supply inflamed  or con-
gested parts, to moderate both the pain and the other symptoms of in-
flammation or congestion, I deem it proper to  point out to  surgeons the
rules to be followed in this operation.
  To fulfil the indication in question, the operator should  act so as to 
TREATMENT OF ARTERIAL  LESIONS.
681
compress as few parts as possible along  with the artery, and exert a
sufficient degree of pressure to moderate or even  to arrest the course
of the blood, without making it with such force as to  contuse the inter-
mediate tissues, or to  rupture  the internal  or  middle  coats  of the
artery.  It is easy to  perceive also that this  compression, which may,
moreover, be prolonged to a greater or  less length of time, and main-
tained for some minutes only, or for the space of  twenty-four hours, ac-
cording as the case requires, is  not to be made with violence, also that
it may be advantageous to diminish it, and even to suspend it from time
to time, or to renew it or moderate  it  again  before removing it alto-
gether.   To do it well, we should in general discard circular  bands ;
the fingers or the thumb, or a seal protected by a pelote of  lint, answer
better than any  other  kind of instrument.  The  tourniquet and  other
kinds of compressors, all are attended with  the inconvenience  of  se-
lecting for their point d'appui certain parts that  are sound, and  making
therefore unnecessary  pressure upon these  parts.  As it  is important.^
if we do not wish to interrupt the return of  blood, that we should mak
as little pressure as possible upon the veins accompanying the art
neither instruments with large pelotes, nor any  other  machines, ,»
ever be employed, unless the fingers and the thumb  appear absc
insufficient.
   There are a great number of arteries  to which this mode  of coi
sion is applicable.  Those of the limbs, neck, iliac fossse, and ev
aorta, readily admit of its application.   As the compression shou.
regulated according to certain uniform rules, whether  it be as a reix
for some disease, or to arrest hemorrhage, or  to  suspend  the course
the blood during an operation, I shall now briefly describe how we ougi
to proceed in applying it to the vessels I have enumerated.

                      I.—Arteries of the Head.

   a.  If it should be required to make  temporary compression upon the
supra-orbital artery, we  would  be enabled to effect  this  without any
difficulty, by placing the finger at the distance of about an inch outside
the  root  of the nose, immediately above or under the  supra-orbitar
notch, taking care at the same time to  push back the eyebrows towards
the forehead.   But as the compression of the  artery  involves also that
of the frontal nerve, it would probably be of little use in this region.
   b.  The Temporal  Artery. The most convenient place for compress-
ing the temporal artery is at the distance of about three  lines in front
of the cartilage  of the external  ear, and a little above  the zygomatic
arch.  Being in that place  not yet bifurcated, and also  separated from
the bones by only a thin layer of libro-muscular  tissue, it  would  easily
allow of being  flattened by the finger, or any kind of pelote.
   c.  The Occipital Artery could not  be conveniently reached except
by placing a pelote or some mechanical compressor, properly made be-
tween the  mastoid  process and  the upper extremity  of  the complexus
muscle; also it would be necessary that the compressing  power should
have a tendency downwards between the muscle mentioned and  the
sterno-mastoid, while pressing  at the same  time against the occipital
ridge.
   Vol. I.                      86 
682           NEW ELEMENTS  OF OPERATIVE SURGERY.
  d. In the face we could not compress the arteries of the lips, but by
seizing  each  lip  near the commissures  between the fingers  and the
thumb, and directing the  pressure from below upwards  for  the  upper
lip, and from above downwards  for tho lower  lip.   Compression  upon
one side only, as  it would not prevent the blood from returning by the
other, would  be manifestly of no avail.
  e. We might compress the facial or  external maxillary artery, in
the most effectual manner  possible,  by placing the finger or projecting
part of the mechanical instrument, upon the notch which is felt at  about
an  inch in front of the angle of the  jaw, or upon the outer  surface  ot
this bone, between the anterior border  of the masseter  muscle and the
posterior border of the depressor anguli oris muscle.

                     II.—Arteries of the Neck.

,   The carotid and vertebral are the only arteries that can be  compressed
 n the neck.  The compression of the thyroid, lingual, and inferior pha-
   r<real.wmld be too difficult or too imperfect to be  worth the trial.
    * I  should add that the entrance of the  vertebral arteries into  the
      of the transverse  processes, is too variable to admit of positive
      upon this subject.   Nevertheless, if we are guided by  the tubercle
        sixth cervical vertebra, designated  by  M.  Chassaignac (Arch.
      de Mid., 2e serie,  t. IV., p. 458) under the name of the  carotid
      cle we may perhaps in a considerable number  of cases succeed in
    jting a sufficient degree  of  pressure upon them.  The patient being
   c this purpose laid upon his back with his head a little inclined forward,
  ^ well supported,  the  surgeon  should cautiously  insinuate  his thumb
 or one  of his fingers between the trachea and the inferior extremity ot
 the sterno-mastoid muscle,  until he has felt  the  tubercle  in question.
 Then pressing  transversely upon the surface a little under  this tubercle
 to the  extent  of about  an  inch, he would almost inevitably  flatten the
 vertebral artery.                               .      _,,        ,., .
    b  Carotids.  The mode of applying  compression to the carotids is
 the one which  has principally occupied the attention  of practitioners.
 Parav  M Blaud, and M. Trousseau, more especially have  attempted to
 demonstrate its  advantages.   Before deciding upon it  however  it is
 well to recollect that we run some risk; and as I have  already said if it
 should be carried to excess, we may rupture the coats of the artery.   If
 ♦he  iuo-ular vein  were  compressed at the same time, we may conceivo
 what would be the result of this upon the  brain.   Nor could the pneu-
 mo-o-astric or great sympathetic nerve be long compressed without incur-
 rin^some danger.   One of the patients of  M. Sestier,  and  one of whom
 M "Dezeimeris (Expir. t. I., p.  70) speaks, were  thrown into  such a
  state of alarm by it, that they could not afterwards  bear to hear it men-
  Honed  It would be necessary, therefore, if we  should  make   up our
  minds'to attempt it, that we should endeavor to press  upon  the artery
  in such manner as not to injure the other organs.   For that purpose we
  should select  the omohyoid space, that is, we should place  the finger be-
  tween the sterno-mastoid muscle and the thyroid cartilage.  The artery
  Ja not only situated at less depth in  this region than  lower down, but
  £ also here surrounded with a less  considerable number  of veins  and
   nerves than higher  up.  The surgeon, taking care when he feels the pul- 
TREATMENT OF ARTERIAL  LESIONS.
683
eation  of the  carotid to push it a little towards the median line, might
easily succeed in compressing the artery alone against the bodies of the
cervical vertebrae ; while if he made the pressure perpendicularly and
inclined his finger or seal a little outwardly, both the vein and the nerves
might  be endangered.   There also as in other cases, should it be ne-
cessary to continue the pressure for a long time, we should make use of
both thumbs or two fingers of each  hand,  alternately  applied  in  such
manner as  to relieve each other.
   [Compression of the carotid artery, sometimes  produces  more imme-
diate serious consequences than ligature of that vessel.  In an instance
where the carotid on one side  had been  tied  a short  time  previously,
Mr. Crosse, was so alarmed by the effects of pressure on the other that
he did not as he intended, secure the vessel.  Dr. Brainard, of Chicago,
for the same reason, was afraid in  another case, to perform the second
operation.   Mr. Fergusson, in referring to the case of Mr. Crosse, states
that beino- about to place a ligature on  the common carotid, some doubts
were entertained as  to the immediate results  of the proceeding, in con-
sequence of the singular symptoms caused  by pressure in the course of
the  vessel.  The ligature was applied, however, and no unpleasant re-
sults followed, from which he concludes that the peculiar effects did not
depend on the mere obstruction of the  carotid. (Practical. Surgery, 3d
Lond. Ed. p.  630.)   G. C. B.]

               III.—Arteries of the Thoracic Extremity.

   a. In the fingers we may, as Parry has done, easily compress the col-
lateral arteries with the view of moderating  the pain of whitlow or the
acute suffering from certain kinds of inflammation, should any one have
the patience to keep the fore-finger and  thumb applied over each other
for a day or two at a time.   We could also  effect  the  same object by
maintaining a small graduated compress at the junction of the palmar
surface with  each  border of the diseased finger, and fixing it in this
position by a few circular turns of bandage.
   b. The  radial artery  could be compressed with great ease either by
means of the finger, a pelote, or a mechanical compressor, on the lower
fourth of the anterior surface of the radius, at every point in fact where
it is sought for as the pulse; but as it communicates  extensively  wdth
the ulnar artery in the  palm of the  hand, it would be requisite that the
ulnar artery also should be compressed at  the same  time.  We should
be enabled to do this by placing the thumb crossways upon the forepart
of the ulna, at the distance of an inch above the wrist; while the two first
fingers of the same hand should take a  point d'appui behind.   It is to^be
understood, however, that when we do not wish to use the fingers, the
pelote of the compressor or of the  bandage or seal should  bear on the
same  point.  In the remaining part of the continuity of the fore-arm,
the compression  of these arteries would neither be easy nor secure.
   c. Nor in the  bend of the arm can we make compression with sufficient
 effect to rely  upon it, which is the less to be regretted, inasmuch as we
 obtain the same result on the arm itself.
   d.  The brachial artery, if necessary,  could be compressed any where
 on the whole length of the arm, by following the track of a line which 
684
NEW ELEMENTS OF  OPERATIVE SURGERY.
would reach from the middle of the hollow of the axilla to the middle
of the bend at the elbow.  The most convenient point, however, is to be
found above the upper insertion of the brachialis internus, and better
yet under the surgical neck of the  humerus between the two borders of
the axilla.  At this  point, in fact, confined  by  the  coraco-brachialis
muscle in front, and by the teres major or the  latissimus  dorsi  behind,
it is not separated from the bone by any layer of soft parts, and  neither
the nerves nor the veins form a complete sheath to it.   This point being
selected, we may moreover adopt  several  modes.  The  thumb  passed
into the hollow of the axilla, generally suffices, if we take care to select
a point  d'appui on  the outer surface of the arm for the other fingers,
and to press directly  against the  humerus  between  the tendons above
mentioned.  We succeed  still better, by grasping the upper part of the
arm with the two hands, in such manner that the fingers may all press
against the humerus in the hollow  of  the axilla, while the thumbs serve
as a point d'appui on the outer side of the shoulder.
  In the supposition that the fingers alone might be insufficient, we should
place  either a roller bandage  or any description of pelote possessing the
requisite  solidity upon the same point, in the follow of the axilla, after
which the pressure should be made upon this solid body,  either with the
fingers, or by means  of a bandage or a garrot.  There is no necessity
of adding that the different instruments that have been contrived for the
compression of the arteries, are  applicable also to the  arm and to the
point  of the axilla which I have just designated, as well as to the other
portions of the limbs.
   [It is sometimes exceedingly difficult to maintain permanent compres-
sion of the brachial  artery.  Mr. Barnard Holt, of the  Westminster
Hospital,  treated  a case  (Sept. 1853) of aneurism of the right radial
artery.   It was found almost impossible to secure the  continued adapta-
tion of the compressing pads, as the slightest movement of  the patient's
arm, or finger, sufficed to roll the vessel from beneath them.  Santori-
no's tourniquet was found to  be of the most easy management, but even
this failed, and  Mr. H. was obliged to resort to the ligature.   G. C. B.]
  e. The  axillary artery.   None  of the indications  above mentioned
can make it advisable to compress the  axillary  in preference to the bra-
chial  artery.  If it were deemed desirable to  diminish the  afflux of blood
to the shoulder as well as to the rest of the arm, it would be the  subcla-
vian  artery to which we must direct our attention.  AVe might also by
making the pressure a little higher  in  the hollow of the axilla, compress
the axillary artery against the head of the humerus near the clavicle.
But this compression being impracticable except where there is no tumor
in the upper part of the arm, is  not applicable to aneurisms.   It has
been  proposed  in that case also to make pressure upon the axillary ar-
tery through the whole anterior wall of this region, and in this  manner
to flatten it  as it passes upon the  second rib.   The finger or the thumb
pressed  with a certain degree of force from without inward, and from
before backward, upon the pectoralis major muscle, immediately under the
clavicle and upon the interstice which separates the head  of the humerus
from  the thorax, generally enables  us by this means to suspend the arte-
rial circulation throughout the whole extent  of the limb.
   If  it  were required only to obstruct in a slight degree the course of 
TREATMENT OF ARTERIAL  LESIONS.
685
the blood, we could effect this by carrying the arm behind the trunk, in
such manner as to draw the shoulder forcibly downwards.   Only it is to
be remarked that this movement, involving also the compression of the
nerves and  vein, is  apt  to occasion shortly after a considerable degree
of numbness in the hand.  If it were necessary to continue the compres-
sion a long time, or entirely to suspend the circulation, we should find
advantage in making use of the tourniquet of Dahl, or some of the other
compressors invented since.  The pelote of these instruments being ap-
plied upon the point where I have advised the thumb to be placed, ena-
bles us by  means  of the elastic arc which suports it, to select a point
d'appui between the shoulders or under the axilla of the opposite side.
It is however  very seldom that we are obliged to have recourse to this
kind of compression.  There are only certain amputations of the arm, and
some unusual operations that  would call for its employment.
  /. The Subclavian Artery.  The compression of the subclavian arte-
ries is precisely that  which is now substituted for the compression of
the  axillary artery, in those  cases in which the compressor of Dahl was
formerly  employed.  It  is upon the first rib, between the two scaleni
muscles, that  this artery may be most  easily flattened.  Resting as it
here does, naked upon the bone, with no intervening muscle between it
and the skin, and bridled as it were by the fibro-muscular attachment of
the two scaleni, it admits of the application of all the different kinds of
compression.  The most simple, and at the same time the most effectual
process  consists in pressing with the thumb or two first fingers of the
hand in the supra-clavicular depression. Pressing thus from above down-
wards and from  without inwards, we soon perceive either the pulsations of
the artery, or the tubercle of the first rib which borders its track below.
Nothing  more  is then required than to press with a little more force in-
wardly and backwards, in order to be sure of acting directly upon it.  In
this manner the vein remains intact in front while all the nervous branch-
es of the brachial plexus are  given off above.  As the thumb and fingers,
however,  would soon become fatigued, it  is advisable when we wish to
continue  the pressure upon  the  subclavian beyond the period of some
minutes, to  effect this object by means  of a seal furnished with a pelote,
or with   some compressor similar  to the tourniquet of Dahl, which we
should take  care to apply with accuracy  upon the region which I have
designated.

                IV.— The Artery of the Lower Limb.

   The lower aortic system may also be compressed upon many points of
its course.
   a.  The Dorsalis Pedis  Artery.   In the  toes the collateral arteries
are so small and short that it would be difficult and is scarcely ever ne-
cessary to undertake  their  compression.   The plantar arteries, being
deeply  concealed in the soft parts, are also placed beyond the reach of
the modes of compression which I have now under consideration.   The
dorsalis pedis artery, therefore, is the only  one that can, under this point
of view,  claim  our attention.  This artery  is to be sought for between
the instep and the commencement of the first inter-osseous space of  the
metatarsus; that is to  say,  on the dorsal surface of the scaphoid bone, 
686
NEW ELEMENTS  OF OPERATIVE SURGERY.
or of the two first cuneiform bones.  By placing the two thumbs trans-
versely  upon  that space, and over the  other, while the fingers take a
point d'appui on the  plantar surface of the foot, we compress the artery
with certainty and in such manner as not to be over-fatigued.  The pe-
lote  of  any kind of  compression applied to that region, might easily  bo
substituted for the  thumbs, if the  operation was to continue for a con-
siderable length of time.
  The nerves, veins, and other tissues in the neighborhood of this arte-
ry, are  of too  little  importance  to be any obstacle to its compression.
But as the blood returns directly to the dorsalis pedis^through the plantar
artery, we cannot see how this  compression can, in reality, be of any
great assistance.
  b. Arteries of the Leg.  Buried, as  it  were,  in the depth of the
muscles, the  arteries of the leg  do not readily admit of compression
between the knee and the lower  part of the calf.  It is only, therefore,
in the vicinity of the tibio-tarsal articulation, that  we  are  enabled to
reach them, and the  anterior  and posterior tibial moreover are the only
ones that the surgeon should look to in such cases.
  Tho anterior tibial artery, where  it courses upon the outer surface of
the tibia, might be  perfectly flattened, if in selecting a point  d'appui
for  the  thumb  above and  behind the internal  malleolus, between  the
tendo Achillis  and  the bones, we should compress  it from without in-
ward, and from before  backwards, with the fingers placed crosswise.
If we were to apply a tourniquet, garrot, &c, to tho same point we
would effect the same result.
  To compress the posterior tibial artery, we must place  the fingers  of
one hand, or of the two hands, crossing each other, in the groove which
separates the tibia  from the os calcis, and by this means press from
behind forwards, or from within  outwards, against the posterior border
of the internal malleolus, while the  fingers take  a point d'appui on the
outer part of the instep.  It is evident that we could obtain the  same
result by placing the fingers in front and the thumbs behind the malle-
olus, in  the same way as we  could  by applying the projecting  part of
any compressor whatever upon this  last point.
  Were it absolutely requisite to do so, the compression of the posterior
tibial, regulated  upon  the same principles, might also  be practicable
nearly as high as the upper part of the calf; but then it would be almost
impossible to flatten  the vessel perfectly.
  c. The Popliteal Artery.  The artery Of the  ham being situated  at
considerable depth,  is  utterly incapable of being flattened by indirect
compression.  As it  would also be  impossible to reach it without com-
pressing at the same time both the  nerves and the  accompanying vein,
the operation  in  this part would be attended with  more disadvantage
than utility.   It would not be advisable, therefore, to think of attempt-
ing it except  as a temporary means of relief in  certain hemorrhages of
the leg.  In  this  case it would be  necessary to place the compressing
force in the hollow of the ham, above the line of the  articulation, a little
nearer  to  the internal than the external border of that region, and to
select a  point d'appui above the  patella, upon the front  part of tho
thigh ;  the tourniquet or  the mechanical  compressors  would  in  such
cases be manifestly preferable to the fingers. 
                 TREATMENT  OF ARTERIAL LESIONS.               687

  d. Arteries of the Thigh.  The femoral artery may be compressed
near its two  extremities, that is, at the fold of the groin, and at its
entrance into the fibrous plane of the adductor muscles.
  1. Formerly, during  amputations of the leg, the femoral artery was
often compressed at the lower third of the thigh.   It is true that in
placing the two thumbs from within outwards,  so as to fall between the
vastus  internus and the adductor muscles, we  soon flatten it against the
inner side of the femur, if the fingers take a proper point d'appui upon
the outside of the limb.   But it is rare that  the hands  suffice for this
compression, and we accomplish it best by means of the tourniquet, or
ordinary compressors.  We should not, however, if we wish to  make
use of the fingers, attempt compression at this point, unless some disease
or some abnormal condition  should prevent our effecting it in the groin ;
for we can effect the compression of the femoral artery with the tourni-
quet with much  greater certainty and  ease in  this region than in the
upper  part of the thigh.
  2. To compress the femoral  artery at the fold of the groin, we rarely
employ any other means than the fingers.
  The  best mode consists in  fixing the thumb upon the outer part of
the thigh, a little below the great trochanter, and the four fingers on
on the fore  part  of the  gracilis and  adductor muscles, directing them
outwardly  and backwards,  and placing over  them the  fingers  of the
other hand  to serve as a support.  The artery is so perfectly confined
by the  adductor muscles behind, the triceps in front, and the femur out-
side, that it is impossible for it to escape or slip in the slightest degree.
The thumbs substituted in the  place of the fingers, or vice versa, would,
it is true, produce the same  effect, but would cause more fatigue, and be
less certain.  It would be the same with a padded  seal, or any pelote
whatever.
  3. Most usually we compress the femoral artery against  the body of
the pubis;  this in fact,  is one of the  most convenient places to  do it.
There we find the artery at an equal distance from the anterior superior
spinous process of the ilium  and the symphisis pubis.  By placing, then
the fingers, the thumb, or the pelote of a seal on this point, so as to press
from before backwards, and slightly from below upwards as if we wished
to push back or depress  the middle of Poupart's ligament, we are almost
sure to succeed.   It is  requisite, moreover, that we should not apply
the compressive means in  such cases until after having  distinctly felt
the pulsations of the artery with  the  fingers.  The most sure and least
fatiguing mode, however, of  compressing this  artery, as well as all the
others, consists in placing the  pulp, either of the fingers  or the thumb,
across  the course of the vessel, and in  such manner that the fingers of
the other hand, pressed  against the first, may thus serve to  add to their
force, and take their place when they are tired.
  If it is the right  side, for  example, the surgeon, turned  towards the
feet of the patient, places his  left thumb transversely upon the place I
have designated, and immediately puts the thumb or fingers of the right
hand upon the nail of the first, so that the thumb acts with its own indi-
vidual force while it is not fatigued, and acts the part of a pelote under
the fingers  of  the other  hand  when it has need of repose, and so on in
succession as long as the compression is to be continued. 
688            NEW  ELEMENTS OF OPERATIVE SURGERY.
   To make permanent compression, and to avoid as much as  possible
any interference with the course of the venous blood, it would be neces-
sary to make use of pelote compressors that have more projection than
width, and which should be directed a little outwardly, and applied so
as to take their point d'appui upon the posterior surface of  the pelvis.

                   Y.—Arteries of the Abdomen.

  The enormous volume of the arteries in the lower belly would render
their compression, if it were possible, a matter of great importance ; but
there are none except the aorta and the iliac arteries that are accessible
in this cavity.
  a, To compress the iliac artery it is requisite, after relaxing the pari-
etes of the abdomen, that we should exert with the fingers, thumbs, or a
pelote, a pressure sufficiently strong to fall upon the contour of the upper
strait of the vessel,  or between this and the inner  border of the  psoas
muscle, upon the track of a line which would reach from the side of the
sacro-vertebral angle to the middle of the crural arch.  By this compres-
sion we may temporarily suspend, or prevent where they have not already
taken  place,  hemorrhages from the thigh.   We might also, in the same
way, by pressing upon the common iliac, arrest hemorrhages from the
branches of the  hypogastric artery.   It is  evident, however, that com-
pression upon the iliac fossae cannot be indicated but for certain disartic-
ulations of the thigh, and for lesions at the commencement of the femoral
artery, or at the lower part of the iliac artery itself.
  b. The  Aorta.  Since surgery  has  presumed to penetrate even into
the abdomen to reach aneurisms, we have felt the necessity of some means
whereby we might make pressure through  the abdominal walls on the
aorta itself.   Treating of the relations of this artery, I had already said
in 1825, (Anatomie des  Regions, le edit., t. II., p. 126,) "  Cases might
occur in which the aorta would have nothing intervening between it and
the umbilical wall except the peritoneum and omentum ;  so that in wounds
of this great arterial trunk it would be possible, in fact, after having re-
laxed the muscles by the flexion of the trunk  forwards, temporarily to
suspend the hemorrhage by pressing on the  left side of the spine."
  From that epoch the compression of the aorta has become the subject
of particular researches, and of  applications altogether new.  I employ-
ed  it,  in the year  1831, upon  an occasion in which I was made  fullv
sensible of all its advantages, in a case of wound  of the  external  iliac
artery.  It is easy  to conceive what assistance might be derived from it
if we  were applying a ligature to the common, or to the external or in-
ternal iliac, and in all cases of wounds of those very large trunks.  The
compression of the aorta however, has  principally attracted the attention
of practitioners,  as a means of suppressing  external hemorrhages, and
especially  those that occur after parturition.
  Since the period at which M. Trehan (Bullet, de Firussac, t. XVI.,
p. 452) and M. A. Baudeloque (Jour, des Conn. Med.  Chir., 1.1., 1834)
contended for its discovery, in 1820 and 1828, it has been ascertained
that Saxtorph, Plouquet and Schweighaeuser, had already extolled  it
under various forms, and that Boer, Madame Lachapelle, and Duges had
also spoken  of it.  There are  also a multitude of practitioners, as for 
TREATMENT OF ARTERIAL LESIONS.
689
example, MM.  TJlsamer, Eichelberg, Siebold, Blount, Lovenhart, Bros^
sart, Latour, and Martins, whose observations I have elsewhere referred
to,  (Tocologie, ou Traite  de l'Art des Accouchem., 2d  edit., t. IL,
p. 545,) who assert that they have employed  it with advantage in  cases
of excessive flooding from the uterus.  I will add, that I have recommend-
ed it, or performed it, four times with success, under similar circumstan-
ces, since 1834. This compression, suspending tho whole circulation in
the uterus, as well as in the  lower extremities, necessarily, as we may
perceive, puts a period to the dangers which the woman is then exposed
to.   Had it no other value  than to give time to act, and to  enable • the
surgeon to  promote by suitable means  the retraction of the uterus, it
would be a most important resource ; but from what I have seen, and it
is in accordance with the observations of M. Baudeloque, I feel author-
ized in giving it as my opinion, that if it should be continued for a quar-
ter or even half an hour  at a time, and alternately si»epended and re-
sumed, it will, in  a certain  number of cases, be sufficient to put an
effectual stop to the hemorrhage.
   Three conditions may be met with where it may be considered neces-
sary to make compression upon the aorta.
   1.  In pregnant  women.   If the pregnancy has  not advanced beyond
three months, the  state of the womb requires no  change to  be made in
the manipulation of the process.  At a later period, and especially after
the fifth month, it would become necessary  in the first place, to compress
the uterus, and this is the aspect  under which the first authors, whom I
have  mentioned, seem to  have considered this  subject.   By pushing
upon the womb from below upwards, and from before backwards, with
the hands or with  a bandage, taking care to incline this  organ gently to
the left, we would then  succeed without  difficulty  in compressing the
aorta.  It  is  probable that  the  compression of the belly, of which so
many writers have spoken, and which has been employed  in hemorrhages
during pregnancy or parturition, owed its success  to this principle.
  2. In a woman who  has just been delivered, the walls of the abdomen
are ordinarily so pliant and flabby, that it becomes exceedingly easy to
press them into  contact with the  vertebral column.   The surgeon, after
elevating the head  and thighs of the patient, by means of pillows, presses
the abdomen opposite to  the umbilicus, or a little  below it.   Taking
care  to push aside all the  neighboring organs  by  certain undulating
movements, he quickly comes to the spine,  where  he  soon perceives the
pulsations of the aorta.
  To flatten  this artery  he has  then nothing more to do than to place
one  of his thumbs  crosswise upon it, and  to  support, that thumb by the
other, in the same  manner, as  I have said in speaking of the femoral
artery.  We may make use of the fingers  as well as the thumb, or  of
the pelote or the seal properly arranged ;  but the thumbs are evidently
better.  By pressing also a little more to  the left  than to  the right, we
should avoid the vena cava sufficiently, so  as not to interrupt any other
than the arterial circulation.
  3.  In a man, or  in women who  are not pregnant, the operation is per-
formed  in  the same  manner, but with more difficulty, because of the
little pliancy, and  also the thickness of the walls of the belly ; also, it
   Vol. I.                     87
       • 
690
NEW ELEMENTS OF OPERATIVE SURGERY.
would require greater precautions in the relaxation of the muscular sys-
tem, and in the exact application of the compressive forces.

     B.— Compression  of the  Arteries in  the Case of Wounds.

  When an artery has been wounded, and a hemorrhage results from it,
compression is the first thought that presents itself, not only to the mind
of the surgeon, but also to that of the bystanders.   Whether  the blood
escapes outwardly, as in  traumatic hemorrhages, properly so called, or
that it is effused and infiltrated into the tissues, as  in diffused aneurism,
compression nevertheless  may  be employed  in various ways to remedy
the difficulty.  The  practitioner, in such  cases, is  to  look also to two
indications :  first, either he has no  other object in view than  to  arrest
the hemorrhage temporarily, while permanent means are being  pre-
pared ; or, secondly, he  attempts at  once a definitive cure by compressing
either on  the point wounded, or  on some other region of the bleeding
artery.

                    I. Temporary  Compression.

  In cases of arterial wounds, temporary compression  is  always indi-
cated.   We perform it  either on the wound itself, or outside of it.
  a. To compress outside  the wound, we  must conform  ourselves in
every  respect to the rules laid down  in the preceding  chapter.   This
kind of compression will  not in general answer in certain regions of the
body.   On the  carotids, for example, it sometimes allows  the blood to
return to  the upper end  of the  vessel, whereby the hemorrhage is re-
newed. If we should compress but one of the arteries of the fore-arm,
in a wound of the hand  or wrist, the  other  artery in  the  same region
might in like manner keep up the hemorrhage.  It is important  there-
fore to compress  at the  same  time the radial and  ulnar  artery, if we
have it not in our power to make the compression both below and above
the wound.  What I say  of the fore-arm must be equally understood of
the foot and leg.  There  are cases also in which, in consequence of some
anomaly in the  arm or  thigh, the same difficulty is experienced in at-
tempting compression upon  the root of the vessel only.  To effect this
compression there are also required certain anatomical conditions which
are not always present.   The wounds of the subclavian and of the lower
third  of the  carotid, render it manifestly inapplicable.   [See note 30,
Mott, infra.]   When the  size or  rigidity of the belly is  an impediment
to the compression of the aorta, we should be in a  similar embarrass-
ment for wounds of the iliac arteries and those of  the upper part of the
femoral.
  b. From this we may perceive, that  compression on the wound itself
ought to be in more general use, and that it would  be  sometimes more
efficacious than upon a sound portion of the track of the artery.  In
this mode compression may be  made by means of the  thumb, fingers,
bandages, &c.  The fingers or the thumb should be preferred as often as
they can be applied to the bottom of the wound.  If there  should be
too much inequality in  the division of  the tissues, and too many difficul
ties encountered  in searching for  the wound 'of  the vessel, we should 
TREATMENT OF ARTERIAL  LESIONS.
691
 succeed better  by tamponing or by small balls of lint, pieces of agaric
 or graduated  compresses, than with  the fingers.  In  case  this wound
 was very oblique, and the situation of the artery not very deep, it might
 be advisable to seize it in a flap of the soft parts, between  the  thumb
 and forefinger, or between the two first fingers.   There is no necessity
 of adding that this  kind of compression is attended with the serious
 inconvenience of irritating the wound, and of preventing the surgeon
 from being enabled to examine its interior.   It is consequently only ad-
 missible in the event of the failure of the other method, or while we are
 looking for a suitable point upon the root of the artery.

                     II.— Curative  Compression.

   II.  If we should desire also to put  a definitive  termination to the he-
 morrhage by means of compression,  we may recur  to either  one of the
 two preceding methods.   The ancient  surgeons having  but very vague
 ideas upon the circulation of  the blood, and ignorant of all the advan-
 tages that were to be derived  from the strangulation of the vessels,  had|
 for the most part, no other remedy  for arterial hemorrhages than com-
 pression, caustics, or astringents, which they applied  directly to the
 wound itself; but since the ligature  has become known, and that  sur-
 geons have  demonstrated the impossibility of arresting certain trau-
 matic hemorrhages without obliterating the artery that supports them,
 compression  on the wounded  point  is  rarely any  longer  employed.
 Nevertheless  there are some surgeons  who  still recommend it in prefer-
 ence to the  ligature, and who do not   accept the aid of this last until
 they  have ascertained  the  insufficiency of  compression.  Mr.  Guthrie,
 (Malad. des Arteres, p. 320,) for example,  recommends that before we
 come to the ligature, we should always make  trial of compression, un-
 less the wound is manifestly upon the principal  arterial trunk of the
 limb.   There are  also an infinite  number of facts  to prove that we  may
 by this means effectually control hemorrhages from arteries of very  con-
 siderable calibre.

                     A.—Direct Compression.

   By means of direct compression and astringents, Jacques  Demarque
 ( Traiti des Bandages,  p. 504) cured a wound of the brachial artery
 in four patients.  A similar case has been published by Chappe, (Jour.
 Gen. de Med., t. XXV., p. 26.  Caestric (Gaz.  Salutaire,  1767,  No.
 46, p. 3) was not  less fortunate  in  compressing by  means  of agaric,
 and by  bandages and the hand,  a  wounded  carotid.  Special instru-
ments had  obtained two similarly fortunate results  for the father of
Muys.   Formi (Bonet,  Corps de Med., t.  IV., p.  190) cites a  he-
morrhage of the fore-arm, which he radically cured  by plugging  and
compression.   In a case of wound of the fore-arm, the ligature upon  the
radial artery not having arrested the  hemorrhage, compression was had
recourse to, which put a termination  to the  difficulties, (Dudaujon,
 These, 1803,  p. 20.)   Bourienne, who blames the  ligature and  too
strong a compression, says he  has cured, by moderate  compression, a
hemorrhage from the  inter-osseous artery of the fore-arm.  A  hemor- 
692
NEW ELEMENTS OF OPERATIVE SURGERY.
   rhage from the leg, caused by  fracture, was thus arrested by Colomb,
   (Obs. Mid.  Chir., p. 403.)  I have  several times, and  once  also  in
   1838, at the hospital of La Charite, effectually  arrested, by direct com-
   pression, a hemorrhage from a wound in the  palmar  arch.   M. Champi-
   on has not been less fortunate in compressing a primitive false aneurism,
   and it is not to be doubted that a great number of wounds of the brachial
   artery were  formerly cured by the same  means.   Among^ the curious
   examples of them that science  possesses, I cannot avoid citing the fol-
   lowing :  Sent for to a  lady of eighty years  of  age, and who had  been
   bled twenty days before, Myngelouseau  found a hemorrhage which had
   resisted astringents and bandages.  It was  arranged that students in
   surgery should hold their fingers upon the opening  of the artery night
   and day for twenty days, by which means a cure was obtained.
     We should not, however, rely upon the efficiency of this  means but
   in a very small number of cases.  On the dorsum  of the foot, behind
   the internal malleolus, above the instep,  at the  palm of the hand, a lit-
   tle above the wrist, and sometimes at the bend of  the  elbow,  it  may
  "Suffice ; everywhere else direct compression  would  expose to too many
   dangers, and present too slight a  prospect of success, to  authorize its
   general use.  It would not, in fact, be allowable, under the circumstan-
   ces I  have mentioned, until after we had assured ourselves of the  diffi-
   culty  or impossibility of seizing hold of, twisting  or tying the  injured
'   artery at the bottom of the wound.
     As  to the manipulation of this mode of compression, it is the same as
   for indirect compression, or that which I shall point out iu the next ar-
   ticle,  in speaking of aneurisms.
     [Dr. Mott has recently treated  what  he believed  to be a  wound  of
   the subclavian  artery, by the  immediate application  of a small portion
   of compressed sponge upon the bleeding  part, situated at nearly the
   depth of the forefinger.  The artery was wounded during  an  operation
  for the removal of a small tumor above the clavicle.   The first, was fol-
  lowed by other small portions of sponge, until the wound  was entirely
  and compactly filled.  An entire flat piece of sponge, just the size of the
  external opening of the wound, was now nicely adjusted over the ten or
  dozen smaller  pieces which had been  previously impacted.  Finally, a
  larger flat piece of  sponge, of still greater dimensions than the last, was
  used to cover tho  whole mass, and to extend some distance  on every
  side beyond  the margin of the wound.   Pressure with the* hand  was
  then made, by a succession  of assistants, unremittingly  for three days
  and three nights.   After this, the pressure  was confided to adhesive
  straps and a bandage, until suppuration made it  proper to commence
  the removal of the  sponges.  This was done from day to day with the
  utmost care, and by taking  away  piece  after piece,  without  the  least
  violence, until the last was separated, which  was  finally effected at the
  expiration of a week from  the time that this surgeon commenced with
  their  removal.  The wound then granulated  and healed beautifully.
  The advantage of this method, in  the  opinion of  Dr. Mott, consists in
  the application of a number of small and separate pieces,  by which por-
  tion after portion, at a suitable time, may be  removed, without the least
  possible violence to the wounded  artery.  T.] 
TREATMENT OF ARTERIAL  LESIONS.
693
                     B.—Indirect Compression.

  Applied to wounds, compressive means cannot be  maintained there a
long time without  causing acute pains,  and occasionally endangering
very serious accidents.  When we wish to effect, by this  means, the ob-
literation of the  diseased  vessel, we  should  give  the preference to
making the compression at some distance above, or, if the condition of
the arteries required it, below the  wound.  Numerous examples of suc-
cess obtained by this method have been published  at every  epoch of
science.  It is for this kind of compression that Verduc (Pathol.  Chir.,
chap. II., art. ler,  p.  147) contrived his collar, and  that M. Chiari
(PI.  Portal, Clin. Chir., t. I., p.  154) boasted of his.  A  compressing
bandage, extended from  the wrist  to the  shoulder, enabled Faivre
(Ancien Jour, de  Mid.,  t.  LXXIII. p. 376) to cure a wound of the
radial artery without ligature.  M.  AVytterhoeven (Rev.  Med., 1835,
t. I., p. 231) speaks of a wound of the  brachial artery, followed by a
severe hemorrhage, which was arrested by making circular compression
above the wound for thirty-six hours only.  I  have  seen a case nearly
similar to this in  La Charite, in 1837.  A  young workman,  while
breaking a square  of glass,  had made  a large  opening into the ulnar
artery, in the lower third  of the fore-arm.  To arrest the  hemorrhage,
his comrades bound the arm up tight with a pocket handkerchief, twisted
in the form of a cord.  Having on the following day removed this spe-
cies of bandage, with the intention of tying the artery, I saw no he-
morrhage re-appear,  and the cure took place without any necessity of
applying a ligature.  Nevertheless, the artery had been completely di-
vided, as well as the nerves, tendons, and muscles in its neighborhood.
Consequently, the  temporary compression which we are sometimes com-
pelled at first to make above the wound, upon the track of the injured
artery, might in certain cases be  converted, with  some chances of suc-
cess, into a curative means of compression.   Nevertheless, as  it  is im-
possible  to effect it without  interfering with the venous circulation,  the
distribution of the  nervous fluid, and all the  other functions of the part;
and as it is generally painful, and  of doubtful efficacy, I  would not ad-
vise to have recourse to it, unless it should be found  too difficult to
reach the artery, at the bottom of  the wound.  I shall, however,  in  the
following article,  treat of the means by which this is to be accom-
plished.

                       [Alveolar  Hemorrhage.

   Tamponing or Plugging, properly and carefully performed as in  the
case related by Dr. Mott, (supra,) with  pieces of  sponge to the subcla-
vian artery, will succeed,  when  all manner  of  styptics, cauteries, caus-
tics, and ordinary  modes  of plugging, fail.  Dr. Balaffa of the General
Hospital of Vienna, appears to have acted thus very judiciously in  the
case of a butcher,  who was  attacked with one  of those fearful hemor-
rhages which are so well known to follow occasionally extraction  of  the
teeth, in this instance a lower carious incisor, as he  had  already  expe-
rienced, after the extraction of another incisor in this jaw ten years  be 
694
NEW ELEMENTS OF OPERATIVE SURGERY.
 fore.  For three days and nights the bleeding continued profuse. Brought
 to the Hospital, Dr. Balaffa, (see the case as drawn  up by Dr. Joseph
 Hartraann, Jour, des Connaissanc.es, Sec, Paris, Oct.1844, p. 163,) pre-
 pared a conical dossil of lint and wax the size of which corresponded to
 the diameter of the alveolus: this dipped in a mixture of oau de The-
 den, creosote and sulphuric acid, was adjusted firmly  into the bleeding
 socket.   Upon the top of this cone  he applied a layer of the same na-
 ture, above this a second, wider and thicker, and still  over that a small
 square plate.  This arrangement adapting itself exceedingly well to the
 jaw, from the  patient having lost the adjacent  teeth on the left side,
 M. Balaffa ingeniously secured  the whole by means of a rather narrow
 bandage, which was passed in a  transverse direction, towards the angles
 of the mouth, and downward towards the chin, from  which latter  it
 was conducted to the occiput towards the vertex,  finishing with circular
 turns around the forehead.  This bandage while it firmly secured the
 plug, made also pressure upon it.  The hemorrhage  ceased and the pa-
 tient slept well.   On the third day after the most rigid repose the dres-
 sings were renewed, and on the  sixteenth he was  discharged.  T.]

           C.— Compression in the Treatment of  Aneurisms.

    Two kinds of compression—indirect  and direct have been  employed
 for aneurisms.
    Aneurisms of the carotid and subclavian, have been cured by Acrel,
 by means of methodical compression made upon the tumor.   Those of
 the ham, thigh, groin, hand and elbow, have been successfully treated
 in the same  manner by Fabricius of Hilden, (Bonet,  Cours  de  Med.,
 p. 96,)  AValtin, (Ancien Jour,  de Med., t. LXV.,) Tulpius, (Bibl. de
 Manget, ou, Obs. Mid.,  p.  305, lib.  IV., cap. 17,) Platner, (Thiden,
 Progres de la  Chir., p. 26,) De Haen, Trew, (Ibid.,) Plenk, Petit, The-
 den, Guattani, and a multitude of others ; so that we cannot call in ques-
 tion its efficacy ; it has been employed in a great variety of ways ; some-
 times the compression was made upon.the aneurism only ; at other times
 on the aneurism and the rest of the  limb simultaneously;  in other cases
 on the contrary, it was only made below or above the  tumor.
    a.  On the  Tumor or the  Diseased Part.  Galen  is one of the first
 who used compression in the  treatment of  aneurisms;  plasters,  aud
 pieces of sponge  kept on by bandages, perfectly  succeeded  with him in
 curing a patient who had the artery  wounded in bleeding.   At the time
 of Dionis, (Huitieme Demonstr., p. 693,) they applied upon the wound
 pieces of papier-mache, agaric or tinder, supported by a piece of money,
 then  by other pieces of a larger size, so as to form  a pyramid  whose
 point would  correspond to the  opening of the artery ; the whole being
 supported by an appropriate  bandage.  The Abbe Boudelot (Diomis.,
 edit. Lafarge, p. 697) relates that he cured himself of a false consecu-
• tive aneurism, by keeping for a year a cushion strongly pressed upon the
 tumor.
    Since then, in the first half of the last  century  especially, Surgeons
 occupied  themselves  much with  improving this kind of  compression.
 Arnaud, (Mem. de Chir., t. 1./) Heister,  Ravaton, Verduc, &c., pro-
 posed different  bandages with a view of rendering  it more easy and
• 
LESIONS OF THE ARTERIAL SYSTEM.
695
sure ; each one of them proposed to modify the compressive instrument
of Scultetus or the tourniquet of J. L. Petit, and  all supposed that they
had  found the means of curing aneurisms without an operation. Foubert
had  a steel ring  constructed  of oval form, carrying upon  its broadest
part a plate, provided with a cushion ; the other part of the ring being
perforated by a  quick screw  which was also provided with a cushion
upon its extremity, so that on being applied it was intended to compress
only the diseased point and the part of  the limb diametrically opposite.
This machine more ingenious than many others, and better than those
plates of lead, silver, or iron, whether provided or not with cushions, or
sponges, and which were fixed upon the aneurism by means of ribbons,
straps of leather  or bands, was  nevertheless attended with this serious
inconvenience ; viz., that of being easily displaced, and of not establish-
ing any compression, except upon a diseased  and  very  limited  portion
of the artery, while it  also produced engorgement of the part situated
below, and was not supportable but by a small number of patients.
   b. On the whole  extent  of the limb.   Compression on the whole length
of the  diseased limb has therefore seemed preferable to local compres-
sion.  Gengha practised it  in  the following manner.  I make, says he,
on  each finger an expulsive bandage by means of a small band ; then I
envelop the  hand  and fore-arm in the same  manner nearly up to the
wound; I place  on this last a large tent (which  word now means a
plug, T.) of fine linen, saturated  with a melange of red earth, Arme-
nian bole, dragon's blood,  haematite stone, plaster, white of egg, and
plantain;  I apply  over that a layer of thick lead, some compresses,
and  three  or four turns  of bandage till it reaches above the elbow;
afterwards by means of the the same bandage I fix upon the track of the
artery, on the inner side  of the arm, a cylinder  of wood,  enveloped in
linen to serve as a splint: I then bring my bandage upon the wound to
fasten it there by a few more turns; after which I moisten  this bandage
with an astringent liquid, and put  the patient under a very restricted
and cooling regimen.
  This, with  the  exception of  the cylinder of wood, is what is general-
ly known at the present time  under ihe name of the bandage of Theden,
(Progres ultirieure de la  Chir., etc., p. 27,)  who  moreover made appli-
cation  to  the tumor of compresses  saturated with eau vulneraire.   In
this  manner  there  is less to apprehend of infiltration in the limb; tho
pain is  less acute  and the compression more easily supported; but the
circulation of the  collateral or supplemental arteries is thereby rendered
much more  difficult than  by  the  other method,  and so much the more
so as we are obliged to make the compression with so much the greater
force.
  c.  Below the   Tumor.   According to Boyer, (Boyer, Mai. Chir., 2d
edit., t.  IL, p.  157,)  a military surgeon, named Arernet, had conceived
the  design of curing aneurism of the limbs by establishing a point of
compression on the  course of the artery below the tumor.  Yernet tried
this  method on  a patient  affected  with inguinal aneurism;  but the pul-
sations  in the sac  increased with the greater force, and the author felt
himself compelled  to renounce his invention ; it is a method which has
generally  been censured, even by those who adopt the ideas of Brasdor
for  the  ligature, but which nevertheless does not  appear to have merit- 
696
NEW ELEMENTS OF OPERATIVE SURGERY.
 ed unqualified proscription.   If, for  example, we had to treat an aneu-
 rism above which it would be impossible or at least exceedingly danger-
 ous to apply a compressive dressing or a ligature ; and if, on the other
 hand, no important branch was given off between the cardiac extremity
 and the free part of the tumor, it does not follow that by compressing the
 artery upon the  other side of the tumor, we might not succeed in inter-
 rupting the circulation in the aneurism, promoting the formation of a
 solid  coagulum in its cavity, and ultimately effecting the obliteration of
 the arterial canal and a perfect cure.
  d. Above the  Tumor.  Remarking that the bandage of Theden, that
 of Guttani, and all  the  machines for partial compression tend to inter-
 rupt the collateral circulation in the limb, or to induce the rupture of the
 aneurism, if it does not yield to their action, surgeons at an early period
 directed their attention to some mode of compressing the diseased arte-
ry at the point where it is most superficially situated, between the tumor
and the heart. M. Freer (Caza Mayor,These No 151, Paris,  or, Obser-
vation on Aneurisms, 1807) has greatly extolled the bandage of Sennefio,
 designed for this  object.  This practitioner first surrounded the whole ex-
tent of the limb  with a roller bandage moderately tightened, and after-
wards placed a small cushion at some inches above the tumor.  A plate
was applied to the opposite surface of the limb, which he surrounded
with a tourniquet  in  such manner as to enable him to press the artery
upon a siugle  point  by means of a screw.  At  the expiration of a few
 hours, says M. Freer, the limb becomes cedematous and tumefied ; after
 which the tourniquet may be removed, and no other dressing used but a
 cushion and a bandage applied sufficiently tight.
  This bandage, which is a combination of those  of Theden and Foubert,
 might, as  it appears to me, be employed with  some prospect of success.
 Dubois, (Bullet,  de la Facul. de Mid., 6e  annee, p. 40,)  a long time
 ago, effected the  cure of an aneurism of the thigh, by making use of a
 species of spring, constructed upon  the principles of the tourniquet of
 Petit, and which acted only on two narrowly circumscribed points of the
 limb.   Albert of Bremen (Caza Mayor,  Oper.   cit.)  obtained  similar
 success from  a bandage  which he calls the inguinal compressor, which
 is composed of a pelote intended to be  applied against the pubis on the
 track  of the femoral artery, and of two leather straps, which embrace
 the whole circumference of the pelvis and the upper portion of one of the
 thighs.  M. Verdier (Appareil Compressif de l'Art. Iliaque, 1822) ef-
 fected  the  same  result by means of a bandage which has some analogy
 with the hernia bandage of Camper.   Dupuytren (Bullet, de la Facult.,
 t. VI., p. 242) had another constructed, which is composed of semi-cir-
 cle of solid steel, surmounted on one side by a broad, thick, and concave
 pad which was to  be applied  upon the surface of the limb opposite to
 the artery ; and  having on its other extremity  an iron plate which, by
 means  of  two  uprights, and  a quick screw, sustains a rounded pelote,
 which was to be applied to the artery, and could  be made to approximate
 or recede from the other pad at pleasure.   By means of a species of
 dog-collar, making  compression above the tumor, M. Viricel (Bullet, de
 la Facult., 6e annee, p.  132)  has effected in the hospital of Lyons un-
 questionable cures.   The author of an ancient thesis (Morel, These de
 Strasbourg, 1812)  asserts that we should succeed yet better, if the com- 
TREATMENT OF ARTERIAL  LESIONS.
697
pression were made at the same  time upon  many points of the limb.
This  last precaution, the  suggestion of which has been  contested by
MM.  Leroy  (Depot, a l'Institut, 1830.—Gaz. Mid.  de Paris, 1835,
p.  202, 239) and Malgaigne, (These de Concours pour la Clin. Chir.,
1834,)  is  described  with care, and warmly extolled by M. Guillier de
la  Touche.  ( These, Strasbourg, 1835.)  Finally, M.  Blizard, and M.
A.  Cooper (S. Cooper, Diet., etc., trad. Franc., p. 120) have employed
another  instrument, not less  ingenious  than those that have been men-
tioned.   A long piece  of steel is first adjusted to the outer side of the
knee  and the great trochantar ;  from the middle of this piece there pro-
ceeds another which advances in a half circle towards the femoral arte-
ry, and carries upon its extremity a plate provided with a pad,  capable
of  being  moved by means of screw, and of  compressing the  artery
with  such force as to cause a cessation of pulsations of  the aneurism
without interrupting the circulation in vessels of less calibre.
   The compression employed in this manner may without doubt succeed,
and should be had  recourse to in some cases, for example, in aneurisms
of  the neck, of the subclavian artery, and the upper part of the femoral,
if from any cause whatever, we were prevented from using  the ligature;
in other cases, it is certain it will but seldom  answer.   The patient of
whom M. Cooper speaks, could not support it but a very few hours.  In
one of those whom Dupuytren treated, it became necessary to shift the
bandage  successively to  different points of the  artery, and in  a short
time  to lay it aside altogether.  M. Roux relates  a similar case, and in
the patient mentioned by M. Verdier, it  required  all the constancy and
resignation that he exhibited, not to reject  the apparatus, a few days
after  having begun  the  use of it.  To obtain moreover every advantage
possible from it, we should associate with compression, a rigid regimen,
and also topical refrigerants or astringents.  It has, I know, succeeded
without these adjuvants, even in persons who persisted  in using violent
movements and the most fatiguing exercises.  Lassus (Medecin. Operat.,
p. 452) speaks of a man who, after having applied to an aneurism in
the ham a bag filled with  salt, fastened by four long bandages of linen,
and then  effected compression upon  the artery of the  thigh, imagined
that he could accelerate the cure  by making every day a forced  march,
and taking far more exercise than he had been  accustomed  to, and who,
in fact, ultimately succeeded by this means, after the expiration of eight
months, in curing himself of the disease ; but the surgeon must not take
exceptions like these for his guide.
  e.  Appreciation.   If the compression did not at the same time act
upon  the veins, and also  occasionally upon the nerves, if it were true
that it would at least prepare the way for the application of the ligature
by  forcing the collateral arteries to dilate, and that  it was  never at-
tended with danger, we should  undoubtedly be wrong in neglecting to
have  recourse to it under all circumstances ; but the ligature in these
latter times has been rendered so easy and simple in its application that
we  can no longer, in reality, place any great  degree of reliance upon
other  means.
  Even up to the time of  Scarpa, compression had been warmly advo-
cated, because in conformity with the prevailing doctrines of J. L. Petit,
(Acad, des Sciene, for 1731,1732,1735,) it appeared  to be  naturally
  Vol.  I.                   88 
 698            NEW  ELEMENTS OF OPERATIVE SURGERY.

 calculated to effect a cure of the aneurism without obliterating the artery.
 When the blood is arrested, saysFoubert, the wound upon which a suffi
 cient compression has been made closes  up; the skin, the  fat, and the
 aponeurosis cicatrize ; the wound in  the artery, however, does not unite
 primitively, but leaves a round aperture occupied  by a clot of blood.  If
 the compression is continued for a sufficient length of time  to effect the
 induration of this clot, the patient is radically cured ;  but  if we allow
 the arm to be  moved before the clot has  acquired sufficient solidity to
 complete  the  adhesion of the tissues, it escapes  from the opening, and
 the blood insinuates  itself around it, and detaches it from the place it
 occupied.   It  has since been ascertained,  however, that cures thus
 obtained were radical;  that the clot  which constitutes a kind of cork or
 nail, as J. L. Petit called it, and which fills up the opening of the artery
 never becomes identified with  the tissue  of  the vessel; that  sooner or
 later it is driven  out,  and that the aneurism  then  returns.  Thus, in the
 case related by Saviard, of an aneurism  at the  bend of the arm, the
 patient, to all appearance, had been  cured for the space of  near  fifteen
 years,  when, in  consequence of some effort  made, the tumor  returned.
 It is, therefore, useless to hope for the  cure of aneurism by any other
 mode of compression  than that of the obliteration of the artery.
   This point  being conceded, it remains  only to  ascertain which one
 among the methods that have  been  proposed is  the most  suitable for
 effecting this result.   Scarpa thinks it absolutely necessary that the two
 opposite walls of the  canal should be placed and kept in contact during
 a certain length of time, but that the  compression  upon the tumor  effects
 this  result with difficulty;  consequently he advises us to  act above the
 tumor, except, however, in cases of recent traumatic aneurisms.   Experi-
 ence does not corroborate the opinion  of Scarpa.  Guattani has cured four
 aneurisms out of  the fifteen which he treated by  applying his bandage
 upon the tumor  itself.   Flajani has  obtained the same proportion  of
 cures, under the same circumstances, and  every day we still hear of the
 announcement of  similar results.
  The  aneurismal varix so well described  by  Guattani  (De externis
 aneurismatibus, etc., 1772) and W. Hunter, accommodates  itself much
 better than any other kind of aneurism to the compressing bandage, and
 is often cured by this  application.  The two Brambilla and  Monteggia,
 each relate an example of this kind ;  it is, at least,  a palliative remedy,
 even though it may not succeed in accomplishing a radical cure.  An
 elastic  sleeve, or a simple laced  stocking arrests  the progress of the
disease, and gives to the  limb the power of fulfilling its customary func-
tions, without exposing the patient to the  slightest  risk of danger.  A
lady thus treated by Scarpa, wrote to this  surgeon at the expiration  of
fourteen years, that she  experienced no other inconvenience in the af-
fected arm, except occasionally  a slight degree of numbness.
  If Cleghorn, instead of advising his patient  to change his trade of
 shoemaker for that of barber, that he might be enabled to  hold his
 arms elevated, had employed  compression, he would, without  doubt,
 have obtained the same  advantage from it.  But  inasmuch as the state
 of the patient of whom Hunter speaks, had not, after the lapse of thirty-
 five years, grown  any worse, that in three several  cases Pott did not
 feel himself obliged to perform the operation, and that B. Bell, as well 
TREATMENT OF ARTERIAL LESIONS.
699
      as Bertrandi,  and many  others have  seen the same result, prudence
      recommends  that in cases of aneurismal  varix, we  ought, before pro-
      ceeding to the ligature, to make trial of  compression.  A man who has
      an aneurisin of this kind in his thigh since 1813, and whom I have had
      an opportunity of seeing during the space of two months at La Charite",
      has never worn a bandage, and is scarcely sensible of his infirmity.
         [If it be true, as  stated in the text, that patients  frequently do not
      suffer serious inconvenience from this affection, there  are exceptions, as
      the reader may satisfy himself by perusing the details of the unfortunate
      case in which M.  Roux  operated in 1834.  Mr. Tarral has given an
      excellent description of  this  case  in  the article " Arm, Bend of," in
       Costello's  Cyclopedia of Practical Surgery.  Another fatal  case has
      been reported by Mr. Hilton, in the Lond. Lancet, Am. Ed. July, 1851.
      Mr. Cock, of Guy's Hospital, has also furnished us with  the details of a
      case involving the popliteal artery and posterior tibial vein, which led to
      the necessity of amputating the limb.   We might refer to other cases of
      a similar nature,  but these are sufficient to show that a  simple  laced
      stocking  is  not  always  sufficient  to arrest the progress  of the dis-
      ease.   G. C. B.]
         If we wish only to support the parts, the laced stocking,  or the simple
      roller bandage of Theden suffices ; but if our object is to obtain a radi-
      cal cure, compression  requires other precautions to  be  adopted, the
      same, in fact, as  for other kinds of aneurism, that is  to say, that in ad-
      dition to  the roller bandage carefully applied from  the free extremity
      to the upper part of the  limb, where it  is  to be fastened by one or two
      turns of spica around the trunk, it is requisite that we should previ-
      ously place upon the tumor,  supposing that a tumor exists, some lint,
      sponge,  or graduated compresses, saturated with cold  and  repellant
      liquids, and that we should apply a long compress over the track of the
      artery between the wound and the heart, and adjust over that, after the
      method of Sennefio, a special compressor, one for example, like that of
      Foubert or Dupuytren.
         Wherever  these aneurismal arteries rest upon  bones or other solid
      parts capable of furnishing  them with  a sufficient point   d'appui, and
      where they  are not separated from the surface of  the body but  by the
      common integuments, the aponeurosis or cellular tissue,  compression
      offers every possible advantage, and should be frequently had recourse
      to, in conformity with the rules laid down  in the chapter which I have
i      devoted to this subject  above.
         [In the Gaz. des Hopitaux, April,  1851, our author has reported a
      case of false aneurism of the  radial artery, which he successfully treated
      by compression of the brachial artery.   The instrument used was Petit's
      tourniquet, and it was applied on a level with the attachment of the co-
      raco-brachialis muscle.   In  consequence of excessive  swelling of the
f      arm, it was relaxed the  same evening, and the next morning removed
5      altogether.   Notwithstanding the discontinuance of the  instrument, the
      tumor rapidly diminished in  bulk, and its pulsations ceased.  In May,
      1853, in another  case, he tried the  injection of the perchloride of iron,
      but without success.  In this  instance, he was compelled to tie the
      brachial artery.   M. Thierry has cured  a case  by forced flexion of the
      limb, the latter being retained in  this position for  a fortnight.   This, 
700
NEW ELEMENTS OF  OPERATIVE SURGERY.
however, is a painful and inconvenient method of employing compres-
sion.   (Vid. Lond. Lancet, vol. 2. 1852. p. 445.)   G. C. B.]
  [A case occurred to Mr. Curling in January, 1852, showing that com-
pression and the ligature may often come in to the aid of each  other.
The sac was opened and a ligature applied above it.  Hemorrhage oc-
curring on the fifth  day after the  operation, a tourniquet was applied
over the  brachial artery and kept on for eight  consecutive days.   The
patient was discharged cured  forty-four days after admission.  (Lond.
Lancet, April, 1853.)  Dr. Jameson of Baltimore  has also reported in
the Maryland Med. Recorder (Vol. HI., 1832, p. 40) a case of wound
of the ulnar artery which was cured by  compression, after the ligature
had failed.   G. C. B.]

                    §"II.—Direct Compression.

  It often happens, that surgeons find themselves so situated as to ren-
der it impossible for thena to tie an artery which they have opened either
by mistake  or design; in such cases  it is their usage, in order to save
their  patient from death, to plug up the wound and compress the vessel
by applying to it, directly, the  different substances  eulogized by Trew,
Teichmeyer, &c.  This method, besides being much less frequently em-
ployed than indirect compression,  possesses in fact much  fewer advan-
tages, and ought, at the present day, to be wholly  rejected : some suc-
cess  has nevertheless been  imputed to to it.  (See observations of
Dr. Mott, supra et infra.   T.)
  a.  Plugging or  tamponing—Guatanni, having to treat a very  large
inguinal  aneurism, caused it to be opened by Maximini, with  the  inten-
tion of applying,  immediately upon the artery at the bottom  of the sac
and against the pubis, graduated compresses, firmly secured by a spica
to the groin.   Everything succeeded to the satisfaction of the surgeon ;
the dressing was removed at the end of thirteen  days, and the.patient
was perfectly restored.
  A man had an aneurismal tumor on his groin as large as the head of
a child.  Mayer (Rougemont, Bibliot. du Nord, p. 189) took it at first
for a hernia, and  deciding to lay it bare in order  to reduce  it, did not
discover his mistake until after having divided  the common integuments
and the aponeurosis.  A great quantity  of bloody matter, which had accu-
mulated between the sac and the adjacent  parts was now removed ;  in
place of laying open the tumor, whose pulsation  sufficiently  indicated,
its character, Mayer confined himself to making methodical compression
upon it, which he subsequently renewed with every possible care.   The
patient was cured.
  Desault,  in a case very similar,  compressed, it is said,  the upper end
of the artery with two  pieces  of wood, united  together in the  manner
of a forceps, by means of a portion of thread, by which  means he was
enabled to dispense with the ligature.  A young student of medicine,
aged"fifteen, saw the blood burst from the femoral  artery while he was
dressing a wound in the groin ;  his dressing forceps served him instead
of Desault's pieces of wood;  it was left undisturbed, and M. Champion
assures me  that the artery was rapidly becoming  obliterated, when the
patient was attacked with hospital gangrene, and died  on the  fourth 
TREATMENT OF ARTERIAL LESIONS.
701
day.  But  this procedure, excusable at the epoch at which it occurred,
and in so young a student, would be censurable at the present time.  If
the aneurism is so high up  as not to admit of our cutting down to, or
compressing the femoral  artery between the tujnor and Poupart's liga-
ment, we apply a ligature to the iliac artery, and  avoid the  danger
which Guatani and Desault made their  escape from, only as it were by
a miracle.   Sabatier himself, nevertheless, thought it advisable to un-
dertake direct compression for an aneurism in the upper third of the
thigh; the patient was a young man aged twenty-two years ; two tour-
niquets were applied—one on the fold of the groin, and the other a little
lower down.  The  tumor  being  opened and  freed  from  its clots, the
aperture of the artery was discovered, and found to be perfectly round.
Sabatier passed under this vessel, above  and below the opening, a needle
armed with a strong thread, with  the  intention of completing the liga-
ture, should that become  necessary.   A  pad was placed on the posterior
part of  the thigh opposite the wound, which latter was filled up with a
pyramid composed of pieces of agaric and compresses ; lint well sprinkled
with colophane was arranged around the pyramid, in such  manner as to
support it, and every thing kept in place by compresses and an ordinary
bandage ; some slight hemorrhages supervened, but the patient ultimately
recovered, and was enabled to walk at the expiration of  two months.
   [Mr. Armstrong of the Naval Hospital, Plymouth, and Dr.  H. N. Ben-
net of Conn, have reported cases of popliteal aneurism cured by direct
compression, and in this manner Drs. Dudley and Kirkbride  have success-
fully treated many cases  of wounded arteries.  ( Trans. American Med.
Association, Vol. III.)
   The  use of the  sponge in compression was successfully  adopted in
1807, by  Dr.  Twitchell  of Keene,  New Hampshire. Ligature of the
common carotid having failed to arrest a hemorrhage from sloughing of
the internal carotid following a gun-shot wound, he placed a  small piece
of dry  sponge directly  over the orifice in the artery, and renewed the
compression till  a rather larger piece could be procured.  This was
placed upon the first, as were other  pieces gradually increasing in size,
by which pressure was made obliquely upwards and  backwards against
the base of the skull, the wound being filled with a firm cone of sponge,
the base  of which projected two or three inches  externally.  A linen
roller was  then applied  in such a manner as to press firmly upon the
sponge, passing it  in repeated turns  over the head, face, and neck.
(Am. Journ. Med.  Sciences, Vol. V., N. S. 1843, p. 510.)
   With the sponge  we once succeeded in arresting the hemorrhage from
the internal maxillary artery, caused by a plunge of the patient whilst
we were disarticulating  the lower jaw; the retraction of the artery
having rendered its ligature impracticable.  G. C. B.]
   Notwithstanding  so many fortunate  results, obtained by surgeons of
the first rank, we ought  nevertheless  to reject this  mode of treatment
from sound practice.  The only cases in which we would be permitted
to make trial of it, would be those of false primitive aneurisms.   At the
farthest, it would be applicable only to arteries of the fourth order, or
in those cases where, after having opened an aneurismal sac, it becomes
impossible to find  the  artery—a difficulty which we can  scarcely con-
ceive possible, and which, moreover, could not become a source of em- 
702
NEW ELEMENTS OF OPERATIVE SURGERY.
barrassment at the present time, except in cases where the disease was
in too close proximity with the splanchnic cavities.
   b.  The  Artery-presser.—Desirous of avoiding the vein, nerve, &c,
and of concentrating  as  much  pressure  as ^ possible upon  the artery,
many surgeons have substituted instruments in the form of a forceps, in
lieu of the bandage and lint formerly in use.  Percy, (Soc Med. d'Em-
ulat., t. VIII., p. 689,) in order to fulfil this intention, recommended, in
the year 1792, first a plate of lead;  then, in 1810, a steel forceps, ter-
minated by two small  plates, and  cleft in the direction of its length, in
order that we might be enabled, by means  of a button, to  graduate at
pleasure the  pressure  upon the artery, (Soc. Med. d'Emulat., t. VIII.,
p. 711.)
   In  the same year, Duret,  of  Brest, (These  Paris, 29 Aout,  1810,)
made known  an instrument constructed upon similar  principles ;  that is
to say, a forceps similar to the valet a patin, and which he denominates
the aneurismal forceps.   According  to M. Roux, (Med.  Oper., t. I.,)
an artery-presser, almost in every  respect similar to this, had been de-
vised, in 1808 or 1809, by M. Levesque, a description of which is given
in his Thesis.  (These No. 153, Paris, 1812.)
   A third kind of artery-presser,  invented by Assalini and formed of
two branches of silver united in the manner of a dressing-forceps, and
having between their handles  an  elastic spring which constantly tends
to shut them, bears much resemblance to  that of Duret.'  Assalini  af-
firms that he has cured aneurisms in the  thigh and ham, by leaving his
instrument in place for the space only of three or four  days, and even
after an interval of twenty-four hours.  The artery-presser of M. Henry
(Soc. Med. d'M. t. VIII., pi. 6, fig. 7, 8 et 9,) shaped after the man-
ner of the angular extremity of  the shoemaker's podometre, or that  of
the pelvimeter of Coutouly, has  the advantage  of being  kept more
securely in its place, and of  giving less fatigue  to  the parts than those
of Percy, Duret, and Assalini.   (Manuel de Chirurgie, Sec)  Forceps
and other metallic instruments, which have also been proposed for effect-
ing the same object, by  combining  them with ligatures, will claim our
notice a little further  on.  Such are  the artery-presser of Deschamps,
Dubois, Crampton, Ayzer, Ristelhueber, and the  one which M. Chiari
(PI. Portal,  Clin. Chirurg., t. I.,  p. 156,) says  he  has made use  of
eight or ten times with success.
   [The treatment of aneurism, especially popliteal aneurism, by pressure
would seem to be now established  on a  permanent basis.   This result
is due to the persevering efforts of the Dublin surgeons, among whom
the names of Hutton, Bellingham,  and Tufnell, deserve especially to be
remembered.   From  a misapprehension  of the true principles which
should govern this treatment, patients have been subjected to cruel and
unnecessary tortures, and the treatment itself has been brought into dis-
repute.  Experience has shown that to effect a cure  we need not arrest
completely the current  of blood through the artery leading to the aneu-
rismal sac, but  that the  deposition and consolidation of the laminated
fibrine in the latter require  that the quantity  and force of  the current
be merely restrained and  moderated.  Indeed, as Mr. Tufnell observes
the great point is  to control the circulation with  the  least possible
amount of pressure, and  not, as was  formerly  supposed, to excite in- 
TREATMENT OF ARTERIAL LESIONS.               703
flammation, adhesion and obliteration of the  canal.  The favorite in-
strument with the Dublin surgeons,  is  the " circular compressor" of
Mr. Carte, of that city.  (A. is a compressor for the groin :  B. another
for the middle of the"  thigh.)  The comfort of the patient is  greatly
promoted by the alternate use of these two instruments.   Chafing of the
skin may be prevented  by shaving its hairs, dusting its surface with hair
powder, and by padding the compressor completely in every part.   The
limb having been smoothly bandaged,—supposing  a case of popliteal
aneurism,—and the instrument applied to the groin, the screw is turned
until pulsation in the tumor ceases, though  it is  unnecessary to arrest
entirely the flow of blood through it.  When the pressure at the groin
becomes too painful, the compressor for the middle of the thigh is to be
applied, and tightened, while the  other is gently loosened, which gene-
rally suffices to relieve  the pain.  Mr. Luke has employed an apparatus
which  consists of a strong elastic strap, passing around  the limb, and
attached behind to a  broad leather splint.  The  strap supports the
bridge apparatus in which the  compressing screw works. This instru-
ment is very light.  Two  are to  be used.  The duration of the  treat-
ment varies", according  to the condition of  the tumor and the constitu-
tion of the patient. In some instances a cure has been effected in a few
hours or days, and  in others it has  required from two to  three months.
The average treatment,  we have  found by examining the reports  of 32
cases, in which the time  is mentioned, was 35 days.  Prof.  Syme com-
puted the average duration  in 23 cases, " not of the treatment, but of
the actual compression, excluding the  intervals of its discontinuance,''
at 38  days, upon which  he thus  comments: " Thirty  eight days and
nights of misery, to escape a few  minutes of trivial uneasiness! "  Now
we have already shown that much of the suffering inflicted upon patients
was not necessarily connected with this mode of treatment, and statistics
furnish us with abundant proof that from  the ligature of the  femoral
artery a patient has  something  more to  escape "  than  a few minutes 
704           NEW ELEMENTS  OF OPERATIVE SURGERY.

of trivial uneasiness."  We have taken  some  pains to calculate, from
the cases collected by Dr. Norris, the time that elapses before the liga-
ture comes  away, and we find  that  in 117 cases in which the fact is
noted, the average time is 2015 days.  The patient is certaiuly not safe
until the ligature  has separated and  the wound healed, therefore both
the patient sand the surgeon must have 20{_ " days and nights of misery,"
and the surgeon's anxiety cannot be diminished  when he remembers  an-
other fact likewise  furnished by  statistics, viz., that 1 in  4  of all that
submit to ligature of the femoral artery,  die or  are maimed for life.
Contrast with this the following  statement of Mr. Tufnell in his excel-
lent work " On the Treatment of Aneurism by Compression."  Of 39
cases in which compression was employed in Dublin, 30 were  completely
and perfectly cured.   In  2 cases, the ligature succeeded ; 3 died, 1 from
erysipelas, which prevailed as an epidemic, and which occurred after the
use of galvano-puncture ; and 2 died from disease of the heart.  In  1
case the  treatment was discontinued, but the tumor did not increase in
size, and in  3 amputations became necessary, and in the latter cases, the
ligature of the vessel could only have added to the dangers of the pa-
tient's life.   But the warmest advocates  of compression  would  not
wholly discard the ligature ; they maintain only that in ordinary cases
this  method should be preferred  as the  general rule.  But upon this
point, we cannot do better than  to give Air. Tufnell's own language :—
  " You may  ask me, then, what are the cases  in which I recommend
pressure, and what those  I would  resort to the  knife ?   I  will tell you.
" I  consider compression applicable to every  ordinary circumscribed
aneurism in  an extremity where there is sufficient room for the applica-
tion of the compressing medium of two different points above the tumor,
premising, of course, that pressure on the trunk  of the vessel  completely
controls  pulsation in the sac, thus  proving that  no high bifurcation
exists."
  " I do not advise  it  in  cases which are rapidly extending in size, or
where they continue to do so after compression has been tried.  These
aneurisms have no distinct sac ;  and to afford any chance of saving  the
limb, the blood through the  main channel must be cut off,  and at once,
by securing  the vessel.
  " 1 do  not advise or sanction it in cases where the  disease  has been
allowed to run on unchecked, where the limb has become oedematous
and swollen, and the surface of the aneurism a dusky, yellowish red. In
such a case,  the vein is most probably engaged, and, if  it be  a popliteal
aneurism, the  knee-joint  inflamed.  Here, I believe amputation  is  the
only resource.
  " Understand me, then ; compression I advocate only in cases where
the  sac is entire, and where sufficient room exists for applying the pres-
sure on two  points of the artery above.   At the same time, cases have
so frequently occurred where the  application of a single instrument has
been sufficient for a  speedy  cure  (such, for  instance, as one that I  saw
under the care of Dr. Hutton, where popliteal aneurism of a  consider-
able size, was, in  seven hours and a half, by means of a  single instru-
ment, constructed on Dr.  Carte's plan, rendered completely solid,) that,
although, for prudence sake, and as a general principle, I advocate the
employment of two points of pressure, yet I by no means  hesitate to 
TREATMENT OF ARTERIAL LESIONS.
705
employ a single instrument, and give the patient every chance, prepared
at the same  time to use ligature, if any necessity arise."   (pp. 45-7).
In the London Medical Times and Gazette, for November, 1853, p. 500,
we find the  following  summary  of the results of the treatment in 23
cases in that city.  Thirteen  of these were cured  in periods varying
from  60 hours to 5 months.  In 10 cases, compression was  abandoned,
in one of these, palliative treatment was adopted, and in 9,  the ligature
practised.  Two  of the latter cases  died, in one, pulsation continued
after  ligature, and 5 were cured.   In several  of these cases the tumor
was of unusual size, and many of  the patients were  not  favorable sub-
jects.  In the majority of those cured, the  solidification of the contents
of the sac took place only after long continued, interrupted or inefficient
pressure.   The importance of attention to diet, as recommended by Air.
Bellingham, was strikingly illustrated in one of the cases treated by Air.
Erichsen.  The  aneurism (popliteal,)  was the size  of a large  fist, and
Mr. E. ordered  for breakfast, 4 ounces of bread, 1 pint of milk;  for
dinner, 4 ounces of bread, a chop, and  a small  quantity of water ;  for
tea,  2  ounces  of bread,  1  pint  of milk.   Occasional  small  bleedings
were practised, digitalis was administered, and a cure accomplished in
six weeks.
   In cases like the above, it  is likewise of essential service to  support
the  sac  by well adjusted pressure.  Air. Bellingham  states  that  it is
utterly impossible to apply the pad of the compressing instrument so as
to avoid making pressure  on the femoral vein.
   This fact is urged by Prof.  Syme as one of the most serious objections
against this method of treatment, but Mr. Bellingham  asserts that in
several instances where patients had died from other causes, after com-
pression had been used, he had found the vein uninjured.  If it be true,
as stated  by our author in another place, that AL Grillo has in ligating
the femoral artery, at the same time included the femoral vein and nerve
without injury, perhaps the  damage which  the vein may sustain from
compression  has been over estimated.  To obviate, however, this risk,
it has been recommended  to apply the pressure to the brim of the pelvis
instead of the middle of the  thigh, and in the cases treated in  London
it was observed  that when thus employed the pressure was  better toler-
ated.  Aneurisms of the  tubular,  cylindriform or  fusiform variety, in
which the whole circumference of  the  artery in a certain portion of  its
length, is nearly uniformly dilated, are not so well adapted to this mode
of treatment, as  the  sacciform areurism.   Alessrs. Luke, Colles and
Paget have each treated a case of this kind.  From the  peculiar nature
of the tumor, it is difficult, either  by means of the ligature or compres-
sion,  to effect the consolidation of its contents, and  as a general rule, it
is believed that the cure  in these  cases is caused  by the contraction of
the dilated parts.   Though Air. Colles' patient  was cured  by  compres-
sion in 25 days, in that of Air. Paget, it was continued  for 17 weeks,
when one  morning pulsation  suddenly ceased, (vid. Rank. Abstract,
No. XIIL, 1851, p. 222.) Mr. Hilton has recently treated  a case of
tubular aneurism  of the femoral  artery produced  by the obstruction
resulting  from a thickening of the  sheath of the artery and  from the
pressure caused by phlebolithes in the saphena vein.   The  treatment
consisted in efforts to remove  the inflammatory consolidation in the parts,
   Vol. I.                   89 
706
NEW ELEMENTS OF  OPERATIVE SURGERY.
by means of poultices, bandaging  and the  application of a splint, by
which, in a few weeks, great amendment was produced (Times cf  Ga-
gette, Dec. 1853, p. 029.)
  Prof. Dudley, of Ky. has  long  advocated the treatment of aneurism,
by compression, and  states that he  has taught this doctrine, in his lec-
tures since  1818 (Am. Med. Trans. Vol.  III.)  The following  is his
method of applying pressure:  If it is desired to apply the roller  and
compresses,  for  a popliteal  aneurism, for  instance,  the leg  should be
gently encircled by regular  and  successive  turns from the toes to the
lower border of the swelling—just force enough should be employed to
adapt the dressing smoothly and firmly to the limb.   A pledget of cloth
should then be laid over the tumor, and secured by the ascending rolls
of the bandage.  From Poupart's ligament  to the point where the femo-
ral artery passes through the adductor muscle, a long and firmly rolled
pledget should  be placed—the skin being  protected by a slip  of oiled
silk—and then, the bandage must  be brought up around the thigh to
press this in upon the course of the vessel with force sufficient to dimin-
ish decidedly the pulsation in the  tumor.  The bandage around  the  foot
and  leg  prevents swelling,  and tends to diminish  the amount of fluid
circulating in the limb.   At each  successive application of the dressing,
the pressure  may be increased  without additional pain to the  patient.
Perfect quietude should be enjoined—the  limb sustained in a slightly
elevated position—and medicines employed  to lower the action of the
heart  and  arteries.   We have seen several cases thus treated  and the
suffering was really inconsiderable.  It is not necessary to apply force
enough to close the artery completely, and it is rare that a patient  will
be found of  sufficient fortitude to  tolerate a degree of pressure,  thus ap-
plied, which would be productive of injurious effects; so that we have,
in the sensations of the patient, and  the  condition  of  the tumor,  sure
and  safe indices by which to direct the treatment.
  Mr. Bellingham remarks, that, it is a point of some interest to deter-
mine whether an external aneurism can be considered as cured, although
the channel  of the artery at the seat of the disease, is  not obliterated,
and  a current of blood continues to pass through the vessel.   In a  sub-
ject examined  by himself, in which, some four years  previously,  two
popliteal aneurisms had been treated by compression, there was no ob-
literation of the artery at the seat of  the disease.   He, therefore,  con-
cludes, that  an aneurism may be so far cured that it can neither enlarge
nor give way, although the  blood  continues  to pass through the  artery
from which it springs.   In  these cases, of course, an impulse continues
to be felt at the part, owing to the  communication  of the pulsation of
the  artery to the sac.  Mr. Alonro, of the  Cold Stream Guards, has
given the dissection of a case, when the patient died  of  aneurism of the
aorta, after  a cure  of a popliteal aneurism by compression.   In this
instance, the femoral and popliteal arteries  remained  pervious to the
centre of the popliteal space, (Lond. Lancet, Am. ed., vol. 1st, 1853.)
Dr. Van Buren, of this city, has  recently shown us a beautiful  prepara-
tion taken from  a patient who died under similar circumstances, and in
this  the appearances are similar to those just described.   The specimen
in the University College Hospital Aluseum, taken  from a patient on
which Sir Charles Bell tied  the femoral artery for  popliteal aneurism, 
                 TREATMENT OF  ARTERIAL LESIONS.               707

shows, that, even though the femoral artery be  double, and the tumor
supplied by the one not ligated,  complete consolidation may occur as it
did in  this case, in the  short space of one week.   Air. Curling has
recently treated a case at the London Hospital, and here the pulsations
continued not only after compression, but the ligature of the femoral
artery.  If the opinion of Air. Bellingham be true, and it certainly seems
strongly corroborated  by the cases  which we  have just quoted, the
simple return of a pulsation in the tumor, need not be a cause of serious
apprehension.  In concluding this subject, we would observe that com-
pression on the distal side of the  tumor has been  successfully employed
in the  treatment of axillary aneurism, by Dr. Aliddleton Goldsmith of
Vermont, and with some benefit by Prof. Syme, of Edinburgh, and Mr.
Lyons  of Glasgow, in cases of aneurism of the innominata.  G. C. B.]

                      § II.— Various Means.

   A.  Cauterization.—Cauterization  has  been applied in two modes, in
the treatment of aneurism.  Some, in fact, before the knowledge of the
circulation of the blood, ventured to apply escharotics more or less
powerful  upon  aneurismal tumors  and the  skin  which covers them.
Others commenced by opening and emptying the bloody sac ;  afterwards
they  cauterized the lacerated  part of the  artery, either with red-hot
iron, or the concentrated acids, or by introducing into  this  orifice
lozenge-shaped plugs and pegs of alum or vitriol.  Then also,  and even
since, they confined themselves  sometimes to filling the whole wound
with lint  or  oakum, impregnated with the  same cauterizing  substances.
Such means were good when the nature of aneurisms was unknown, and
when no one was possessed  of anatomical knowledge sufficiently accu-
rate to venture to use the bistoury; but  at the present time  they are
named only to be proscribed, and to show how advanced modern surgery
is from that of  the ancients.
   B.  The  Suture.—Towards the middle of the  last century,  Lambert,
(Med. Obs. Se Inquir., t. II.) an English surgeon, proposed to cure arte-
rial wound3 by  means of the twisted suture.  From the fact that, after
phlebotomy, veterinary surgeons  usually close the vein by a stitch with
the  needle, he  thought that if this means, which Guy de  Chauliac
(Traict. 3, doct.  1, chap. III., p. 254) seems to have  hinted at, were
applied to man, it might be attended with the  same advantages^  Some
trials  confirmed him  in his opinion ;  and his efforts,  it is said, were
crowned with complete success  in the case  of a man who  had a trau-
matic  aneurism  in  the arm, and  whom he presented  for examination
before the members  of a medical society at London.  The great impor-
tance of the suture, however, according to Lambert, consists in its en-
abling us to  preserve  the calibre of the  artery.  But  Asmann,  (De
Aneurismate, Groningue, 1773,)  having  proved that he was  deceived
on this point, and shown, as  Galen has done, that the suture can effect
a  cure  only by obliterating the vessel, his proposition, which has not
been since revived, and which does  not  merit any further description,
was soon forgotten.
   C.  Torsion.—Torsion having been examined as a haemostatic means,
(Vid. Vol. I.,)  I have only to consider it here in its relations with aneu-
risms. 
 708           NEW ELEMENTS OF OPERATIVE SURGERY.

   Torsion being found sufficient to  arrest traumatic hemorrhage, when-
 ever the gaping extremity of the  bleeding vessel pan be isolated  and
 conveniently grasped, seems, according to tho experiments of AI. Thierry,
 (De la Torsion des Arteres, Paris, 1829,) to be of a nature  calculated
 also to effect the cure of aneurisms.   After having  publicly sustained
 this idea in a concours, AI. Thierry made a certain number of  experi-
 ments on the  carotid of  horses.  His process consists in raising up the
 artery  with the  needle  of Dcschamps, which he  afterwards  makes use
 of as a garrot to twist  it, always  in the  same direction, and a certain
 number of times, in proportion to its calibre ; that is, four  times for a
 small artery,  six for a middle sized  one, and eight to  ten for the trunks
 of the  largest volume.  The experiments were  invariably followed by
 the complete  obliteration  of the  twisted vascular canal, so as to admit
 of immediate reunion, and leave nothing  at  the  bottom of the  wound.
Nevertheless, I do not think that  this method  should  be adopted.   To
perform it, it  is necessary that the artery should  be isolated  to  a very
 considerable  extent, and  the shortening which  it is  to  undergo  must
have its influence on  the ultimate success of  the  operation.  It would
 appear to be almost impossible to avoid  making traction upon the veins,
 nerves, and other surrounding parts, even in proceeding in the  manner
 of M. Lieber, (Anal, de Hecker, 1830,) who has also  occupied himself
 with this subject; moreover, it is not certain that the twisted  vessel will
 not, in mortifying, constitute a foreign  body more injurious than the
 simple ligature.
   D.  Crushing.—Others have thought, after Briot, (Soc. Med. d'Emu-
 lat., t.  VIII., p. 276,) who had  already  spoken of crushing, that if,
 after having laid bare the artery, it was seized  with  two forceps with
 flattened points, to twist it laterally, in order  to  crush its internal and
middle coats, and that if these ruptured, tunics were  then crowded up
into the cellular coat, and the solution of continuity were  immediately
closed, it would enable us to arrive  at the same result.  M. Carron du
Villards says he has made numerous experiments on this point with AI.
Maunoir, and that he has generally succeeded.  " These  experiments,"
 says he, " were suggested to  me  in 1820, by Professor Alaunoir, who,
 at this  epoch, spoke  to  me of an  instrument for crushing the internal
 coats of the arteries without  recurring to the ligature.   This instrument
 consists of a forceps much resembling that of AI. Amussat for  the torsion
 of the vessels, but  it has no teeth, and  its free extremity is formed by
 two catches,  of  the  shape of barley grains, which, encountering  each
 other when they are  pressed  together, crush  the artery and break its
 internal coats, without altering the  external one."  By means  of this
 instrument of AI. Maunoir, we can  in general effect the obliteration of
 the arterial canal.
   With this instrument,  also, when used upon an artery of  large calibre,
 and rupturing only a third of its canal, by making  only two turns  with
 the forceps, as if for the purpose  of removing a flap  from its tube, we
 may obtain almost always, in a short space of time, an aneurismal tumor.
 «I have shown," says  AI. Carron to AI.  Pacoud of  Bourg, " a tumor
 created in this manner."
   The experiments of AI. Carron have since been repeated, by M. Amus-
 sat with entire  success; but, with this  surgeon, the pushing up of the 
TREATMENT OF ARTERIAL LESIONS.
709
ruptured coats is the principal part of the operation, and that by which
his process is characterized.  It is to be apprehended, however, that we
should deceive ourselves in relying upon this last-mentioned modification
as an advantage.  The membranes thus crowded back would sometimes,
doubtless, shut up the artery ;  but, in addition to the objection that such
a result would not always take  place, I  see in  it, also, that of being
obliged to  lay bare the vessel completely, and to isolate  it all around
and to a great extent from the veins and nerves, as in the  process of
M. Thierry; all  which circumstances are calculated to thwart immediate
reunion, and to render the  operation longer, more  painful,  and less cer-
tain, than  by the ligature, properly so called.   This, therefore, is a me-
thod which must also be rejected.
   E.  Acupuncture.—While I  was  endeavoring,  some years since, to
disengage in a dog the femoral artery  from its accompanying vein, and
had separated it with a pin, some one came in and obliged me for a mo-
ment to suspend my operation.   A movement  of the animal  caused the
the pin to  penetrate through the artery, and become lost in  the tissues
of the limb ; it  still remained  there on  the fifth day.  In  examining
the parts  with  care, I was enabled to satisfy myself that the oblitera-
tion of the vessel had been the result of this  puncture.  Such an effect
was calculated to  surprise  me,  and at first appeared very extraordinary.
Nevertheless, I  soon explained it, in a manner that seemed to me satis-
factory.  Impressed with  the  idea that  the  contractions  of the heart
have  less influence upon the  movement  of the blood than is generally
supposed, I was soon enabled  to comprehend how a foreign body, even
though very small, when placed at rest across a vascular canal, or mak-
ing  some  projection in its interior, is capable of producing the  same
effect as a  ligature.
   Thus, if an osseous or calcareous plate or  lamella, free at one of its
borders  and adherent at the other, should be turned back and  make a
projection  into  the  artery at  the point  where it had been  developed,
there is every reason to believe that it  might become the nucleus, root,
or source of the fibrinous concretion, capable of deadening to a greater
or less degree the  impulsion of the blood, and of ultimately conducing
to the obliteration  of the vessel.  The observations published  by AI. Tur-
ner, (Transactions Medico-Chir. of Edinburgh, Vol. III., p. 105, 172,
part I.,) those which AI. Carswell has communicated to me, and some
others of my own, place this fact beyond doubt.   What I say of a bony
plate, is evidently  applicable to all kinds of  projections, roughness, or
inequalities, to those which are the result, for example, of  a  laceration,
or of a deposit of  fibrine, plastic lymph, or any growth whatever; in a
word, to everything which  in any way  whatever  diminishes  the normal
regularity of the tube through  which the blood is obliged to flow
   Wishing to ascertain if it   could be possible  for me to  procure at
pleasure the result which I had obtained  by  chance in the experiment
related above, I made some new essays.   An acupuncture needle, about
an inch and a half long, was, without any previous dissection, plunged
into the thigh of a dog, over  the course  of the artery; I  placed two
others on the opposite side, in order to see the difference of effect which
might result from  them.   In examining the  parts, on the  fourth day, I
found my first needle transfixed through the outer third of  the  femoral, 
710
NEW ELEMENTS  OF OPERATIVE SURGERY.
  which, however, had not closed up, except to the extent of one half its
  calibre.  Of the two  others, one was found entirely outside the vessel,
  which latter was obliterated by a solid clot of blood of about an inch in
  length, pierced through its  middle by the remaining needle.-
    I renewed these essays in the month of November, 1829, and after-
  wards in the month of February, 1830 ;  and they  have since  been re-
  peated by AI. Nivert, then prosector for  my course of operations, and
  now Doctor  of Aledicinc  at Azai-le-Rideau ; I have subjected them to
  farther trials in the hospital of La Pitie, and their effect has been inva-
  riably the same.
    In these last experiments, in order to be more certain of not passing
  outside the artery,  I have always taken the  precaution to lay it bare :
  sometimes I have  made  use of but one needle ; at other  times I have
  employed two, or even three, according as the vessel upon  which I was
  operating was  of greater  or less size.  As often as the foreign body has
  been enabled to keep itself  in  its place at least for four days, a clot of
  blood has formed at the point punctured, and the obliteration of the vas-
  cular canal has resulted from it;  the aorta, however, thus healed under-
  went no change, but as the  needles did not remain in it but a little over
  twenty hours, I do  not think it just to draw any conclusions  from this
  experiment.
    It is proper  also to  premise, that up to the present time my experi-
  ments have been made upon dogs of rather small  size, and that the fe-
  moral artery is the largest  vessel I have  perforated.   It  is enough to
  say, that before drawing  rigorous  conclusions  from them, they should
  be repeated  and varied  upon  larger animals,  for example,  upon the
  horse.   I ought also  to  add,  that according to  AI. Gonzales, (These
  No. 233, Paris, 1831,) my experiments, as repeated  by AI.  Amussat,
  have not been attended with results as conclusive.
    A single pin, or a single  needle has appeared to  me  sufficient  in ar-
  teries which  do not exceed  in size that of a  writing quill;  two or three
  would be necessary for vessels  of one-half larger calibre,  and nothing
  would prevent  our employing four or even five  for very large arteries.
  When we place in several it is  proper to insert them at the distance of
  four to six lines from each other, and in a zig-zag direction, rather than
  upon the same  line.
    If such a thing could be relied upon, immense advantages would re-
  sult from it.   In the place of incurring the risk of wounding veins and
  nerves, and making that minute dissection, often so dangerous, which is
  required for the ligature,  torsion and pushing up of the artery it would
  be sufficient, in order to  procure its obliteration, to lay bare one of the
  sides of the artery to the  smallest extent possible,  and without the ne-
  cessity of displacing anything whatever.   Perhaps by this means  we
  might succeed  in curing  aneurisms of the most formidable character,
:  among others those of the thigh and popliteal  space, without  dividing
»  the skin ; that is to say, by  confining ourselves to piercing the femoral
  artery in the fold of the groin with a pin, needle, or any  metallic sub-
  stance whatever, or by perforating, with  these foreign bodies,  the aneu-
  rismal sac itself, in various directions.
    An English  Surgeon, AI. B.  Phillips, (A  Series  of Experiments  on
  Acupuncture, &c,  London, 1832,) who was in  Paris in 1830, and re- 
LESIONS OF THE  ARTERIAL SYSTEM.              711
peated my experiments  in London in 1831, writes me, that proceeding
upon these principles he  had succeeded in curing an  aneurismal tumor
in the parotid region.  We shall see further on the new methods which
have been projected for these results for the treatment of varices and
erectile tumors.   I have,  nevertheless, my  fears  that for aneurisms,
properly so called, it will be with acupuncture  as it  has been with the
seton, torsion, suture, and crushing, and that the ligature will  for a long
time to  come be preferred to these different modes,  in  spite of the spe-
cies of infatuation upon this subject which has taken possession of many
practitioners otherwise respectable.
   Very recently, and since  the  publication of my experiments upon
acupuncture of the vessels, it has been recommended, as it  had also
been by me, but with another object in view, to plunge a needle into the
sac so as almost completely to  transfix  it, and  to attach to this needle
a metallic chain or rod by which electric shocks  and galvanic currents
could be transmitted through it.  I know of no fact which exists in sup-
port of this proposition.   All that I am  aware of is, that AI. Pravaz has
endeavored  to  assimilate such a process to that of  cauterization, and
that it would not be too unreasonable to suppose, that by means of such
experiments we might sometimes  promote the coagulation of the blood
in the tumor, and perhaps the cure of the aneurism.   M. Liston, (Gaz.
Med. de Paris, 22  Scptembre, 1838,) however, after having in vain
tried it in  a case of aneurism of the subclavian  artery, felt himself
obliged to abandon this means and proceed to the ligature of the vessel.
   [Galvano-puncture, which  has  been  so highly recommended by AI.
Petrequin, of Lyons, but which,  according  to  Mr. Erichsen, was first
practised by Air. B. Phillips  in 1832, (Erichsen's  Science and Art of
Surgery, London,  1853.  p. 500,)  has been attended with some success.
Mr. Boinet has collected some 23 cases in which this method of treat-
ment had been  adopted; up to July  1851, 9 were reported as success-
ful ; and 13 as failures.  In 7 of  the successful cases, compression  and
ice were simultaneously employed, so as is remarked by AI. Boinet, it is
doubtful whether the cure was  not due to these means, or the inflam-
mation and suppuration  of the sac.   AI. Amussat presented a patient to
the Academy of Medicine of Paris, July 1851, in whom he had success-
fully treated a  false aneurism of the brachial artery by galvano-punc-
ture in October 1847.   The  cure  was perfect.   (Lond.  Lancet, Oct.
1851, p. 312.)
   Air. Eyre, lias reported in  the  Lond.  Lancet, July, 1853, a  case of
aneurism of  the external iliac  which  he cured by means of galvano-
puncture.  He refers also to another, of popliteal aneurism, which came
to his  knowledge,  and  which  was  cured by  the same method.   He
thinks it a  hazardous mode  of treatment, and  declares that he should
reluctantly resort to it again for aneurison of the external  iliac.   (Vid.
Braithwaite's Retrospect,  Part XXVIII, p. 170.)   AI. Nekton  has
also treated  in this  manner, an erectile tumor over  the nasal eminence
with success.
   Sir Everard Home published a  paper in the  Philosophical Transac-
tions, 1826,  " On  the Coagulation by Heat  of the Fluid in an Aneu-
rismal Tumor."  He gives the details of a case in  which he tried this
mode of treatment,  at the Chelsea Hospital, in October,  1825.  The 
712
NEW ELEMENTS OF OPERATIVE SURGERY.
 aneurism was seated in the external iliac, for the cure of which he had
 previously tied,  but  unsuccessfully, the  femoral artery below  the  sac.
 Heat was applied to the needle, already  introduced into  the aneurism,
 by means of a spirit  lamp.  Pulsation ceased after a while, and as the
 tumor appeared  to be solid, the progress of the aneurism was  thought to
 be arrested.  Mortification  of the extremity finally occurred, and  the
 patient died on the nineteenth  day after the operation.   The  credit of
 first suggesting this  method of treatment, according to Mr. Wardrop
 (Costello's  Cyclopedia, p.  218)  is  due to Alonteggia of Milan.   In
 1826. Mr. George Bushe,  of New York,  treated a case of carotid  aneu-
rism, by means  of a  cataract needle, heated to a white  heat.  (Med.
 Chir. Bulletin, Vol.  IL, 1832, p. 209.  Galvano-puncture has been suc-
cessfully employed by AI.  Abeille, in subclavian aneurism.  G. C.  B.J

                      § III.— The  Ligature.

  If the obliteration  of arteries is  indispensable, or nearly sp,in the
cure of aneurisms, the ligature must be the  surest mode of obtaining it;
this is a truth which no one questions, and which never has  been con-
tested.   But in order to  apply a ligature upon an artery, it becomes
necessary to perform a serious operation ; we are  obliged to divide vital
tissues  with a cutting instrument.  Hence the attempts so often made to
 substitute for it some milder means.
  A.—Nature dnd Forms of the Ligature.  Nearly up to the present
 time, threads of flax or hemp only had been employed; a single  round
 thread  was preferred to small arteries;  for the large trunks, however,
 several were united together with wax, in the form of a ribbon.   It ap-
 pears, however, that the ancients  had already  used silk to tie the arte-
 ries.  Guy De  Chauliac (Traict.  3. doct.  1., chap. Ill, p. 255) asserts
 it positively of Avicenna, in cases of wounds  accompanied with  a flow
 of blood.   Things were in this state when Scarpa and  Jones proceeded
 to submit to the test of  experiment  and  reasoning what had hitherto
 been adopted only by imitation.
  I. Scarpa, the first of these authors, proved,  that to obliterate an
 artery, it was necessary to place its  walls into contact without lacerat-
 ing them,  and to promote adhesive  inflammation.  He, therefore  re-
 commends that we  should  make use  of flat ligatures  formed  of six
 flaxen  threads;  and moreover, that  we  should place between  the
 ligature and  the  artery a small  roll of linen  six lines  long and
 three broad, which roll is  spoken of also by Pare, Platuer, and Heis-
 ter, used  also  by almost all the Italian  surgeons of the last century,
 by Funchall, and also by Forster, who substituted for it a small cylinder
 of wood, a quarter of an inch in  breadth  and three quarters of an inch
 long, a roll,  which Savdard (Observ. Chirurgie, p. 172) mentions as
 being in general employ  in his time, but one which Le Dran did not ap-
 prove of, and for which Cline afterwards substituted a piece of cork. By
 this means the internal and middle coats of the vessels  are neither
 bruised nor  torn ;  their contact  is perfect, and  they unite solidly, and
  are blended together before even they can be cut  through by the ligature
   hich embraces them, and which with difficulty affects their ulceration.
  m   Mott thinks there cannot  be a doubt that the small round ligatures. 
LESIONS OF THE ARTERIAL SYSTEM.
713
either of silk, flax, or hemp, (that of silk the best,) are preferable on all
occasions; that the flat ought to be abolished ; and that there should
never be any  thing  whatever interposed between the kuot  and the
artery.]
   II. Jones. _ According to Jones (On the Use of the Ligature, &c.
1806,) the opinion of  Scarpa is wholly erroneous; it  is not by inflam-
mation upon the internal surface that arteries  close, but by means of the
effusion of coagulable and organizable matters which follows the rupture
of their two inner coats ; consequently, in place of flat or broad liga-
tures, and all kinds of rolls  of linen, or cylinders, which to a greater°or
less extent impede this rupture, Jones recommends that we should make
choice of threads which  will do  it in the neatest and best  manner.
Numerous experiments were made by him upon dogs and horses, and all
have been attended with results conformable to  this theory, which soon
became a law with most English surgeons.  According to M. Hodgson,
(On the Diseases of the Arteries, &c, 1815,) the truth of this hypo-
thesis is so  evident that he cannot conceive how some  persons still ven-
ture to  use  the broad  ligatures, and little rouleaux of Scarpa.  AI. S.
Cooper also, with some degree of bitterness,  censures the French  sur-
geons for having been  so reluctant in adopting the practice recommended
by Jones, a practice which has been carried so far as to induce some of
his countrymen  to make use of threads of an extreme degree of tenuity,
those for example made of gummed silk, and  used  by  dentists  and fish-
ermen, so fine, in a word, that in cutting them near the knot,  after the
manner of AI. Lawrence, there remains  in the wound the weight only of
the twentieth, or even the forty-sixth part of a grain.   [This  practice
Dr. Alott has also tried, and the absurdity of it consists in this, that the
wound will be healed by the first intention, and the ligatures by being left
to remain as an extraneous  substance, will, in the course of five or six
weeks manifest  their injurious action  by producing suppuration.  This
practice is one that goes to the other extreme  of Scarpa.  T.]
   III. Without calling into question the importance of the labors of Dr.
Jones, Af. Roux has persisted, and  still persists, in using flat ligatures,
which he usually ties upon a small roll of adhesive plaster of diachylon.
In support of his practice we may cite the names of Boyer, Scarpa, and
M. Petrunti, (11 filiatre Sebezio, Aprile, 1836, p. 239,) and the author-
ity also of the older writers since  Saviard, in his observations on Sur-
gery, speaks of the little rouleau as a thing in common  use.   AI. Cramp-
ton, in Ireland, has never employed any other method, and has had no
reason to be dissatisfied with it; he has in fact  opposed the doctrine of
Jones with such force of reasoning as to prevent its  being universally
adopted in the three kingdoms.
   AI. Richerand supposed he could reconcile those different opinions by
calling attention to the fact, that a flat ligature becomes rounded, in pro-
portion as we tighten it, and that its final  result is like that of the cy-
lindrical ligature, to rupture the internal and middle coats of the artery ;
which argument would go to strengthen the mode adopted by the prac-
titioners of Great Britain.
   l\r. Jameson.  But  next  comes AI. Jameson, (Journal des Progres, t.
YL, p. 117; t. VII., p. 126;  t. IX., p. 150,) who,  on the strength of
new experiments, rejects the principal assertions of Jones as erroneous.
   Vol. I.                     90 
714            NEW ELEMENTS OF  OPERATIVE SURGERY.
 It is not true, says he, that the rupture of the delicate coats of an artery
 is an advantage ;  on the contrary we should do every thing in our power
 to prevent  it.   The fine threads and round ligatures are dangerous, both
 because they cut the internal  and middle coats, and especially because
 they strangulate the vasa vasorum of the cellular coat.   AI. Jameson
 nevertheless rejects every kind of  foreign  body recommended  to  bo
 placed between  the vessel  and the ligature; also ligatures  of thread,
 whatever may be  their form or size.   Strips of untanned deer skin  ap-
 pear to him to be infinitely preferable in all  cases, inasmuch as  these
 ribbons have an elasticity and pliancy which allow of their gently closing,
 and bringing into contact the sides of the artery, without rupturing any-
 thing, and without lacerating the vasa vasorum,  and because also they
 may be left in the wound with impunity.
   V.  Threads of animal  matter.  Another question naturally connects
 itself with this discussion.   It has been asked if it would not be possible
 to substitute for threads of vegetable substance, cords of animal matter,
 which are of a nature to soften and dissolve in such manner as to be car-
 ried away  by  interstitial absorption in  the  midst of the living tissues,
 without incommoding, in any manner,  the reunion of the  divided parts.
 A series of trials of this kind, with silk, were made at London in 1815 ;
 an experiment of AI.  Lawrence and another of M. Carwardine (S.
 Cooper's Surgical Dictionary, p.  131,) were attended with all the suc-
 cess that could be expected from them ; the wound was cicatrized in the
 space  of four, five, or six days, and the small knot left upon  the artery
 was attended with no  disadvantage ;  other experiments, however, have
 been less fortunate ;  either the immediate reunion did not take place, or
 there  appeared  at a later  period, small purulent  collections  and ab-
 scesses which did not dry up until after the expulsion or exit of the por-
 tions of silk that had been left in the  tissues.  In a patient operated
 upon the 29th of Alarch, 1819, by AI. Lawrence  himself, the cure was
 not completed till the end of  Alay.   In  a patient in whom M. Watson
 had tied the brachial artery by this  method, he found the silken knot
 had lacerated the cicatrix, and that it did not come away  until after the
 expiration of two months.  The same result with AI. Hodgson did not
 take place until the expiration of six months;  the Neapolitan surgeons
 (De Renzi, trad. Ital. de ce livre, p.  81,) were not more fortunate ; and
 M. Cumin cites a case of a patient who retained one of these ligatures in
 him for the space of two or three years.   So that the result is, that silk
 has not been found susceptible of being destroyed by absorption.
   AI. A. Cooper succeeded perfectly by using a small cord of cat-gut; this
 substance dissolves much better than silk, and would be preferable to it
 in every  respect, if it  were not necessary from its want of strength to
 use  it of so large a size.   In AI.  A.  Cooper's first patient the cure was
 completed on the twentieth  day; in another patient, who was eighty
 years  of age, the wound  took but four days to cicatrize, and in neither
 case did  the  ligature ever reappear.  M. Norman (On the  Operation
for Aneurism, 1819)  was not so fortunate.   This physician  made trial
 of the method of AI. A. Cooper, on two occasions, and in  both cases the
 cure was protracted  to a long period.  M. Wardrop, in some of his ope-
 rations, conducted upon the plan of Brasdor, (On Aneurism, &c, 1828,)
 made  use  of the  intestine of the  silk-worm in lieu of thread.  By em- 
TREATMENT OF ARTERIAL LESIONS.
715
ploying raw silk, immersed for twenty-four hours in saffron, in order to
color it, AI. Carron du Villards obtained the same results that AI. Law-
rence had in view.
  According to  AI. Jameson  and Dorsey, Physick, in  the year 1814,
was the first who  made use  of ligatures  of animal matter; those that
he prefers are  round, and made of deer-skin or cat-gut; but like MAI.
Lawrence and  A.  Cooper, (Dorsey,  Elements  of Surgery, vol. II.,)
Physick's intention was to cut through or rupture the arterial coats, while
AI. Jameson positively advises that they should be saved.
  The surgeon  of Baltimore, gives to his deer-skin ligatures as much
as two lines of breadth, and increases their resistance and strength, to
a greater or less degree, by drawing them between the nails.  Applied
upon the artery, these strips do not require to be drawn tight to efface
its calibre;  from whence it happens, that though there is no intermediate
foreign body, they produce the same effect as the ligatures of  Scarpa,
without  arresting, like these last, the circulation in the vascular system
of the cellular coat.  M. Jameson asserts, that after having been drawn
between the nails, these  ligatures may, when tightened with considera-
ble  force, partially divide the arterial  coats, like the flat ligatures of
thread' or silk;  while in their state of natural  suppleness they are inca-
pable of producing this effect.
  VI. Observing that lead, gold, silver and platina but slightly irritate
the  parts with  which they are placed in contact, Physick at first enter-
tained the  idea of constructing  ligatures out  of these metals.   AI. Le-
vert (Journal des Progres, t. XVII., p. 65) availed himself of the sug-
gestion of Dr.  Physick, and  submitted it to a considerable number of
experiments; he made five  upon the carotid of a  dog, with threads of
lead drawn  very tight, then cut very near the knot and left at the bottom
of the wound.   The  reunion  was  effected at  the  expiration  of the
seventh, eighteenth, nineteenth, twenty-eighth, and forty-second day ; the
vessel was constantly found obliterated.  The small circle  of lead occu-
pied a cellular  cyst  of greater or less density.  Three experiments on
the carotid,  and  two on the femoral, with gold threads;  three other liga-
tures on  the femoral, and the two carotids with silver threads; and three
on the carotid with platina, produced the same effects as the threads of
lead ;  finally, M. Levert obtained similar results, by making use  of small
cords of waxed  silk, gum elastic ligature, and even of fibres of grass.
  VII. Recapitulation.  The  results  of all these researches, as it ap-
pears to me  is, that the nature and form of the ligature in the treatment
of aneurisms, are not as important as has generally been supposed during
the last  thirty  years, and that French surgeons have been right in not
adopting  precipitately, and without reflection, the conclusions deduced
in England from the experiments of Jones.
  [If, as is generally  supposed, the hemorrhage which destroyed the pa-
tient on whom Sir Philip Crampton  tied the  common iliac, was caused
by the dissolution or  rupture  of the animal ligature which was  used in
that case, surely the nature of the substance employed, cannot be a mat-
ter of  indifference.  G. C. B.]
  The massive  ligatures of Scarpa irritate the wound too much, keep
up  too abundant a suppuration, and require too great a length of time
before they can be extracted, to be deserving of  any exclusive prefer- 
716
NEW ELEMENTS OF  OPERATIVE SURGERY.
ence; this appears to me to be indisputable ; but in flattening the artery,
without folding  it: [i. e., without causing the inner tunics to fold upon
themselves, as they do  when cut through by a small round ligature of
silk, &c.   T.] they keep its walls in perfect'contact, without necessari-
ly dividing  the  vasa vasorum.  In becoming inflamed under such pres-
sure, the cellular coat soon transmits its organic action to the two other
arterial tunics, and the  whole is soon blended together in such manner
as to form an impermeable cord.
  The objections, therefore, that Af. Hodgson makes to them, are far
from being  founded in truth.  AVhen we make use of a fine ligature, in
order to be  more sure  of rupturing the internal and middle coats, we
strangle  at  the  same time, as AI. Jameson maintains, the small vessels
of the external  coat; and  it  is  not true as Jones contended, that the
obliteration  of the  artery is mainly effected by an internal effusion of
organizable lymph.  The ligature itself is speedily surrounded with con-
cretable  matter; the continuity  of the  small ruptured vessels is soon
re-established upon the  outside  of it, and the ligature ultimately finds
itself in the centre of an organic  ring, analogous to that which Duhamel
had  supposed in the  formation  of the callus of fractured bones.  This
albuminous virole, the  formation of which in  dogs, has been carefully
investigated  by  AI.  Precot,  (These No. 155, Paris, 1822,)  becomes,
after the extraction of ligature,  gradually harder, retracts upon  itself,
and little by little blends itself with the two obliterated ends of the arte-
ry.   Scarpa, and MAI. Crampton and Jameson then  are wrong in imput-
ing to fine ligatures a  greater  tendency to produce  secondary hemor-
rhages, than to flat, and broad ligatures.
  [The experiments of Air. Spence, of Edinburgh, (vid. Monthly Journal
May, 1843,) show, that plastic exudation after the application of  a liga-
ture, is not confined to  the  interior of the vessel.   He observes, that it
occurs, and even more extensively on its exterior, and that it is of more
importance than  the internal clot, in preventing hemorrhage, during the
separation of the ligature.  In ligating  an artery,  therefore, the vessel
should not be unnecessarily separated from its sheath, and the surround-
ing soft parts should be disturbed as little as possible.   In Air. Aliller's
Principles of Surgery, (3d Am. ed. p. 537)  may be  found some illus-
trations, derived from Mr. Spence's unpublished drawings, which cor-
roborate the views of the subject now entertained by this surgeon.
                                                        G.  C. B.]
  As to ligatures of animal substances, there can  be no question, that
by permitting the wound to be immediately closed, they may be of great
value in practice.  The point to be ascertained is, what should be their
form and precise nature.  If you wish to have them very fine, silk only
may be  used; unfortunately, this  substance,  we  have  seen, does not
yield to  the interstitial action of the parts.   The  cat-gut  has  not the
same solidity, and moreover is not very easily absorbed.  The strips of
deer-skin, endowed with a great elasticity, and readily  dissolving, offer
greater advantages; but before  adopting them surgery requires new ex-
preiments ;  and also, that the result, mentioned by M. Jameson  should
be confirmed by other practitioners.  If we admit that these ligatures,
when left around the  artery do  not act  the part of foreign bodies, that
they may be absorbed by the system, and are not  necessarily obliged  to 
TREATMENT OF ARTERIAL  LESIONS.
717
be expelled from it at a period sooner or later, there is no  person who
cannot comprehend at a glance what  advantages they would give to the
patient.   With them the plastic ring, described by M. Pecot, would be
rendered  perfect, and protected from all  perforation  or interruption;
supported  by the exact approximation  and immediate reunion of the
parts, it would run no risk of being  destroyed by  suppuration, or torn
by the removal of the thread.   Moreover, whether this ligature should
possess a  little more or less breadth, whether the internal coats were or
were not ruptured, or the vasa vasorum strangulated to a greater or less
extent, the final result, in my opinion, would be nearly the  same.  Ex-
perience has now indisputably demonstrated  that hemorrhage is neither
more nor  less frequent with flat than with round ligatures, with those of
silk than with those of thread.  The tenuity then  and  animal composi-
tion of ligatures would possess influence only in the eyes of those who
would wish to sacrifice every thing to the immediate union of the wound.
But even  though we should obtain this re-union, what advantage would
it be in such a case ?  In admitting that there was no longer any wound,
where is the surgeon who would venture  to allow his patient to walk in
ten or fifteen days after an operation for aneurism of the femoral artery ?
Since it so happens that even in those cases where  we have recourse to
secondary union, it is not the wound which retards  the definitive cure ;
I cannot see, in conclusion, what  particular utility there would be  in
reviving  at  present the discussion respecting  the  form and nature of
ligatures.
   [Air. Fergusson  coincides with  the views of  the author that too much
importance has been attached to the size and material of ligatures.   He
generally  employs those  made of small, smooth, and well  spun twine,
which, he observes, is sufficiently stiff, without the aid of  beeswax, to
permit a noose to be cast without trouble from the ends being too limber.
Fine dentist's silk he thinks is objectionable, as in the bustle of an ope-
ration, it  does not possess sufficient bulk to be  felt readily  between the
fingers.   (Pract.  Surg.,  3d  Lond. Ed. p. 36.)  Vid. Remarks of Dr.
Mott, infra.   Mr. Erichsen asserts that the best material for the ligature
when applied to the continuity of an artery, is the dentist's silk, or com-
pressed whip-cords, well waxed.  Liston's bull-dog forceps have been
so modified of late, by increasing the expansion of the blades just above
the points, that a ligature  can be slid over the  end of an artery deeply
seated, as between bones or close  to  the inter-osseous membrane of the
leg.  (Erichsen's Science  and Art  of  Surgery; Lond. 1853, p. 132.)
                                                         G. C. B.]
   B.— The  Permanent  Ligature.   Every  vegetable  ligature, drawn
sufficiently  tight to intercept the passage of  blood in an  artery, is a
foreign body which will not  leave  the  wound until  after having  cut
through the cord which it embraces.  In order, therefore, that its separ-
ation may not be followed by hemorrhage, it is necessary that the vessel
shall have had time to  close  itself  firmly above and  below; otherwise
the  albuminous virole which surrounds it, possessing  too little  consist-
ence to resist the force of the blood, and  having, moreover, been al-
ready laid bare in the direction of the skin, will be speedily lacerated.
If it [the ligature]  were  restricted, as  is generally supposed, to  pro-
ducing adhesive inflammation in the strangulated portion of the vessel, 
718
NEW ELEMENTS OF OPERATIVE SURGERY.
there would be nothing to dread from its separation; for before  the
artery would allow itself to be cut through, it would  be necessary that
it should have become inflamed.   But the experiments of AI. Pccot tend
to prove that this  is not the case; the portion of the artery included in.
the noose of thread, according to this author, almost unavoidably morti-
fies, a little sooner or later, whatever may be the degree of  constriction
which it sustains, and it can only be  by the steps of an eliminative pro-
cess, analogous to  that which in gangrene separates the dead from the
living parts, that the ligature can be detached  from the surrounding
tissues.
  When this process is  not disturbed, when the organic elements, upon
which it acts, continue to remain in  the  normal state, and nothing pre-
vents them from contracting adhesive inflammation, the ligature  is not
eliminated until the fifteenth or  twentieth day.  As the  upper end of
the arterial canal is no longer  permeable on the fourth or fifth day, we
may, therefore, so far as this  is  concerned, rest perfectly easy.  If, on
the contrary, the walls of the vessel have unfortunately become softened
and  steatomatous,  yellow  and inflamed, the  ligature will  have soon
divided them ; if the  artery shall not have become completely closed,
its coats will ulcerate, and there  will be no interruption to the course of
the blood ; finally, if these coats are indurated and encrusted with cal-
careous concretions, as so frequently  happens in old men, we may under-
stand why  their inflammation  will most  usually be too feeble, and  too
irregular to admit of the effusion of those  concretible matters required
either externally  or  internally, and why the ligature, though it  come
away at a very late period, may give rise to a serious hemorrhage.
  C.—Precautionary Ligatures.  To obviate  these  inconveniences it
was proposed  to  use ligatures d'attente,  that is  to say, ligatures which
are useful only when the first that have  been applied  have cut through
the artery before its perfect obliteration; in a word, Ligatures of Pre-
caution.
  One of these ligatures was passed around the vessel without tighten-
ing it, at the distance of a few lines below the principal ligature.   An-
other, composed of two threads,  was placed  a little above the principal
ligature ; the lower half of this ligature  was to be tied in such manner
as to strangulate  the  artery only to  the degree required to  deaden the
force which the column  of blood exercised upon the point we desired to
obliterate ; a third, also double,  was placed still higher, and this, in the
same way as the  upper half  of the preceding, was left free.   On  the
supposition that the fixed ligature had failed, force was immediately ap-
plied upon the  first threads of  the  upper precautionary  ligatures, and
successively on all the others, in case  of need, in such  manner  as to
arrest the hemorrhage.
  The same was  done with  the double thread of the lower ligature,
which  was  intended  only to  oppose  the  reflux of blood  from  the
wound.   Such, for a long time  were  the  arguments and  the  course
adopted by A. Monro, Guattanni, Hunter, Desault, Deschamps, Pelletan,
and even Boyer.   At the present time precautionary  ligatures have al-
most entirely disappeared from  practice.  Far from being thought use-
ful, they are on the contrary deemed exceedingly dangerous.  At first
they were censured,  with  reason, as irritating the  wound too much 
TREATMENT OF ARTERIAL LESIONS.
719
keeping upthe suppuration, and forming an insuperable obstacle to im-
mediate union.  Moreover, Dupuytren and Beclard have shown that the
part of the vessel immediately adjacent to them, in proportion as it in-
flames, undergoes a fatty degeneration, exceedingly susceptible of being
cut through, and altogether incapable of sustaining the  action of any
kind of ligature  whatever; from  whence it happens that  their applica-
tion of itself is sufficient to bring about the ulceration  of the artery,
which they, in like manner, afterwards cut through with the same facili-
ty  that  they  would  through a slice  of lard  or cheese, as soon as we
attempt to make the slightest degree of constriction upon them.
   D.— Temporary Ligature.  Not only have  the precautionary liga-
tures  been rejected, but it  has  even  been  proposed to  ascertain if it
would not be  possible to remove, without  endangering the success of the
operation, the only  ligature  which had  been employed, and  before it
should have  had time to cut through  the vessel.  This  is a two-sided
question.  Such practitioners as have occupied themselves  with this
subject have been influenced by two different and even opposite indica-
tions.  According to some, the temporary ligature should rupture and
obliterate the artery  in the most  prompt  and perfect manner posssble ;
the others, on the contrary, proposed to close the artery by degrees, and
not to rupture it by any special means designed for that purpose.
   I.  Sudden Obliteration.—It is now more than thirty years since this
 question has  been a  subject of discussion in England.   Jones asserted
 that he  had  ascertained  that by rupturing at  three or four different
 points, at certain distances from  each other, the internal and middle
 coats of  an  artery, with that number of fine ligatures, an effusion  of
 lymph would be effected, which would be sufficient to accomplish the de-
 sired obliteration, and to allow of the ligatures being withdrawn in a
 few minutes.   The results obtained by AI. Hutchinson, (Practical Ob-
 serv. in Surgery, p.  103,) fully confirm those of Jones.  But AIA1. Dal-
 rymple, Hodgson, and Travers have not been so  fortunate: their experi-
 ments were made upon horses or sheep, and the artery was never, in any
 case, obliterated; they found it only in a slight degree contracted, upon
 killing the animal at the end of thirteen, fifteen, or eighteen days.   AI.
 Tavers, however, (Observations upon the Lig.  of Art., Trans. Medico-
 Chir., Vol. IX.,) was of the opinion that he might turn the suggestion
 to some advantage by modifying it.  In the  place of removing the liga-
 ture immediately after having strangulated the artery, he  determined not
 to withdraw it until after the expiration of a period of time sufficiently
 protracted to allow of the clot and the effused lymph to acquire a certain
 degree of solidity, and a consistence capable of resisting the momentum
 of the blood.   His experiments on horses led him to the  conclusion that
 a ligature kept upon the  carotid for the space of six, or two hours, or
 even for one  hour only, generally effected a permanent  obliteration of
 the artery.  In 1817 he applied  the ligature  upon the brachial artery of
 a man, and removed it in fifty hours, without the pulsation in the tumor
 having returned.  AI. Roberts, (J. Bell, trad. d'Estor, p. 200, en note)
 went still further:  a ligature which he  left only twenty hours on  the
 femoral artery of a sailor, who had an  aneurism in the  ham, effected a
 perfect cure in the space of twelve days.
    In repeating these  experiments the same success, unfortunately, has 
720
NEW ELEMENTS OF  OPERATIVE SURGERY.
 not always attended them.  M. Hutchinson  has seen the circulation im-
 mediately re-establish itself in  the  femoral artery, though it had been
 strongly constricted by a ligature for six hours.   The same thing hap-
 pened to M. A. Cooper, (S. Cooper Dictionary, &c, p. 123,) after thirty-
 two and forty hours.  AI.  Travers himself, after removing a ligature
 which had been applied to the artery of the  thigh for twenty-five hours,
 noticed that the pulsations gradually returned in the aneurism, that they
 would not yield to indirect compression continued for a long time, but
 required the application of a ligature in the ordinary mode; so that he
 ultimately  abandoned  this practice, which the experiments of Beclard
 have prevented from being adopted in France.
   At the moment when the temporary ligature was losing its warmest
 partisans in London, it was seized upon by the surgeons of Italy.  Scar-
 pa (Bull, de  Ferussac, XXI,,  p.  115.   Arch. Gen.  de  Med., t. IL,
 p. 82) made new experiments with it, and  exerted himself to procure
 its adoption.  Flat ligatures, tied upon a small cylinder  of linen, be-
 smeared with cerate, and placed around the carotid of a number of
 sheep, and withdrawn on the third, fourth, or fifth  day, always effected
 the solid obliteration of the vessels.  Repeated on horses, by AI. Alislei,
 a veterinary surgeon, at the school of  Alilan, these experiments were
 followed by results  precisely similar.  The experiments  were not less
 fortunate when used on a man.   Paletta, communicated two remarkable
 cases of this kind to Scarpa, (Arch.  Gin.de Mid., t. II., p. 82 d 101.)
 The first was a man forty years of age, who had had an aneurism in the
 ham for two or three months; the ligature was applied upon the artery
 on the 8th  of  January, 1817, and removed  on the 12th.  The second
 was a patient sixty  years of age, and who had an aneurism at the bend
 of the arm.  A ligature placed  upon the brachial artery was removed
 on the fourth day; and, as in the first patient, this operation also had a
 fortunate termination.  A popliteal  aneurism treated in the same man-
 ner by  M.  Morigi,  (Valentin,  Voyage en  Italie, 1826,) terminated
 equally  well.  The same result took place in the fourth patient whose
 brachial artery had been wounded, and who  applied for relief to the
 hospital at  Padua.   MM.  Alolina, Fenini,  Alaunoir, Graefe, (J. Bell,
 trad. d'Estor,  p. 200,) Dolcini, (Bulletin de  Firussac, t. II., p. 334,)
 Medoro, Solera,  Falcieri,  (Ibid, t.  XIX.,  p. 277,) Uccelli,  Giutini,
 Alalago  and Balestra, (Ibid., t. II., p.  334,)  have  also  used the tem-
porary ligature with success  for aneurisms of  the carotid  artery, femo-
ral, &c.  Vacca, (Reflections  sur la  Ligat. Tempor.,  &c,  1823,)
however, soon raised the objection, that  after  having removed the liga-
ture, the artery, nevertheless, a little time after, was  sooner or later  di-
vided, and the experiments of AI. Pecot, contrary to  those of AI. Seiler,
tend to confirm this opinion, which however  does not in any respect de-
 tract from the value of the facts and reasonings adduced by Scarpa.
  The difficulty in these cases, as is proved by a fact related by Alorigi,
 (PI. Tortal, Clinica Chirurg., t.  I., p. 162,) consists in  removing the
ligature without making traction upon the artery and disuniting the lips
 of the wound.  All  the modes resorted to in England for  this purpose
 are objectionable.  The two single  threads which Paletta and Roberts
 previously  place  between the vessel, or the small  cylinder,  and  the
 thread which serves as the ligature, in order to untie this last in draw- 
TREATMENT OF ARTERIAL LESIONS.
721
ing the others towards us,  effect  the  object proposed but very imper-
fectly.  The same may be said of  the piece of grooved sound which M.
Uccelli at  first includes in the same ligature with the cylinder of linen,
and upon which  he proposes, at a later period, to divide the ligature.
M. Giuntini, in order to extract the foreign body fixed upon the artery,
aud  to facilitate the section of the ligature, makes use only of a waxed
thread, which he attaches to the extremity of the  small cylinder before
adjusting it.
  For  all  these  modes  Scarpa substitutes the following: a  grooved
sound, cleft at its extremity, and having two small flattened rings upon
one of its lips, one at half a line from the point, the other at near an inch
from  the  plate,  serves  to guide  a  very  small  knife  to  the thread
of  the ligature  which embraces the artery.   The  manner of pro-
ceeding with this small apparatus is perfectly simple.   The end of the
ligature, which has been left outside, is first passed successively through
the two rings which  are  designed to  receive it;  and the beak of the
sound is then securely guided to the small cushion of linen which arrests
its progress, (Archiv. Gin. de Mid., t. II., p. 245.)  Then  the  small
knife  penetrates without difficulty  down to the ligature, which it divides
transversely, and which may then be withdrawn, says the author, with-
out exposing the artery to the slightest risk.
   II.   Gradual  Obliteration.—Some trials have also been made with the
temporary ligature, by combining it with direct compression.  From the
fear of suddenly interrupting the  circulation in the limb, and the dread
of hemorrhage after the  ordinary ligature, many  French surgeons, be-
tween the years 1790 and  1815, proposed that the constriction  of the
artery should only be accomplished by degrees.   The instruments made
use of to effect  this object, by allowing us to augment or diminish the
constriction of the vessel at  pleasure, and to remove or replace them
whenever wre should desire to do so, may be united very advantageously
with the process of a sudden obliteration.
   a. Process ofDeschamps.—In 1793, before the temporary ligature was
thought of in England, and consequently, before it was employed in Italy,
 Deschamps (Mim. de la Soc d'Emul, t. VIII.,  p. 689) proposed  his
 artery-compressor, that is,  an instrument composed of a flattened me-
 tallic stem, about three inches long, cleft at its free extremity, and ter-
 minated at the other end by a horizontal plate resembling the flat head
 of a nail, whose length exceeded its breadth, and was pierced with two
 long  openings near  its edges.   He first inserted into  and  conducted
 through the two  openings of the instrument, the  two halves of the liga-
 ture passed under the artery ; then, on drawing upon the one he  caused
 the other to descend; by which means the vascular trunk was flattened
 between the portion of the ligature which compressed it from behind for-
 wards, and the plate of the artery-compressor, the action of  which was
 to press against the artery from before backwards.   The operation was
 finished by fastening the extremities of the ligature upon the cleft of the
 instrument.
   b.  The little rundlet, of Assalini, (Bullet, de Ferussac, t. II., p. 84,)
 the compressors employed or recommended byFlajani, Buzani, Garnery,
 Ayzer, (Dissert, etc, Gotting., 1818.   Soc.  d'Emulat., t. VIII., p. 692,
 and MM. Crampton, (Medico-Chirurgical Trans., vol. VII., 2d part, p.
   Vol. I.                  91 
722
NEW ELEMENTS OF  OPERATIVE SURGERY.
341,) Ristelheuber,  (Mem. de la Soc. d'Emulat., t. VIIL, p. 685, pi.
7, fig. 9, 10,) Deaze, Jacobson, (Bull, de  Ferussac, t. II., P- 84,) and
Chiari, PL Portal, Clin.  Chirurg., t. p. 154,) though differing in some
respects  from that of Deschamps, or from the forceps of Schmucker,
(Bullet, de Firussac, t. II., p. 84,) have, nevertheless, all been  con-
structed upon the same principle, that is to say, with  the intention of
flattening in place of strangulating the vessels, and  of withdrawing the
ligature or the compression, at the expiration of a determined period of
time.  Like that, also, they all have the inconvenience of greatly irritat-
ing the wound, of favoring the ulceration of the artery,  and most gener-
ally of effecting only  an incomplete closure of the vessel.
  c. New Process.—-If it were allowable  to deduce conclusions  from
some experiments  made  upon dogs, the following process would be as
easy as it would be certain  to effect  the  obliteration of the vessels by
means of  temporary  ligatures.   We insert  under the   artery a simple
pin, whose two extremities are then to be  embraced by a noose of
thread, as in the twisted  suture, which  is to be tightened  sufficiently to
arrest the current of the blood.  A second thread, attached to the head
of the pin, allows of our extracting it when we judge  it  suitable to do
so.   The ligature being thus left  free, offers no  farther resistance, and
falls out as it were  of itself.  This process, which will  be treated of
more fully  under the article (varices,) and which, in  certain cases,
would enable us to dispense altogether with an  external wound, is of
such easy application, and succeeds so well upon  veins, that  we cannot
see why it should not procure the same result for arteries.   The  experi-
ments  undertaken by  AI. Franc (Journal des  Connoiss. Med.-Chir.,
1835, t. III., p. 15, ou, These, Alontpellier, 28 Mars,  1835,) fully sus-
tain, moreover, what I  had written upon  this  subject in 1831.   The
process used by M.  Alalago, (Bullet, de Ferussac, t.  XVIII.,  p. 82,)
and which consists in twisting the  two heads  of the  ligature  without
tying them, would in truth be  still more simple, but it does not offer the
same degree of certainty.
  d. Process of Dubois.—The idea which Deschamps had in using his
artery-compressor, of obliterating the  vessel  only  by  degrees, was
adopted by Dubois, (Soc. Med. d'Emulat., t. VIIL, p. 706,  pi. 7, fig.
5, 6,) who in 1810, proposed to found upon this method  a new process
for  treating aneurisms.   After  having placed the ligature of  thread
(ruban de fil) around  the artery, this practitioner passed its two  ex-
tremities into the knot-tightener of Desault,  (Bullet, de  la Faculte, 6e
annee, p. 40,) in  such  manner  as not to intercept the  course of the
blood except by degrees, and not  to effect an  entire  obliteration until
after a period of six or  eight days.  His  object in acting thus was  to
permit the collateral vessels to dilate themselves gradually, and to pre-
vent the gangrene which was produced at this epoch, also by the sudden
strangulation of a large  artery.   The two fortunate results which were
obtained by this process at the  clinique of the faculty, at first  strongly
attracted public attention, but the third  attempt having  been followed
on the fifteenth  day  by hemorrhage,  which rendered amputation neces-
sary, and caused  the death of  tho patient, though  the  pulsations  had
 ceased to be perceptible in the tumor from the tenth day, soon  put  an
 end to such flattering hopes.  Since then I was not aware that any one 
TREATMENT OF ARTERIAL  LESIONS.
723
had  again  attempted this  process, notwithstanding the two  fortunate
results that MM. Viricel and  Larrey (Clin.  Chir., t. III., p. 246,) say
they have obtained from it.  Now that we know in what light  to con-
sider the dangers of suddenly suspending the  circulation in the principal
artery  of a limb, a process  like  this has  necessarily fallen into disre-
pute ;  and  what I have  said of precautionary ligatures, shows sufficiently
that it  would be one of  the most dangerous that could be proposed.
  e. The  gradual closing therefore of arteries, ought  to  be rejected
from practice, unless  it could  be effected by one of the  modes of indi-
rect compression, as for example, by one of the processes of MAI. Viri-
cel,  Leroy, or Alalgaigne, already related.  As to the  temporary liga-
ture, properly so called, I am of opinion that it ought still  to be made
trial of.  Could the artery be thus  disembarrassed in four or five days,
of every kind of extraneous substance, it would run no risk of becoming
altered or divided ; the hemorrhage and  purulent collections would by
this means become less  frequent, and the success of the operation would,
in every respect be rendered more certaia.
   E.— The Double Ligature  with the  section of the artery between.
Celsus, (De  re Mid., trad, de  Ninnin,  t. II., p.  17,) Galen, (Lib. v.
 Therapeut., cap. III.,) Aetius, (Tet.  4., Serm.  3, cap. X.,)  Guy de
Chauliac,  (Grande  Chirurgie,  trad, de  Joubert, p.  173,)  Rufus,
Rhazes, Gouey, Severin, (Med. Efficace,  bibl. de  Bouet,  p. 98,) and
Purman, (Thierry, Tliese 1750, Choix de Haller, trad. Fran^., t. IV.,
p. 15,) were in the habit of applying two ligatures at a certain distance
apart,  and of then dividing the artery transversely between them. Pel-
letan (Clin.  Chirurg.,  t. I., p. 192,) following the advice of Tenon,
was upon the point of adopting this process, which  was entirely forgot-
ten towards the end of the  last century, and  strongly censured by Heis-
ter, Callisen, and Richter.   Abernethey  (Dorsey, Elements of Surgery,
vol. I., p. 213,) however adopted this method  in his first operations of
ligatures upon  the external  iliac artery, without being aware  that  his
countryman,  Bell, (Traite  des Plaies, trad.  Fran^., p. 102, 115, 117,
122,) had mentioned it, and considered himself the author of it. With
this precaution, says  he, the two ends  of  the artery retract towards the
tissues, suffer no traction, and are  placed  in the same condition  as after
amputation.  AI. Maunoir,  (These No. 328, Paris, An XIII.,) in a me-
moir on this  modification, which he also  regarded as  belonging unto
him, declared  himself its unqualified  champion.   Like Morand he ac-
cords to the arteries a great retractile power, considers  that the circu-
lar  ligature,  by puckering them, shortens their length,  and  exposes
them to violent traction by the impulsion  of  the heart at each throb of
the pulse; and that the best means of preventing secondary hemorrhages,
must be to allow the artery which we have just tied, to withdraw itself
into the soft  parts, to an extent proportionate to its natural retractility
(retractilite.)   Some facts related by  Abernethey, and  Blacke, and
MM. A. Cooper, Alaunoir, Dalrymple, Post, Guthrie,  &c,  seemed  at
first to give a favorable reception to  this method, which  MM. Roux,
Larrey, and Taxil, in France, were  not  opposed to adopting, at least
for the large  arteries.   Having been made trial  of, however, in 1807,
by M.  Norman, of Bath, it  gave rise to  an  alarming hemorrhage, and 
724
NEW ELEMENTS OF  OPERATIVE SURGERY.
Scarpa, who rejects it, arrays against it the cases  of Alonteggia, Assal-
ini, &c, in which it was followed by hemorrhage of a fatal character.
  The truth is, that the reasons which have been advanced for dividing
the artery between the two ligatures are poorly sustained.  The retrac-
tility imagined by Aloraud and AI.  Maunoir, and which has been so much
insisted upon since by Bonfils, (These de Strasbourg,) and Taxil, (J°ur~
nal Universel des Sciences Medicates, 1816,) and  more recently still by
M.  Guthrie, (Diseases of Arteries, London, 1830,) can scarcely be said
to exist, as has been proved by the experiments of Beclard, (Soc. Med.
d'Emulat., t. VIIL, p. 569,) the truth of  which I  myself have had very
frequent opportunities of attesting.  If, after amputation of  the limbs,
the arteries sometimes recede to a great distance, it is because they are
drawn up by  the muscles, and not  in consequence of a retraction which
properly belongs to them.  Moreover, supposing that when strangulated
in a ligature, they undergo a certain degree of traction, nothing is more
easy than to put a stop  to this without affecting the continuity of  any
tissue.  To effect this object we have only to adopt the recommendation
of Lyng, (lb. p. 719,) namely, to  put the limb in semi-flexion, and all
the muscles in a  state of relaxation. This  section is not only unattended
with any decided advantages, but may incur the  risk of most serious
consequences.  Suppose, for example/the ligature upon  the  upper  end
of the artery should happen to slip off and become loose, as happened
to MM. A. Cooper and Cline, (Dorsey, Elements  of Surgery, vol. II.,
p. 214,) there would necessarily result from it an  alarming hemorrhage,
which might  speedily prove fatal, if the  patient was not instantly re-
lieved.   Let  a similar  accident take  place  after a ligature upon the
carotid artery at the lower part of the neck, or  of the  subclavian, or
either  iliac, and death will almost  inevitably be the result.  We must
therefore come to  the conclusion, that the advice given by Abernethey
and M. Alaunoir, to apply two ligatures, and to divide  the vessel in the
intervening space, is a method dangerous in its  consequences,' and in-
sufficient for the end proposed, even though we should place, as M. Pe-
trunti  (PL Portal. Clin. Chirurg., t.  I.,  p. 168,)  recommends, the little
rouleau of Scarpa under each thread.
   F.—Ligature through the Artery.  For sometime past attention has
been  drawn  to  a  process,  already mentioned  by  Dionis,  and which
Richter describes  in these terms: " The artery being drawn outward,
an ordinary ligature, should be passed round it twice ;  this should be
made tight by a knot, and when  the  artery is of considerable size, one
of  the  ends  of the ligature  should be passed through it by means of a
needle."  This is  the plan which  Cline thought it proper to recommend,
in order to  prevent the  ligatures  in  the process  of  M. Alaunoir from
becoming loose and escaping from the ends of the artery.  M. A. Cooper
made  trial of it for aneurism in  the popliteal  space, in a man  aged
twenty-nine  years.  The two ligatures  were  first  made tight  at the
bottom of the inguinal  space, then the  needles  were passed  between
them, through the coats of the vessel; the ends of each of the threads
were afterwards fastened on  the  knots  of the first ligatures, with the
view of opposing an  impediment to their  slipping.  AI.  S.  Cooper,
 (Dictionary of Surgery, Art. Aneurism, p. 129,)  and all  other sur-
 geons, very properly as I think, censured this process which has neither 
TREATMENT OF ARTERIAL  LESIONS.
725
analogy nor experience in its support, and the employment of which has
nothing to justify it.
  Nevertheless, it might very naturally have suggested the  one  which
AI. Jameson appears to have frequently made trial of with success upon
animals.  This physician thought that all that was necessary to oblite-
rate a large artery, or a  large vein, was  to pass a seton through it of
two or three lines in width.  Experiments made by him upon the caro- .
tid  and  jugular of horses, with  ligatures  of deer-skin, have always .
caused an effusion of plastic lymph in the interior of the vessel, a thick-
ening of the perforated  tunics, and  soon after a complete interruption
to the current of blood.   I learn from AI. Chaumet, of Bordeaux, that
these experiments were  repeated at the Val-de-Grace, and followed by
similar results.  AI. Carron du Villards, has also made a series  of ex-
periments on animals, which  demonstrate that the same effect may be
produced by piercing  the artery with a linen thread, or with iron, steel
or  silver wire, &c. ; this,  therefore, is a new question which, without
being a matter of any  great importance, nevertheless, in  my opinion
merits  the  attention  of practitioners.  A  ligature of deer-skin, or a
conical piece of the same substance, passed through an  artery, and then
left at  the  bottom  of the wound, would in  no respect interfere with
immediate reunion, and would render the operation for aneurism exceed-
ingly simple, if the cure would as certainly follow as after the ligature.
   G.—Indirect Ligature.   The ancients, deficient in the required ana-
tomical knowledge, did not take the trouble  to lay bare the artery, and
confined themselves in some  cases  to  inserting the ligature through the
whole thickness of the limb, between  the vessel and the bones, tying the
ends afterwards upon  a compress  placed between the ligature and tho
skin.  This  is  what Thevenin recommended,  and what both Le Dran
and Garengeot  did  not  think discreditable to adopt even at the  com-
mencement of  the last century, in order to suspend the circulation  in
the brachial  artery while they were disarticulating the shoulder. Though
aneurisms may have sometimes been  cured by this method, there  does
not seem to be  any necessity for my discussing the subject to any greater
length at the present time, in order  to demonstrate its inconveniences
and dangers if it  should  be applied to the  deep-seated or lage-sized
arteries.  The superficial arteries, and those of the fourth or fifth order,
are the only ones, in fact, to which it could be  at all applicable.  In the
fingers, wrist, face, and  cranium, a pin  passed under  the  artery, then
surrounded by a thread crossed in figure of 8, or made tight in circular
turns under its extremities, would probably succeed as  well as the direct
ligature.  The thread  passed with a  curved needle, under the  artery,
and then tied into a  knot  upon a  small compress, would answer the
same purpose.  The  operation would thus  be rendered more simple,
easy and prompt, and  less  painful.
  H.— The Direct Ligature.  AVhen it was the practice to  search for
the artery at the  bottom of the aneurismal sac, it was sometimes so
difficult to isolate it from the surrounding tissues, that the question was
asked whether it might not be allowable to include at  the same time, in
the thread, both the vein and the nerves.   Molinelli (Alem. de lTnsti-
tut. de Bologne, Clin. Chirurg. de  Palletan,  t. I.,  p.  143,) maintains
that it is useless to observe so much precaution, and that the strangula- 
726
NEW ELEMENTS OF OPERATIVE SURGERY.
 tion of the large nervous cords rarely endangers  the success of  the op-
 eration.   This was  also the  opinion of  Thibault, (Dionis, edit, de  la
 Fave, p. 703,) Surgeon of the Hotel Dieu.   Thierry ( These de  Haller,
 trad. Franc.,  t. IV., p. 16,) arrived at the same conclusions, after hav-
 ing  made a number of experiments on  dogs, sometimes by tying the
 axiliary and femoral arteries,  without touching the nervous plexus ;  and
 sometimes by including this  plexus in  the  ligature, in none of which
 cases did gangrene or  permanent paralysis take place.  The moderns
 nevertheless  have rejected his views on this  matter, and think unless
 there should  be  insurmountable difficulties in the way, that the artery
 alone should be  embraced  bv the ligature.  Though  even the case
 quoted by  Pelletan, (Clin.  Chirurg., t. I., p. 143,)  from a letter of
 Testa's, in which it  is seen that a patient operated upon by Falconnet,
 who had included in the  same  ligature the popliteal nerves, vein, and
 artery, was seized with frightful pains in the limb, which  became gan-
 grenous the very evening of the day of the operation, might  not  make it
 imperative to conform to the  practice of surgeons in our  time, reason
 alone would have sufficed to persuade us to do so.  That the section, in
 fact, of one, or of several of the nerves, does not necessarily cause para-
 lysis, may be  conceived; that a ligature upon  a large  vein should not
 be constantly followed by gangrene, we may also understand, whatever
 M. Guthrie may say on this matter ; (Diseases of the Arteries, &c, p.
 128,) but let  those two kinds  of organs  be  strangulated at one  and the
 same time, with  the principal artery in the same limb, and it  is unde-
 niable  that mortification and loss  of  sensibility will take  place, if not
 always, at least in the greater number of cases.  In recommending that
 we should  pay no attention to parts so important, have not surgeons
 wished to justify the little trouble they took  to isolate the artery, and
 thereby to depreciate  the advantages of an  opposite course ?   At the
 present time therefore it is the rule not to allow either  the vein, or the
 smallest nervous filiament, or any  of the surrounding  tissue, to be  in-
 cluded in the  ligature with the artery;  and this, without doubt, is one
 of the reasons why the operation  for aneurism, once  so formidable, is
 now so simple and easy.  AI.  Ghidella, {Bullet, de Firussac, t.  XXIAr.,
 p. 172,) who, in adopting the advice of Alonteggia, included the nerve
 and the vein  in the same ligature, in tying the femoral artery for a he-
 morrhage, following amputation of the  leg, will not succeed in causing
 this practice to be revived, notwithstanding the success he boasts of.
 M.  Grillo also, ( Gaz.  Mid  de Paris,  1834, p. 539,)  who asserts that
 he cured fifteen  patients by  tying the  femoral  artery in  this  manner,
 places himself beyond the pale of my comprehension.
   I.— The Double Ligature.   Since precautionary ligatures have been
 rejected, some persons have thought that for greater  security, it would
 be well to apply on the large arteries two ligatures, at a certain distance
 from each  other.  Vacca says, that by proceeding in  this manner we
r gain nothing, since the  intermediate portion of the vessel between the
 two ligatures, necessarily becomes gangrenous.  But  this  reasoning of
 the Professor of Pisa is  not  valid ; for  AI. Briquet states, according to
 Beclard, that a segment of artery continues to retain its vitality, though
 it may no longer have  any connection with the trunk from which it is 
TREATMENT OF ARTERIAL LESIONS.
727
separated; it is therefore for other reasons  that  it has been  thought
advisable to proscribe the double ligature.
  [Professor Mattei, of Corsica, has prepared a new kind of ligature, the
advantage of which, is,  that it may be  removed as soon as the vessel is
obstructed, and before the included portion has been eaten  through by
absorption, thus obviating one grand  impediment to the healing by the
first intention,  and rendering less  liable the  occurrence  of secondary
hemorrhage.    This ligature consists  of two loops,  intercrossed, and
with the  ends in opposite directions.  The end of the vessel is placed
between these loops, and constricted  by pulling at the ends  ; or if it is
an entire and  undetached trunk which has to be tied, one  loop is first
passed around the vessel in  one  direction, and then the other around it,
in a contrary direction, the ends  being threaded in such a way around the
silk forming the  first loop, as  to  secure  the  necessary intercrossing.
When the vessel is of large  size, the ends of the loops  are made to have
an  extra turn upon each other.  After the vessel is  tied,  one  end of
each loop is cut away close  to the vessel, and the  other end is brought
out of the wound, the two remaining ends  being disposed  as nearly as
possible  in opposite  directions.  When the  vessel has become oblit-
erated, they may be removed by gentle traction at each of the protrud-
ing  ends, each loop slipping  away from  the other with facility, and
without disturbing the parts.  M. Afattei sometimes attaches a thread to
their bends, without clipping away any part of the loops.  The threads
are brought out of the wound along with the ends of the loops.   He has
tested this form of ligature  in amputations of the breast, leg and arm.
The ligatures were removed from the principal vessels on the fourth 01
fifth  day, and from the smaller vessels in the course of the next day,
without any loss  of blood.  Ranking's Abstract, No. 18, p. 120, from
the  Rev. Med.  Chir.  Ap. 1853.                           G. C. B.]
   B. Paul of Egina (Paulus Mginet.,l\h. VI., cap.  37,)  speaks of  a
process  which consists  in passing a needle with a double ligature behind
the middle of the aneurism, tying  one of  these ligatures  above and the
other  below the  tumor, which is thus  strangulated  above and below,
afterwards  opened, and almost the  whole  of it  excised.   Thevenin
(CEuvres, 1658, in fob, p. 57,)  also mentions this process which, as we
see, is very similar to that which was formerly used in applying a liga-
ture to lupus and  many other tumors.  It is  this,  doubtless, which  Guy
de Chauliac (Grande Chirurgie, etc., p. 173,) has reference to when he
asserts  after Albucasis, that we may cure aneurism  by employing the
ligature, so as to burst  it.
   C.  Guy de  Chauliac points  out another mode which, though it ap-
proaches that of Paul of Egina, nevertheless  differs from it under soma
points  of view,  and seems in  reality to be more rational.  "It is ne-
cessary," says he, "that the artery should  be laid bare,  and  tied on
both sides, that the part between the two ligatures should be cut through,
and then treated like common wounds."   The process described at such
length by Bertrandi,  towards  the middle of the last century, being only
the "repetition  of that  of Guy de Chauliac, does not require any further
 mention.  It is also so far from being new, that Philagrius  (Mlius, tet.
 IV., Serm. 3, cap. X.) had already had recourse to it.
   D.  Guillemeau, (CEuvres  Completes, in fob,  p.  690,) rival and dia 
728
NEW ELEMENTS OF OPERATIVE SURGERY.
 ciple of Pare, simplified the method of the ancients ; ho  contented him-
 self with tying the  artery above the tumor, opening this last, emptying
 it of its  clots, and  then dressing it  as  an ordinary wound ;  it  is this
 which forms at the present day the basis of the ancient method of treat-
 ing aneurisms, a method which up to the last century,  no one had the
 courage to apply except to aneurisms in the bend of the arm.
   E. Keysleire, (Lettre d Cotugno, Pelletan, Clin. Chir., t.^I.,) sur-
 geon of Lorraine, in the service of Austria, about the year 1774, is the
 first who asserts that he had many times performed it with success for
 aneurism in  the ham.  Keysleire, in place of commencing  by  laying
 bare the artery above the  tumor,  proceeded, after having arrested the
 current of  blood  in the limb by means of the garrot or tourniquet, to
 lay open the aneurismal sac in its whole length, then carefully cleaned
 it, sought the opening of the vessel, introduced  the end of a sound to
 raise it up, tied its  upper end, moderately compressed its lower end,
 and  treated  the wound afterwards  by the known means.   Guattani,
 Molinelli, Flajani, and almost all  the  surgeons  of Italy, employed  the
 same method, which soon became  generally adopted in  France, Germa-
 ny, and England, after  having undergone,  however, some slight modifi-
 cations.
  F.  In place of confining themselves to compressing  the lower  end of
 the artery,  Molinelli, Guattani, &c, found  it more prudent to surround
 that also by a ligature.  The two Alonros, Hunter, Desault, Pelletan,
 Deschamps, and Boyer, thought  it would be advisable also to leave
 some threads above and below the first ones, in order  to make use of
 them if required, to check consecutive hemorrhages ;  from thence came
 those precautionary ligatures which have been described farther back.
  G.  Anel. A  method different from this, and  the elements of which
 are found  in  the processes of Aetius and  Guillemeau, was put in prac-
tice at the  beginning of the  last century by  Anel.   (Observ.  sur la
 Fistule lachrymale, etc.,  1714.)   Having to treat an aneurism  in  a
missionary  of the Levant, Anel applied on the 30th of January, 1710,
in the presence of Lancisi, a simple ligature  upon the  brachial  artery,
immediately above the tumor, and without touching  the sac.  On the
5th of Alarch following, the patient had entirely recovered.   Neverthe-
less, this event, though remarkable,  did not at first  excite  attention,
notwithstanding the trial which Leber and V. Hanspel  (Verbrugge, De
 Aneurismate, etc., 1773,)  made of it, and was  not rescued from obliv-
ion until between 1780  and 1786.  Desault (GZuvres  Chirurg., t. II.,
p. 568 ; et  Boyer, t. II.)  is the first who endeavored to restore it to its
honors, in the month of June, 1785, by tying the popliteal artery with-
out opening the aneurismal sac.   On the nineteenth day there escaped
 from the wound a great quantity of  matter mingled with blood, and a
 short time after the  cure appeared to be complete ; but  the patient ulti-
 mately died at the expiration of seven or eight  months.
  The idea, however, of tying the aneurismal arteries  at a certain dis-
 tance from  the  tumor, dates far back.  It is difficult, for example, not
 to recognize it in this passage of Pare :  (CEuvres, liv. VIIL, Chap. 34,
P. 218, in fol.)—" I advise the young surgeon," says  this great prac-
 titioner, "  to be careful how  he opens aneurisms, unless they are very
 small, and  in a measure not dangerous ; after incising  the skin over it 
TREATMENT OF ARTERIAL LESIONS.
729
and separating it from the artery, we then pass a seton needle, threaded
with very strong thread, under the artery on the two sides of the wound,
letting the thread fall out of itself, and by proceeding in this manner,
nature engenders flesh, which will be the means of  stopping up the ar-
tery." ^ Guillemeau went still farther than  his master, for he concludes
his article with  this remarkable sentence :—" If  such  an aneurism
should present itself to the surgeon in some other external part, he may
safely lay bare the body of the  artery  at  its root  and its upper part,
and tie it in the same manner without any other ceremony."  Is it not
evident that we here find the  parent-thought of the method called that
of Anel or Hunter ?   In the  supposition that it was not  in the mind of
the author, it  cannot be denied, at least, that it is  deducible  from his
language.
   According  to the  assertion of AI.  Martin of  Marseille, Professor
Spezzani had entertained the design in the year 1781, of tying the fe-
moral artery itself, without touching the sac, for popliteal aneurism, a
project carried into  execution under his eyes by Assalini, (PL Portal,
 Clin.  Chirurg., t. I., p. 154.)  It was in the month of December, 1785,
that Hunter, on his part, carried this suggestion into effect.  As his op-
eration was completely successful,  it made much noise in the surgical
world, and was in reality the signal of a revolution in our ideas re-
specting the treatment of  aneurisms.
   To set out from this epoch, we find  the method of Anel, described
under the name of  the New Method, the  Modern  Method,  and the
Method  of Desault  or  of Hunter, all of them  inappropriate phrases,
and  which ought to give place to the title of the Method of Anel,  its
true inventor.  In calling it a modern method, we  make use of an im-
proper expression, which specifies nothing, and which  ought to cease
to have the least value as  soon as another mode of  operation should be
devised.   To-day, for example, the modern method  is the method of
Brasdor, and  no longer that of Anel.   In calling it the method of Hun-
ter, as the English surgeons  do, and what is more singular, as many
persons have been in the habit of doing in France, a double act  of in-
justice is committed  towards our nation.  In fact, this method devised
by Anel, if not by Guillemeau and Pare, was by Desault rescued from
oblivion.   Is it for having applied the ligature at three inches above the
point selected by Desault, that Hunter  merits  the  title  of  inventor in
this  affair ?  In that case, this honor would  in reality  redound to an-
other, for it is generally in the inguinal  space, as  Scarpa advised that
we operate, and not  as Hunter did in  front of the adductor  magnus.
Again, if it is  true that Brasdor proposed from the year  1780, for many
years in  succession in his course at  the schools  of  Surgery, that we
should tie the  femoral artery in the middle  of the thigh, as his pane-
gyrist in  the Collections of the  Society of Medicine  affirms,  is it not
probable that  young Englishmen, who then,  as at  present, were always
found in  considerable numbers at Paris,  may have carried the suggestion
to London, and that in this way it had come  to the  knowledge of Hun-
ter ?  It should be the name of Anel, therefore, that ought to be affixed
to this process, whatever AI. Guthrie may say to the contrary, (On the
Diseases of the Arteries, &c, 1830,) and who, in order more effcctu-
  Vol. I.                   92 
730
NEW ELEMENTS OF  OPERATIVE SURGERY.
ally to oppose Dupuytren on this subject, goes to the extent of calling in
question the part  accorded in this matter to Desault.
  H.  Method of Brasdor.—Another method has since been introduced
in science.   Embarrassed by the difficulty or impossibility of placing the
ligature between the aneurism and the heart, and by the danger of open-
ing the sac when  the disease was found too near the trunk, and unwil-
ling, nevertheless, to rely upon the method of  A^alsalva, or upon topical
refrigerants, some surgeons in  that  case  supposed that it might be al-
lowable to place  the ligature below the tumor, between the tumor and
capillary system.  According  to  Boyer, (Malad. Chir.,t. II., p. 569,)
it is to Vernet, a military  surgeon, to whom we are to ascribe  the first
suggestion of this method, since it is to  him that we are indebted for the
attempt to compress the  femoral artery  below an inguinal  aneurism.
Brasdor, nevertheless, is  the  first who  formally proposed to  apply  the
ligature at  that  place.   Desault, (CEuvres Chir., t. IL, p. 569,) at  a
later period, urged the same thing.   Deschamps (Ibid., p. 572) carried
it into  execution  for a very large  aneurism  in  the  fold of the groin
which threatened  to  burst.  The  pulsations immediately became much
stronger  in  the tumor, which it became necessary at the end of a few
days to lay open freely, and the patient died in  consequence of  this  last
operation, after having lost a very considerable  quantity  of blood.
From that time the proposition of Brasdor appears to have been defini-
tively adjudged ;  A. Burns (Surgical Anatomy, 1823, p. 186,) qualified
it as absurd, and it was generally rejected as dangerous.  The attempt
of Deschamps  seemed fully to confirm the  fears, that reasoning a priori
on the subject, had suggested.   It had been said that by strangling the
artery below the sac, it is evident that  the  blood arrested at this point
by an insurmountable obstacle, must distend with greater violence than
ever the aneurismal tumor, and also  attenuate  its walls, and ultimately
rupture them.
  AI. A. Cooper,  (S. Cooper, Dictionary, art. Aneurism,)  convinced
like Brasdor, that when the circulation is  arrested in the artery, below
the aneurism,  the blood would  soon  flow into the collateral vessels, to
reach the lower part of the limb, and that it would fall into a  state of
stagnation, and coagulate  in the tumor, and in all that  portion of  the
vessel comprised between  the ligature  and the first branch of  any con-
siderable size  lying  towards the heart, did not feel inclined to yield to
those  reasons.  He ventured, therefore, in 1818, to renew the attempt
of Deschamps  in a  case  of aneurism, which  raised  up Poupart's liga-
ment, and  appeared to occupy a great portion of the iliac fossa.   The
pulsations of the tumor continued,  but the progress of the disease was
arrested.   At the expiration of a certain period of time, the tumefaction
of the neighboring parts  disappeared ; the separation  of the ligatures
was not succeeded by any accident;  the wound cicatrized, and  about the
sixth week the patient was sent to pass his convalescence in the country.
It was ascertained afterwards that the  tumor had ruptured, and that the
man died about two months after the operation.  The body was not ex-
amined.
   Notwithstanding this unfortunate result, the operation of AI. A. Cooper
was nevertheless of a nature to inspire hopes, and to deserve new trials.
M. Alarjolin also said (Dictionnaire de Medecine, art. Aneurisme, 1821) 
TREATMENT OF ARTERIAL  LESIONS.
731
that before  abandoning it entirely, it would be advisable to make some
new trials with it, especially on the primitive carotid.   AI. Pecot (These
No. 155. Paris, 1822,) afterwards distinctly recommended it for certain
descriptions  of aneurism  of the primitive iliac, the external iliac, and
even the subclavian, when the size or situation of the tumor prevented
our laying bare the  artery by  the method of Anel; provided we could
at the  same time tie the collateral branches which might be found  be-
tween  the  principal ligature and the sac.  AI. Casamayor (These No.
151. Paris, 1825,) also, after passing in review all the facts  and reason-
ings that had been adduced in favor of or against the method of Brasdor
asserts that it might perhaps be employed in  those  cases of aneurism
where we should be enabled to suspend by this means the current of
blood, or at least reduce its  column to such dimensions that it would  be
incapable of preventing the contraction  of the tumor.  Dupuytren, on
his  part, has declared that the  partial  success  of AI. A. Cooper  was
rather calculated to  encourage than to dampen the zeal of surgeons,  and
that by restraining the patient to a severe diet, and diminishing the
mass of the fluid by repeated bleedings, either  before  or after the ope-
ration, we might by this means, probably, by allowing the  blood accu-
mulated in the tumor to become coagulated, promote a favorable issue.
   Alatters were in this state when, in spite of the reasons of A. Burns,
and of Hodgson, and many other English authors, AI. Wardrop, (Archiv.
 Gen.  Mid. t. XX., p. 557,) in 1825, carried  into execution  the ideas
of Brasdor, in the case of an aneurism of the primitive carotid. It was
in a woman  aged seventy-five years,  and  in whom the tumor, approxi-
mating very close to the  sternum, would  not have  allowed of placing a
ligature between it and the  heart.  On the fourteenth day the aneurism
had diminished one  half, and the  pulsation was no longer felt in it; it
terminated by bursting and emptying itself like an abscess ; but the
ulcer was speedily cicatrized, and  the patient perfectly restored.  Was
it in reality an aneurism ?
   In the course of  the same year, AI. Wardrop (The Lancet, Vol. I.,
1826) had to treat  another woman who was fifty seven years of  age,
affected with an aneurism situated immediately under the sterno-mastoid
muscle upon the right side.  The carotid artery was tied, Dec. 10th,
with a ligature made of the  intestine of  the silk  worm.   On  the 13th,
the wound  had entirely closed, and  on  the 21st, the  patient believed
herself perfectly cured ;  nevertheless she died on  the 21st  of Alarch  fol-
lowing, in  consequence, however, of symptoms of hypertrophy of the
heart,  and  of accidents which did not seem to have any connection with
the operation itself.   On the 1st of Alarch, 1827, AI. J. Lambert, (Ibid.,
1827, vol. XII.,) of Walworth, had occasion to  adopt the plan of  AI.
Wardrop in a .case of aneurism of the right carotid in a woman aged
forty-nine years.  On the third  day  the tumor had  much diminished in
size, and only slight pulsations were felt in it.  On the tenth day a he-
morrhage came on,  which did not prevent the wound from  closing.  The
tumor  loon disappeared.   On the 17th of April, the  cicatrix had be-
 come ruptured, and a red  fleshy growth occupied its centre.  On the
 18th,  a new hemorrhage took place, and occurred several times up to
 the 30th;  and on the 1st of Alay it became so abundant that the patient
 died at 11 o'clock in the forenoon. 
732
NEW ELEMENTS OF OPERATIVE  SURGERY.
  On opening the dead body, it was found  that the carotid  artery had
ulcerated above the ligature, that the aneurism had become entirely ob-
literated, and that the'hemorrlnme had been  produced by the reflux of
blood from one carotid to the other.  AI.  Bushe (The Lancet, A ol. I.,
1828 ; and Vol. IL, p. 149,) on the 11th of September, 1827, performed
the same operation on a woman aged thirty-six years, with perfect suc-
cess.  AI. Wardrop ( The Lancet, Vol., 1,1827 ; Vol.L, 1828 ; V ol. IL,
1829.  Alcd. Chir." Rev., No. 21.   Bullet, de Ferussac, t. XX., p. 2-_l,)
performed it a third time on the 6th of July of the same year,  on a wo-
man aged forty-five years.   This time he  tied  the subclavian  artery in
place of the carotid, which evinced no pulsation, and  appeared to  have
become obliterated.   A month after, the patient quitted London to re-
side in the country, and towards the latter part of August found herself
perfectly restored. Various symptoms of affections of the chest after-
wards occasioned some apprehension.  On the 9th of  September, 1828,
the health of this lady, which was the occasion of a suit of slander, ( The
Lancet, 1828. Vol. I., p. 775,) had never been in a more perfect state ;
but she, nevertheless, died  on the 13th of September, 1829.  On the 2d
of July, 1828, AI. Evans (The Lancet, November, 1828,) also employed
the method of Brasdor in a case of aneurism of the trunk of the carotid,
in a man aged thirty years, and on the 28th of October, the patient re-
sumed his usual occupations.  Accidents afterwards supervened, and it
became  necessary to  perform a new operation, and to tie  two tumors,
and excise them.  The patient  was  ultimately cured.   (Letter of M.
Evans to M.  Vilardebo, Alay, 1831.   These  No. 158.   Paris, 1831, p.
58.)
  A negro operated upon in the same manner by AI. Alontgomery, ( Gu-
thrie, op. cit., p. 191.   The Lancet, 27th  June, 1823,) on the 10th of
March, 1828, in  the Isle of Mauritius,  at  first seemed to do well, but
died on the 11th of July following.   The patient of AI. V. Alott, Journal
des Progres, 2d ser., t. II.,  p.  213, or American Journal of Medical
Sciences, 1830.) also, whom he had operated upon on the 20th of Sep-
tember, 1829, and whom he had supposed to be cured, died on the 22d of
April, 1830.  A woman operated  upon by Af. Key, (London Medical Ga-
zette, July, 1830,) on the 20th of July, 1830, died the same day.  An at-
tempt of the same  kind was made on the  12th of June, 1829, at the
Hotel Dieu, by Dupuytren, for  an aneurism at  the origin of the  right
subclavian artery; the patient died on the ninth day after the operation,
more perhaps  owing to the great loss of  blood than from the operation
itself.  AIAI. White (Guthrie, Diseases of the Arteries;  Vilardebo, p.
28,) and James, (Med.  Chir. Trans., Vol. XVI., 1830,) who repeated
the operation of AI. A. Cooper, were not more fortunate.  A patient op-
erated upon by AI. Laugier, at the Necker Hospital,  also died ;  but a
case of Af. Fearn, (Arch. Gin.  de Mid.,  3e serie, t. II., p.  364,) an-
other of AI. Alorrison, (lb., p. 367,) a third of AI. Tilanus, and a fourth
of AI. Rigen, seem to give support to the first successful cases of AI.
Wardrop.
  Thus have we  three methods of treating aneurism by ligature.   It re-
mains now to see which is the one which ought generally to be preferred,
and in what cases it may be proper to have recourse to the others. 
TREATMENT OF ARTERIAL LESIONS.
733
           § V.—Relative Value of the Principal Methods.

  A.  In the ancient method it is necessary that  the seat of the tumor
should admit of our making between it and the heart a sufficient degree
of pressure temporarily to suspend the entire circulation in the limb.  The
opening of the sac requires a very extensive wound, leads to an abun-
dant suppuration, renders the isolation of, and ligature upon the artery
sometimes very difficult—frequently obliges us to place the ligature upon
a part of the vessel more or less altered,  exposes in a remarkable de-
gree to secondary hemorrhages, and to gangrene  from deficiency of cir-
culation, and does not cicatrize  but very slowly.   If the aneurism is
deep-seated, this method obliges us to divide the muscles and  aponeu-
roses, and to produce a  good deal of destruction  in the midst of the
tissues ; in a word, it is a painful, long, laborious, difficult and  danger-
ous operation.   The reasons  in favor of it are, that it preserves all the
important collateral arteries, permits no reflux into the sac, and exposes
less than the others to erysipelatous, phlegmonous and purulent inflam-
mations in the  depth of the muscles.  Perhaps, therefore, it would still
be advisable frequently to give it the preference near the upper part of
the limbs, and  to adopt it generally in  traumatic aneurisms,  whether
primitive or consecutive.  M. Guthrie, (Oper.  cit., p. 270, 283,) who
will allow of no other in such cases, no  doubt goes too  far ; but in re-
jecting it altogether from  practice, modern surgeons have gone to the
other extreme, which is equally as objectionable.
   [The perusal of modern  British works on surgery is calculated to pro-
duce the impression that Air. Guthrie was the first to promulgate and to
establish the practice of tying an artery both above and below the wound
in cases of traumatic hemorrhage.   Air. G. was born in 1785,  and pub-
lished his paper on wounded arteries, in the new Med. and Phys. Journ.
1811. Air. McGill published about 1732, in  the Ed. Med. Essays, Vol. II.,
p. 224, his recommendation  of the use of a probe to facilitate  the liga-
ture  of a punctured  artery  at the seat  of the  wound, and Air. Sharpe
 (in his Treatise on the Operations of Surgery, 1739, pp. 208, 9,) incul-
cates the doctrine of ligating  the  vessel above  and below the wound.
De la Faye, in his annotations to the  Cours d' Operations &c, of Dionis,
1746, (p. 705) most ably refutes the opinion of Dionis, who thought the
 single ligature sufficient in  these cases.   Mr. Warner, whose  Cases in
 Suro-ery was  published in 1784, just one  year before  Air. Guthrie was
 born, declares (p. 143) that a second ligature should always  be  made
 below the wounded orifice of the  artery.  John Bell in his Principles
 of Surgery, Edinb. Ed. 1801,  Vol. I., p.  187, in speaking of wounds of
 the  radial artery, remarks that it was the rule commonly laid down at
 that time, to tie above and below the wound.   Dr. Physick in 1804,
 treated in this manner a varicose aneurism at the bend of the arm, Phil.
 Med. Museum, Vol. 1st, p.  65.  Indeed, as related by Bertraudi in his
 Traite des  Operations, p.  362, 1763, Guattani actually experimented
 upon the brachial artery,  by injecting above  the  ligatures, and as the
 fluid issued from the opening made below, he argued  the importance in
 similar cases of tying above and below the wound.   Air. Kast in lltio,
 tied both upper and lower ends of a wounded  femoral artery.  (Mass. 
734
NEW ELEMENTS OF OPERATIVE SURGERY.
Med. Society, Reports.)   Our author  is not  alone  in  asserting  that
Air. Guthrie goes too far, in allowing no other practice.
   Prof. Beck, of Freiburg,  has  published an elaborate monograph On
the Application of the Ligature to Arteries or their  Trunks at a Distance
from the  Wounded Part, and nearer  the Heart,  being a Contribution
to the  Treatment of Traumatic  Hemorrhage.  This was  translated by
Dr. Davis, of Philadelphia, we believe in 1836.  In it the reader may find
abundant  proof  in favor of such a proceeding in many cases of trauma-
tic hemorrhage,  and especially where the arterial lesion is accompanied
with fracture, as advocated  by Delpech, Roche, Sanson, Dupuytren and
 Roux.   Air.  Crisp, in his Treatise on the  Blood-Vessels, has likewise
freely commented on the opinions of Air. Guthrie, and has shown even
by the cases selected by Mr. G, to establish his doctrine, that although
it is advisable  to tie  both ends of the artery, when  practicable, the
successful cases  of ligature of the main artery  on  the proximal  side of
the wound are sufficiently  numerous to warrant  the belief that this oper-
ation will, in many of the cases, arrest the  hemorrhage and lead to
a favorable result.   G. C. B.]
   B. By the method of Anel,  we act on tissues in the normal state, and
whose relations  have not been disturbed.  It is easy to include only the
arterial trunk in the noose of the  ligature, and to avoid the nerves, veins
and all other tissues whose strangulation might compromise the success
of the operation; the  previous  compression of the vessel is not indis-
pensable ; and we  may look for it in the place where it is most easy to
to  lay it bare, or where it  is most superficially situated.   The  wound
which is smooth, and of little  extent, cicatrizes promptly and with faci-
lity ; the operation is simple, easy, and  infinitely less painful and not so
long as by the other  method; and when the artery  is tied upon a portion
of it which  is perfectly sound, the secondary hemorrhages must  be less
formidable and  less frequent.  The continuity of the tissues not being
so much disturbed, the circulation below the ligature is more easily re-
established ;  and the constitutional reaction is necessarily less  intense,
and the gangrene of the limb less to be apprehended.
   I. To those who say:—By opening the sac; 1, we may apply the li-
gature  as low  as possible, and  the tumor is  immediately emptied; 2,
we do  not  add another  lesion  to the first; 3, that tumors placed too
near the  trunk, (i. e., of the artery.  T.,)  to treat them  by the method
of Anel, will, by the  process in question, allow of the two ends of the
artery  being  tied;  4, that when an arterial  trunk has been wounded,
and we know the  place that the opening occupies, it appears more ra-
tional at  first sight to  lay it bare in this place than to proceed by means
pf a new  wound to search for it higher up;  the partisans of the method
of Anel reply:—1, After a ligature upon an artery, the circulation ceases,
not only  in  the part which is nearest approximated to the ligature, but
moreover also as high up as the first collateral of any considerable size
which is  met with  in the direction towards the heart;  2, in placing a
ligature upon the  popliteal artery, the femoral itself, for example, be-
 comes obliterated  as  high as to the origin of the profunda, for which
 reason  there is in this respect no advantage in cutting down to the ves-
 sel at the lower third  of the thigh; 3, that in respect to tumors situated
 very near the  upper  part of the limbs, there are none  of them at the 
TREATMENT OF ARTERIAL  LESIONS.
735
present day to which the method of Anel would not apply, so long as they
admit of being operated upon by opening into the sac; 4, that in diffus-
ed aneurisms it cannot be denied that the embarrassments caused by the
effusion of blood, the  displacement and disorganization of the tissues,
the difficulty of  cutting down exactly upon the point wounded, and of
finding the vessel itself at the bottom of a  wound more or less irregular
in its shape, and the depth to which it would sometimes be necessary to
penetrate, are inconveniences calculated to justify the practice of those
who, even  under  such  circumstances, operate  upon  a part of the limb
higher up ; so much the more so because hemorrhage which might return
by the lower end of the artery, could easily be arrested by pressure pro-
perly applied.
  II. The  opponents of the method of Anel might however rejoin, that
in placing the ligature at a certain distance  from  the disease, we incur
the risk of seeing the blood and pulsations return in the sac, and of hav-
ing thus performed, to no purpose whatever, an operation of a danger-
ous nature.   The blood, by means  of the  anastomosing branches may
return into the arterial  trunk  between the  tumor  and the ligature, re-
enter the aneurismal sac  by its lower opening, or arrive  there directly
by some secondary branch.   Though experience  may have  shown that
these pulsations soon cease, and that they are generally easily overcome
by a moderate compression, the  contrary also is equally possible. Rea-
son, moreover, perfectly explains this result.  The blood which arrives
to the aneurism,  under such circumstances,  can not do so but after hav-
ing traversed the capillary system, until after having passed from very
small channels into branches of greater  and  greater calibre, and conse-
quently not until after  having lost in a  great degree  its  natural force,
but if it be sufficient in order to effect its coagulation that it should remain
in a state of oscillation or stagnation, and  that it should cease to circu-
late in  any given point whatever of the vascular system, we may  also
conceive that in  certain cases it might remain liquid, keep up the dis-
ease to an indefinite period of time, and bring on  inflammation  of  the
sac; and that if  the inconvenience  in question is far from meriting the
importance that was at first given to it, we  should do wrong on the other
hand to pay no attention to it.
  As  to the  subsequent opening of the sac, and  its inflammation  and
suppuration,  both of which  have, with good reason, been deemed of
a nature calculated to jeopardize the success of the method of Anel, they
are inconveniences which, when  they do happen,  render  the  operation
still less formidable than that of Keysleire.  They are, moreover, rarely
met with but in cases where the disease is far advanced,  or where the
aneurism is contained within walls that are greatly attenuated and more
or less disposed to mortification.
  III.  In reality  the method of Anel has numerous and indisputable ad-
vantages over the ancient method.   Nevertheless this last should not be
entirely rejected ; we  should  give it  the  preference, for example, in
diffused superficial aneurisms, in  those which are situated  upon  the
brachial artery very near the axilla, and even in those of the axillary
artery, when the  shoulder is infiltrated or so altered that it would be
dangerous  to attempt the operation in front of or above the clavicle ;
also in all aneurisms of very large size that are in danger of becoming gan- 
736
NEW ELEMENTS  OF OPERATIVE SURGERY.
 grenous, or that are in the vicinity of a large and  important collateral
 vessel; in fine, in a varicose aneurism which requires that the artery
 should be tied  above and below its opening.   This doctrine, zealously
 advocated by AI.  Guthrie, seems to me to be  exceedingly sensible,  and
 altogether conformable to the principles of sound  surgery;  many facts
 which will find their place elsewhere, have satisfied me  that it is cor-
 rect.
   C.  The method of Brasdor, being a mere modification of that of Anel,
 has consequently as an operation, all its general advantages  and incon-
 veniences.  It is in fact nothing more than a substitute or dernier resort
 which is applicable only to cases which do not admit of the two other
 methods.   The cures  that are obtained by it are  explained in the  fol-
 lowing manner ;—the blood circulates with less force in the aneurism
 than above and below it, and this in  consequence of a physical or hy-
 draulic cause which is easily understood.  From this condition of things,
 the first effect of  a ligature when applied upon the  distal portion  of an
 artery, should be to completely arrest its  circulation first in the tumor,
 which from that  moment is  converted into a barrier, and secondly, as
 far as to the supplemental branches, through which the blood may obtain
 egress, and be diverted from its accustomed channels^  Let,  for  ex-
 ample, the carotid be tied near  its bifurcation, and it will become  ob-
 literated gradually down to  its  origin, that is to say, down to the point
 where it separates itself from the  aorta, or  the  subclavian  ; it will be
 the same respectively with'the tibial, radial, ulnar, popliteal, brachial and
 femoral arteries, &c.   But if by  constricting  an  artery near its  distal
 extremity, we are  enabled to  obliterate its  canal down  to its origin, it
 is evident that an aneurismal tumor existing between those two points,
 ought to be made to disappear with almost as much ease  and certainty
 when we placed the ligature upon the distal as upon the cardial side of
 the disease.  It is in fact, to be presumed that by the method  of Brasdor
 the pulsations would be less apt to return or to be kept  up  in  the sac
 than by the process of Anel, unless there should happen to  be  found a
 number of large sized collaterals between the ligature and the aperture
 of the artery.  In this last  case, without doubt, the operation would
 present fewer chances of success, but it  nevertheless would, in  my
 opinion, often  succeed ; provided the supplemental  branches  should  be
only one half or a third of the  size of the principal trunk ; that they
should not furnish to  the blood  a circuitous route, which  would  prevent
its stagnation in  the aneurismal  sac, and that  the walls  of this last
should have sufficient  thickness  or density to resist the  violent efforts
and pulsations which they are ordinarily obliged to sustain immediately
after the operation.
  [There  is  in  the Aluseum of  University College Hospital, London, a
 preparation taken from  a patient on whom  Sir Charles Bell  tied  the
 femoral artery, for popliteal  aneurism.  The  patient died on the sixth
day  after the  operation, and  notwithstanding the  femoral  artery was
double and, as a consequence, the  tumor supplied by the untied vessel,
 complete consolidation of its contents took place.   This fact  shows that
 even if collateral branches exist, we may still hope for success.
                                                       G. C. B.]
  We must not,  however, exaggerate the value of this new method. 
TREATMENT OF ARTERIAL  LESIONS.
737
Out of about twenty subjects who have hitherto been  submitted to it, at
least fourteen have died,'while a fifteenth was exposed to the most immi-
nent danger.   A great number of facts here and there to be met with
in scientific works prove that the arteries are far from always becoming
obliterated to a great extent on the cardial side of the ligature.   War-
ner cites the case of an aneurism of the brachial which succeeded to an
amputation above the elbow, and in which it became necessary to tie the
vessel near  the axilla.  An amputation of  the leg presented the same
difficulty to M. Roche at Tarragona, in 1813, so that it was found neces
sary to tie the posterior tibial between the aneurism and popliteal artery.
We find in M. Hodgson two examples of aneurism, closed on their distal
side,  and which, nevertheless, ultimately  ruptured or became gangre
nous.  AI. Guthrie says that many specimens in the collection of Hunter
show a  complete obliteration of the artery on the distal side of the sac,
without a cure  of the disease having been thereby effected.   In his liga-
ture upon the external  iliac by the method of Brasdor, AI.  White  found
the artery impermeable, and yet the aneurism continued to increase.  In
a woman on whom I performed amputation at the knee, a month before,
strong  pulsations of  the  popliteal artery were still  perceptible at the
bottom  of the wound.   And who has not been witness to the same phe-
nomenon after  amputations of every  kind ?  But if the arterial trunk
continues  pervious on the distal  side of the collateral  branches,  at an
inch or two from the  suppurating surface of an  amputation, or from a
spontaneous obliteration of the vessel, we can scarcely comprehend why
the same  difficulty would  not exist after a methodical application of the
ligature.
   To understand ourselves on this subject,  and appreciate the  method
of Brasdor, it is necessary after  the  example of M. H. Berard, (Diet.
de Mid.,  2d edit., t. III., p. 59 a 62) to divide the facts which relate
to it into  two classes.  1, if there is no  collateral  branch remaining
between the ligature and  the sac, we  have every possible chance of suc-
cess ; the aneurism is then converted into a cul de sac, where the  blood
is concreted and closes the upper end of  the artery.  2, If  collaterals
exist between the tumor and the ligature they serve to divert and keep
up the circulation  to  that point,  and  hinder the  blood  from concreting
in the sac.  3,  And even  supposing that there should be no collaterals
beyond the tumor, we should still have to  fear the presence of arteries
which take their origin  from the sac itself, or from the immediate neigh-
borhood of its  upper  orifice.  AI. Berard (Jour. Hebd.; et Archiv.
Gen. de Mid., 1830) it is true, has shown that the roots of these arte-
ries raised up and displaced from the line of the principal arterial axis,
soon lose  their permeability, by becoming like  the aneurism, filled with
bloody concretions ; but this fact, or  this process must be subjects ex-
ceptions, and we  cannot, in my opinion, fully rely  upon it.   It is very
obvious  from these facts, why the operation of Brasdor upon the femoral
artery and the axillary  artery  has not succeeded, while in the primitive
carotid it has'been attended with very advantageous results.  We should
do wrong, however, at present to receive this opinion as conclusive ; I
shall, when speaking  of  arteries in  particular, show that though the
carotid and subclavian give off enormous collaterals, this has not always
prevented the patients from recovering, and that it  remains to be proved
  Vol.  III.                   93 
738            NEW ELEMENTS  OF OPERATIVE SURGERY.
that the  establishment  of the circulation  through these collaterals has
been the cause of failure in other cases.   The question whether death or
the  cure in these cases depends, as AI. Guthrie (Oper. cit.,  p. 207—
208) maintains, upon an inflammation which is transmitted from the in-
terior of the sac to the heart, will be discussed in treating of the arteria
innominata.
                     §  VI. Operative  Process.

  Is it requisite before applying a ligature to an artery that the  patient
should undergo a preparative course of treatment ?  Should we wait un-
til a very advanced period of the aneurism, or is it better to operate as
soon as we are perfectly satisfied of its existence ?  The previous com-
pression  recommended  with the view of favouring the development of
the supplementary vessels, is, comparatively speaking, useless.   Latterly,
in our times, it has generally been rejected ;  in fact, it would be  idle to
make trial  of it, except in cases where it might possibly offer some pros-
pect of  aiding in the cure.   By the ancient method there was no risk
incurred by deferring the operation ; the interruption to the  course of
the  blood, caused by the  development  of the tumor, favoured to the
6ame extent the  establishment of the collateral circulation, and the pros-
pect therefore of obtaining in a number of cases a spontaneous  cure.  At
present we  attach no importance to those feeble  reliances, and by the
new processes more especially we undertake  the operation as soon as
possible.   Some persons go to the extent, but erroneously, as I  conceive,
at least in  formidable cases, of  rejecting all  precautions  of regimen or
general treatment.  One or two bleedings if the patient is robust or of
the sanguine temperament, a diminution to a greater or less extent in the
quantity  of aliments, with  drink  slightly  bitter and diluent, and ano-
dynes tepid baths and anti-spasmodics if there are nervous symptoms and
a great deal of irritability ;  preparations of  digitalis to weaken the im-
pulsion of  the heart; a mild purgative when the bowels are costive;
and leeches if any local inflammation should supervene, will not be omit-
ted by the  practitioner who knows how to unite the principles of  sound
medicinal treatment to the rules of judicious surgery.
  A. The  Ancient  method.—I. Instruments.   In  the ancient  method
the instruments employed are a convex, a straight, and a blunt-pointed
bistoury, a female  sound, blunt probes, a spatula, needles of different
forms, iigatures, a tourniquet, a garrot, agaric, lint, compresses, bandages
sponges scissors, &c.  The skin upon the aneurism and surrounding parts
should be carefully shaved.
  II. Position of the Patient and  the Assistants.—The  patient  being
placed upon a bed properly prepared, or upon a table, an assistant who
can be relied upon, is charged with the duty of compressing the artery
between  the tumor  and  the heart, by means of his fingers, a rolled ban-
dage, a bureau seal provided with a pelote, the garrot of Morel, the tour-
niquet of  Petit, or some other similar instrument; a second assistant
garsps the  sound limb, or places himself in front of the operator ; a third,
hands or receives the instruments as they are required or no longer need-
ed ; a fourth and fifth, when  there is room for them, attend to holding in
proper position  the head or any other part of the body whose movements
might  produce some disturbance. 
                  TREATMENT OF ARTERIAL LESIONS.               739

  III. Operation.—The course of the artery being well ascertained,
the surgeon divides with the convex bistoury, first the skin and the adi-
pose  tissue, then with a second incision the whole thickness of the sac,
commencing his incision a little above and not  terminating it  until he
has reached an inch below the tumor.  After having removed the clots of
blood and sponged and wiped the bottom of the wound, he seeks  for the
opening of the vessel, slackens the compression a little if necessary, iu
order to discover the artery with more certainty, introduces into this open-
ing a blunt probe, or a female or a grooved sound, then raises the upper
end of the artery, assures himself again  that it is this which he has under
his eyes, isolates  it from the vein, nerves  and other tissues which it is
important to avoid, passes the ligature under it as  if with the intention
of including the sound at the same time with it, seizes  immediately the
two heads of  this ligature which he draws towards him with one  hand,
while he applies the forefinger of the other upon the raised trunk in or-
der to identify its pulsations, and to be certain that the artery is proper-
ly secured, and that  the ligature which is  about to  be placed around it
will effectually constrict its calibre;  afterwards  there  remains nothing
more  to do than to  tighten  the ligature by a simple knot, while, at the
same time, the sound is withdrawn, then to secure this first knot by anoth
er, after which one of the threads of the ligature  is to be divided  by
the scissors very close to the artery.   We proceed  in the  same manner
for the lower end of the artery ; the bottom  of the wound is then to be
filled with  agaric, or better  still, with  balls of soft lint, which are cov-
ered with the perforated linen and large plumasseaux of lint, spread with
cerate, and which are kept on by the  aid of a few compresses and a sim-
ple containing bandage which completes the operation and dressing.
   B.  Method of  Anel.—When we operate without opening the sac, cer-
tain precautions required in the  ancient method, become useless.  The
position of the patient and the assistants is not materially different, but
there can be no longer any  object in making compression of the  artery
above the tumor, (i. e., on the cardial side,)  except as a matter  of pru-
dence.   The  place at which the ligature should be applied upon it, not
being determined by  the presence of the aneurism, requires somewhat
more attention on the part of the surgeon.
   I.  The place of choice.—In spontaneous aneurisms we should cut as
far as possible from the tumor, because the nearer we approach to it the
more danger is there that the coats  in this part of the artery are  dis-
eased.   In traumatic aneurism we must adopt a contrary rule, because
in additiou to the certainty that in placing the ligature very low down
we shall find the artery as sound there as anywhere else, we have the ad-
vantage, also, of preserving intact collaterals of greater or less impor-
tance.  Nevertheless, if it should be considered that the operation would
be much more difficult near the aneurism, we should, unless we are oblig-
ed to sacrifice a large sized supplemental branch, proceed to  seek for the
vessel where it is most easy  and least dangerous to cut down to it._  The
more distant we are from the sac, the less danger is there of causing its
rupture, inflammation and suppuration.   We  must not, however, in order
 to avoid one extreme, fall into the other; that is to  say, place the ligature
immediately beyond, (i. e., on the distal side of,) a large secondary arteri-
 al branch.  In fact the consequences of such an operation rarely fail to be- 
740
NEW ELEMEMTS OF OPEARTIVE SURGERY.
 come alarming, not because, as has been too frequently asserted, the bloody
 clot, which Jones has dwelt upon so much, cannot be formed, but because
 the blood, finding a free and very wide passage immediately above (i. e.,
 on the cardial side of)  the  ligature, does not  allow  the  walls  of the
 artery to approach each other and to contract adhesions between them.
   II.—Incision.  The Surgeon placed on the side of the aneurism commen-
 ces by stretching the integuments either cross-wise by means of the thumb,
 fore-finger and ulnar border  of the hand, or by applying the extremities
 of the four fingers  upon  the track of the vessel  parallel to its direction,
 and then makes an incision into the  skin of from  two to four inches in
 length.   This incision  should be made with a bistoury convex  upon its
 cutting edge rather than with  a straight bistoury; it is better that it should
 be rather long than otherwise.   An incision, moreover, of  from two to
 three inches in extent, so long as we are not obliged to go  deep, will be
 found to answer in the greatest number  of cases.   Most frequently we
 make it correspond with the  direction of the  artery, but sometimes we
 go in the direction  of the muscular  fibres, in which case it crosses  the
 vessel more or less obliquely.  We must take care not to go too deeply
 at the first cut; and it is much better to make two cuts in dividing through
 the skin than to come down to the artery with the first incision.
   [Air. Hargrave, of Dublin, insists that as a general rule, the transverse
 or oblique incision  should be adopted in  exposing arteries.   This  prac-
 tice has also been advocated by Scarpa, Dupuytren, Guthrie, Costello and
 Skey.   G. C.  B.]
   After the integuments we divide the aponeurosis in the same manner if
 the artery is still at a certain depth.  In the contrary case  or when the
 operator is not very sure of his hand, he  inserts under the aponeurosis a
 grooved sound which serves as a conductor  and guide to the  bistoury.
 The other laminae should be divided successively with the same precau-
 tions and to the same extent.
   Ill-—To Isolate the Artery.  Having reached the vascular and ner-
 vous fasciae, we must now attend to the  opening of the common sheath.
 The  grooved sound is then of the greatest  importance.  We  insinuate
 the sound (i. e., director) from above downwards, or from below upwards
in the interior of  the sheath, taking care to raise up this only, and not to
let any of the parts which it would be dangerous to wound, slip in between
the sound and the instrument.   To separate the parts afterwards we also
make use  of the same director, which should be flexible, or slightly  coni-
 cal shaped, without any  cul de  sac, and not so blunt, as the ordinary groov-
ed sound ; holding it in the hand as a writing pen, we pass its  extremity
between the vein  and the artery, then making  gentle movements with it
backwards and forwards, with a moderate but steady pressure, we detach
and separate the two  vessels from one  another to the extent of a few
lines.  In proportion as this separation is effected, we incline the sound
 more and more backward, in order that its point making its way by de-
 grees under the posterior surface of the artery, may as it reaches around
 it show itself on the opposite side ;  then  use the fore  and middle  fore-
 finger  of  the other hand to  separate the nervous  trunks from it,  or to
 push backwards and outwards all the parts that we wish to avoid.  It
 is important therefore to  manage the sound with a great deal of address
 otherwise instead of going round it we might run the risk of  plunging 
TREATMENT OF ARTERIAL LESIONS.
741
it into the vein or the artery, as AI. Rienzi, (Med. Oper., trad. Ital., t.
I., p.  105,) accu.ses a skilful surgeon of Italy of having done.
  IV-—To aPPly the Ligature.   Before withdrawing it the sound is to
perform  another duty ; for it is on this that we pass down the ligature,
whether for this purpose we use a simple silver probe, having an eye at
one of  its  extremities, or  prefer for deep ligatures the curved needle,
attached to a forceps, as figured in the work of Dorsey, (Elements  of
Surgery, Yol. II., pi. 23,) or the needle of J. L. Petit, or that of Des-  .
champs, &c.   Desault  (CEuv.  Chir., t. II., p. 554,) contrived for those
cases where we are obliged to manipulate at  the bottom of a narrow
and deep cavity, a spring needle much resembling the sound of Bellocque,
and which has  been modified in England, by A1A1. Ramsden, Earl and
Brenner, (S. Cooper,  Diet., p. 151.)   AI. A. Cooper  in  these difficult
cases makes use of a steel stem, supported  by a  handle, and  strongly
curved  backwards at its free extremity, and terminated by an olive  bit
in the  thickness of which  is situated the opening destined to receive the
thread.  AI. Mott has frequently employed an  instrument  of the  same
kind, and the needle of  M. &msse(Riv. Mid., 1828, t. III., p. 388)  is
but a modification of that of Petit.   Scarpa has greatly extolled a small
spatula of pure silver, very thin, and so flexible that it can adapt itself
to  all the parts we wish to include.  But the  grooved sound, aided by
the probe such as I have pointed out, will generally be found to answer
in  the  hands of a skilful  surgeon ; it has  besides, in preference to all
special instruments and the numerous needles  whose forms have been so
carefully delineated by AI. Holz, (Trait, des Ligat. Arterielles, Berlin,
1827.)  the immense advantage  of enabling us to denude the artery in the
neatest manner possible, and almost without any laceration of surround-
ing tissues.  As  soon  as it has  reached the other side of the vessel we can-
not see why it would be impracticable to slide along upon its groove the
head of a flexible probe and in this manner pass the ligature ;  so much the
better could this be done as there is nothing to  prevent our having an eye
near its point, to conduct the  ligature at the  same time that the point
detaches and lays bare the circumference of the artery.  However, every
one understands the nature of these instruments, and can make up his
own judgment  which to give the preference  to.
   It  is not  only improper but also  dangerous to  attempt, as  Scarpa
has advised, to raise  up and  separate the  vessel  from the surround-
ing parts  by  means of the fingers.  By  this means  we tear the tis-
 sues  and make a contused wound, which will  almost inevitably proceed
 on to suppuration; when in fact it is important to make  this  wound
 as neat and as regular  as possible.   Those who recommend shaving with
 the bistoury flat-wise all the layers of cellular tissue that envelop the
artery, run the risk of  wounding it in spite of  the most minute precau-
tions, or even in the most favorable cases, of unnecessarily prolonging
the operation.   The sound (i.  e., director) protects us from  these incon-
veniences, enables us to act with greater security and promptitude, and
 to pass the thread around the  artery, so to speak, without displacing it,
 or disturbing its natural relations or laying  it  bare more than to the very
 smallest extent possible.
    V.— To Tighten the Ligature.   It is not possible to determine  what
 degree of force should be employed to strangulate the artery.  The liga-
 ture should be drawn so tight as to hermetically shut up the artery to the 
742
NEW ELEMENTS OF  OPERATIVE SURGERY.
passage of the blood not only at the moment of the  operation  but also
afterwards ;  this is the only  rule that we may be permitted to lay down
upon  this subject!  AVhen'it includes with the artery  some  portion of
muscular  tendinous, aponeurotic, or even cellular tissue, the object in
view may be defeated, because those fibres in wasting away soon cause the
ligature to become loose, and thus render it  almost useless, at  the same
time that they prevent it from coming away at a proper time. To obtain
this last result we must also avoid passing the ligature twice round upon
itself so as to form  what was called in other times the surgeon's knot.
Even with this knot, notwithstanding the greatest degree of constriction
employed, the centre of the circle remains  sometimes  gaping open, or
permeable.  This it is said (Pelletan, Clin Chir., 1.1., p. 122) happened
to Chopart,  when among the first in France he  proposed in  1781, to
apply a ligature on the popliteal artery.  Alany ligatures were successively
used without however succeeding in effecting the entire suspension of the
circulation in the limb;  (can that be true ? ) when it became necessary
to have recourse to immediate amputation,  and an examination of tho
parts afforded  an opportunity of ascertaining that not one of  the liga-
tures had completely effaced the cavity of the vessel.   We confine our-
selves therefore to two simple knots.   If the ligature is of animal tissue
we cut off the two ends in order to enclose the remainder in the wound;
in the  contrary case we reserve one  of the extremities which is to be
left  hanging outside.  If after having laid bare the artery, we discover
that it is diseased, and  that its walls are yellow, friable  and encrusted
with calcareous lamellae, it would  perhaps be prudent to flatten it as
Scarpa recommends, instead of strangulating it as in the other processes;
for that purpose we place  upon its anterior surface, between that and the
ligature, a small compress of linen, cork, gum elastic, or adhesive plaster,
from four to six lines long, from one to three in thickness, and  about the
same in width.   MM. Lawrence, A. Cooper, and Briot, however, have
obtained satisfactory results in pursuing an opposite course, and in ventur-
ing to use only a simple thread upon arteries that were obliterated, and
brittle, and entirely altered from their natural state.  It is in such cases
especially that the ligatures of AI. Jameson (vid. supra,) might be of
great advantage, when we have no chance of doing better, by making a
new incision in order to perform the operation  higher up.
   VI.—Dressing.  The wound being cleaned and freed of all the foreign
bodies that  may be contained in it, should be partially brought  into union
immediately.   Nothing is more formidable  than the  suppuration  that
follows ligatures upon arteries; immediate union on the  contrary would
almost always ensure us success ;  but it is from the bottom towards the
borders that this union is desirable, and not from the skin  towards the
 deep seated parts, as  the tendency  is, from the manner  in which the
 stitches of  the suture are arranged by some surgeons.   The presence of
 the ligature around the vessel and of a foreign body between the lips of
 the wound, is moreover under these  circumstances an obstacle almost
 insuperable to an immediate agglutination.  The consequence is that we
 limit ourselves to keeping the sides of the wound correctly approximated
 by means of graduated compresses, adhesive plasters and the position.
 After having wrapped up the ligature which  hangs outside, we  turn it
 back towards the most  dependent or nearest  angle  of the  wound  or 
TREATMENT OF ARTERIAL LESIONS.
743
merely place it crosswise  between two strips of adhesive plaster.  The
perforated linen  is  then  applied, or we make use of the fringed linen
bandelettes, (vid. supra. Vol. I.)   A plumasseau of soft lint, and  one
or two long or square-shaped compresses, cover over the preceding por-
tions of the dressing, and we terminate as in the ancient method by some
turns of bandage to  support the whole.
   C.—Method of Brasdor.  The manual of the  operation is precisely
the same in the method of Brasdor as in that of Anel.
   D.— Subsequent   Treatment.   The patient is carried back to his bed
and placed in such a position that the muscles of the part upon which
we have been operating may be in a state of relaxation.
   I.—The limb supported'upon cushions, ought, according to  some, to
be surrounded with bladders containing hot aromatic substances, sachels
filled with sand, ashes  or  bran,  at the temperature of 30 degrees ;
(Reaumur;) according to others, it  should  be  merely supported with
soft pillows sufficiently warmed ; there are  also  others who, indifferent
to all special precautions, add  nothing  to the natural furniture of the
bed unless  the sensation of  cold which comes on at that time should be
very  uncomfortable.   This last mode is the one which should be adopted
as obviously the  most rational.  One of two things takes place, either
the circulation is restored to the parts which have been momentarily de-
prived of it by the  operation, and their  temperature by this means is
raised  to the proper elevation ; or it  is  not  re-established, in which
event the artificial  heat can  scarcely be otherwise than calculated to
hasten the  development of the gangrene.   On the supposition then that
the sensation of  cold docs not incommode the patient, we may dispense
with heated cushions.   In the contrary  case  we  may, during the two or
 three first days,  place in contact with the parts that are suffering from
cold, cushions of sand kept  constantly warmed.
   II.—In other  respects we may proceed as we do after all serious oper-
ations.   Diet, repose, and the most perfect tranquillity, and mild acidu-
lous  drinks slightly anodyne or anti-spasmodic, are  necessary at first.
General bleeding may also become necessary with the view of preventing
 or relieving the congestion of the blood in the viscera.   Alost frequently
 it is found  advantageous  in the first twenty  hours to  administer  some
 spoonfuls of a drink,  blended with  slightly  aromatic  mixtures, as the
 tincture or extract  of opium,  or occasionally with a little ether or the
 liquor of Hoffman, in  order  to calm the  nervous  state of excitement and
 agitation which the patient frequently falls  into.   In such cases the most
 suitable drink is linden water tepid.  On the morning  after I allow the
 patient light broths, (bouillons,) and soon after soups, eggs, and diluted
 wine andVater ; then meat if no general re-action should supervene ; a
 rigorous  diet would jeopardize the success of the  operation.  [This sanc-
 tion of a rather  generous course is perfectly in accordance with, and m
 anticipation of,  the now  recently adopted  and  certainly  most rational
 views of the consecutive treatment of aneurisms ; for by  this it is truly
 said  as in the cure by compression, (vid. notes, supra et infra,) we thus
 favour the  deposition  of  plastic lymph in the aneurismal sac, &c.   1-J
    III.—The first  dressing is not made until the  third or fourth day at
 the earliest.   The greatest  care should  be taken not to disturb the limb
 by any movement, and to make no traction upon the ligatures, nor when 
744
NEW ELEMENTS OF OPERATIVE SURGERY.
removing the portions of the dressing to derange the position of the lips
of the wound, at least in those cases where we are attempting immediate
re-union.  The same attentions are also necessary  afterwards, until the
ligatures come away, which they do from the tenth to the twentieth or
thirtieth day, but which also may not happen until the fortieth or even
the fiftieth ;  and we may promote this separation as soon as the obliter-
ation of the  artery appears to be complete, by pulling  from time to time
gently upon  the threads, if they are slow in becoming detached.  AVhen
the time of reaction is passed by and the first symptoms are  subdued,
and the limb has  regained its natural temperature and sensibility, the
patient  should  from that  time  be  considered as  convalescent.  Nev-
ertheless, even after the cicatrization of the wound is complete,  he ought
not for a considerable length of time, to be permitted to make any other
than very slight or  trivial movements, if he  does not wish to run the
risk of losing his life  by  a secondary hemorrhage, and of having his
wound reopen afresh, as happened in a case cited by Beclard.

        § VII.— Consequences and accidents of the operation

  The results produced by the  operation for aneurism are sometimes
complicated  with accidents or symptoms that require particular atten-
tion.
  A.—In general the limb during the first twenty-four hours  becomes
cold to a greater or less degree, as has been already said, then it after-
wards by degrees re-acquires its  usual temperature; but it is not uncom-
mon to see too great a degree of heat succeed to this state of things,
causing by this means so much irritation in the part as to result in  gan-
grene.  Vacca and some modern writers  have given  examples of this
kind ; in such  cases the  limb should  be wrapped in flannel,  wet with
emollient liquid, or covered with cataplasms of the same emollient nature;
perhaps even it would be found useful to apply leeches  upon those points
which were most likely to  become inflamed.  For certain reasons also I
am induced  to believe  that a roller bandage  applied  moderately tight
would overcome this difficulty better than any other means ;  cold water
of itself would  also be  another resource that we might make trial of.
  B.— Gangrene, the two common consequences of ligature upon arte-
ries, is not always preceded by this excess of heat; it is often caused by
the circulation not being  re-established.   Then the lower  part of the
limb remains cold and insensible  and  becomes  discolored, and the seat
of phlyctenae, and soon after of all the other characters of mortification.
The patients who are about to be affected with it are  ordinarily seized
with violent  pains, which nothing can assuage, throughout the whole ex-
tent and especially  towards the lower extremity  of  the limb.  In one
case it will not  show itself until  the eighth day, in another not until the
twelfth, though the pain from the  arteritis may have continued incessantly
from the day of the operation.   This gangrene, as AI. Laugier has re-
marked, (Archiv. Gen. de Aled., t. XXX., p. 162,) is announced  by  a
livid, violet, greenish, milky  yellow color, rather than by the signs of
ordinary gangrene ; it seems more like an organic decomposition than a
disease.  If the gangrene has not extended to a great degree, or seems
disposed to become  circumscribed, we proceed as in those cases where it 
TREATMENT OF ARTERIAL LESIONS.
745
is produced by any other cause.   We wait until the escars are detached,
and the ulcers which result  from them are cicatrized ;  but if it invades
the whole thickness of the limb there is nothing but amputation that can
save the life of the patient, though that also is a resource which often
fails.
   [In Dr. Alott's remarks on aneurisms in another part of this work, it
will be seen that during all  his immense experience—during nearly half
a century—in tying arteries, he has lost but one patient from mortification
of the lower extremity.  His judicious management after the operation
is worthy of careful study,  for to  this must  much of his  extraordinary
success be attributed.   G. C. B.]
   C.—The sudden interruption  of the course of the blood through an
artery  of large size, sometimes occasions so great a disturbance in the
general circulation as to excite an intense fever, with symptoms  of ple-
thora and congestion, and a strong tendency on the  part of the princi-
 pal organs to become the seat of severe inflammations.   It is under such
 circumstances that the antiphlogistic regimen should be adopted in all its
 rigour, and  that we should have  recourse to bleeding, general or local,
 and even to be repeated frequently,  while the  strength  of  the patient,
 or the  severity of the disease, seem to justify it.
   D.—In other cases, it is  the  nervous symptoms which  make their ap-
 pearance and  create alarm  ; the pulse becomes irregular, small and fre-
 quent ;  delirium supervenes, convulsive movements take place, and most
 of the symptoms of ataxic fever may  become  developed.   Experience
 has shown that  anti-spasmodics  in general, and  especially opiates, are
 the best remedies  for this  kind  of accident.   It would  appear  from a
 case that occurred  at  the Val de  Grace, that in order to  subdue the
 symptoms AI.  Gama was obliged to  administer laudanum  to a very  great
 extent, and that the delirium which takes place in  such  patients has
 some  analogy to  that with which drunkards  are so often affected, in
 other words, delirium tremens.
    E.—Ordinarily  the tumor shrinks, or at least  diminishes, and ceases
 to pulsate immediately after the ligature ; at a later  period, it hardens
 and retracts ; the blood contained in it concretes and is gradually ab-
 sorbed, and the whole terminates after  the expiration  of a greater or
 less period of time, by disappearing altogether, or leaving  only a small
 tumor or simple hard," movable kernel, without any pain.
    [In some cases, after the operation, the  aneurismal sac  entirely dis-
 appears, as in the case related by Scarpa, where the femoral artery had
 been  tied  twenty-seven years  before.  Again, as  in the  specimen  to
 which Air. Paget  refers, in his Lectures on  Surgical Pathology (Am.
  Ed. p. 38)  the aneurismal sac remained  even after  the  lapse of fifty
 years.  This case is more  fully noticed in  our note under  the head of
 popliteal aneurism.   G. C. B.]
    In the  place  of these  phenomena, others sometimes  supervene ; the
 pulsations, which had temporarily  ceased, reappear at  the end of some
 hours or days; the tumor  retakes its original volume, and  the operation
  appears to have had no effect upon the  disease.   This  is  owing  some-
  times to large collaterals, which open either directly into  the tumor, or
  between the  tumor and the ligature, and which bring the blood  there in
  too great quantity ; sometimes to this fluid returning  to the sac by the
     Vol. I.                    94 
746
NEW ELEMENTS OF OPERATIVE SURGERY.
lower end of the artery.   It is, however, a less serious accident than it
was first thought to be.  Observation has proved that, in a majority of
cases,  the  system  succeeds in triumphing  over  it.  Nevertheless, if
topical refrigerants, the methodical application of the roller bandage, or
any kind of  compression  whatever, continued  for  some weeks, should
not bring about any favorable  change in this respect, it would be ad-
visable  to  ascertain if there would not be  more security, in  case the
thing were  possible, in applying a new ligature very near  the tum0J'
either above or below it, or, in fact, in operating by the ancient method.
  F.—In place of shrinking or becoming hardened, or ending in fact in
resolution,  the aneurismal sac becomes heated,  and  sometimes  even
inflamed, with a tendency to become converted into an abscess.   If cold
topical  applications, astringents,  and compression  do not  produce at
first the benefit that we had a right  to  expect from them, leeches and
emollient cataplasms  should  be promptly  substituted in  their place.
Also, if suppuration, or an actual purulent fluctuation take place, it will
be necessary  to  t^eat the aneurism, as a simple abscess, to open it
freely with  the bistoury without waiting too long  a time, and to empty
it of the matters that it contains, and afterwards to dress  it as any other
suppurating wound.
  G.—Immediate union is not effected always, though  we may have
done everything to obtain it.   Pus  sometimes stagnates at the bottom of
the wound, extends itself to a great distance, and separates the tissues ;
the muscular sheath and that of the artery, in their turn, become inflam-
ed, and soon  end in suppuration ; it  is  then that the patient is exposed
to the most imminent dangers.  Prom  thence come erysipelas, diffused
phlegmons, angioleucitis, phlebitis  and purulent infections, whose  dan-
ger it is difficult to estimate.   It  is important, therefore, to resist this
unfortunate tendency as soon  as it  is  ascertained, to  dilate the integu-
ments freely, and all other tissues which oppose a free and easy exit to
the pus or  other effused matters—to  lay bare the  bottom of the wound
throughout its whole extent—and to give up every idea of union by the
first intention.
  H.—AVhen, in spite of his  efforts, the surgeon  finds that suppuration
takes place, and is diffused and protracted to so great  a length of time
as to enfeeble the whole organism  and lead to the  apprehension of ady-
namia or exhaustion, it behoves  us to  look to the arrestation of this
drain by general medication, and to sustain the strength of the patient
by administering the  extract, syrup, decoction, and other preparations
of cinchona, also an allowance of good wine, and light, but substantial
aliments, &c. ; at the same time, to  take  care to cleanse the  condition
of the ulcer  and abscesses by proper topical applications or incisions.
   I.—The accident resulting from the application of a ligature upon
arterifs, which  has more especially interested the  attention  of prac-
titioners, is  hemorrhage; fortunately, the  perfection  which operative
processes  have attained  makes this accident more rare  now than  it
formerly was.   It occurs  more particularly when, in  tying a trunk very
near the heart, we have been obliged to place the ligature close up to a
large collateral trunk ; or when tho ligature has been badly applied,  or
 become displaced,  or not  been drawn sufficiently tight, or fixed upon a
 diseased portion of the vessel; or when, from any cause whatever the 
TREATMENT OF ARTERIAL  LESIONS.              747
vessel  becomes diseased either above or even in some  cases  below the
ligature.
  Hemorrhage may also be produced by the rupture of the sac, and may
occur after the first few days of, or not until a considerable  time after,
the operation, or it  may depend upon the irritation which exists in the
wound, or be only a simple exudation.  Without admitting that, in the
process of Anel, it  will  occur in one out of every  six cases, (as  a
surgeon in our times, by an erroneous statistical  computation, has at-
tempted to prove,) we must nevertheless concede that it  happens suffi-
ciently often to claim all the  solicitude of practitioners.   It is from the
lower  end of the  artery that this  most frequently takes place, and ob-
servations prove that it may thus occur on the seventh day as well as on
the fifteenth, thirtieth or fortieth.   Pressure, made upon the artery on
the side of the heart, or on the opposite side—compresses and lint, sat-
urated with cold  water, or impregated  with  bonafoux  powder, or the
lotions of Binelli, Talrich and Halmagrand, or with any other  hemostatic
substance, applied upon the place from which the blood appears to issue,
are the first means to be made use of.  When they are not sufficient, we
are obliged to remove the dressing and all the effused blood, and to have
recourse to  tamponing and indirect compression.
   If these last measures should still prove insufficient, there will be noth-
ing left to be done but to choose between the application of a ligature
upon each of the two ends of the artery at the bottom of the wound, or
at a point higher up on the limb.   But fortunately, we  may in most cases
dispense with proceeding to such extremities, and arrest the hemorrhage
without recourse to a new operation.
   [A  Hemorrhagic Diathesis is  to be taken  into the  account in  all
wounds of, or operations  upon, the  arteries.  It would appear  from a
case related by  Dr. Alph. Guepratte, (Journal des Connais.,  &c, Paris,
Juin, 1844, p. 239, &c.,) that the  remarkable tendency, in some  consti-
tutions, to excessive hemorrhage upon receiving the slightest wounds or
punctures, is not, as has been supposed, always hereditary, but sometimes
acquired.  This case was a West India boy, aged nine years, at Guada-
loupe, of respectable, healthy, white parents.  This disposition to hemor-
rhage  is imputed, by AI. Guepratte, to the defective nourishment afford-
ed by  the milk of  the black nurse  when the patient was a child, and his
constantly persisting in living with  her in a damp, unhealthly situation,
and indulging in too much fruit.   The patient was pale, emaciated, hag-
gard, the superficial veins on  the skin clearly visible and of violet color,
and when the hemorrhage occurred, the blood was exceedingly attenuat-
ed, without scarcely any fibrine or red color—all of which appear to be
naturally explained by the patient's course  of life and the  food used.
A radical cure was effected, after  some  years, by change of residence,
food, &c, time, tonics,  meat, exercise, pure air, in order to  give health
and force and color to the blood, together with other judicious means.
   AVe have, however, known this remarkable peculiarity to exist  in three
children of  the  same parents, not any of whom nor any of their relatives
were ever known  to have exhibited  any  indications of it.   They were
the grand children of the present venerable Peleg Almy, Esq., of Ports-
mouth, Rhode Island—a family of  the highest respectability,  wealth, and
rank, and noted for their sound, healthy and robust constitutions—having, 
748
NEW ELEMENTS  OF OPERATIVE SURGERY.
 from the first settlement of New  England, constantly  resided on their
 patrimonial estates, from the year 1640 to the present time.   Therefore,
 had such a predisposition been hereditary, it would certainly have been
 recorded.   We have not the details of these  cases, but  they  all died
 under the age of  16 years—one  while an infant, from the physician hav-
 ing punctured a small abscess, while another bled to death from having
 knocked out a tooth in a fall.  Air.  Almy informed me,  (1844,)  while
 I was at his residence, that these children had all been in  the enjoyment
 of excellent health. T.]

 § VIII.— Changes which are  effected in the vessels of  a  limb after  the
                      obliteration of an artery.

  When an artery ceases to become  permeable to the blood, there are
 certain changes produced in the neighborhood of the wounded part which
 it is proper to notice.   Among these alterations, there are some that are
 generally conceded; others that are  as yet questionable, or very imper-
 fectly understood.
  A. Collateral Arteries.—The  blood, compelled to take  another  route
 in order to reach  the  lower part of the limb, enters the collaterals, by
 degrees dilates them, and soon produces anastomosing arcs of such large
 size, that branches which  were scarcely visible in their natural state some-
times acquire the  dimensions  of  a  crow-quill, while other branches, of a
little larger volume, ultimately acquire  a third of, or even half the size
 of the  primitive  trunk.  It  is  where  such supplemental channels are
readily  formed, established, or developed, that operations for aneurism
 are attended with a prompt and successful issue, and that the  pulsations,
which had been momentarily suspended, soon  reappear below the liga-
 ture.  Though this point be universally conceded, it is not so on the ques-
 tion whether or not new  arteries are created to re-establish  the current
 of the blood after the division of the diseased trunk.
  B. New  Arteries.  Parry {An Experiment  on the Art. puis., 1819)
 was one of the first who conjectured that new vessels  were  generated,
 a fact which he considers indisputable.   He has seen,  he  says, the two
 ends of the carotid communicate with each  other by  numerous  small
vascular branches, a long time after it had been tied or divided.  It was
with difficulty at first that this statement  was  believed, in consequence
 of which his assertions did not attract as much attention  as  one  would
have supposed.   At the  same time, or a short time  after, AI.  Ebel, a
 physician belonging to the military service, had arrived, acording  to AI.
 Foerster, at results nearly similar, by  means of experiments  repeated
 upon more  than thirty different animals.   AI. Salemi, AI. Seiler, and AI.
 Zuber obtained similar results.   Alore recently, AI. Schoensberg, (Chris-
 tiani, Journal  des Progres, t. XII., p. 70,) has renewed the experiments
 of the English physician  upon the carotid of  goats and rams.   He affirms
 that he has  seen in these animals new branches of very considerable
 size, forming a very complicated net work between the  two  ends of the i
 divided tube.  If the delineation given by M. Foerster, (Jour, des Prog., ,
 le serie, t. XII.,) accurately represents what the Surgeon of Copenhagen .
 professes to have ascertained, nothing  can be conceived more  beautiful i
 than the process which the organization establishes under such  circum- ■
 stances. 
TREATMENT OF ARTERIAL  LESIONS.              749
  It appears to me, however, that we are under an error in respect to
the importance _ of this  reproduction of vessels, and that it is a result
also which we imagine to take  place  much  more frequently than it in
reality does.  In contradiction to the facts related by AI.  Schoensberg,
though it were even allowable to accord to them an entire faith, we may
oppose the observations now almost  without  number, which  have been
made upon man.   If new arteries reunited the two ends of that  which
had been divided, they would have been  met with in the  dead body in
subjects who have died at the expiration of a greater or less period  of
time after the operation for aneurism ; but never have  the finest injec-
tions or the most careful and delicate dissections been enabled to demon-
strate their  existence.   AI.  Alaunoir (Oper. cit., 1802, et These,  an
XIII.) alone says he has found in a carotid which he had divided between
two ligatures, a hollow  filament going from the  upper to the lower end
of the artery.  In place of this  complicated  net-work spoken of by the
authors whom I have quoted, I have found nothing but a cellular cord,
pliant and impermeable to  fluids, and which blended imperceptibly with
the cellular tissue of the neighborhood, but no new arteries to re-estab-
lish the continuity of the principal trunk.
   If I do not deceive myself, the assertions of Parry, Bell, and MM.
Alayer, (Arch. Gen. de Med., 1838, t. XIX., p. 567,) Foerster, Seilcr,
Zuber, and Schoensberg, are founded upon a phenomenon which has hith-
erto been but imperfectly examined,  but  which  will  readily furnish an
explanation to the results which those authors imagine they have estab-
lished.  The albuminous effusion which takes place and coagulates about
a ligature to form the virole of which AI. Pecot speaks, (vid. supra, vol.
I.,) may,  as has been remarked,become the seat when it is organized, of
a vascular net-work of new formation, in conformity to a very general
law, observed in  a great  number  of accidental organic productions ;
these small vessels which at first present  themselves under the aspect of
tortuous capillaries, or simple canals excavated in the midst of an amor-
phous substance, and in which the fluids and blood circulate rather under
the influence of the laws of chemistry than by the impulsion of the heart,
continue while the virole remains isolated and  does  not  make part  of
the surrounding tissues ;  but as this  growth  shrinks  little by little, and
gradually  assumes the appearances and nature of cellular tissue properly
so called,  the small canals  in question contract in the  same proportion,
and ultimately in their turn present no longer any  differences from the
capillaries which pervade the lamellar system in general.   These vessels
being susceptible  of distension, by  injections, may be  recognized and
possess even a certain degree of magnitude during the first  and second
week after the operation, while at a period more advanced it will scarce-
ly be possible to identify them any longer, as their purpose is not that
of re-establishing the general circulation of the limb.   Numerous experi-
ments instituted by M.  Manec, (De la Ligature des Arteres, &c, Paris,
1833,) have  illustrated this fact, and seem  to  me confirmative  of the
opinion I have just given.
   [Prof. Porta, in his  splendid  work "Delle Alterasioni Patologiche
Delle Arterie per la Legatura " &c. 1845, states (p. 191,) that during his
visit to Berlin, 1843, the celebrated physiologist Aliiller showed him a
preparation taken  from a sheep on which the  carotid had been tied, and 
750            NEW ELEMENTS OF  OPERATIVE SURGERY.

in this specimen there were some  four or five new vessels  which had
sprung from the divided extremities of the vessel.   Prof. P. has detail-
ed some  twenty experiments (pp.  164-188) made on different  animals
to elucidate this subject, and from  the  delineations which he has given
in Plate iii, we  do not see how any one can longer remain sceptical as to
the occasional formation of new vessels.   G.  C. B.]
  C.  Remote Capillaries.—A result of the same  kind but more impor-
tant takes place, where the capillary branches of the upper collaterals
communicate with the capillaries of the lower branches of the obliterat-
ed artery; circulating canals of every variety are formed at this point,
and what takes place is quite a different result  from mere dilatation of
the natural capillaries.  According to the  experiments of MM.  Kalten-
brunner,  (Exper.  con. stat. sang., etc., 1826,) Wedmeyer, (Jour, de
Prog., le serie,) Doelinger, (Ibid.,  t. IX.,) and Blainville, (Cours de
Physiol, compl., t. I.,) the arteries pour out the blood they contain into
the amorphous or parenchymatous  cellular tissue, before it is taken up
by other  vessels; in  this organic woof the fluids  oscillate rather than
circulate, and act so to speak like water which  has escaped and over-
flown  from a river, while  excavating for itself a  thousand channels,
through a plain of sand; that is to say, that at every instant new  con-
duits are being  formed, while others are disappeariug.  The blood not
being enabled any longer to pass by its central  primitive canal, creates
for itself a number of passages, which afterwards become organized by
degrees in order to transmit it from the upper into the lower portion of
the closed vessel; and it is without doubt  to this  process  that we must
impute the heat, sensibility  and even  redness which manifest themselves
under the skin in some patients, at the expiration of one, two or three
days after the operation for aneurism.


                 RUPTURES  OF  THE HEART.                       [
                                                                        I1
  [We insert in this  place an account of a remarkable case  of rup-     i
ture of the heart,  which occurred in the practice of Dr. Mott, many
years ago.

(A Case of Sudden Death, from  a  Rupture of the Left Ventricle
  of the Heart, with Remarks, By Valentine Mott, M. D.   Trans.     ■
  of the  Physico-Medical  Society of New-York, Vol. I., p. 150—160,
  year 1817.)                                                           "
                                                                        i
  Instances  of  rupture of the heart, from violence or disease, are seldom
met with in practice and less frequently recorded in medical writings.     '
The following case of rupture of the parietes of the left ventricle, from     1
an abscess, with a view of the parts, is respectfully presented to the soci-     <
ety ; as an interesting specimen of morbid anatomy.
  The subject of this case, was a young woman, about  twenty-two years i  i  -.
of age ; of a robust and plethoric habit.  She had led an irregular and .  .  t
dissolute life ; and from appearance and from what could be learnt had 1  I
been addicted to the liberal use of  ardent  spirits.   For some time'pre- •  ■
vious to  her death, she had made no  complaint which could be consid- •  ■  3 
TREATMENT OF ARTERIAL LESIONS.
751
ered as  amounting to indisposition.  Her friends recollected to have
heard her mention some slight pains, which she called rheumatism.  They
state, also, that she had entered into a marriage contract with a gentle-
man, who had broken it off a day or two before her death.  Since which
time, they say, she appeared dejected, and  had been seen sobbing  and
in tears.
   She  took supper as usual, appeared somewhat dejected, and retired
to bed at the ordinary time.  As  she  remained  longer  in her chamber
than common in the morning, some person was sent to awake her ; but
to the terror of the family she could not be roused—she was dead.  From
the posture in which she was found lying on the left side, with the knees
drawn up,  she was thought to be in a profound  sleep;  but  it was the
sleep of  death.

              Examination and Dissection of the Body.

   No marks of violence were to be seen on any part of the body.   The
lips were  purple, one side of the face appeared  somewhat livid.   The
whole  countenance, with  the integuments  of the neck, and  upper  part
of the  chest, were suffused with a deep red colour. The features of her
face were not the least distorted ; nor was there any apparent contortion
of the limbs.  It may be said that she slept through death ;  for she did
not appear to have suffered any of its agonies.
   The dissection was commenced by cutting through the parietes of the
abdomen in the direction of the linea alba.   The contents of this cavity
upon a general inspection, appeared to be in a natural and healthy state,
excepting  the liver, which  seemed larger than natural, and of a  pale
white color.  In continuing the examination more particularly, the  liver
was the only viscus in this great cavity, which was found in an unhealthy
state.  It had contracted strong adhesions  to the peritonaeum where it
lines the  parietes  of the chest, abdomen, and lower surface of the dia-
phragm.  The connecting organized coagulable lymph, was very beautiful-
ly arranged, and appeared like small delicate shreds; some were an inch
long, others of a greater length, and from one to two inches in width.
   The thorax was next examined.   On raising the sternum from the
diaphragm, there was nothing preternatural to be seen.  The lungs on
each side were free from adhesions; but the  pericardium was, to the feel,
perhaps more tense than common.  On opening the pericardium, a large
coagulum of blood presented itself, covering the heart on all sides, and
completely filling the cavity of the pericardium.  This, when removed,
amounted to eight or ten ounces with an ounce or two of serum.
   The heart was of the usual size  and very fat.   Upon  lifting its apex,
it was immediately discovered that the blood proceeded from an opening
in the upper  part of the left ventricle, about half an  inch in diameter,
of an irregular lacerated appearance.  The  parietes of the ventricle,
around the opening, were considerably thinner than natural; and, upon
attentive  examination with the fingers, a fluctuation could be distinctly
discovered, to the  extent of an inch on one side of the opening; and
upon pressure, flakes of a cheese-like substance were discharged.
   The pericardium was generally of a natural appearance ; excepting a
portion of  it, about the  size  of a  dollar, or a little larger, opposite the 
752
NEW ELEMENTS  OF OPERATIVE SURGERY.
opening which showed strong marks of inflammation : an adhesion, about
the size of a six-pence, had also taken place a little above the opening,
between it and the surface  of the ventricle.  The external surface of
that part of the aorta, which is generally said to be within the pericar-
dium, likewise exhibited, on one side, some traces of inflammation.
  In order  to give  an opportunity for a more minute examination, the
heart, pericardium, and large vessels about it, were taken out of the body.
On opening the right auricle from the inferior cava, nothing unnatural
was to be  seen.  The dissection was continued from the auricle into the
right ventricle ; and  this also exhibited a natural  appearance.   The left
auricle was next opened from one of the pulmonary veins,  and then the
left ventricle ; both of which,  in  general, appeared natural.  On more
minute inspection, however, of the left ventricle, an opening of an ellip-
tical form was discovered, sufficiently  large to admit the little  finger,
about an inch from the origin of the aorta, on the  left side, and immedi-
ately under the left columna carnea.  It was considerably  smaller than
the external opening, to which it  was almost  directly opposite.  Both
openings communicated with an abscess in the parietes of  the ventricle,
about the size of  a  pigeon's  egg.   It was to the upper surface  of the
thin covering of this abscess, which was more prominent than other parts
of the heart, that the pericardium was adhering.
  The aortal, pulmonary,  and ventrical  valves, were all in a natural
state.
  From this case may be deduced, a very important fact in Pathology,
though perhaps of  little practical utility.   It teaches us that considera-
ble  disease may exist in so  essential an organ  as the heart, and  yet be
unknown,  or even  unsuspected, from  there not being a single symptom
present by which it can be characterized.  Authors  and  practitioners
concur in  opinion, as to the intricacy of most of the diseases  of  this
highly important organ. In their commencement, they are so exceedingly
obscure and insidious, that  the most attentive and sagacious physicians
are perplexed and  embarrassed.  Some are abruptly and suddenly fatal,  ,
as in the  present instance  ; others, continuing for a considerable time,  ,
are mistaken for affections of some other part, but ultimately prove fatal.
This is the general result of all diseases of the heart, as dissection  con-
firms.  Though the ravages of disease are extensive, there are often no  >
predominant symptoms which cau be considered as pathognomonic ; the
nature and  seat of  the diseases are guessed  at, until an opportunity
after  death is afforded for dissection to  develope them.   Every  fact  ;
which  morbid anatomy furnishes, is important, as it tends to elucidate
an obscure part of pathology, and must regulate our prognosis.
  It is a curious and an interesting fact, that  the  left ventricle more
frequently gives way, than  any other part of the  heart.  At first sight,  ,
it appears strange, that the  aortic or systemic side (which all anatomists  i
know to be much stronger  than the  right or pulmonic side) should actu-  ■
ally give way, or burst by its own action.   This fact is confirmed by the  .  i
experience of the celebrated Portal, (Cours d'Anatomie Aledicale,)  who  i  i
informs us, that he has found the heart burst by its own action;  the left  ;  ;
more often than the right side ; and the left ventricle more frequently  r  '
than the auricle.
  Verbrugge, in his  Dissertation on Aneurism, makes a similar remark 
TREATMENT OF ARTERIAL LESIONS.
753
that though the left ventricle, from its  organization, might be consid-
ered less subject to rupture, it is  however the most  frequent seat of it.
Morgagni also mentions one or two facts of a similar nature.  Profes-
sor Chaussier communicated to Portal, a case of rupture of the left auri-
cle from a carriage wheel passing over  the arch of the aorta.
   When organic lesion of the heart  occurs, in the sound state, it has
most generally been induced  by some violent and sudden  effort, or by a
burst of anger.   We see an analogous effect produced upon other power-
ful muscles of the body, and particularly the strong fibers of the gastroc-
nemius which are lacerated by their own strong and sudden contractions.
   The present  case cannot  be  considered a fair  specimen  of organic
lesion of the  heart, in a sound state ;  but an example of abscess  or ul-
ceration in the parietes of the left ventricle, which, upon bursting, prov
 ed suddenly  fatal.  The habit of our patient, no doubt, very much ac-
 celerated the fatal termination :  " for we uniformly find,  (says  the late
 much lamented Allen Burns,) that in almost every organic lesion of the
 heart, stimuli are the bane of the patient:"   As extreme grief has been
 anciently  said to break the heart, the disappointment in love which this
 unfortunate young woman experienced, ought not perhaps to be wholly
 overlooked in an investigation of the cause of her fatal disease.
    The existence of rupture  of the heart, where the  muscular parietes
 have been diseased, is additional)' confirmed by this case.   In most of the
 examples, it would appear,  that hectic, and other  symptoms of  decay,
 have  been the  attendants.   This  appears to  have  been the^ condition
 of a  man  whose  case is related by Marchettis.    This patient, after
 lingering  for some time,  died suddenly, and dissection showed an ulcer,
 which had destroyed, not only the pericardium, but also a large portion of
 the heart;  and the ulceration had ultimately penetrated into the  left
 ventricle, and  sudden death was  the consequence.   Other observers have
 recorded similar cases.   (Alorgagni.)  Alorgagni found on dissection in a
 spleeny old man, who died on the third day after a slight indisposition,
 that  blood  was effused into the cavity of the pericardium, through three
 holes, which communicated with the left ventricle.
    Organic lesions of  the heart,  and spontaneous  rupture from abscess,
 or ulceration, or the bursting of an aneurism of the aorta within the peri-
 cardium,* are uniformly  and quickly fatal.  In each of these  instances,
 the pericardium becomes filled with blood, aud the heart is oppressed, and
 no longer  able to act.  Perforations  of the heart from wounds, are ob-
  served to be less suddenly mortal than  the lacerations just referred to.
  We  are informed by Fanton, that he saw a man  live  till the twenty-
  third day, who had been wounded in the heart.   The left ventricle  was
  pierced, and, as he  states,  the  internal fibres corroded and destroyed.
  Though but few will be willing to give credit to a case so astonishing, we
  have, nevertheless, a number of  very remarkable examples of wounds of
  the heart, by Morgagni  and  others, where it has been  pierced through
  and through, without being  followed by instant death.  Charles Bell has

    Whilst a pupil in Guy's Hospital  (London) I saw an instance of instantaneous death, from
  the rupture of an aneurism of the aorta within the pericardium, about the size of half a nut-
  meg.   The man was on the operating table undergoing the operation for popliteal  aneurism.
  and just as A. Cooper was about to raise the  lower  edge of the sartorius  muscle, he  sud-
  denly expired.
    VOL. I.                             95 
754
NEW ELEMENTS OP  OPERATIVE  SURGERY.
seen a man who was wounded during the embarkation of Sir John Moore's
array at Corunna, in whom the right ventricle of the heart was pcnetrat-
ted by a ball; and he  lived for  fourteen days.  In the  2d vol. of the
Medico-Chirurgical Transactions, we find a case related, in which a bay-
onet had  wounded the  heart.   It extended about three  quarters  of an
inch into the muscular substance of the left ventricle, about  two inches
from the  apex.   The  bayonet penetrated  the  substance of  the   ven-
tricle, and divided one of the fleshy colums of the mitral valve.   This man
lived forty-nine hours after receiving the injury.   He expired  suddenly
in the night, experiencing just before his death, a chilly sensation, which
admonished him of his  approaching dissolution.
   [Cases of rupture of  the heart  have been reported  by  Dr. Claudi, of
Germany, Dr Bigger, of Dublin, and in the majority of the cases related,
the left ventricle has been the seat of the lesion.   It is not, however, con-
fined to this part as supposed by Cruveilhier, for in the Memoir  published
by Dr.  Townsend in  the Dub.  Jour.  Med. Science, vol. 1st, it appears
that in  twenty-five cases, there were three examples of rupture of the right
ventricle, and Bayle, in his  statistics, found  this condition  to exist in
three out of nineteen cases, so that in forty-four cases,  six  occurred in
 the right ventricle.  G. C.  B.]
                      EXPLANATION OF THE PLATES.

Figure 1st.  Represents the heart unopened :  the whole extent of the left Ventricle is seen ;
    at the upper part of which is the hole, or  rupture, and the diseased appearance around
    it.  Likewise  the pericardium  adhering  a little above and reflected back  to show the
    diseased part more completely.

  1. The left ventricle unopened.
  2. The hole or rupture, large enough to admit the end of the little finger.
  3. Diseased  part, showing a prominence of the abscess, and a dark coloured inflammation
    surrounding it : at this point the fluctuation was plainly to be felt.
  4. A portion of the pericardium folded and thrown back.
  5. Point of adhesion with the ventricle.
  G. Left auricle.
  7. Pulmonary artery.
8-8. Division of the pulmonary artery into right ani left.
  9. Ascending aorta.
 10. Superior cava.
Figure 2d.  Shows the left Ventricle cut open through the middle, and reflected back to
   expose the internal opening through which a bougie is passed.

  1. The aorta.
  2. Pulmonary artery.
 3-3. Bight and left pulmonary arteries.
  4. Superior cava.
   B. Divided edge of the left ventricle as turned up.
   6. Lower edge of the same with the external surface of the ventricle.
   7. One of the mitral valves.
 8_8. Cordae tendinae.
 q 9 Divided edges of the left columna carnea.
     The internal pectinated surface of the left ventricle,
   i Internal opening with a bougie introduced. 
TREATMENT OP ARTERIAL LESIONS.
755
RUPTURE OF THE HEART.
(Fig. 2.)
 
756
NEW ELEMENTS OF OPERATIVE SURGERY.
   SECTION  FIVE.

ARTERIES IN  PARTICULAR.
                           CHAPTER I.

                  ARTERIES OF THE ABDOMINAL LIMB.

   The  arteries  of the  lower extremity being exposed  more than any
where else to the action of external agents, and being at the same time
numerous, and for the most part of considerable magnitude, are naturally
subject  and more liable  in fact than any others to all the diseases of the
arterial system.  The surgeon therefore is frequently called upon to per-
form serious operations upon this member ; nevertheless the trunks and
their  principal branches are the only ones upon which  these operations
can be  practised with  advantage;  consequently there are scarcely any
others in this point  of  view that ever require our attention, except the
dorsalis  pedis, anterior tibial, posterior tibial, peroneal, popliteal, and
femoral, and the circumflex and iliac arteries.

                 Article I.—The  Dorsalis Pedis.

                          § I.—Anatomy.

  The Dorsalis Pedis artery, being a mere continuation of the anterior
tibial, takes its origin under the annular ligament of the  tarsus, a little
nearer to the internal than the external malleolus ; thence it passes ob-
liquely inwards  towards the first inter-osseous space of the metatarsus,
which it traverses from  above downwards, to reach  the plantar surface
of the foot, and  to form the plantar arch, in anastomosing with the ex-
ternal branch  of the posterior  tibial.  Separated  from the bones and
from their ligaments  by  a simple  cellulo-adipose layer, and accompanied
on the inner side, sometimes  on  the outer, by the  internal branch  of
the deep dorsal nerve of the  foot, and by its  accompanying vein on the
opposite side, this artery is covered  as we proceed from the deep-seated
parts towards the skin : 1st, by a thin fibro-cellular  lamella which  sepa-
rates it  from the surrounding tendons; 2nd, by a cellulo-adipose layer
which is not constant; 3rd, by the dorsal aponeurosis of the foot; 4th,
by the sub-cutaneous fascia, upon which  moreover are distributed the
superficial  dorsal  veins and nerves ; and 5th, by the skin.   The first
tendon of the  extensor  longus digitorum  pedis, is found upon its outer
side;  that  of the extensor proprius pollicis  pedis, upon its inner side,
while the first bundle of  the  extensor  brevis digitorum pedis  muscle
crosses  it very  obliquely from  without inwards, and from behind for-
wards, on its anterior portion.
  Though  the tarsal and metatarsal branches which the dorsalis pedis
artery furnishes, may be of too little importance to require any descrin- 
ARTERIES OF THE ABDOMINAL LIMB.
757
tion here, it is quite otherwise with its anomalies: I have once met with
it directly under the skin; but it happens more frequently that it is en-
tirely wanting; and a branch of the fibular artery sometimes takes its
place ; at other times it is replaced by a very large branch of the poste-
rior  tibial.  Though it be  true  that  these varieties are of a nature to
cause much embarrassment to young surgeons who practise on the dead
subject, I do not see how this can be so on the living body.  In fact if
the vessel does not exist, no lesion  can make it necessary to look for
it;  if it is  given  off by the posterior arteries  of the leg, its position at
one  of  the  borders of the foot, supposing it becomes necessary to tie it
in consequence of a wound, will preclude the idea of our searching for
it in its customary situation.

                         § II.—Indications.

   Boyer  asks  the  question  if an aneurism of the dorsalis pedis artery
has  ever been seen.   Neither Pelletan, Scarpa, nor Dupuytren appear
to have met with it; from whence we may conclude that it is af least very
rare.  Nevertheless, Guattani says  he has seen an example of this kind
caused  by  venesection, and M.  Roux mentions two cases of wounds of
this artery, which were the source of alarming  hemorrhages.   M. Vidal
has  published in the Clinique, a similar case observed in the Hospital
of Beaujon.  M.  Champion  informs me of another, and the only one
perhaps in which  there  has been a false consecutive  aneurism  of this
artery.    It is evident moreover, if such a thing should be met with, that
the  compression which  succeeded in the case of M. Champion, would
generally answer, and that if we operated according to the modern me-
thod, it  would be the anterior tibial and not the dorsalis pedis, which it
would be necessary to tie ;  [See note of Dr. Mott, above,] but as it may
be  required to obliterate the vessel in front and behind the lesion, in
consequence of the plantar arch, that is, to operate after the ancient me-
thod, the surgeon  ought consequently to know where to find the artery
itself.

                     § III.— Operative Process.

   The  patient should be laid upon a bed, with the limb slightly flexed
and the foot moderately extended; an assistant holds  the limb  steady
by grasping it  above the ankle-bones.  With a straight or convex bis-
toury, the surgeon makes an incision into the  skin of about two  inches,
in the direction of an oblique line carried from the middle of the instep
to  the  first inter-osseous space; and divides  the sub-cutaneous layer,
while he endeavours to avoid the principal venous and nervous branches
which it contains ;  he then comes down in  succession to the aponeurosis,
then  between the  tendons of the  two  first toes, then upon the second
fibrous  layer, and  finally  upon the  artery itself, which he isolates by
means of a grooved sound from the veins and from the collateral nerve
and cellular  tissue, before applying  the ligature, which he ties, after
having  perfectly  assured  himself that he has included nothing in it but
the artery.  Two strips of adhesive plaster bring the lips of the wound
together, and the operation is terminated. 
758
NEW ELEMENTS OF  OPERATIVE SURGERY.
                [Wounds of the Arteries of the Foot.

  The treatment of wounds of the larger arteries of the foot, is in the
opinion of Dr. Mott, a subject which has not received a sufficient degree
of attention.   In recent wounds for example, of the dorsalis pedis, both
ends of the cut artery ought to be tied on the spot.   If some days should
have  elapsed  after the injury, it would be necessary to tie the anterior
and  posterior tibial arteries, and generally he has  found this sufficient
to arrest the hemorrhage.   But in one instance where several days had
elapsed after a wound of the dorsalis  pedis, and in which  strong com-
pression  over the  wound had been made, without, however, preventing
considerable hemorrhage from time to time ; he found when visiting the
patient some  miles in the country, that though after immediately tying
the anterior  and posterior tibial  arteries, the bleeding ceased, yet in
about a week it was renewed to an alarming degree.  Being again sent
for, he found  himself much embarrassed, not knowing whether the hemor-
rhage proceeded from the inter-osseal or some communicating branch of
the anterior or posterior tibial arteries above where they had been tied.
Thinking  that  it might proceed  from a  branch of the anterior tibial
above  the  ligature, communicating with the trunk below, he concluded,
rather than to tie the femoral, that he would cut through the annular lig-
ament as near the wound as possible, and there apply a ligature, which
being done had the desired effect.   The patient was a wheelwright who
had been wounded by an adz.
  In  recent  wounds of the plantar arteries where some days may have
intervened before surgical  assistance is obtained, you cannot tie the plan-
tar arteries themselves, and it is infinitely preferable in  fact, indispensa-
bly necessary to tie both the anterior and  posterior tibial.  For Dr. Mott
has  several times seen after tying the posterior tibial only, that profuse
hemorrhage has returned  at the expiration of a week or ten days, and
which could only be controlled by tying also the anterior tibial.   It must
be  obvious to any  person,  that it takes some time for the collateral cir-
culation  to be established, and that when established, the reflux or dis-
tal  hemorrhage may prove serious  in those cases in which only one of
the tibial arteries has been tied.
  Dr. Mott  has seen  the  same difficulty  occur, and the same  practice
necessary and  effectual, where the communicating  branch  has been cut
in a wound between the great and adjoining toe.  T.]

               Article II.—Anterior Tibial Artery.

                           § I.—Anatomy.

  The anterior tibial artery, after  taking its rise from the popliteal,
and after having  pierced almost at a right angle the upper part of the
inter-osseous ligament, follows as it descends to the middle  of the instep,
the direction of an oblique line drawn from the middle of the space be-
tween the head of the fibula and the spine of the tibia.   Resting almost
denuded upon the inter-osseous ligament in its two upper thirds  then
upon the outer side and front part of the tibia ; it  is consequently situ- 
ARTERIES OF THE ABDOMINAL LIMB.
759
ated at  so much the greater depth, the higher up we seek for it upon
the leg.   The two  veins  which  accompany it repeatedly communicate
with each other in front of the artery by small  transverse branches ;  the
nerve of the same name crosses its anterior surface very obliquely from
above  downwards, and from without inwards ;  sometimes however it
continues outside as far down as the instep.  A thin pliant  cellular tis-
sue, envelopes and unites these different parts, but does not furnish them
a true sheath.  The anterior tibial being situated between the extensor
longus digitorum pedis, and tibialis anticus muscles above, and the tibia-
lis anticus, and extensor proprius pollicis pedis in  the middle portion, and
the extensor proprius  pollicis  pedis, and the extensor longus digitorum
pedis far below, but rarely presents anomalies of  sufficient importance to
require the attention of the surgeon ; nor are the branches that proceed
from it with the exception of the anterior tibial recurrent, of any  impor-
tance in  surgical operations.
   Anomalies.  I have twice  seen the anterior tibial artery lying super-
ficial at the  middle of the leg. In one  of these cases it originated as
usual from  the popliteal.  In  the other, in the place of piercing the in-
ter-osseous  ligament, it turned around outside of the fibula and  follow-
ed  the course of  the musculo-cutaneous nerve.  It is to one of these pe-
culiarities that we  ought  doubtless to attribute the  pulsations observed
on  the fore-part of the legs in a  patient of Pelletan's, (Clin. Chir., t.
II.,) and which misled this practitioner so far as  almost to induce him to
believe in the existence of  an aneurism.  Fortunately we have  only to
recal the possibility of such  an anomaly, to understand how we are to
avoid the mistakes or errors that might arise from it.

                          § II.—Indications.

   Supported by  the inter-osseous ligament behind,  by the bones of the
leg upon its sides, and by muscles  in front, which are firmly held down
by a strong aponeurosis, the  anterior tibial must  rarely be the seat of a
spontaneous aneurism.  For myself, I do not know  a single instance of
it, unless we may regard as such the case of a bloody tumor described
by Pelletan, which had destroyed by erosion a great  portion of the upper
extremity of the tibia.   Traumatic aneurisms on  the other hand,  are ob-
served here quite frequently; these which are sometimes circumscribed,
but more frequently diffused, are produced by pointed and cutting instru-
ments, balls and all sorts of projectiles, fragments of bones  in fractures,
&c.  J. L. Petit, (Matad. des 6s, t. II., p. 46,) Desault, ( CEuvres Chir.,
t. II.,) Deschamps, (Journal de  Fourcroy, t.  III.,  p. 85,) Dupuytren,
(Repert. d'Anat. et de Phys., &c, t. V., p. 217,) Pelletan, ( Clin. Chir.,
t. IL, p.  266,) Boyer,  MM. Roux, (Mid. Oper., 1.1.,) and Cowan, (The
Lancet, 1829, "Vol. I., p. 719,) relate examples of them, and show  that
they may occur at all the different points of the leg.
  Deschamps in the case mentioned by him of false consecutive aneurism,
operated by the  ancient method.   This also is  the method which M.
Guthrie  exclusively adopts in  such cases.   If  the blood  should  still be
flowing, if the  accident  should have  existed only for a short time, and
the wound of the artery appears easy of  access, we might, and ought in
fact, to adopt the course of these two authors ; but otherwise the meth- 
760            NEW ELEMENTS OF  OPERATIVE SURGERY.

od of Anel is preferable.   It does not appear at all necessary to place a
second ligature under the tumor or wound, as some surgeons have recom-
mended, inasmuch as a moderate  degree of compression will answer that
purpose advantageously.                         -        m
  If however, the disease should  be situated in the upper third of the leg
it would be difficult  to lie the artery above, without encountering the tu-
mor, and  consequently we should not have  it  in our  power to avoid
adopting  the ancient method.   In that and in all cases where it would
be attended with too much difficulty to perform the operation on the leg,
there remains as a last  resource, the ligature upon the popliteal or the
femoral itself.   Dupuytren first employed this practice  with success in
1809, in conformity  to the recommendation of Pelletan, (Clin. Chir., t.
I., p. 178,) upon a woman aged sixty years, who was brought to the Ho-
tel Dieu, with fracture complicated with a diffused aneurism of consider-
able  size in the leg.   M. Roux derived the same advantage from it in a
case  of hemorrhage following amputation below the knee, and  Delpech
has frequently obtained similar fortunate results.  M. Guthrie however
(Injuries of arteries, Sec, p. 283,) who  avers that he has seen this oper-
ation performed at Albufera and  Salamanca, long before our countrymen
thought of it, condemns it in most energetic terms.   In a soldier oper-
ated upon in May 1814, the hemorrhage  returned to the wound : it became
necessary  to amputate and the patient died.  The same thing took place
in another soldier wounded at Salamanca.   According to M. Guthrie it
is infinitely better to lay open the tissues  freely at the risk of dividing
the muscles ; here is a proof of it:  a young man let the point of a sabre
fall upon  the fore-part of the leg  and wounded the anterior tibial artery.
A false circumscribed aneurism  was formed.   M. Josse, (Melanges de
Chir.,-p. 247,) ties the femoral artery ; the ligature comes away ; hemor-
rhages take place ;  the pulsations in tho tumor are uninterrupted.   The
operation  by the ancient method  is performed, and the patient recovers.
Though it may be true as a general rule  that the operation by the ancient
method is  more certain,  Somme (Jour. Hebdom. Univ., t. II., p.  242,)
has shown, and M. Neve, (Communique par M.  Champion, 1838,) of
Bar-le-duc, has also recently proved that tho advice of Dupuytren may
be followed with advantage.

                     \ III.— Operative Process.

  The patient  placed as  for the  dorsalis pedis ought to have the  leg in
slight  pronation, and arranged in such manner that the muscles  of its
anterior portion may be stretched or relaxed at pleasure by the assistant
when he acts on the foot.   To arrive upon  the artery it  is  necessary to
divide the skin, the  subcutaneous layer and the aponeurosis, to the extent
of about two inches upon the line mentioned above ; then with the fore-
finger or  the extremity of a grooved sound, we separate if  we are above
the extensor longus pollicis pedis from the tibialis anticus, pushing it
outwards ; and from the extensor longus digitorum pedis, on the contra-
ry,  and pushing the latter inwards, if we are far  below.  This being
done, there is  nothing left but to isolate the artery from its accompany-
ing veins  and collateral nerve, in order  to tie it, then to unite the lips of
the wound and apply a suitable bandage. 
ARTERIES OF THE ABDOMINAL LIMB.
761
  In its middle part, or its two upper thirds the artery may be cut down
upon in many different ways.
  A.  Process of M. Lisfranc.—In the process attributed to M. Lisfranc,
by  MM. Coster (Manuel  des  Op.  etc., 3e edit.,) and Taxil, (These
No. 142, Paris, 1822,) the incision of the skin is oblique from below up-
wards, from the  crest of the tibia towards the fibula, and distant about
an inch or two from the  horizontal line.   After having divided the apon-
eurosis transversely, we seek for the interstice which separates the tibialis
anticus from the extensors, and as it is the first we meet with outside the
tibia, nothing is more  easy than to distinguish it.
  B.  The  Ordinary  Process.—In the common process we cut parallel
to the direction of and upon the track of the artery, taking for our guide
the line mentioned above, or the middle of the space which separates the
fibula from the crest of the tibia; or the slight depression which natural-
ly exists opposite to the interval of the muscles that we intend to separate
apart or what in fact  is as well we carry the bistoury directly to about.
an inch outside the anterior border of the leg; the aponeurosis like the
skin should be divided to the extent  of three to four inches; the muscu-
lar interstice where we should  use  the fore-finger, in order to separate
the muscles and to come perpendicularly upon the inter-osseous ligament,
is indicated by a yellowish line.  At  the bottom of this interstice is seen
the vessel which we endeavor to isolate and raise up, but this is the most
difficult part of  the operation.
   C. After h&Ymg flexed the foot and properly  separated the  muscles
apart, the best mode of managing with the artery is to pass under it a
grooved sound, very obliquely from below upwards and from the fibular
towards the tibia, in place of passing  it transversely or from the anterior
to the outer border of the leg.   To appreciate the utility of this remark,
we have only to recall to mind, that the fibula is almost  always  on the
same plane with that  of the vessels, while the crest of the tibia is much
above their level.  We may moreover apply  the ligature by means  of
the needle of Deschamps, or any other of the numerous  porte-ligatures
which have been contrived for this purpose.
  D. Appreciation.—It is needless to remark that no one will  venture
at the present time to imitate  Hey  (Estor dans Bell., trad., Fran<j., p.
205,) or Logan,  (Hey's Practical Observations, 1814,) by  cutting out
a portion of the  fibula to arrive with more ease upon the tibial  artery,
as these Surgeons declare they have once done with success, and  as Gooch
(Bell,  Op. cit., p.  199,) has the boldness to  recommend.  The  oblique
incision, it is asserted, enables us to come down  with more ease  than
the parallel incision, upon the guiding interstice  and the trunk of the
artery.   The remark is  true for the first point, but not for the  second
and experiments frequently repeated show that we should give  the  pre-
ference to the ancient method at least in ordinary  cases, and whenever
there are no special indications to fulfil.
Vol.  I.
96 
762
NEW ELEMENTS OF OPERATIVE  SURGERY.
               Article III.—Posterior Tibial Artery.

                            § I.—Anatomy.

   From its origin a little belqw the popliteus muscle down to its division
 into the internal and external plantars, the posterior tibial artery follows
 almost exactly the direction of a line very little convex inwardly, which
 would extend from the middle of the upper  part, of the calf, to half an
 inch  behind the internal malleolus.   Two veins of considerable size or-
 dinarily accompany it, and by their frequent  anastomoses sometimes form
 around it a complete network.  Upon its fibular side is found the poste-
 rior tibial nerve which is rarely  distant from it more than three or four
 lines.  Supported throughout its whole extent by deep seated muscles, it
 is covered over by the aponeurosis which is situated between  the two
tfleshy layers of this  region; also by muscles, or cellular tissue, and
 other fibrous lamellae, afterwards by the common  integuments, but  with
 peculiarities in certain parts of its track which it is important  to  note.
   A. In the Tibio-calcanean Groove,  the posterior  tibial artery  rests
 against the fibrous sheath of the flexor longus digitorum pedis, at about
 three lines  from the posterior  border of  the malleolus; the nerve  is be-
 hind  and the veins are on the inside ;  a lamellar or adipose tissue envel-
 ops it; the internal ligament of the tarsus, a kind of fibrous layer which
 is continuous with the aponeurosis  of the leg covers the artery and binds
 it down where this ligament blends with the  dense and filamentous tissue
 which separates it from the skin.
   B. Between the  Malleolus and the termination of the  calf, the poste-
 rior tibial artery is a little farther  distant from the tibia.  The nerve  is
 rather outside than behind.   The lamellae which  immediately  surround
 it are very  pliant, and frequently covered with fat.  The deep aponeuro-
 sis which is quite thin in this place, holds it firm, against the tibialis pos-
 ticus muscle, the flexor longus digitorum pedis, and  the flexor longus
 pollicis pedis ;  outside of this lamella is seen the tissue which forms the
 sheath of  the tendo Achillis, then the tibial aponeurosis properly so
 called, before we arrive at the skin.
   C. At the Calf, the tibial artery is situated very deep, and almost on
 the same plane with the posterior surface, and much nearer to the ex-
 ternal or fibular than to the internal border  of the bone which has given
 its name to it.   The aponeurosis which covers it and which in some sort
 it lies in naked contact with, and  which  is ribbon-like  in  appearance,
 and silvery with longitudinal and very strong fibres is concealed by the
 tibial portion of the soleus  muscle, the gastrocnemius internus, the tibial
 aponeurosis and the sub-cutaneous tissue, in  which are found situated the
 great saphena vein and the internal saphena nerve.
   D. It is an unusual  thing to find  the  posterior tibial  artery  wanting,
 but it may happen that it is of very small size, and that the fibular artery
 takes its place on the surface of the foot.  More frequently it  continues
 upon the median line  until it reaches near the malleolus ; in  that  case,
 the nerve is on its inner border.   I have on  one occasion seen it proceed
 along side of the fibular artery for two thirds of its extent, and pass under
 the arch of the os calcis  at near an inch behind the malleolus. 
ARTERIES OF THE ABDOMINAL LIMB.
763
                         § II.—Indications.

  Like the anterior tibial, and for the same reasons, the posterior tibial
artery is very rarely the seat of spontaneous aneurisms, or even of false
circumscribed aneurisms ; Ruysch, nevertheless, cites a case of aneurism
near the heel, which could only  belong  to this artery, and which  was
opened by mistake for an abscess.   M. Dorsey (Elements of Surgery,
Vol. II., p. 271,) gives an example of varicose dilatation and hypertro-
phy of this artery in  a case of aneurismal varix.   Guattani also speaks
of pulsating  tumors,  which, without doubt, were the  result of certain
lesions of the posterior tibial.   Wounds, in fact,  accompanied with he-
morrhages or diffused aneurisms, have in latter times been noticed in this
artery, by Scarpa, Dupuytren, MM. Hodgson,  Marjolin, Earle, and Vin-
cent.   (The  Lancet, 1829, Vol. I., p. 719.)
  The ancient Method, according to Boyer, is  the only one which should
be  applied to these  affections, since, by the method of Anel, the blood
would soon be brought back to the inferior end, by means of the plantar
arch  and the anterior tibial.  Others, influenced  by the same fears, but
not wishing to act upon the diseased point, have proposed an intermedi-
ate method ; that is, to place one ligature  above and one below the aneu-
rism, without touching the  tumor.  I confess I do not see the necessity
of proceeding in this manner.   On the supposition that the return of the
blood would  be au obstacle  to the cure, as in the patient  of Alancon,
(Man. Prat, de l'Amput.,n. 164,) all that would be necessary probably
to prevent  it would  be to  make methodical  compression upon the
course of the dorsalis pedis artery, as M.  Marjolin has done, or even be-
low (that is, on the distal side of) the wound, if  its position permitted.
On  the  other hand, when  the seat of  the difficulty is in the sole of the
foot, and compression does not succeed, the ligature upon the trunk of
the tibial evidently  cannot be  applied, except by the modern method.
The only case where the ancient  operation might  strictly be admissible,
or at  least  be preferable, if we should not be inclined to tie the  popli-
teal or  femoral  artery, is that where the aneurism  occupies the  upper
half of the leg.
  Nevertheless,  diffused traumatic aneurisms do not come under this rule,
and  should I think be treated as Boyer and M. Guthrie recommended ;
that is, by the method of Keysleire.  Though  Pelletan, (Clin.  Chir., t.
II., p. 266,)  unable to tie a wounded posterior tibial, succeeded by an
incision  and  by  tamponing, and  by compressing the artery  upon the in-
ter-osseous ligament; and Colomb, already quoted, confined himself to
simple compression in a case of  this kind; and though Gelee put a  stop
to the hemorrhage, by cutting  down and introducing a thread in order
to pass a piece of agaric against  the artery, we see that compression was
followed by gangrene in the cases of Bourienne, (Journal  de Horn, t.
VII., p.  281—282,) by convulsions and death in two patients that Boyer
speaks of, (Malad. Chir., t. I.,  p.  262,)  and  proved  ineffectual in the
cases of  Wiseman, Deschamps, Briot, and a great number of other  sur-
geons.  The  ligature  which was placed  upon the anterior tibial artery
by Ginies, (Anc Journ.de Mid.,t.  LXXVL, p. 71,)  and on  one of
the other arteries  of  the leg by  M. Ouvrard, (Obs. de  Mid. et de Chir., 
 764            NEW ELEMENTS OF OPERATIVE SUCGERY.

 1828, p. 245,) had entire success, and is therefore in every respect to
 be preferred.
   [The following judicious remarks of  Mr. Lawrence, of London, are
 worthy of note in connection with this subject.  They are taken from a
 clinical lecture of this distinguished surgeon, on wounds of the blood-
 vessels of the lower  extremities, published  in  the  Lond.  Times  and
 Gazette, June 11, 1853.   " When arteries under the calf of the leg are
 wounded, it is difficult to follow the well-founded and generally received
 rule  of exposing and securing the injured vessels, even under the most
 favourable circumstances; that is, if  we see the case at an early period,
 when no considerable swelling has occurred, and the natural relations of
 the surrounding parts are not obscured by ecchymosis.
   Frequently, we do not know what  vessel is wounded, nor the precise
 locality of the mischief.   Sooner or later, and often  very quickly, the
 whole limb becomes swollen by extravasation of blood, while all the soft
 structures may be lacerated, contused, and infiltrated with blood.   Ex-
 ploratory incisions  for discovering the injured vessel, would be under-
 taken with  very little chance of success ; in such a state of limb, they
 might be attended with dangerous loss of blood, and would certainly in-
 volve  the necessity of extensive and  deep  incisions in the injured parts.
 Thus, wo come to the  conclusion, that  amputation is necessary in some
 of these cases, in order to prevent worse  consequences."   He then re-
 lates  the details of a case, of  violent  contusion of the leg, with rupture
 of the anterior tibial artery, in which he resorted to amputation of the
 thigh with  success.  In this instance, the posterior tibial vein was also
 wounded, and was supposed to have caused the great effusion  of blood.
 A patient was under  the care of Mr. Stanley at the same hospital, in
 which the posterior tibial vein was ruptured by the wheels of a carriage.
 Great extravasation of blood took place  under the calf of the leg, in-
 flammation followed and extended, and  the patient died.  G. C. B.]

                     § III.— Operative Process.

 ^ Whatever  may be the point where we wish to lay bare the posterior
 tibial  artery, the leg  should  be  flexed and laid upon its external side ;
 and  in the  same way as for the anterior tibial, if compression is to be
 made, it is to be made  upon the thigh or upon the body of the pubis.

                     A.  Behind the Malleolus.

  a. Process of th°. Author.—I make  an  incision slightly curved, with
its  concavity forwards, which,  commencing an inch  above, finishes an
inch below, and passes at three or four lines behind the posterior border
of this projection.   When we arrive  at the beginning of the groove of
the os calcis, it is of importance to proceed with caution, and to cut the
tissues layer by layer,  and pass  the grooved  sound under the aponeu-
 rosis, before  dividing it with  the  bistoury, if we do not  wish to incur
 the risk of wounding  the  artery, which is sometimes very superficial;
 in making the incision  nearer  the malleolus, we might readily penetrate
 into one of the fibro-synovial grooves which  it assists  in  forming  and
 nothing would be more  dangerous than such  a mistake, because of the 
ARTERIES OF THE ABDOMINAL LIMB.
765
inflammation which  might  result from it.   Farther back, the artery
would be difficult to  find, and the operation much more laborious.
  b. Process  of M. Robert.—M. Robert proceeds in another manner.
Here is the method which  he  has  communicated to me:  The incision
extending and directed from the  posterior angle of the malleolus to the
upper border of the  os calcis, should  be perpendicular to the course of
the vessel.  " Thus placed, it enables us," says M. Robert, " to isolate
the artery without difficulty, as soon  as the  aponeurosis, which is very
thick in this place, has  been divided."
  In a case of a recent opening in the tibial  artery in this region, M. H.
Berard, (Arch. Gen. de Mid., 2e series, t. VII., p. 453,) having  se-
cured its  two  ends, found  that the hemorrhage continued, but  that it
proceeded from a vein which it was unnecessary to tie.

                         B. Below  the  Calf.

   I make a straight incision, from two to three inches long, at an equal
 distance  from the inner  border'of the  tibia and the tendo Achillis.
 The skin, the  adipose tissue, and the superficial layer (feuillet) of the
 aponeurosis .having been divided, we endeavor, by means  of the sound,
 to  denude the deep-seated aponeurosis; and then  divide  this tissue to
 the same extent as the skin, being careful always to guide the bistoury
 upon the groove of a director.  In that case, we are certain to encoun-
 ter the artery, especially when we have  taken the precaution to divide
 the tissues perpendicularly;.that is  to  say, by carrying the bistoury
 from behind forwards, and from the inner towards the outer  border of
 the leg, as though we were going to prolong  it to the fibular side of the
 tibia.   It is important to recollect, that if the integuments are attacked
 nearer the bone  than the place mentioned, we should have but  one
 instead  of two aponeurotic layers to divide ; but  that, in thus coming
 down  upon the muscles at a great distance from  the vessel, we should
 run a much greater risk of being led astray, than by proceeding in the
 manner I have indicated.

                    C.  In the thick part of the Leg.

   M. Guthrie, on  one occasion, undertook to  cut down upon the posterior
 tibial, by cutting through the whole thickness of the calf.   Gelee, in the
 case described by him, made a counter opening, passed a ligature between
 the two muscular layers, and then tied it upon compresses on the front
 part of the limb, after having inserted into the depth of the wound sev-
 eral pieces of linen  between the muscles and the artery, in order to act
 upon this last with a sufficient  degree of pressure : his patient recovered.
   b. Most authors, on the contrary, recommend that we should penetrate
 on the inner side of  the leg, and dissect and turn back the corresponding
 portion  of the soleus muscle  from the  posterior  surface of the tibia.
 But then the  operator would run the  risk of denuding the bone, of not
 reaching the  vessels without much difficulty, and of meeting with such
 interference from the muscles as to oblige him, after the operation, to di-
 vide their fibres transversely upon the posterior lip of the wound, as hap- 
766
NEW ELEMENTS OF OPERATIVE SURGERY.
pened to M. Bouchet, of Lyon.   In proceeding in the following manner,
we are protected from all such inconveniences.
   c.  The Author.—Placed on the outside of the limb, the surgeon makes
an incision of about four inches long, in the direction, and at the distance
of, considerably more than the width of a finger  from the inner border
of the tibia, then separates the saphena vein, divides the aponeurosis, and
falls  perpendicularly upon the fibres of  the soleus muscle, which he di-
vides, layer by layer, as though he were cutting for the posterior surface
of the  tibia very near its outer  border ; in a short time he perceives a
fibrous, thick, pearl-colored layer, upon  which the muscular  fibres are
inserted; this is the deep aponeurosis which is traversed by many vas-
cular branches.  We divide it upon a grooved sound to a sufficient extent,
and the artery being situated immediately above, and surrounded by its
satellite  veins  and accompanied by the nerve which is  distinguishable
from it by its rounded form, size, and yellow color, is then easily raised
up and tied.

                Article  IV.—The Fibular Artery.

   It is seldom, except at its upper portion, that the  fibular artery can
require  the interposition of operative surgery.  Below it is too small
and too deep-seated to make it necessary to pay any regard to its wounds.
On the supposition that aneurisms might be developed  on some part of its
track, an example  of which was  seen in the  Hotel Dieu in 1830, sound
practice  perhaps would suggest that we should proceed to  tie the popli-
teal or the femoral, rather than the diseased trunk  itself.   If, however,
we should, owing to any particular circumstance, feel ourselves obliged
to pursue a contrary  course, as  occurred to Ouvrard, (Oper. Citat., p.
251,) the following is tb.3 process which it would be necessary to adopt:—

                      § I.— Operative Process.

   Since it would be necessary, if in the calf, to look for the fibular artery
at the depth of several inches, whether we  adopted the process of M.
Guthrie  or proceeded according to the rules indicated for the posterior
tibial; and inasmuch as it is a vessel of no importance  in its lower fourth,
there is no other point  in fact where it is allowable to attempt to tie it,
except at a place  where  the soleus is separated from the  gastrocnemii.
A wound three  inches long, parallel  with the posterior  border of the
fibula, and inclined towards the axis of the limb, and comprising the skin,
adipose tissue, superficial aponeurosis, the outer  root of the soleus, and
the deep-seated aponeurosis, would in fact  put it in our power  to lay it
bare, and to isolate it in the midst of the fibres,  or  upon  the posterior
and inner side of  the flexor longus pollicis pedis.   M. Guthrie, ( Oper.
 Cit., p. 298,) who is a declared enemy of the method of Anel in trauma-
tic aneurisms, preferred, in order to reach this vessel in a case in which
it had been wounded by a ball, to cut into the calf vertically to the ex-
tent of seven inches ; then to divide transversely the  outer border of the
wound, and afterwards  to constrict the  artery indirectly by means of a
ligature introduced in a suture needle, rather than  lay it bare above. 
ARTERIES of the abdominal limb.
767
We should in fact, in my opinion, in a case of this kind, follow his mode
rather than decide upon tying the trunk of the femoral.

                                 §11.

   The rule which recommends that for all these ligatures the incision
through the integuments should cross the track of the artery at an angle
of thirty-five degrees, instead of being made parallel to it, might without
doubt be adopted, and in fact should not, perhaps, in some cases be dis-
regarded ; but in the majority of cases it  does not appear to me to pos-
sess such  advantages over the ordinary method, as to require any special
recommendation.

                Article  V.—The Popliteal Artery.

                           § I.—Anatomy.

   The ham, which has acquired importance in surgery for a century past,
in consequence of its principal artery, is a hollow of a rhomboidal form,
composed of two  triangles united at their base, and having its broadest
part  situated above the condyles  of  the femur.
   A. The popliteal artery  courses  through it from above downwards,
keeping a little nearer to its inner border, which conceals the vessel at
its origin, than to its outer border, until it reaches the point where it en-
ters into the notch between the condyles. In its femoral  portion, the vein
is closely united to it  upon  its  posterior  and  outer side;  the  internal
branch of the sciatic nerve  is still more superficial;  from  three to five
lymphatic ganglions and cellular  and adipose tissue surround it, and sep-
arate the  whole of this portion of it from the aponeurosis.   In the leg it
is not so deeply situated ; quite frequently the vein and nerve are found
on the inner side of it;  at  other times the first is found upon its fibular
aspect, while the second is placed upon its tibial  side.   On  its posterior
surface it is concealed, first  by  adipose cellular tissue, and afterwards,
a little farther down, by the origin of the gastrocnemii,  while its anteri-
or surface rests against the   posterior ligament of the  articulation and
the popliteal  muscle.   This artery, moreover, has been  wounded by a
necrosed fragment of the tibia in a  patient whose case is mentioned  by
M. Porter, (Journ. des  Conn. Mid.  Chir, t. I., p. 27.)   It  is  proper to
add that the external saphena vein is no longer superficial after it enters
into this region, and where it is generally  found  upon the median line;
and that, after having received from the thigh its descending branch, it
empties into the  popliteal vein a little above the condyles.  In  a speci-
men which M. Manec exhibited to me, it was given off  by the ischiatic
artery, but was wanting  in  the case mentioned by M. Caillard, ( These
No. 307, Paris, 1833.)   The five articular arteries, and the two surales
which arise from it, serve to re-establish the circulation of  the  leg and
thigh  in cases of  aneurism of the ham.

                         §  II.—Mechanism.

  In no part are aneurisms more common than in  the ham.  Spontaneous 
768
NEW ELEMENTS OF OPERATIVE SURGERY.
aneurism is that which is more especially met with here ;  traumatic aneu-
rism is not unfrequent; varicose  aneurism has also been sometimes met
with in this artery, (J. Terry Encyclograph. Mid., 1836, p. 100.   Larrey
de Toulouse, Press. Mid., 1.1., p. 25. Lassus, Pathol. Chir. Ribes, Bullet.
de la Faculte, t. V., p. 284.)  The great frequency of the first has special-
ly occupied the attention of surgeons ; some have imputed it to the effort of
extension of the leg upon the thigh ; Scarpa and Delpech have taken ground
against this opinion, by maintaining that an aneurism, which is not direct-
ly occasioned by a wound, is always  produced by a disease of the inter-
nal or middle coats of the artery.  M. Richerand considered the first opin-
ion conclusively established ; lftit M. Hodgson speaks of facts which have
given opposite  results, and the  majority of the moderns adopt the opin-
ion of Scarpa.  May it not be possible to  reconcile these two  modes of
treating this question ?  While  the artery continues perfectly sound, no
extension  of the  leg, it is true, appears capable of rupturing  its coats ;
but if its  interior is encrusted  with calcareous plates, or is the seat of
any ulceration ; if one of its coats has lost its flexibility and become brit-
tle, how can we reject the cause  assigned by the ancients ?   It  is certain
that  laboring men  and those who are  habitually in the erect posture;
postillions, for  example, are those who are most frequently the subjects
of this disease.
  The form  and the accidents of popliteal  aneurism, and everything
that  concerns its development, find  a natural explanation in the ana-
tomical arrangement above-mentioned.   Restricted by the bones in front,
and the aponeurosis behind, the tumor first increases in breadth, or from
above downwards, and remains a long time before it makes  any  promi-
nence outwardly.   Most  frequently however, the aponeurosis  yields,
and soon after becomes attenuated, so that the aneurism ultimately makes
a projection under  the  skin.   Anatomy also  teaches us that we must
not judge  of  the seat of the arterial  opening by the position which  the
tumor occupies outwardly.  The resistance presented by the  soft parts
of the popliteal region  being less in its middle portion than any where
else, is the reason why the sac always has  a tendency  to make its  way
towards that  part.   This, moreover, is a peculiarity which  we must
not lose sight of when we decide upon operating by the ancient method.

                        § III.— Circulation.

  The anastomoses which enable the arteries of the leg  to  communicate
with each  other, are too numerous and too large for the surgeon  to have
the least inquietude about the re-establishment of the circulation  in this
part of  the limb after the operation for aneurism ; but in the hollow of
the ham we no longer operate with the same confidence.   Here the artery
is solitary, and the supplemental branches are but of small size.  Thus the
ancients, being  persuaded that the obliteration of a trunk like this could
not fail to  bring on mortification of the parts that derive their nourishment
from it, had, in order to cure aneurism and external wounds in the popliteal
space, no  other resource after  compression and depleting  means, than
that of amputation of the  thigh.  J. L. Petit and Pott were tortured
with  these apprehensions.  N. Guenaud  (These  de Haller, t.  V.  r>
153 ; trad., t. III., p. 389) vainly endeavored to dispel them,'and Brom- 
ARTERIES OF THE ABDOMINAL LIMB.
769
field (Med, de Chir. Etrang., t. III., p. 354) still qualified as extrava-
agant the proposition to tie the femoral artery.  If some more fortunate
results were announced, they explained them by saying  that  an abnor-
mal division of the vessel was the cause.  It required nothing less than
the operations performed by Guattani, Pelletan, Desault, and Hunter, and
especially the splendid researches of the indefatigable  Scarpa, towards
the beginning of the  present century, to give  predominance to an oppo-
site opinion.   To-day there is no longer any uncertainty in this matter;
going from one extreme to the other, an aneurism in  the ham is attacked
almost with the same boldness as that of one of the tibial arteries.

                         § IV.— Treatment.

   Nevertheless, we should do wrong to dissemble  that this  operation is
a serious one, and should not be performed for slight  grounds, so much
so, that for aneurisms in the upper third of the leg, for example, I should
decidedly give the preference to the ancient method, or even that of Bras-
dor.
   A. The depleting regimen, applied to aneurisms of the popliteal ar-
tery, is a resource too uncertain and too dangerous  to be seriously recom-
mended.
   B. Neither cold applications nor ice, to which  all the patients at the
Hospital of Incurables at Naples, are still  submitted, (De Renzi, trad.
Ital.  de ce traite, p. 71,) and which, M. Zaviziano  informs me, he has
often seen succeed in this establishment; nor  potter's clay, with which,
as a topical application, M. Kanelski has obtained complete success, have
been followed by any considerable number of cures, unless in the  prac-
 tice of MM. Guerin and Dutrouilh, of  Bordeaux.
   C. Indirect compression either upon the tumor or above it, (i. e., on
the cardial side,) or upon the whole limb, has been more frequently fol-
lowed by advantageous results than have the preceding methods.  Guat-
tani,  Boyer,  (t. IL,  p. 308—324,) Pelletan, (Clin.  Chirurg., t. I., p.
121,) Desgranges, Dupuytren, (Bulletin de la Faculte, t. VI., p. 242,)
MM.  Richerand, Ribes, (Ibid., le annee, p. 87,) and Viricel, (Ibid., 6e
annee, p. 132,) relates examples of cures  obtained  by this means ;  but
in the patient of Eschard, (Pelletan, Clin. Chir., 1.1., p. 115,) it required
eleven months of treatment and absolute rest.   M. Roux mentions a case
where compression, applied successively upon different  parts of the thigh,
was followed by accidents of the most alarming character, and this with-
out arresting the  progress  of the aneurism.   Nevertheless,  we may in
timid, young, and feeble persons, who have  a great repugnance to an
operation  properly  so called, have recourse to it, either alone or com-
bined with the refrigerants and the treatment  of Valsalva.
   A patient treated  in that manner by M. Fabris,  (Bullet, de Firussac,
t. I., p. 346,) was  perfectly cured.   M.  Chiari  (Renzi,  Med.  Oper.,
trad., p. 346) thinks that his compressor above the tumor succeeds as
well as the ligature by the method of Anel.  Cumano (Bullet, de Ferus-
sac, t. XXL, p. 121) also says he has cured a popliteal aneurism by the
compressor of Dupuytren.   A. Dubois (Bulletins de  la Fac. de Mid.,
6e annee, p. 40) obtained a similar successful result at the beginning of
this century.  Upon the supposition that the patient may not bear it
   Vol. I.                    97 
77J
NEW ELEMENTS OF OPERATIVE SURGERY.
 well, or that it aggravates instead of ameliorating the  symptoms, it is
 easy to lav it aside and come  to  the last resource.  When the disease
 has a tendency to disappear spontaneously, it cannot be denied that com-
 pression is calculated  powerfully to aid the salutary efforts  of nature.
 In such cases, at least, it may be followed by success.
   D. In some cases also, we must add, the tumor has disappeared with-
 out any assistance.  A man from the country came to the Hospital of
 Tours to be treated for an aneurism in the ham.  The principal surgeons
 of the town were called in consultation.  The necessity of the operation
 was unanimously conceded.   But on the day after, the pulsations in the
 tumor had in great part ceased, so much so that in three days more they
 could not be perceived at all, and in two months the patient found him-
 self perfectly cured, without having undergone an operation.   Rest and
 regimen  effected  a similar result in a case cited by E. Ford ;  examined
 at a later period on the dead body, the popliteal artery was found a lit-
 tle dilated, and  of about the  size  of  a hazel-nut.   We tried, says the
 author,  to introduce a  probe  into  its canal; it was obliterated, and it
 was not possible to penetrate it, even in using some force.  This part
 of the artery was shut up by a firm and solid substance.   The same pa-
 tient had a fenioral aneurism, which had terminated by gangrene of the
 tumor, which had caused his death, without producing either hemorrhage
 or  effusion  under the  skin,  though there was a crevice on its anterior
 part; a very thick clot by its strong adhesion to the gangrened integu-
 ments, presented  an  obstacle to the exit of the blood.  Blizzard and
 Salmade have each related a similar case, and scientific collections afford
 a number of others that  are not less  remarkable.  Moinichen (Bonet,
 Corps de Med., t. IV., p. 56)  saw a popliteal aneurism burst and reco-
 ver without an operation.
   E.—As to the ligature, it would seem from a letter of Testa to Cotug-
 no, (Pelletan, Clin. Chir., t. I., p. 137,) that  Keisler or Keyslere, had
 used it a great number of times before it was spoken of in Italy.  Loch-
 man, another  surgeon  of Lorraine, operated in the same manner  with
 success upon a patient at Florence in 1752, while Birchell (Guthrie, Op.
 Cit., p. 144) ventured to do the same at the infirmary at Manchester in
 1757.  It  was these facts,  no doubt, which awakened the attention of
Mazotti  and Guattani.  In his  two operations Mazotti placed a second
ligature below the arterial perforation ; and it is with this modification
that the method of Keisler was for the first time made trial of aniono- us
in 1780  by Pelletan.
  In fact the ligature upon the popliteal artery might be  performed by
the three known  methods.  It has been performed a great number of
times in France by Pelletan, Desault, Deschamps and Boyer, by the an-
cient method; but by this mode, it has appeared to present so many diffi-
culties and dangers, that  it has generally been renounced since the last
ten or fifteen years.  It is rare also, that the  process of Anel taken liter-
 ally, is had recourse to in aneurisms of the ham.  Desault is the only
 one who  made use of it, and his case  tends to prove that under such cir-
 cumstances it is better to tie the femoral itself.  Though  the method of
 Brasdor has not yet been tried on this artery, I have not considered it
 right to  pass it over in silence.  If the  tumor in fact should not have
 displaced the parts to too great an extent, or should not be too volumi- 
ARTERIES OF THE ABDOMINAL LIMB.              771
nous, or should occupy the femoral portion of the popliteal space, it has
appeared  to  me  probable, that we might sometimes succeed by placing
the ligature below the disease,  (i.  e., on  the distal side of the tumor, or
by the method of Brasdor;) at  the present day especially when we have
the process of M. Marchal, I should not hesitate to attempt it.  In con-
clusion then, it  is only  for aneurismal  affections of the upper  third
of the leg that it may be advantageous to tie the popliteal artery, and
consequently after the method of Anel only.   We may after all, succeed
with it without any great difficulty ; perhaps  also, we ought to prefer it
when the subject is thin, and when every thing leads us to believe that
the  disease does  not extend to  the ham itself.

                       § Y.— Operative Process.

   A.— The ordinary process.   The  patient  is laid upon  his belly and
 the leg held moderately extended.
   I.—To reach the portion of the  artery in the leghj the common meth-
 od, we incise upon the  median line, parallel with the axis of the  limb   •
 and to the extent of three or four inches,  both the skin and the sub-cu-
 taneous tissue, taking care to push the external saphena vein to the out-
 side, if it presents itself  under the edge of the bistoury.   The aponeu-
 rosis  being once divided, the instrument is no longer required; we tear
 apart with caution  the  cellular and  adipose tissue ; then  separate the
 attachment of the gastrocnemii muscles, and  isolate the vessel from the
 nerves and the vein or veins which surround  it, by means of  the grooved
 sound.
   II.—Above the Condyles, it is easier to avoid the saphena, and the
 incision should be longer, and  a little nearer  to the internal  than the ex-
 ternal border of the ham, at least at  its upper part, and following a di-
 rection slightly oblique  in descending upon  the  inter-condyloid notch;
 under the aponeurosis are found the nerves,  the vein soon after, and the
 artery quite at the bottom, and generally difficult to be detached from it,
 (the vein,) and  always more deeply situated than in its lower half.
   B.—Process of Jobert and Ashmead.   In place of incising  upon the
 posterior  surface of the popliteal  region, M. Jobert  (Bibliot  Med.,
 1827, t. I., p.  229,) advises to cut down upon the artery by penetrating
 into the depression which is  observed  above the  inner  condyle of the
 femur, between the vastus internus and the internal border  of the ham,
 when the leg is  semi-flexed.  In acting in this  manner  difficulties are
 created which- do not exist in  the ordinary  method, and I do  not think
 that the  modification of M. Jobert ought to be adopted, notwithstand-
 ing the very precise rules which M.  Ashmead, who believed himself the
 inventor of it, laid  down for this  method in 1829.
    C.—Process of Marchal.   Maintaining with reason that  the ligature
 upon  the popliteal artery, is,  all other  things being equal, less serious
 than that upon the femoral, M. Marchal  (These No. 156, Paris, 1837,)
 proposes a new mode of  proceeding.   The patient is laid upon his back,  .
 having the leg turned outwardly, and moderately flexed.   The surgeon
 keeping along the outer side of the semi-tendinosus, divides the integu-
 ments to the extent of about three inches  upon an oblique line which ex-
 tends from the hollow of the ham to the internal border of the tibia, taking 
772            NEW ELEMENTS OF OPERATIVE SURGERY.

care to avoid the saphena.   After having cut through the  aponeurosis a
little farther  behind he inserts his finger between the inner portion  of
the gastrocnemius internus and the  popliteus muscle, in order to separate
the cellulo-adipose tissue.   A greater degree of flexion of the log then
allows him to distinguish the vascular bundle and to pass the ligature
around the artery.   This process, which could take the title of the meth-
od of Brasdor, if it was applied to aneurism in the popliteal space, and
that  of the  method of Anel, in cases of disease of the arteries in the
calf  or upper part of the leg, is evidently preferable to the ancient, and
while it does not allow of our attacking the femoral artery for wounds
of the arteries of the leg,  relieves us from  the  necessity of following
the precepts of M. Guthrie, (vid. supra.)
  D.— Consequences  of the Operation.  Whatever may be the mode,
method or process, which has brought about the cure, when the popliteal
artery is in question, the resources which nature  employs to re-estab-
lish the course of the blood are always the  same.  The obliteration  or
the vessel is prolonged to a certain  extent above and below the wound  of
the part included in the ligature ; the branches which allow the perforat-
ing arteries to communicate with the superior articular arteries, and the
latter and some branches of the  superficial femoral with the  inferior
articular arteries, surales, and the tibial recurrent of the knee, gradually
augment in volume, and ultimately form a very beautiful net-work about
ulation.  The blood then passes with sufficient ease from the thigh to the
the artierial canals of the leg.
  There  exists in  the Museum of the Faculty an anatomical  specimen,
prepared by Ribes, and  taken from a subject who had been a  long  time
before cured by Sabatier, which gives the  proof of this arrangement.
  We find  a  sketch of a similar preparation  in the first volume of the
Clinique  of Pelletan.   MM. A. Cooper, Hodgson, Dupuytren, &c, have
observed the  same fact in  a number of dead  subjects; and  I had  an
opportunity of corroborating the truth of it in 1823, upon the dead body
of the first patient operated upon at Paris, by the ligature, for popliteal
aneurism.  It was in  1780 that this man came to receive the  advice  of
Pelletan; he was then thirty-two  years of age, and  died  consequently
at the age of eighty-four.   The trunk of the popliteal artery was trans-
formed into a fibro-cellular  cord,  quite small and  of little  resistance
throughout its whole extent; the superior articular arteries,  internal
and  external, the anastomotic and a branch of the superficial muscular
supplied  by the femoral, had acquired the size of huge crow's quills, and
formed large tortuous arcades upon the sides of the patella and the con-
dyles, becoming continuous  with the  recurrent of the anterior tibial, the
inferior articular arteries, &c.; the limb moreover was exceedingly well
nourished and did not differ in other respects from that of the opposite
side.

                  Article VI.—Femoral Artery.

                           § I—Anatomy.

   Reaching from the crural arch  to the lower  third of the  thigh  the
femoral artery follows the direction of a line slightly spiroidal (spiroide^ 
ARTERIES OF THE ABDOMINAL LIMB.
773
which from the middle of Poupart's ligament, would  descend obliquely
inwards, and following also the track of the popliteal, terminate between
the two condyles.   The vein attached to its inner and posterior surface,
is united to it by dense cellular tissue, which forms a species  of common
sheath for both.  [Mr. Porter  asserts, that, in cases  of popliteal  aneu-
rism, the femoral vein is always more closely adherent to the artery than
in the healthly subject.   G.  C B.]   The principal branch of the crural
nerve, lying first on its outer side, gradually gets upon its anterior sur-
face and sometimes even to its inner border"in proportion as it descends,
but far below leaves it altogether in  order to pass between the muscles
which form the border of the ham.  Another nerve of not less  size,
sometimes  crosses its upper portion, and continues before it and the vein
down to near the middle of the thigh.
   A.—Relations.   A fibrous  sheath, formed out of substance  of the
deep layer of the fascia lata, envelopes the whole of it,  and presents
an arrangement which it is important to notice.  The anterior wall of
this sheath gradually increases in thickness in proportion as it descends,
so that in the groin we can easily tear it with  the sound, while below it
often opposes a great degree of resistance ; below it is continuous  with
the fibrous expansion, or more  properly with the terminating  aponeuro-
sis of the second and third adductor muscles.   The artery is afterwards
covered by the  sartorius  muscle which  crosses it very obliquely from
without  inward, and which does not  in reality  conceal but  its two lower
thirds, leaving it free above to  the extent of some inches.   In the last
mentioned portion,  it is covered by the deep lymphatic ganglions and by
pelotons of filamentous cellular tissue.   It is only when it approaches the
gracilis muscle, to form the apex of  the inguinal  triangle, that its inner
border begins to separate itself from the superficial layer  of the apon-
eurosis  of  the thigh, which lies in almost naked contact  with it in the
fold of the groin.   In proceeding toward the skin, after leaving the sar-
torius, we find the first layer of the facia lata, then  the sub-cutaneous
fascia  enclosing the  branches  of the  saphena, which latter is almost
always situated within the line  of the course of the artery.
  Among the branches of the femoral, there are several which the  sur-
geon should not forget; these are :—1, the profunda, which is given off
from it at about two inches from Poupart's ligament, in order to pene-
trate down to the level of the little  trochanter, under the  aponeurosis,
and to furnish as it  divides the  three perforating ; 2, the circumflex ar-
teries, which ordinarily rise a little higher up or some lines  below, and
more frequently still from the profunda itself; 3, the superficial muscular,
which gives off the  external circumflex and which descends down to the
knee to anastomose  with the branches of the popliteal; 4, the great an-
astomotic, which has its origin near the commencement of  the popliteal,
and proceeds to the inner side of the knee while continuing by the  side
of the upper surface of the third adductor muscle.
  B.—Anomalies.  The secondary branches of the femoral are  subject
to numerous anomalies ; but they are very seldom found on the trunk it-
self.   Morgagni, who thinks  it is often  double, had imagined it so, but
had never seen it; the same may be said of Haller ; nevertheless, Gooch
gives three instances of it;  M.  Casamayor points out a fourth, and I
have met with a fifth.  In that  of my own the supernumerary artery was 
774
NEW ELEMENTS  OF OPERATIVE SURGERY.
evidently only a continuation of the  profunda, which, after having fur-
nished the perforating, retained sufficient  size to descend to below the
knee.  In a subject affected with aneurism in the ham, M. Bell found the
femoral divided into two trunks of equal volume, which did  not  unite
until they formed the popliteal.  M. J. Houston, Conservator of the An-
atomical  Museum at Dublin, cites a similar fact.   MM. Bronson and
Cromwell pointed out to me, in 1825, in the rooms  of the  School of
Practice,  a different variety.   In place of remaining contiguous to the
artery, the crural vein had, on the contrary, separated itself from it at its
origin, so as not to rejoin it, until at its entrance into the popliteal space,
after having formed a long arch, whose convexity  was  turned towards
the internal border of the thigh.  I have since met, in one instance, with
the same arrangement, which moreover it is only necessary to point out
that each  one may estimate the value that is to be attached to it in  oper-
ative surgery.   In a subject of which M. Manec has shown me the speci-
men, the femoral artery, which was wanting in front, was replaced behind
by the descending branch of the ischiatic.  In a dead body dissected by
M.  Caillard, it lost itself at the lower part  of the thigh, without giving
off  the popliteal.   (These No. 307, Paris.)

    § II.— The Different Kinds of Aneurism, and the Indications.

  If traumatic aneurism is quite rare in the popliteal space, it is not the
same in the thigh, where the  artery badly  protected in front is obliged
to follow the movements of the hip joint.   M. Champion writes me, that
though engaged in a very extensive practice of more than  thirty years,
in a circuit of twenty-five  leagues, he and M.  Moreau, of Bar-le-duc,
have never met with  a spontaneous aneurism in the thigh.  I have,  how-
ever, myself already seen seven examples of it.
  [Mr. Syme has  reported (Monthly Journal Oct. 1844, p. 823, et  seq.)
a case of  popliteal aneurism in a child, aged 7 years, in whom the tumor
extended from the lower part of the popliteal space under the bellies of
the gastrocnemii muscles so as to distend the calf of the leg.   The whole
tumor nearly disappeared under temporary compression of the tumor it-
self or of the femoral artery.   It rapidly increased between the age of
7 and 9 years, at  which latter period  Mr. Syme tied the femoral, and in
a month dismissed his patient with a solid tumor of coagulum in its  place
of much smaller size.  Aneurisms are not  common in early life.   Sir
A. Cooper never met with an aneurism earlier than at the age of eleven,
and that  was  of the anterior  tibial in a boy.  (Lectures  on Surgery,
vol. II.,  p. 41.)   Dr. Peach,  however informed Mr. Syme,  (Monthly
Journ. ib., p.  824.) that he had  witnessed  the  amputation of a child's
thigh for popliteal aneurism of a very large size.   Dr. Croft  also  men-
tioned to  the professor of Edinburgh (Ibid.) that  he  had seen in the
museum of an English provincial hospital the preparation  of a carotid
aneurism, for which the artery had been tied without success, in a  child
of seven or eight  years of age.  T.]
  We often meet, in  this part, with diffused, and also with false circum-
scribed aneurism ; nor is it any more protected  from varicose  aneurysm
as is proved by a case of M. Larrey.   MM. Fleischer, {Bulletin de Firus-
sac, t. VI.,p. 343,) Guersent, the son, Perry, (Rev. Mid., 1836, t. II p 
ARTERIES OF THE ABDOMINAL LIMB.
775
421,) Venturoli,  (Gaz. Med. de Paris, 1736, p. 200,) and before them
Bourguet, (Sur un Anew., &c. an IV., in 8vo,) have also published ex-
amples  of  it: and  I have myself seen  two cases, (Diet, de Med., 2d
edit., art. Femorale.)
  Inferiorly, the sartorius tends in general to make the tumor glide for-
ward ;  superiorly it would  push  it  rather inwards ;  which, with the
slight degree of density  of  the  aponeurosis near Poupart's ligament,
sufficiently  explains ^ a remark made by  a number of practitioners, to
wit, that in the groin the opening of the vessel corresponds almost al-
ways to the lower third of the aneurismal  sac.  Surrounded with parts
having but little  solidity, aneurisms of the femoral  artery may rapidly
acquire  a  very  great degree of development;  nevertheless, as  they
neither  involve  nerves  of large  size,  nor any important  articulation,
they are, all other things  being  equal, accompanied with accidents less
numerous than those of the popliteal artery.
   [Among the various circumstances which may, by  some, be  regarded
as rendering an operation for aneurism unjustifiable, there is one which
we believe Mr. Fergusson, in his  excellent work on Practical Surgery,
was the first to notice.   He  remarks,  that Mr. Watson, his former col-
league  in  the Royal Infirmary  of Edinburgh,  had a  case of popliteal
aneurism in  a female six months  gone  with child ; an operation was
determined  on,  though   not performed.   The  opinion  of Professor
Hamilton was requested  as to the propriety of operating on a patient
in this condition, and he  advised  against it.   In due  time, the  female
was delivered.  In  the interval the  disease had greatly  increased in
size, and in childbed the  limb became additionally  swollen, the  limits
of  the  tumor less  distinct, and ten days  afterwards  the  patient died
from puerperal fever, during which the  aneurism had suppurated and
burst into  the knee-joint.   Notwithstanding  the  high obstetrical au-
thority  which was  opposed  to  the operation  in  this instance, Mr. F.
observes, that were a similar  case  to  occur to him, he should feel
inclined to resort to  it at once.  Would  not  pressure under such cir-
cumstances, be the most prudent treatment to adopt ?  G. C. B.]
   A.—Spontaneous  Cure.   Notwithstanding  the size  of the artery
which has given  origin to them, aneurisms of  the thigh, left  to  them-
selves, are  not always fatal. In a case, cited by  M. A. Severin, the
inguinal tumor was attacked  with gangrene;  after the fall of the escars
the wound  cicatrized little by little ; there was no hemorrhage, and the
limb returned to its  natural state.  Lancisi  has seen  an aneurism of
the same kind, though very  large, diminish by degrees, and ultimately
disappear under the treatment of simple fomentations, warm baths, and
diluents.   Guattani, at Rome, in 1765, saw in a cook  the same  thing
occur, as in  the  case of M. A. Severin.  In  1784, Clarke noticed a
similar  case.  Ford  has seen an aneurism in  the thigh get well without
any other assistance that diet and rest.  In  1808, M.  Spalding, after
having opened and cleaned an enormous crural aneurism, was astonished
to find the  artery obliterated above and  below its laceration, and  that
not a drop of blood  flowed from it.  M.  Hodgson  has met, in the dead
body, in the lower  third  of  the thigh, with an aneurismal sac, whose
coagulum,  of remarkably solid  texture,  completely  obliterated the
artery,  to the origin of the profunda in  one  direction, and down to the 
 776           NEW ELEMENTS OF  OPERATIVE SURGERY.

 commencement of the leg in the other.   M. Marjolin makes mention of
 an  aneurism in the middle of the femoral, in a man  aged sixty years,
 and which became transformed into an abscess, and ultimately  got  well
 after  a long suppuration.   M. Guthrie (Oper.  Cit., p. 97) mentions a
 similar case, noticed in the  hospital at York.  The  varicose aneurism,
 noticed by Bourguet, also recovered without an operation.  The autopsy
 of the dead body, at a later period, allowed of an opportunity of verify-
 ing the state of the parts.
  B.—The Refrigerating Method.  Antiphlogistics, regimen and com-
 pression have also procured  some fortunate results in the thigh.   Hodg-
 son gives many cases of this kind.  At Bordeaux, M.  Treyran succeeded
 in curing a femoral aneurism by bleedings, cold applications,  &c, in a
 patient who had another in the opposite  leg.  M. Larrey  speaks of a
 sergeant of the guard, who,  in April, 1817, received  a sabre wound in
 the upper part of  the right thigh.  A false circumscribed  aneurism
 was the result, but the  treatment  of Valsalva, aided by cold topical
 applications, soon  succeeded  in curing  the  disease.   The successful
 case cited by M.  Andreini,  also has reference to an  aneurism in the
 thigh.   According to M.  Ribes, Sabatier succeeded in the same manner
 in a patient who had two aneurisms in the  same limb, one in the thigh,
 the other in  the ham.  A patient of M. Lyford (Bulletin de Ferussac, t.
 XVIL, p. 394) was also cured without an operation.  The aneurism,
 in the case of M. Faulcon ( Gaz. Mid. de  Paris, 1837, p. 313) did  not
 shrink until  after all compression had been suspended.
  C.— Compression.  The observations of Arnaud, Mayer, Kinglake,
Albert, (London Midical Gazette, t. IX., p. 28,) Dubois, (Bullet, de
 la Fac, 6e annee, p. 40,) Dupuytren, and M. Pigeaux, prove that com-
 pression alone is capable of  producing  the same results ; it is for this
purpose that  Guattani and Theden have so warmly urged their mode of
bandaging.   If such means  enabled us, as was thought up to  the end
 of the last century,  to cure  aneurism, without obliterating  the artery,
we  ought assuredly  always to make trial of them before coming to the
ligature ;  but  the  contrary having  been demonstrated, it is always
found infinitely more simple to recur immediately  to  the  last.  It is,
nevertheless, true,  that   Professor  Chiari  (Velpeau, Med.  Oper. trad.
 de  M. Renzi, p. 118)  asserts,  that he  has,  within  a  few  years past,
 eight  or ten  times obliterated large arteries, the carotid and  femoral
 especially, by means of a compressor of his invention.  E. Ford (Mem.
 Cit. p. 115)  says, that after having intermitted, in a patient who could
 not bear it, the compression attempted  in the  fold of the groin for an
 aneurism of the femoral artery, he afterwards saw that the tumor ceased
 to pulsate, and that the cure took place.
  [The treatment of popliteal aneurism by compression has now become
 an established mode of practice, as may easily be proved by  a  glance
 at any of  the American or Foreign medical journals.   We have, after a
 very cursory glance at  these, collected some 80  cases  of  cure.  But
 this subject has been more fully discussed in another  place.   G. C. B.]

                      § III.— The  Operation.
The ligature upon the femoral artery is at the  present  time 
ARTERIES OF THE ABDOMINAL LIMB.
777
ration  very frequently  performed.   It is this  which is  preferred for
most of the lesions of the popliteal artery, and  even for  aneurisms of
the leg, as we have seen above.   Nevertheless, many centuries elapsed
before  this operation was hazarded.   Severin  and Trullus had made
trial of it successfully for an aneurism situated at eight fingers' breadth
below the groin;  Buttentuit (Saviard, Observat. Chirurg., p. 277, Obs.
63,) did  the  same, and with a similar fortunate result,  at the Hotel
Dieu, of Paris, in 1688;  Guattani had substituted for it, with the  like
complete  success, indirect  compression made  upon the  trunk  of the
artery, under Poupart's ligament; but  nothing, then, inspired surgeons
with confidence.   It was not until after having reflected  upon  the nu-
merous anastomosing branches pointed out by Winslow and  Haller, that
Heister ventured  to  propose the ligature  of  the  artery  for  certain
cases of aneurism in the thigh.  A short time after, Hamilton, Burchell,
Leber, and Jussy, made it apparent, that after this ligature the circulation
is re-established  with facility in the lower part of the limb, and that it
was an error to entertain any fears of such an operation.  As the trials,
according to Pott, Wilmer, and Kirkland, that were made of it in Eng-
land, from 1760 to 1780, were much less encouraging than they had been
in Italy for twenty years preceding, it required nothing short of the suc-
cessful results of Desault, Hunter, and Pelletan, to give to it ultimately
its proper rank, and to cause it to be generally adopted.  Laugier, (Ann.
de Marseille, t.  I., p.  135,) who had the  boldness to place the ligature
at  two inches below Poupart's ligament, also  obtained a fortunate result.
A recent wound obliged M. Fardeau (Communication de M. Barthelemy,)
to  operate in the same  place, or above the great muscular, and  this pa-
tient also recovered.   Applying  it, in two  cases, on the wound itself,
near the middle of the thigh, M. Champion (Communique  par 1'Auteur)
was equally successful.  M. PI.  Portal (11 Severino, 1834, vol. III., p.
101) was not less fortunate in applying it immediately after the wound
occurred, in the case of a priest aged seventy years.  It is,  therefore, as
at present, a question definitively adjudged.  We may, in fact, for wounds,
for aneurisms, tie this artery, at ali the different points of the thigh, but
not everywhere, however, with the same chances of success.   So long as
the profunda of the femoral is avoided, the danger is not extreme, though
greater than  when the ligature is  applied  upon the popliteal  artery.
When, on the contrary, we have been forced to sacrifice  the great  mus-
cular, it is evident that the blood cannot any longer arrive at the limb,
but by the secondary branches, which are distributed to the pelvis.
   A. Of the three essential methods,  that of Anel is almost  the only one
now in use for the  thigh.  That  of Keisler so frequently  practised by
Desault, Pelletan, Deschamps, and M. Roux, and which has so long pre-
vailed  in France, is no longer  recommended  by Boyer  himself, in the
second edition of his work, except in a small number of cases.   Never-
theless some  persons  have  continued to accord to it the preference in
varicose aneurism and diffused traumatic aneurism, and especially where
the tumor is too  nearly approximated to the  fold of the groin to allow of
our placing a ligature  between it and the profunda without  wounding it.
In 1826,1 saw M. Roux  operate by this  method for an aneurism in the
upper third of the thigh, and the result was perfectly satisfactory.  It
 is true, as Bover says,  if  the tumor extends  up  to the fold of the groin,
    Vol. I.  "                98 
778            NEW ELEMENTS OF OPERATIVE  SURGERY.
we may by opening into it, easily preserve the deep muscular;  which
would be impossible by the new method.   It remains to be  seen if this
advantage is sufficiently important to compensate for the inconveniences
to which we  are exposed.  The ligatures upon the  iliac have  proved
that  in  such cases, the artery in question is not indispensable  to the
maintenance of life in  the  limb.  But what regrets  we should have if
after having voided the aneurismal sac, we should find that  the femoral
artery was perforated   higher up than we supposed, or that the walls of
its upper end were too  diseased to sustain the pressure  of  the ligature  !
Would it not be better  in such cases to follow the method of  Brasdor?
  B. Consequently we  cannot see that there can hardly ever be any ab-
solute necessity  of opening the sac  to tie the  crural  artery, except in
aneurisms produced by external causes,  or in those that are  diffused, or
of very  large size, or situated very high up.
  In employing the method of Anel in  the treatment of aneurisms in
the lower  limb, Desault applied his ligature at the apex of the popliteal
space, and  not upon  the femoral, properly so called.  M. Martin saya
that Spezanni had performed it  on  the thigh four  years before, with
the intention of disarticulating the limb when  the gangrene should be
arrested, and that the patient's limb was saved.
  As I have already said, it  is asserted  on the other hand that for a
long time  before  it was spoken of in England, Brasdor had  publicly re-
commended  it in  his  lectures at the schools of surgery, while Tissot
(Trad, de Bilguer, Sur I'Amputat., p. 115)  had  proposed  in the year
1778  to tie the femoral artery very  high  up.  It cannot nevertheless
be denied  that it is to  Hunter the  merit  belongs of having ultimately
awakened the attention of European surgeons to this  fortunate improve-
ment.  He made  his incision  a little below the middle of the thigh upon
the inner border of the sartorius muscle, laid the artery bare to the ex-
tent of three inches, and passed four ligatures around it.
  Scarpa reccommends that we should operate at only four fingers' width
from Poupart's ligament, justifying himself upon the fact that there is
nothing more easy than to find the vessel in this place, that there is no
important collateral to avoid, and that being also as remote as possible
from the aneurism, we  have much more chance of meeting with a sound
part of  the tube  to sustain the ligature.
  The reasoning of Scarpa has not convinced every one ; most French
surgeons think, and with reason in my opinion, that it is useless to go
up to the  inguinal space, even for aneurisms of the thigh, unless we are
forced to do so by the  situation of the  disease.  They rarely go as far
from fear of approaching  the profunda, of sacrificing too many of the
collaterals, and of thus  interfering with the formation of the clot.  It
is therefore proper to make known also the manner of tying  the femoral
artery in the two principal regions of its track, that is to say, above and
below its middle  portion.
  C.  The  temporary  ligature also has  been often made  trial of in the
thigh.   M. Canella (Bulletin de Ferussac, t. XVIII.,p. 431) withdrew
his ligature on  the fifth day, but the  patient died.  M. Falcieri (Ibid.,
t. XIX., p. 277) did not leave it on even as  long as four days, yet his
patient  recovered.  It was removed  from the artery upon the third day
in the case of  M. Balestra, (Bulletin de Ferussac, t. II., p. 334 ) and 
ARTERIES OF THE ABDOMINAL LIMB.
779
the aneurism disappeared.   M. Morigi, (Valentin, Voyage en Italie, 2d
edit., p.  317,)  who removed his two ligatures on the fourth  day, also
succeeded.  In France the different kinds of artery compressors are no
longer spoken of.
  D. It is surprising, to say the least of it, that the precept to include
the vein and nerve in the ligature with the artery has been renewed in
our days, and principally upon the femoral.   M. Grillo (Gazette Mid.
de Paris, 1834, p. 539) who extols this method, says he has practised it
fifteen times, and that all his patients were cured !  It is also  upon the
femoral  artery that M.  Ghidella (Bulletin de Firussac, t. XXIV., p.
172) has applied this rule with success.  To tie it upon two places with
the interposition of a rouleau of adhesive plaster, and to cut it between
the two  ligatures, is a method  which M. Petrunti  (II filiatre  Sebezzio,
Avril, 1836, p. 244) still perfers, and of which he gives two examples,
one of which recovered and the other died.

                     § III.— Operative  Process.

   A.  Lower half.—It is in this place that it would be  prudent to seek
the vessel, when we are treating wounds or aneurisms either of the leg
or ham by the method of Anel, in the sarrte way as for those of the in-
guinal region we would use the method of Brasdor.  The limb is slightly
flexed and turned outwardly.   An incision of about three inches is then
made into the soft parts, so that half of it extends upon the middle third
and half on the lower third of the thigh.  Lower  down, at some three
or four fingers  width only above the knee, as some persons have doubtless
inadvertently advised, we should not find the artery, because it has  en-
tered then into the hollow of the ham ; higher  up we should come  into
the process of  Scarpa.
   I. In the operations of Hunter, this incision being obliquely from with-
out inwards, fell  upon the inner border of the sartorius, which  was turn-
ed forward in order to lay  bare  the sheath of the  vessels.   Then  we
encounter successively the skin, which is generally  quite thin, afterwards
the adipose layer and the saphena  vein, which  it is important not to
wound, and the superficial layer of the  aponeurosis or sheath of the
sartorius muscle ; and under this last quite deep down and  near the
femur, and in the groove which separates the vastus   internus  from the
adductors, we have a second fibrous layer to divide.
   II.  M. Roux on the contrary recommends that the  incision  should be
made on the outer edge of the sartorius,  which is to be pushed inwardly   •
in order to reach the  artery.  It  is also  the advice which M. Hutchison
gave in 1811, seeing, says he, that in this manner we are sure  to avoid
the great saphena vein ; we have here also the same number  of layers to
divide as in the process of Hunter.
  III.   Seeing  that by one mode as well as by the other, we are obliged
to displace the  muscle which conceals the vessels, and  to turn it aside
either  within or  outwards, M. Hodgson  thought it would  be better to
divide the middle portion  of  it, a suggestion in  fact  which had already
been  made by  Desault, who asserts besides, and  with reason, that we
may without inconvenience  make  a transverse section of this  fleshy
bundle, when it embarrasses the operation by its presence or by its con-
tractions. 
    780            NEW  ELEMENTS OF OPERATIVE SURGERY.

      IV. In the process of Hunter the  wound is not so deep; being  made
    near the inner border of the thigh, it is easy after the operation to give
    it a depending position ;  nevertheless it may be objected that a wound
    of the saphena without  being dangerous in itself may have  a tendency
    to cause gangrene, if the crural vein should  be  found included in the
    ligature or obliterated in any manner whatever, as is seen, for  example
    in a case  mentioned by M. Begin ; also, it is remarked, that if in  the
    place of coming down upon the sheath  of the sartorius we should lay  «  i
    bare the gracilis muscle, we might readily be deceived, and  that the de-
    pending position urged with so  much zeal in theory, may be neglected
    here without any  great  inconvenience.  The process of M. Hutchison
    also may lead to  some mistakes.  In  carrying the  bistoury too  much
    outwardly, it happens sometimes that we fall  upon the  triceps muscle,
    and that if the error is not immediately perceived the operation becomes
    vary laborious.  To avoid this inconvenience, it is sufficiently fortunate
    to recollect that the fibres of the sartorius, parallel to each other and to
    the axis of the muscle or to that of the limb, are without any admixture
    of fat; while  those of the vastus internus, fasciculated or intermingled
    with cellular or adipose lamellae, are all oblique from above downwards,
    from behind forwards, and from the internal border of the femur towards
    the anterior median line  of the' thigh.
      V.  The most prudent course  therefore is to conform to the advice of
    Desault or of M. Hodgson, which allows us,  as soon as the first aponeu-
    rosis  is divided, to arrive almost with equal facility  at the internal or
    external  border of the  sartorius.   As  to the section practised by De-
    sault, though it may be less  dangerous  than was thought formerly, it is
    better not to have recourse to it without there is an absolute necessity.
    In theory it is difficult to  conceive how it can ever become indispensable
    except in the ancient method.
      B.  Upper Half.—Above the middle of  the thigh  an incision of two
    to three inches  suffices  to lay bare the  trunk of the  femoral artery.
    The middle part of this incision should be found at the distance of four
    fingers' width from Poupart's ligament, unless we should be obliged to
    make it immediately under the crural arch, and to  go  down  between
    the profunda  artery  and the  epigastric.   In all cases  we carry  the
    bistoury in the  direction of the line  which represents the track  of the
    vessel, and in  consequence of the saphena vein, rather a little outward
    than too much inwardly.  After passing the  skin and the adipose  tissue,
    the aponeurosis  presents itself to  the  eye  of the  operator;  before
•   dividing it, it is well to recollect that, below, the internal  edge  of the
    sartorius ordinarily separates it from the artery, which is no longer the
    case  in  the upper part  of the inguinal  triangle.  This sheath  being
    opened, and the muscle pushed outwardly  as much as is  necessary, we
    pass a grooved sound to serve as a conductor to the bistoury, under the
    superficial layer of the arterial sheath, in order to cut it without danger
    and to the same extent as the  rest of the wound.   Finally we isolate
    the vessel, seizing it by its inner border and width the usual precautions
    so as  not to wound either the crural  vein or  the nerves in the neighbor-
    hood.
      C.  Consequences of the Operation.—After this operation, whether it
    has been performed higher up  or lower down, the vessels charged with 
ARTERIES OF THE ABDOMINAL LIMB.
781
re-establishing the course of the blood are nearly the same.  The branches
of the superficial muscular pour out this fluid into the great anastomos-
ing artery, the external articular arteries or the tibial recurrent, and
those of  the_ profunda, or the perforating arteries, into the internal ar-
ticular arteries.   It returns sometimes by the intermediate muscular ar-
teries between the ligature and the tumor, whose pulsations may thus be
kept up,  and interfere with the resolution during a variable  period of
time.  This inconvenience which had at first been deemed very serious,
no longer at the present day causes the same inquietude.  Cold and resol-
vent  applications, aided  by slight compression, in general,  causes it
promptly to disappear, when we do not think proper to leave it to itself.
The facts opposed to this statement, however, are less rare and more au-
thentic than is generally thought.
   [Mr. Paget, in his Lectures on Surgical Pathology, (Am. Ed. p. 38)
refers to a  specimen in the College Museum, which was taken from the
fourth patient on which Mr. Hunter operated.  The lower ends of the
tibia and fibula had perished in consequence of the obstruction of the cir-
culation  in the ham produced by an aneurism.   The whole foot was in a
similar  condition.  The aneurismal sac remained, even after the  lapse
of  fifty years.  It was a hard mass, resembling an olive.  G. C. B.]
   I.  Monteith has seen the pulsations  return in the tumor many months
after  the cure ;  an  aneurism operated  upon in 1821, by M. Cumming,
reappeared in 1825 to such extent as to make it necessary to amputate
the thigh.   In a  patient in whom I had tied the femoral artery at  three
inches below the profunda, a hemorrhage from the lower end took  place
after the fall of the ligature on  the  thirteenth day.   A new ligature
above did not arrest the  blood';  it was necessary to unite compression
with it below the wound.  M. Smith, (Journ. des Conn. Med. Chir., t.
II., p. 192,) who had operated in the same way, saw the hemorrhage su-
pervene  on the twelfth day.  A ligature upon the femoral above the pro-
funda did not prevent the hemorrhage from returning eight days  after.
Direct compression arrested it completely.   An aneurism which existed
in the other thigh was cured at the sane  time.   It is  then an accident
quite frequent.   Bromfield cites  an instance of it from J. Hunter, and
M. Guthrie also enumerates several.
   II.  When it has not been possible to preserve the deep-seated muscu-
lar artery, it is by the branches of the epigastric that the circulation is
re-established; the gluteal, the ischiatic, the internal pudic, and obtura-
tor inosculate with the circumflex  and  perforating arteries, and these
disgorge themselves, as has been said above, into the arteries in the neigh-
borhood  of the knee.
   III. Not only has the femoral artery been tied for its own aneurisms
and for those of  the popliteal space, but also for certain diseases of the
leg.  If  those aneurismal tumors which develop themselves in the sub-
stance of the bones, tumors which Pott and Scarpa were the first to men-
tion, of which Pelletan cites many cases, and which  have been  three
times seen  at the  Hotel Dieu by Dupuytren, (Repert. d' Anat., de Phys.,
et de Path., etc.,) should again be met with under the knee, as has been
seen by M. Lallemand, (Archiv. Gin.  de Mid., t, XIII., p. 544,)  in the
canal of the tibia, for example, as has been noticed by  Rossi,  (t. II., p.
66, en note,) or in the thigh, (Lamelland, Bulletin de Firussac, t.  XV., 
782
NEW ELEMENTS OF  OPERATIVE SURGERY.
p. 73,) it would no longer be necessary in order to effect a cure in any
of those cases, as was formerly thought, to amputate the limb ;  the liga-
ture upon  the  femoral, by the method of Anel suffices ; it succeeded
completely with M. Lallemand and Pearson.
   [Dr. Carnochan has reported in the New-York Journal of Medicine,
September, 1852, a case of elephantiasis Arabum of the lower extremity,
which was successfully treated by ligature of the femoral artery.
                                                       G. C. B.]
  IV. Notwithstanding all this, the ligature upon the femoral artery is
an operation much more dangerous  than the observations of modern sur-
geons might induce us to believe.  It is true that in an enumeration of
fifty cases, I do not find but eight instances of death ; that M. Mott has
told me that he has lost but  one patient  out  of that number;  that M.
Roux also  declares that he has cured almost all his cases ;  that every-
where successes are spoken of, and  that no one mentions failures ; but I
deem it just to declare that out of seven persons, who, to my knowledge,
were submitted to the ligature upon the femoral  artery for aneurisms, in
1837 and 1838, in the hospitals  of  Paris, three are  dead ; that a patient
operated  upon  at Naples (De Renzi, Oper., t. I., p. 109,) and  another
of whom M.  Laughlan, (Gaz. Mid., 1838, p. 487,) speaks, both  suc-
cumbed ;  that gangrene made it necessary to amputate  the thigh in that
of M. S. Cooper,  (Arch. Gen.  de  Mid., 2e serie, t. I., p. 281,) that at
the Hotel Dieu, in the department  of Dupuytren, a great number died,
and that all the cases  of this kind  are not known.  Though now they
are scarcely ever any more spoken  of, yet  I find in  about sixty  cases of
this operation, twelve examples of gangrene, and thirteen of hemorrhage,
without  counting abscesses.  The  hemorrhage moreover supervened on
the 3d, 4th, 9th, and 15th days ; twice on  the 16th, 21st, 22d,-12th and
8th days, and  twice on the 40th day.  It is enough I think to  induce
practitioners not to tie the femoral  artery without the necessity  for it is
fully established.
   [The statistics of this operation collected by Dr. Norris and published
in  the American Journal of the Medical Sciences, for October, 1849,
show us that in 188 cases in  which the Hunterean operation was  per-
formed, for the cure of popliteal aneurism, 142 were cured, and  46 died,
being a proportion of a little more than 1 in 4!—The  causes of death
were, as  follows:  from mortification  of the  limb,  23 ;  hemorrhage,  8;
phlebitis, 5 ; tetanus, 3 ; hectic and diarrhoea, 2 ; thoracic inflammation
and abscess in the course of the  artery, 1; sloughing of the sac, 1;
bursting of aneurism of aorta, 1;  fever, 1; absorption  of pus, 1; in 4,
not stated.  G. C. B.]
   The gravity of this operation being well  ascertained, would it not suf-
fice, now that the process of M. Marchal is known,  to induce us in cases
of wounds  or aneurisms of the leg, to tie rather the termination of the
popliteal artery than the  femoral  itself ?  We may, moreover, do this
with much less danger for the arrest of hemorrhages which sometimes su-
pervene after amputation, (Arnal.  Journ. Hebdom., t. VII., p.  209,) or
which are complicated with fractures of the thigh.   Patients thus oper-
ated upon by  MM.  Roux, (Ibid.,  p. 209-10,)  Gerdy,  (Arch.   Gen. de
Mid.,  1834,  Beaugrand,) Jobert,  (Journ. Hebdom., t. VIII   n 210 )
and Ch. Bell,  (J. Bell, Trait, des  PL, 200,) have  recovered 'perfectly. 
ARTERIES OF THE  ABDOMINAL LIMB.
783
Nevertheless M. Roux, (Dubourg, Journ. Hebd. Universel, t. I., p. 45,)
was less fortunate in 1830, in two patients who had had the crural arte-
ry opened.

        Article VII.—Branches  of the Femoral Artery.

  Wounds of the thigh sometimes  give  rise  to  serious hemorrhages,
and even  to aneurisms, though the  trunk of the  femoral artery may
remain intact.   In a patient of Abernetby, who met with a fall, hemor-
rhage ensued from a soft cancer; a ligature at the groin proved insuffi-
cient, but  compression  with the  fingers  effected a cure, (Abernethy,
Milang. de Chir., t. II., p. 469.)
   We find the following case in Hevin, (Cours de Pathol, et de Thera-
peut., t. II., p.  48.)   A wound upon  the middle and inner part of the
thigh, from a sabre-cut, hemorrhage, application of vitriol, compression,
tourniquet, and  tumefaction to a very considerable extent in the lower
part  of the thigh  as well as in the leg, where there were  already
phlyctenae.  Foubert, Petit,  Morand, Ledran,  and Faget decide with
Hevin that amputation  should be  performed.   Though the femoral
artery in  this case remained intact, a considerable branch was  wounded
at four or five lines distant from its  origin in the trunk.   This  probably
is the same case that M. Arbey (Coup d' ceil sur I'Amput., 1815, p. 7)
says he had heard of, from a professor  of Strasbourg.  M. Champion
writes me :—I was called to apply a ligature upon the  femoral, in con-
sequence  of a hemorrhage from the middle and inner part of the thigh,
produced by a wound from an iron pitchfork.  The blood had ceased to
flow under the  compressive dressing; it  had  effused  itself throughout
the whole thigh; but as the engorgement did not increase, I resolved to
wait, and the patient recovered.
   A young man who received a wound above and outside of the patella,
died  at  La Charite  (M'edee  Operat., t. I., p. 283)  in 1838, from
repeated  hemorrhages.   The blood  came  from  an articular branch.
Another patient, who had  a similar wound above and inside the patella,
presented a short  time after similar accidents ;  but  a free dilatation,
with  compression, finally  arrested the flow of blood.  The point of a
knife, striking  perpendicularly upon the fore part of the femur above
the knee has twice  occasioned me similar trouble.  A case  has  also
been  stated (Seance Publique de VAcademie de Chirurgie, 1748) of
an aneurism of the superficial muscular artery, cured by  compression;
and M. Mauban, (Bullet, de la Soc  Mid. d' Emul,  t. VI.,  p. 238,)
making use of  the  same  means, professes  to have cured one  in  the
circumflex of the kuee.
   If one of the  circumflex arteries  or the profunda  should be divided,
or become the  seat  of an  aneurism, it would not in general be very
difficult to apply a ligature to it.  The essential point would be to verify
such a lesion.   In laying bare the trunk of the femoral at its  exit from
the crural arch, we could,  without difficulty, apply  ligature upon  the
root of the affected artery.   M. Roux and another surgeon whose case
I cannot now find, are the only ones who have had occasion to operate
in this manner  upon one  of its secondary branches, namely,  upon  the
internal or external circumflex artery of the thigh.   The danger of a 
784
NEW ELEMENTS  OF OPERATIVE SURGERY.
ligature upon the trunk of the femoral  is too great, in my estimation,
not to make it obligatory on the surgeon before coming to this operation
to search carefully  for the wounded branch, even though it were neces-
sary in order to effect this, to  make a large and  deep incision.
  As an illustration of the singular manner in which a large artery and
vein may escape being wounded, though lying in the track of a ball, M.
Guthrie, (Cormack's  Lond. and Edin. Monthly Journal, &c, Dec. 1844
p. 1243,) has a  preparation showing  where a ball  passed between the
femoral artery and vein without wounding either.   T.]
                  Article VIII.—External Iliac.

                           § I.—Anatomy.

   From the line of the sacro-iliac symphisis, where the primitive iliac
artery bifurcates, to its passage under Poupart's ligament, the external
iliac represents a slight curve, with its convexity outward and backward.
Resting against the psoas muscle outwardly, and upon the iliac vein be-
hind and within, it is covered directly by an expansion of the facia il-
iaca.   The crural nerve is separated  from it by  the tendon of the psoas,
and by a very strong aponeurosis.  A branch of the genito-crural nerve,
sometimes  runs along  its inner  and anterior  surface, which latter is
crossed by the ureter, and  in women by the ovarian vessels.  The per-
itoneum, which at the same time conceals these various parts, adheres to
it but very feebly by means of a very loose adipose layer, and even aban-
dons it altogether in front, to be  reflected upon  the posterior surface of
the abdominal walls.
   At its entrance into  the crural canal, the  external iliac artery gradu-
ally rises upwards, becomes much  more superficial, and contracts  some
new relations.  In that place it is supported by the body of the pubis, and
the origin of the pectineus muscle ; the vas deferens crosses it in descend-
ing into the pelvis ; the testicular cord, as it passes over the inguinal canal
does the same._ The epigastric vein also is  obliged to cross it, in order
to open itself  into the iliac vein, which latter keeps close to it, as in the
thigh;  the  fibrous layer, which binds it down against the psoas and iliac
muscles, has become sensibly thinner; the anterior iliac artery, and the
epigastric, the only ones which it gives off, separate  themselves from it,
the one a little outwardly, the other a little inwardly, ordinarily at the
level of the ilio-pectineal crest, sometimes higher, and sometimes lower,
by from four to six, or  eight lines.  The lymphatic ganglions which sur-
round it, as far as the crural arch, and which, in becoming swollen, might
compress it, have sometimes given occasion to  the suspicion  of diseases
which did not exist.   The coecum, on the right, and the sigmoid flexure
of the  colon on the left, are the only viscera which separate it from the
walls of the belly.   Nothing is more easy in lean subjects, and when all
the muscles are in a state of relaxation, than to make sufficient indirect
 Compression upon it to close it, as has been observed by Bogros, (These
No. 153, Pans, 1823,)  and as I have shown farther above
   Its  anomalies  hardly ever  relate to  other  circumstances than its
 length, its Size, and curvature, and to the points of origin of its nrinoi
 pal branches.  It may however, happen that it will be composed of two 
ARTERIES OF THE  ABDOMINAL  LIMB.
785
trunks, placed by the side of each other, and which pass together under
the crural arch, as M. James has seen in a patient in whom he tied the
iliac artery, by the method of Brasdor.

                         § II.—Indications.

  Tli© external iliac artery is  rarely the seat of spontaneous aneurisms.
If in fact, it should be opened by an external cause, the patient  would
necessarily die from the hemorrhage, before it would be possible to afford
him the least assistance.  M. Larrey, however says, he has seen a vari-
cose aneurism here, and I was fortunate enough, owing to the presence of
raind of MM. Layraud and Durand, to cure, by means of the ligature,  a
boy in whom it was opened by accident.  M. Carron du Villards relates,
that M.  Barbaud (Sanson, These  de Concours, p. 339) had the same
good fortune in a carpenter, who had the fold  of the groin largely torn
by a nail.  But as it is not an external artery, and has only from four to
five inches length, aneurisms, even from internal causes cannot be very
common here.  The case of the young man I have mentioned above is,
probably, unique.
   A fact having  some analogy to the case I have mentioned, of ligature
of the external iliac, from  a recent wound, presented itself in the prac-
tice of M. Mouret, (Gaz. Med.,1839, p, 298.)   A man receives, under
the groin, a cut from a knife which opens the femoral artery.   A ligature,
after the method of Scarpa, is applied between the  profunda  femoris
artery and the wound.   Imprudent  movements cause a hemorrhage on
the twenty-seventh day.  M. Mouret passes then a single ligature around
the external iliac, and effects the cure of the patient.
   The patient in whom M. PI. Portal (Ibid., p. 297) tied the external
iliac artery, in consequence of the excision of a bubo wounding the ves-
sels, died at the  end of  some days.  A ligature upon the external iliac,
by M. Petrunti, for an inguinal aneurism, was, on the  other hand, fol-
lowed by success.
   A patient in whom M. Lallemand (Archiv.  Gen. de Mid., 1838, t. iii.,
p. 370) had tied the femoral  artery, for  a varicose  aneurism,  was at-
tacked on the sixth day by a  hemorrhage, which rendered  necessary a
ligature  upon the external iliac, but did not  prevent the death of the
patient from the renewal of the hemorrhage.
   If the  dread  of gangrene,  from the  obliteration of a large  arterial
trunk, has been enabled to maintain its ground for so many centuries, in
the presence of aneurisms of the thigh, and of the popliteal region, with
much stronger reason, would even  the very suggestion have been repro-
bated, of placing a ligature upon one of the first divisions of the aorta.
Facts passed unheeded by, and science could not profit by them.  In the
case of Guattani, the compression was made above the  profunda artery,
and the circulation maintained itself in the limb.  Baillie had found the
femoral artery obliterated up to within the pelvis, in the dead body of a
man, in whom the pelvic limb was in no ways altered.   Guattani noticed
a similar fact in 1767, in a subject whom he had treated for inguinal an-
eurism, by compression.  In the dead body of a patient operated upon
by Gavina, in 1775,  the iliac artery itself  was completely impermeable.
It was the same in the case reported by Clarke, and many others, (Voy.
  Vol.  I.                     99 
786            NEW ELEMENTS OF OPERATIVE SURGERY.
 Casamaior, These Cit., 1825.)   All these proofs, the injections made by
 Guattani, and those even of Scarpa, which show with what facility liquids
 thrown into the aorta pass into the arteries of the thigh and leg, though
 the external iliac had previously been tied tight, were not sufficient, and
 would probably still have remained a long time without application, in
 spite of the proposition o.f Sue,  who, according to the statement of M.
 Paillard, (Rev. Mid., 1829, t. I., p. 18,) had already recommended the
 ligature of the  iliac artery, in  the  last century,—if necessity had not
 compelled Abernethe3r, for the first time, to appeal to  them in his behalf,
 in 1796.  An individual, who had  already undergone the operation by
 the method  of Anel, for an aneurism of the popliteal trunk, entered St.
 Bartholomew's  hospital, for an inguinal aneurism on the opposite side.
 Abernethey (Journal de Corvisart, t. XXXL, p. 403) applied  the liga-
 ture under the crural arch ; a hemorrhage,  which supervened on the fif-
 teenth day,  left him no other resource than to  penetrate into the belly,
 and to perform upon the iliac artery what he  had done at first upon the
 femoral.   The patient died, some  time after, from a secondary hemor-
 rhage.  A second operation was not more fortunate,  but a third, per-
 formed in  1806,  was followed  by complete  success.  To set out from
 this epoch, it has  been no longer possible to call in question the practi-
 cability of tying the external iliac without  causing mortification of the
 limb.  At present it is one  of the common operations in surgery.
  M. Freer, in 1806, and M. Tomlinson, in 1807, imitated Abernethey,
 and like  him succeeded.  This  last named  surgeon  obtained  another
 successful result  in  1809.   Out of seven  patients, upon whom M. A.
 Cooper had operated upon up  to  1814, four were cured;  one died at
the end of three months, of an aneurism of the  aorta ; another  of gan-
grene  of the limb;  and a third  of hemorrhage.  Delaporte was  the
first  in France, who, in 1810, ventured to follow in the steps of the
 English surgeon; his patient died on the  twelfth day, with a  putrid
fever.  Goodlad and Dorsey, (V. Mott, Biographical Memoir, 1836,)
each succeeded once in 1811.   In 1812, also, M. Bouchet (Bull, de la
Fac, t. IV., p. 173) cured a Spanish prisoner, who died a  year after,
of an aneurism upon the opposite  side.  In 1812, moreover, a patient,
treated by Albers, was carried  off on  the twentieth day, by tetanus.
An old man of seventy-five years, operated upon by Ramsden, died on
the third day.  But  in 1813, two  new fortunate issues were obtained,
one by M. Brodie, ( Trans.  Med. 1828, p. 328,) and  the  other by Nor-
man, {Rev.  Mid., 1820, t. II.)  M. Lawrence, in his turn, succeeded
in 1814 ; it was the same with M. Moulaud {Bullet, de la Facult.) t. V.,
p. 584) in 1815.   Gangrene, on the contrary, upon the fourth  day,
deprived M. Collier of a similar triumph, (Trans. Med.-Chir.,  t. VII.,
p. 136.)   M. Smith—Soden, and Dupuytren (Bullet,  de la Fac, t.  VI.,
p. 319. Lecons, t. IV., p. 524)  were less unfortunate, and each cured
a patient in 1815.  M. Cole, (Jour. Gin. de  Med. etde Chir.,  1818, t.
L, p.  96,) in 1817, M. Albert, in 1818, MM. Wilmofc, Kirby, Anderson,
(burg. Anat. p. 148,) Newbygin, and Post, (Mott, Biograph. Med. p.
18,)  each successively obtained a  similar  success.   The patient of M.
at wn- {Bull,h ?e Fkrussac, *• I-, P. »7) died on the sixteenth  day.
^VT^V^'' \' XJUL'> p'  83*   *°urnal des  P"ogris,  t. X.,p.
247,)  M.  Richerand, (Pegat,  These No.  66, Paris, 1837,)  Vacca, 
ARTERIES OF THE  ABDOMINAL LIMB.
787
(Bulletin de Ferussac, t. I., p.  87,) M. Killian, (Ibid. t. I., p. 450, M.
White, (Guthrie, Opera Citat., p. 16,)  M. Dacrux, (Jour. Hebdom., t.
III.,  p.  451,) M.  Clot, (Trans.  Med.-Chir.,  t. XIII., p. 218,) and
many others may now be added to all these names.  Delpech (Chirurg.
Clin., t. I.) had not the same fortune ;  his patient died at the expiration
of a few days.   M. Tait tied, successively, on  the 8th of May, 1825,
and on the 16th of  April, 1826, both iliac arteries in the same patient,
with entire success, though on one side the peritoneum had been pene-
trated.   M. Arendt,  {Bulletin de Ferussac, t.  VIIL, p. 80,) who did
not leave but eight  days of interval between  two similar operations on
the same individual, was not less  fortunate.
   I, myself, performed the  operation on the 6th of October, 1831; the
ligatures  came  away  on the eleventh and thirty-fifth days, and the
patient was completely cured.   This case is even more remarkable than
any other, in  more respects  than  one.  The  patient, aged seventeen,
tall and strong, while cleaning a  table, in a  dark part of the room, by
accident, ran a carving-knife  into his  groin, and  cut through the ex-
ternal iliac, at three lines above  the epigastric ; the  blood came out in
torrents.   MM. Layraud and  Durand,  (Jour.  Hebd.  Univ., t. VI., p.
346.  Transact. Med., t. IX., p.  17,) who arrived almost immediately,
compressed the artery at two  inches  above the w^pd, and  thus sus-
pended the hemorrhage while they sent to  seek for  me.  Assisted by
these two confreres, as well as by M. Duvivier, I hastened  to  lay bare
the vessel, and to tie it, while they compressed the aorta.  No disturb-
ing symptom made  its appearance in the limb.   The emission of urine,
which was difficult  on the second day, resumed its function without any
inconvenience ;  symptoms of inflammation  about the  side  caused some
apprehensions  during a week ;  the first ligature, placed by means of a
curved needle, very  high up, in  order to allow of an  opportunity of
examining, with ease, the  seat of the wound, did  not become detached
till  the  thirty-fifth day; but the wound finally cicatrized,  (s'est  nion-
difiee,) and the young man is now well.  I have seen him  many times
since, and  know that he is in the enjoyment  of excellent  health.  A
result like this demonstrates how highly important it is to know how to
make compression upon the iliacs and  the aorta, through the  walls'of
the belly, and proves, 1, That we may, without the necessity  of previ-
ous dilatation of the  collaterals, effected either by compression, as has
been proposed, or  by the presence of  an  aneurism, successfully tie the
ilio-crural trunk ;  2,  That the entire and  sudden division of this trunk
is not necessarily fatal.
   In adding  to  these  cases  those which belong to MM.  J. Smith,
(Milang.  de  Chir. Etrang.,) Guthrie, (Injuries of Arteries, 1830,)
Sainclair, (The Lancet, Aug.  6,1833—Gaz.  Med. de Paris, 1833, p.
634—Med.* Chir. Rev. 1833, p. 57,) B. Cooper, (Trans.  Mid., Janv.
1832—Arch. Gener.,  t. XXX.,  p. 116,)  V.  Mott, (Gaz.  Mid. de
Paris, 1837,  p. 650,) Gibbs, (London Medical Jour., 1827, p.  97,)
Liston, (Edinb. Medical Sf Surg. Jour., vol., XVI.,  p.  72,)  Bujalski,
(Bulletin de Ferussac, et Legal,  des  Princep. Art.,)  Salomon, (Bull.
de  Ferussac,  t. XVI.,  p. 449,)  Lisfranc,  (Archiv.  Gin.  de  Med. 2e
srrie t. IL,  p.  514,) Nichet, (Gaz. Med. de  Paris, 1833,  p. 650,)
Morgan, (The Lancet, 1828, vol.  I., p. 412,) Balingall,  (Ibid., p. 618,) 
788            NEW ELEMENTS OF OPERATIVE SURGERY.

Renzi, ( Velpeau, trad. Ital., p. 147,) Mirault, (Acad.  Roy. de Mid.,
136,)Beclard, (Clin.  Surg., 1822,) Baroni, (Gaz.  Med.  de  Paris,
1836, p.  200,) Ruan,  (Ibid., p. 742,) Warren, (Communication Pri-
vee, 1837,) Macfarlan,  (Gaz. Bled de Paris, 1837, p.  285,)  Anderson,
(Surs-ical Anatomy, p. 145,) Hobbart, (Edinb. Med. Se Surg. Jour.,
vol. CXXXVL, p. 84,) and  some others, which I have  had it  in my
power to examine, we find already near a hundred ; but out of seventy-
one, whose results I have  ascertained, I perceive  there  were eighteen
deaths, and  that  fifty-three were  cured ; that is, one  in four.   Such a
calculation, I know, is too incomplete to justify rigorous conclusions ;
but it shows, at least, that the ligature upon the  external iliac  artery,
without being generally fatal, is a very dangerous operation.
   [The external  iliac has now been tied in at least  152 cases, in 50 of
which the operation is  reported to have been followed  by a fatal result.
                                                        G. C. B.]
  III.  Treatment.—Notwithstanding the two  examples  of cure by re-
frigerants, moxas and  depleting remedies, made  known by M. Larrey,
and that which M. Reynaud, (Gaz. Mid de Paris, 1837, p. 565,) has
since  given, the ligature at present should be preferred, in patients who
are willing to submit to it, for all cases of inguinal  and iliac  aneurisms
which  admit of ilf application ; only we should not forget that, in car-
rying it beyond three inches into the pelvis, the neighborhood of the hy-
pogastric artery may render it extremely  formidable.
  A.  The Method of Brasdor.—Also, unless we should go to the primi-
tive iliac, when the tumor  occupies the illliac fossa and  there is not suffi-
cient space in the groin to tie the femoral artery above the profunda, it
would be allowable to try again the method of Brasdor.  The patient
of M. A. Cooper  did not  die till two months after the  operation: the
pulsations in the tumor, which  was  enormous, had  ceased, and it was
not ascertained precisely what had caused his death.  That of M. James,
who was not more fortunate,  had the iliac artery divided into two near-
ly equal  trunks.  Nevertheless, the unsuccessful  attempt of M.  White,
though the femoral artery was obliterated below the sac—the continuance
of the pulsations still  perceptible at  the bottom of the  wound  in the
young man whose history I have just related—and the facts  related by
by M. Guthrie, (Oper.  Citat., 1837, p. 90,)—do not allow of our  plac-
ing any very  great degree  of  confidence in this method.
   [We have already alluded to a case in which Sir Everard Home re-
sorted to Brasdor's method, without success, for an aneurism seated in
the external iliac, and in which he afterwards attempted  to produce
consolidation by the application of heat.   G. C. B.]
   To undertake it with any chance of success, it would require that we
should be enabled to place the ligature  between the tumor and the ori-
gin of the epigastric and circumflex arteries of the ilium, or that those
branches pushed up by the aneurism should have become  filled with clots
and rendered impermeable, by the pathological process pointed out in
the memoir of M. H. Berard, (Arch.  Gen. de Med., t.  XXIIL, p. 363.)
   B.  Method of Anel.—Quite a number  of modes have been devised to
reach the external iliac artery.
   I.  Process of Abernethey.—On the first occasion, Abernethey  made
an incision of about three inches, in the  direction of the vessel above 
ARTERIES OF THE ABDOMINAL LIMB.
789
Poupart's ligament.  It is this process which M. Begin (Diet, de Med.
et de  Chir. Prat. art.  Aneurisme,) advises anew.   In his  second pa-
tient, Abernethey, fearful of wounding the epigastric artery, made his
incision a little farther to the outside of the inguinal ring, and gave it a
direction  slightly oblique from  below upwards, in order more easily to
avoid the peritoneum.
  II.  Process of A. Cooper.—M. A. Cooper made a semi-lunar incision
in the direction of the  fibres of the aponeurosis of the external oblique ;
that is to say, with its  convexity downwards, and which took its origin
at some distance from the anterior superior spinous process of the ilium,
and terminated near the inguinal ring: on  raising  the semilunar flap
thus formed, we perceive the spermatic cord, the opening of the fascia
transversatis, and the epigastric artery ; and in passing the finger under
the cord through this last mentioned opening, says the author, we readi-
ly come to the iliac vessels.
  III. Process of Norman.—M. Norman  decided upon making his in-
cision in the direction of Poupart's ligament, following in other respects
the rules laid down by M. A. Cooper.   M. Roux recommends that the
incision should commence a little above, and at half an inch only distant
from the spine of the ilium, to terminate afterwards upon the middle of
the crural arch.
   IV. Process of Bogros.—Bogros thought that he could advantageous-
ly modify the process of Sir A. Cooper, or that of Norman, by advising
to make the middle of the incision fall upon the point of Poupart's liga-
ment, which corresponds to the artery, and then  to cut  down to the
opening of the fascia transversalis, in order to find with certainty the
epigastric artery, which should serve as a guide to lay bare the trunk  :
we wish to tie.   M. Mirault, (Mem. de  I'Acad. Roy. de Mid., t. VII.,)
who was the first that made a successful application of this process upon
man, considers it secure, and at the same time very easy.
   V. Process Adopted by the Author.—This is the  one which  has ap-
peared  to me to be the most  simple and  the  most  advantageous, and
which I followed in the young man whom I have spoken of above.
   a. First Stage.   The  patient is laid upon his back, with the limb
moderately extended.   While  some of the assistants hold him in this
position, others  stand  ready to serve the  surgeon, who, placed on the
side of the aneurism,  makes an incision, slightly curved, three inches
long, parallel with and a little  above Poupart's ligament, the  middle
part of the incision passing on a level  with the artery.  The  first cut
of  the bistoury goes through the skin, and the sub-cutaneous fascia;  if
the branches of  the cutaneous artery bleed so much as to incommode us,
we apply the ligature or torsion to it,  before proceeding farther.   The
aponeurosis of the  external  oblique comes next; for greater security,
though  not indispensable, it is advisable to pass a grooved sound under
it, before dividing  it.   The  fibres of  the internal oblique muscle, next
present themselves in  their turn;  those who have a practised hand may  i
divide them, without fear, with  the cutting'instrument; otherwise we
separate their  lower portion with the point of  one sound, pushing them
backward and upward, with some  degree  of force, while the left fore-
finger fixes and retains  the lower  border of the wound we tear, in the 
 790            NEW  ELEMENTS OF  OPERATIVE SURGERY.

 same manner, the fascia transversalis, up to the spermatic cord, which
 is pushed aside in the same direction as the fleshy fibres.
   b. Second Stage.   At this  stage, in order to avoid  the  peritoneum,
 especially where it is our intention  to place the ligature, at  a point very
 high up in the iliac fossa, we make use of the finger instead of the sound ;
 in other  cases this latter has  the advantage  of isolating the tissues bet-
 ter, and of detaching them less extensively.   After that, if  the eye does
 not distinguish the objects, the fore-finger inserted into the wound, whose
 lips are kept apart, easily recognizes the artery  upon the inner border
 of the psoas, and the side of the upper strait.  In grasping it, to raise
 it with two  fingers, as Scarpa recommends, and as many practitioners
 have done, we make useless, and sometimes dangerous lacerations; it is
 infinitely better  to rupture with the sound the sheath  that it receives
 from the fascia iliaca, then to direct the point of this instrument upon
 its inner side, and detach it from the vein, by cautious movements for-
 ward and backward.   After this separation, which it is important should
 be made, to  as little  extent as possible, but which should comprise the
 whole  circumference  of the artery, which latter should be  detached,
 with a great  deal of caution, from  the  iliac  vein, and from the  nervous
 branch which creeps upon their surface, we proceed to pass the ligature,
 either by means of the eyed probe, guided upon the grooved sound, or by
 the needle of Deschamps, or any other convenient instrument.
  c. Third Stage.—In  general, this ligature should be  carried rather
 a little higher up than  lower down; the rule, at least, is to  apply it
 above  the epigastric  artery, and it is said that Beclard lost one of his
patients from having  unintentionally  placed it  below.  It is owing, in
fact, to this  inconvenience, and to prevent it with greater security, that
Bogros recommends that we should seek for the epigastric before occu-
pying ourselves with the iliac.   But in proceeding as I have pointed out,
when we have laid bare  this  latter, it is always easy to find the other,
and to leave it below the ligature.  To prevent  either the hemorrhage,
or the  return of blood, or the continuance of pulsations in the tumor,
which  may  be occasioned by the supra-pubic artery, some persons have
thought that, whether  wounded  or not, we should place the  ligature
upon this at  the  same time with that of the iliac.  Though this advice
may in reality be followed without inconvenience, practical  experience,
up to the present time, has shown also that it need not be attended to.
  During the progress of the operation, and especially at the conclusion
of it, it is of the highest importance that the abdominal muscles should
be kept  in  a state  of relaxation,  and that  the patient should make no
effort nor  attempt any  movement.  Otherwise, the intestines would not
fail to  present  themselves at the wound, and the wounding of the peri-
toneum would be almost inevitable ; and although this lesiou, as has been
 shown  by  the two cases of Post, and  M. Tait, is  not as formidable as is
 generally supposed, we should, nevertheless,  do all  in our power to pre-
 vent it.
  VI.  Appreciation.—The incision vertical  or  parallel to the artery,
 and the oblique incisions of Abernethey and M. Roux, present only one
 advantage, which is that of alleging us to penetrate with less  difficulty
 as high as we wish ;  an advantage  counterbalanced by the  greater risk
 we run of wounding  the  peritoneum.   The lower or inner ano-le of the 
ARTERIES OF THE ABDOMINAL LIMB.
791
wound is the only point  which can be dilated to arrive at the vessel; it
is, therefore, an unnecessary  mutilation to make an extensive division
of the walls of the belly.
  In  the process  of M. A. Cooper, modified by Norman and Bogros,
or in  that which I have given, as the incision crosses the vessel  almost
at a right  angle, it is almost  impossible to miss  it.  It is true  an ob-
jection is raised  that it  does not allow us to go sufficiently into the pel-
vis, and that it exposes, more  than any other, to the risk of wounding
the epigastric artery.  But, on the one hand, we  may by means  of this
incision, go even to the  depth of three inches ; and if the aneurism is
higher up still, it is to the primitive iliac that we must address ourselves,
and no longer to the external iliac ; while, on the other hand, the  tissues
being divided layer by layer, and torn rather than cut, as soon as we ar-
rive at the deep aponeurosis, I do not clearly see how we are to wound
the epigastric which  is  behind.  However, experience has  shown that
we may succeed by all these modes ;  and the mode to be adopted is, as
I  am aware, much more  a matter  of  choice  than one of necessity.
Though the transverse  incision, however, is always sufficient when the
tumor does not  extend  beyond the crural  ligament, it may not, never-
theless answer  our purpose  when the disease  goes higher still; it is
then  for the skilful surgeon to  make application of the process suitable
to each particular case.
   VII.  Consequences.—The blood is carried into  the limb after the lig-
ature upon the iliac artery, as after the ligature upon the femoral above
the profunda, by  means of the gluteal, ischiatic, internal pudic and ob-
turator arteries ;  and, moreover, by means of the epigastric and circum-
flex ilii, through their anastomoses  with the internal mammary, with the
ilio-lumbar artery, and  with the lumbar arteries; the proximity of the
urinary and  genital  passages, and of the peritoneum and loose cellular
tissue  of the iliac or lumbar  region, demand all  the attention  of the
practitioner, and the most prompt relief as soon as accidents show them-
selves in this region ;  accidents, however,  which have  nothing  special
 about them, and which are treated by the means generally known.

   Article IX.—The Internal  Iliac (or Hypogastric or Pelvic)
                              Artery.

                           § I.—Anatomy.

   In separating itself from the primitive iliac on a level with the sacro-
iliac symphisis, the internal iliac artery immediately abandons the exter-
 nal iliac in order  to descend almost  perpendicularly  into the cavity of
 the pelvis.  Its outer  surface is  crossed at its origin by the iliac vein,
 and accompanied in the rest of its course by the hypogastric vein which
 separates it from the psoas muscle  and from the articulation. ^ On its in-
 ner side it is united  to  the peritoneum only by a cellulo-adipose  layer
 which is always very loose ; some  lymphatic ganglions are also adjacent
 to it  in this part.  The ureter ordinarily passes above and a little in front
 of it;  on the left the beginning of the rectum lies over it at a greater
 distance, and its relations with the ccecum  on the right are scarcely de-
 serving of notice.  We cannot attempt to reach it except from its origin 
792
new elements of  operative surgery.
to where it gives off the gluteal, that is to say, to the extent of from one
to two inches, in a word, on a line with  the  great  ischiatic  notch ; the
ilio-lumbar which it sometimes gives off in this part, and which then im-
mediately runs outwardly and upward between the  psoas muscle and the
bones, should  also be noted, though the primitive iliac artery or the ex-
ternal iliac, still more frequently perhaps give off this branch.

                         § II.—Indications.

   The trunk of the internal iliac artery is too deeply situated to  be of-
ten the seat of traumatic lesions, and too short to make it necessary that
we should treat of the aneurisms with which it might possibly be affected.
Sandifort moreover  is the only person who relates an example of this
kind.  It is no longer so with its  principal branches.  In leaving the
pelvis they are still large enough for their wounds  or spontaneous rup-
ture to be followed by dangerous  hemorrhage; the  gluteal artery espe-
cially, which terminates as it arrives between the  muscles of the same
name, and which cannot like the ischiatic and pudic be easily cut down
to externally,  has many times caused death in this manner.  Theden re-
lates a case of it.  In dilating a gun-shot wound the gluteal  artery was
divided and the  fortunate soldier soon after died.   The same thing oc-
curred in consequence  of an aneurism in a  patient mentioned by Jeff-
reys,  (Scarpa, p. 407.)   J.  Bell (S. Cooper, Dictionary, trad., p. 146)
was more unfortunate; he  saved  his patient by  applying the  ligature to
the wounded  vessel.   M. Ruyer  (Bulletin de Ferussac, t. XXIV.,  p.
109.—Augur, Rev. Mid., 1832, p. 395) has since  published an analo-
gous result, and in the course of the year 1817, M. Brooke (S. Cooper,
Diet, de Chir., p. 147)  cured, or  at least so  he  thinks, an aneurism in
the breech by compression, digitalis  and laxatives.   But nevertheless it
cannot be denied that the ligature upon the artery is the only means up-
on which we can rely at least in most of the cases  of ancient and deep
aneurisms.

          § III.— Operative Process (on the Internal Iliac.)

  This operation was performed for  the first time in 1812 by M. Stevens,
(Trans. Med.-Chir., Vol. V.,or Anderson, Surgical Anat., p. 148,) on
a negro female who had an aneurism in her left  breech of  the size of a
child's head, and who recovered perfectly.   The woman died ten  years
after from another disease, and M. A. H. Stevens of New-York, informs
me that he saw at London the anatomical  specimen corroborating the
correctness of the assertions of the  Surgeon of  Santa Cruz.   However,
M. R.  Owen, (Bulletin  de  Firussac, t. XXVIL, p. 162,) who has dis-
sected and  preserved the  specimen, says that the  aneurism was  in the
ischiatic  artery and  not in the gluteal, as had been  supposed.  On the
12th of May, 1817, M. Atkinson (Medical  and Physical  Journal, Vol.
XXXVIII., p. 267)  of  York repeated the  operation of M.  Stevens, in
the case of a waterman  who was found in the same situation as the ne-
gress Maila; repeated hemorrhages  and an extensive suppuration caused
death at the expiration of twenty days.  Since then M. P.  White (Jour-
nal des Progres, t. IX., p. 264) of  Hudson, [State of New York,] was 
ARTERIES OF THE  ABDOMINAL LIMB.
793
more fortunate in the case of a tailor aged sixty years ; for the space of
a month there was a great deal  of suppuration, but  the  patient finally
recovered.   M. V. Mott (Gaz.  Mid. de Paris, 1837, p.  650) who at-
tributes this case to M.  Samuel White, says moreover that  the  internal
iliac artery had already been tied successfully in Russia; but I  have not
as yet been enabled to procure any  details of the  case.  On the other
hand I am happy in having it in  my power to add that M. V. Mott (Gaz.
Mid. de Paris, 1837, p. 530-550.  Hosack, Archiv.  Gin., 1837) him-
self has performed this  important operation with entire success, though
he had opened into the peritoneum in endeavoring to lay bare the artery.
   A. M. Stevens first divided the integuments, aponeurosis and muscles
to the extent of five  inches, a little to the outside and in the  direction
of the epigastric artery.  After  having detached the peritoneum by
pushing it inwardly,  from the spine of the  ilium to the division of the
primitive iliac artery, he isolated the hypogastric trunk  with  his  fore
finger ; he then applied the ligature upon  it at the distance of half an
inch below its origin.
   B. 31. Atkinson adopted the same method ;  but the blood  flowed so
abundantly that he was  obliged to introduce his whole hand  into the iliac
fossa to enabled him to reach and tie the artery.
   C. M. P. White made upon the  side  of the  abdomen a semilunar in-
cision, seven inches long, with its convexity  turned  towards the ilium,
and which commenced in the neighborhood  of the umbilicus and termin-
ated near the inguinal ring.  After having thus divided the whole thick-
ness of the walls of  the belly, tied some arteries, and detached the peri-
toneum, he raised the trunk of the internal  below its  origin, and after-
wards used sutures and adhesive plasters to unite the wound.
   D.  As this  operation  is performed upon sound parts far from the dis-
ease, it is easy to practice it upon the dead body, and to assure ourselves
that an incision of five inches, as M. Stevens  made it, is sufficient—even
preferable  to  that recommended by M. P.  White, since it enables us to
avoid all the branches of the epigastric, without our incurring  the risk
of wounding the anterior iliac artery.
   E. Process of the Author.—We  should succeed full as well, in my
opinion, by prolonging to two inches farther, the outer extremity of the
incision, recommended by M. A. Cooper, for the ligature upon the exter-
nal iliac artery.   It is the  process which M. Anderson (Surgical Ana-
tomy, etc., 1822, p. 145,) prefers, in order, he says, the  more  easily to
avoid the peritoneum and to prevent the consecutive hernia, which took
place  in a patient  of Kirby, (Ibid., p. 148,) as well as in that of M.
Stevens, according to M. Scott,  (Ibid., p. 149,) who noticed it also after
an operation  by himself.   But we do not see how the incision of Aber-
nethey would protect  us better from this inconvenience than any other
incision.
   In whatever manner made, we should guard ourselves against attenu-
ating or denuding the peritoneum too much while detaching it with  the
fore-finger.   Having arrived  upon the  inner border of the  psoas, we
should make use of the  fore-finger to separate the artery from the very
large veins which it partially conceals.   We depress its  root, as well
as that of the external iliac downward and towards  the centre of  the
pelvis; then,  by means of the needle of Deschamps  or the S shaped
   Vol. I.                     100 
794
NEW ELEMENTS  OF OPERATIVE SURGERY.
needle of M. Causse, or a flexible  sound having au eye near its point,
we pass the ligature.  The greatest degree of precaution  is here neces-
sary ; the venous trunks must be  respected with  care ;  their walls are
thin,'and nothing is more easy than  to tear them.   In   displacing the
artery, we may rupture  the ilio-lumbar, and  bring on a  dangerous he-
morrhage.
  F.  Consequences of the  Operation.—The  ligature in  question, so
formidable at first sight, is less  serious in  reality as to its influence
upon  the circulation than that upon  the  external iliac or  the  femoral
only.   In fact it leaves  intact all the  appropriate vessels  of the corres-
ponding limb, and  the two  internal iliac .arteries communicate with one
another by anastomoses so large  and numerous, that after the oblitera-
tion of the one the blood must be readily carried  by  the other to the
viscera which they nourish.   But it is dangerous in another sense ;  first
from the difficulties themselves attendant upon the operation, and sec-
ondly from  the. dissections which  must unavoidably be made  in the
midst of an extensive cellular tissue where inflammation  and suppura-
tion are readily propagated to a great distance.
  [The internal iliac has been tied in at least 10 cases, viz. by Stevens, v
Atkinson, White, J\lottr Arendt, Thomas, J. Kearny Rodgers, Kimball,
Bigelow and Tripler. Of these 4 were successful, and 6 fatal.  G. C. B.]

                Article X.—The Gluteal Artery.

  If the obliteration of the hypogastric artery has  the   advantage of
curing irrespectively all aneurisms of the  breech,  whatever may be the
artery wounded, its manipulation  is, in  fact, so fearful that we  should
be fortunate were we enabled to substitute  for it the  ligature upon the
diseased artery itself.   Now this appears  to  me  practicable where we
are treating a diffused or a circumscribed aneurism, or a traumatic or a
spontaneous aneurism, so often as the diseased portion of the artery is
in the breech.  In fact  the gluteal artery on leaving the  pelvis lies
naked upon  the  anterior and superior border of the great ischiatic
notch, so that were we obliged to open  the tumor before reaching the
origin of the vessel, it would still be a thousand times preferable to the
ligature upon the internal iliac artery.   There it would be easy to com-
press it and to cauterize it, and  close it with the  end  of the finger.
Nothing would  prevent us at first from introducing a conical gum-elastic
bougie into the wounded artery, to  arreat  the blood  and  raise up the
vessel until we  should pass a ligature around it.
  Many surgeons,  moreover, had  already put these precepts into prac-
tice, so  that the ligature upon the gluteal artery is no longer a  new
operation.   Mulzell (Rougemont, Chirurg. du Nord, p. 377,) speaks of
a practitioner who had  performed it with  success towards the  middle
of the last century, on the occasion of a wound in the breech.  It has
been  performed since, and with like success, by M. Carmichael, ( Gaz.
Mid. de Paris,) for a false consecutive aneurism.  A patient operated
upon in the same manner by M. Murray (ibid. )for a diffused aneurism,
succumbed.  The  same  ligature applied to arrest a hemorrhage in the
breech, by M. Baroni, (Ibid., 1835, p. 695,)  has  on the  contrary, suc-
ceeded perfectly.                                              J 
arteries of the abdominal limb.              795
  [Mr. Guthrie insists that in all cases of aneurism of the gluteal or ischi-
atic arteries, the internal iliac should be tied.  Commentaries in Surgery,
p. 261.   Now, it is stated by Dr. Reese, in his edition of Cooper's Sur-
gical Dictionary, p. 128, that the late Drs. Cocke and Davidge of Balti
more, tied  the gluteal  artery for an aneurism of immense  size with en-
tire success, and that the extent and boldness of the incision rivalled the
herculean case reported  by John Bell.  This artery has likewise been tied
by Prof.  Syme of Edinburgh, and by Dr. Geo. McLellan.   G. C. B.]
   Operative^ Process.—In the case of  a recent wound the best plan
would be to incise and  dilate  largely, in order to come down upon the
opening of the artery, and  to reach it at the bottom of the wound.  If
it proved difficult to seize hold of it with the forceps,  we might relieve
ourselves of  embarrassment  by transfixing  it with the elastic rod of
which I have spoken.  Thus  closed and held, it would  allow of being
isolated and tied without any trouble.  For a systematic process, appli-
cable to  cases of aneurisms properly so called, I know of none more ex-
act or more easy than that  of M. Lizars  or M. Robert.
   Surgeons who  have described or performed the operation of the liga
ture upon the gluteal artery, have limited themselves, says  M. Robert to
recommending an incision  parallel with the fibres of  the gluteus maxi-
mus muscle.   This want of precision,  taken in connection  with the ex-
tremely deep position of the vessel, has  rendered the  operation one of
the most difficult  that are performed.   We arrive at something better by
basing the operative process upon exact principles of surgical anatomy.
Now, the point from which the gluteal artery leaves the pelvis in turn-
ing round upon the upper border of the  ischiatic notch, is  situated just
at the middle of a line  drawn from the postero-superior spinous process
of the ilium to the apex of the great trochanter. •
   The patient  being lain upon his belly, the surgeon first ascertains the
position  of the  two  boney projections  which  I have  just named, and
which is always practicable, seeing what little thickness there is in the
soft parts which cover them.   He then makes in  the direction indicated
an incision of from four to five inches  in length, an  incision  which  is
then parallel  to the fibres of the gluteus maximus.  Setting out from thence
the operator immediately passes his finger into the wound to identify the
position  of the  boney  border, against  which in a case of necessity  he
might  compress  the  artery if the  violence  of the  hemorrhage  should
satisfy him that it was  necessary.   Separating finally  the pyriform and
gluteus medius muscles, whose approximated borders conceal the gluteal
artery, there  remains nothing more than to isolate the vessel and to sur-
round it with a ligature.
   If the transverse  section of  any muscular bundles  would  lessen the
difficulties, we should decide upon doing it without any hesitation.  The
almost utter impossibility  of obtaining  an  immediate  reunion  in such
cases, and the danger of seeing the pus  or inflammation extend into the
pelvis would  induce me  to fill all the incisions with lint  and not to attempt
to cicatrize the wound but  by second intention.

[Lesions of the  Gluteal  and Ischiatic  Arteries, and the appli-
   cation OF A LIGATURE  UPON THEM FOR WOUNDS, ANEURISMS, &C.

   M. F. Bouisson one of the Professors of the Faculty of Medicine at 
796
NEW ELEMENTS  OF OPERATIVE SURGERY.
 Montpellier has recently in an interesting memoir (Mimoire sur les Li-
 sions des Artircs Fessi.'.re et Ischialique, et surles Operations qui leur
 conviennent, in the  Gaz.  Med. de Paris, t. XIII., No. 11, p. 162, et seq.,
 Mars 15, 1845 ; Mars 22, 1845, p. 180, et. seq., and  Mars 29, 1845, p.
 195, <fec.,) called the attention of practitioners to the subject of wounds
 of the gluteal and ischiatic arteries, which he thinks has been much ne-
 glected,  from  an impression in  his opinion  quite erroneous, that these
 deep-seated anatomical relations present almost insuperable obstacles to
 the application of the ligature to their trunks in wounds, aneurisms, &c.
 The Professor of Montpellier, considers that  the emulous impulse creat-
 ed by the ligature successfully applied by Abernethey  upon the external
 iliac excited the ambition and attention of surgeons, to direct their ef-
 forts upon still larger trunks  in the splanchnic cavities;  a ligature upon
 the hypogastric for example, or even upon the  common iliac for aneurisms
 in the gluteal region, which might have  been relieved  by  confining the
 operation to the sound portion  of the  vessels themselves, implicated,
 ^ather than by undertaking the  hazardous experiment  of  opening into
 the pelvis for  the trunk of the common iliac, which is so variable in its
 length and divisions.
  The shortness of their  trunks external to the pelvis, their deep seated
 position, and the remarkable protection they receive from their situation
 on the posterior part of the body, and the thick masses of muscle and
 other tissue which cover  them, and  the projections of the solid bones of
 the pelvis by  which they are  surrounded, are the reasons why they are
 so seldom  wounded.   This  does however happen  from falls", surgical
 operations in those regions, and especially from fire-arms.   According to
 Theden  death was the consequence of wounding  the  gluteal during a
 surgical  operation.   Guthrie relates the case of Colonel Macpherson in
 whom death was thus produced, by extensive hemorrhage from the gluteal
wounded by a  ball in the hip, and which diffused aneurism might have
been prevented by a timely ligature on the trunk.
  Wounds of  the arteries of  the  gluteal region may cause  diffused false
aneurism, circumscribed false aneurism or aneurismal varix.
  External  hemorrhage  is rare,  as  M.  Bouisson remarks, if the wound
does not extend  deeper than the  external  portion of the gluteus max-
imus, and is easily arrested by compression.   If the wound however goes
through this muscle, even the  trunks themselves may be divided and pro-
duce a copious hemorrhage.   The  anatomical  relations indicate to the
surgeon what mischief the wound has made.   If the wound corresponds
to the inferior third of the gluteus maximus, it is to be presumed that the
ischiatic  artery or its branches have been divided.  As the hemorrhage
from this artery, owing to its  smaller  size, is less serious, compression
may generally be relied upon, the small sacro-sciatic ligament behind it
offering also an excellent point  d'appui for  pressure.   If  the wound is
below and on the inner side of the sacro-sciatic spine, it may  be presumed
that the internal pudic is injured, and here compression is still more ef-
fective upon this bony  prominence which Travers (vid. Harrison on the
 Surgical. Anatomy of the Arteries, Vol. II.,) used in a desperate  case
with great success.
  If the wound  corresponds to the upper half of  the gluteus maximus
 muscle, and especially if on a line with the osseous border of the ischia-
 tic notch, the  branches of the gluteal artery  or the trunk itself  may bo 
ARTERIES OF THE ABDOMINAL LIMB.
797
implicated if the  instrument  has penetrated deep, and  the  injuries to
which are so much the  more  dangerous because this trunk  being very
short and lying under the ischiatic notch, affords  no point d'appui for
pressure.  The hot iron may be used but the ligature is to be preferred.
  M. Bouisson relates in  practical illustration of his valuable memoir,
the case  of a woman  aged about 40, who on May 31, 1842, received
three severe wounds  in this region from a shoemaker's  knife inflicted
by her husband.   The surgeon called in soon after and found her bathed
in blood, pale and exhausted.   On the middle part of the left gluteal re-
gion  he discovered a  wound  of three  centimeters in length and  still
greater depth, from which arterial blood freely issued.  Hastening to
sponge the bottom of the wound he soon reached the gluteal artery which
was found to  have been  divided near the bony border of the  ischiatic
notch ;  a ligature was applied to  it and the  hemorrhage ceased immedi-
ately.  The lips of the  wound were brought together by adhesive plas-
ters, and the whole supported by a compressing bandage.  The other
two wounds were found to be of no importance.  The patient however
continued greatly exhausted for six days, when by means of stimulating
treatment reaction took place and the parts soon after cicatrized perfect-
ly, the ligature  coming away on the 8th day.   An acute  pain however
was now  felt at  the lower angle of the  wound, and radiating from  thence
in the course of the sciatic nerve and  its divisions,  gave reason  to fear
that the trunk of this nerve or its branches had been wounded.  On the
12th day this pain was  so intense as to deprive the patient of rest, and
to excite a high fever and involuntary retraction of the limb of  the af-
fected side, indicative of traumatic neuritis.  Acetate of morphine alone
 relieved the intense suffering,  and in a month she walked  about perfectly
 restored.
   Death  would have undoubtedly ensue:!, he thinks, in this meagre sub-
ject, with an open, unobstructed  wound, had not timely assistance ar-
rived ;  the smoothness of the track made by  the  sharp instrument, faci-
 litated the application of the ligature which was placed around the arte-
ry immediately  above  the  division of the trunk, the latter having  been
wounded precisely at the point where  it is about to give off its terminal
branches.  A single ligature with the forceps and tenaculum sufficed for
the operation.   M. Bouisson  thinks the forceps of MM. Jules Cloquet,
and Colombat, and which  have been called  pinces-porte-ligature (or lig-
ature-forceps) might be used with advantage.
   Among the accidents that may ensue from the application of ligatures
in these  regions, says M.  Bouisson, we  may  mention abscesses, or  if
only one  ligature is used, the re-establishment of the hemorrhage from
the free -anastomoses of  the  branches of the gluteal  with one another,
or with  the  ischiatic itself, which last accident makes it advisable to
apply a ligature on each end of the cut vessel.
   In illustration of this, M. Bouisson  cites the case of Professor Baroni,
of Bologna, (Bulletino delle  Scienze Mediche, 1835,) where a peasant,
aged 22 years falling from a tree, struck his right gluteal region upon his
sickle, making a deep wound on the inferior portion of the gluteus maxi-
mus, and exposing the sacro-sciatic ligaments and the os innominata.  The
hemorrhage  was soon  arrested,  and  the wound healed by first inten-
tion.  But in a few days fever supervened, and a collection of pus form-
ed, which was  evacuated, but followed on the fourteenth  day by two 
798
NEW ELEMENTS OF OPERATIVE SURGERY.
successive and  dangerous hemorrhages.  Though these were suspended
by  compression, M. Baroni  deemed it advisable to lay bare the wound-
ed trunk, upon each of the cut extremities of which vessel a ligature was
readily applied, and the hemorrhage definitively arrested.
  Diffused Hemorrhagial Tumor.—There is  no artery,  according to
M. Bouisson, whose lesion  more  frequently leads to the formation of
false primitive  aneurism, than the gluteal.   The depth of  the vessel, its
volume, and the impossibility of making exact pressure upon it, togeth-
er with  the  arrangement of  the muscular layei'3, all concur simultane-
ously in facilitating the infiltration of the blood, and its reunion into a
vast collection.   Should there be ever so little difficulty for the blood to
make its escape outwardly, by reason of the narrowness or obliquity of
the  wound, or those two circumstances  united, it insinuates itself under
the  gluteus maximus  muscle, which it gradually raises up so as to form
sometimes a tumor of  immense size.   The Professor of Montpellier gives
to Jno.  Bell  the  credit  (Trait, des Plaies, trad, du Professeur Estor,
p. 105, et suiv.) of having been  the first to point out, in a clear manner,
the  danger  of  the  hemorrhage, and the operation for this false aneu-
rism in  the gluteal  artery.  He thinks, however, that the illustrious
English surgeon has somewhat exaggerated the danger of the  operation
and that, if prompt  surgical  means were  immediately had recourse to
in wounds of this artery, the hemorrhage would rarely accumulate to
the  enormous quantity of eight pounds of blood, which Bell asserts it
sometimes does ;  nor  would the operation, if performed in time, require
the  frightful  incision  of two feet, which that surgeon made in one case,
and which necessarily endangers the exfoliation of the ilium.
  False Circumscribed Aneurism.—However favorable the arrangement
of the  tissues  on this part are to extensive effusion on the blood, com-
pression properly made will, by bringing the layers of these tissues into
closer  contact, prevent  the hemorrhage from  diffusing itself  into their
interstices, and thus frequently  establish limits to its progress, and give
rise to the formation of a sort of aneurismal sac.  A pulsation will then
be perceptible to  the hand and ear, a peculiar bruit synchronous with the
dilatation (or expansion) of the  tumor.  As  an example, he quotes a
case of this kind :  Master  West, aged  17, operated upon and cured by
M.  R. Carmichael,  in 1S83,  (See  Gaz. Med., 1834; Dublin Journal,
Sec) From the success of this case by M. Carmichael, M. Bouisson dates
the reception of a ligature on the gluteal as  one that had been recognis-
ed as practicable.  In pointing out the fact, however, that the develop-
ment of the tumor proceeds to much greater extent downwards than in
any other direction, and that the artery  may be left accessible at only
half an inch depth from the surface of the integuments, he deduees there-
from, as it appears to us, a  valuable  argument in favor of  a transverse
incision on a ievel  with the border of the ischiatic notch, in preference
to making  it, as  M.  Carmichael  did, in a  direction parallel with  the
fibres of the gluteus maximus muscle ;  for, in the former case, M. Bouis-
son has frequently ascertained on the dead  body, that  we may easily
avoid opening into the sac, and crowd  it, in fact, downwards and out of
our way, while in the latter we can scarcely escape from penetrating
into the tumor, and  thus recurring to the ancient process,  obviously he
 might have  remarked, more dangerous at  this  artery, because of the 
ARTERIES OF THE ABDOMINAL LIMB.
799
 impossibility  of making  pressure upon the vessel on the cardial side of
 the tumor.
   Varicose Aneurism.   The position of the gluteal vein being closely.
 united with, and more superficial than that of the artery, favors, of course,
 the production also of a varicose aneurism.  Generally, this vein, which in
 some persons is of considerable size, is found on the posterior and inner
 side of the artery, so that it may possibly be wounded by  the instrument
 if we penetrate to any depth.   In a subject upon which he was making
 experiments with the ligature, be accidentally met with a  varicose dila-
 tation of the gluteal vein of the size of a nut,  and  completely covering
 the  artery, so that the vein would necessarily have had to be wounded
 in tying the artery.
   The ischiatic artery may  also be subject to the forms of aneurism de-
 scribed, and also to an aneurismal varix, as shown in the ca3e, described
 by Professor Riberi, of Turin:  (Gaz. Mid. de Paris, 1838.)
   Spontaneous Aneurisms of the  Gluteal and  Ischiatic Arteries.—M.
 Bouisson has seen six cases of these, four on the left and  two on the
 right breech.  The causes  are obscure—sometimes they occur without
 any apparent cause, at  olher times from contusions or from the efforts
 made in evacuations by stool.  Their progress  is slow, especially when
 all the coats of the artery have not been simultaneously  injured  to the
 same extent.   It is often some time before the  patient himself is aware
 of their existence ; which is finally disclosed by a circumscribed pulsa-
 tive tumor under the skin in the middle  of the gluteal region.  Then
 follows  pain in the  part, with numbness and difficulty of  motion  in the
 lower extremity on the side diseased, in consequence of  the pressure
 made by the tumor on the  sciatic  nerve.  The tumor may remain sta-
 tionary for years, as occurred in a  physician whose  case was communi-
 cated to M. Bouisson by  his colleague, M. Dubrueil.  At  other times,
 they go on  increasing until they end in death, by the usual termination
 of all aneurisms in rupture, or death may ensue from the interference
 which the pressure of the tumor causes with the innervation and nutri-
 tion of the limb.
  The diagnosis is exceedingly obscure when the tumor is not large, be-
 cause it is next to impossible to  make behind the tumor pressure of the
 short trunks of the arteries  in question, against any firm support;  while
 no satisfactory information can be obtained by compression of the  capil-
 lary circulation on the distal side, because the arterial trunks in question
 break up so rapidly in their  minute distribution.  From the proximity
 of the two trunks also, an aneurism of the gluteal artery has, he thinks,
 in two instances, been mistaken for an aneurism  of the ischiatic, one that
 of M. Stevens, the other  M. Ruyer's. This error, however, proved of
 no importance in a case where the hypogastric artery was tied.  A cys-
 tous or an erectile tumor also, situated over these trunks, and receiving
 their pulsations, may also erroneously lead to the supposition that an an-
 eurism exists.   So,  also, an  abscess slowly formed  in this region, may
 cause a similar error; while, on the other hand, a true aneurism may be
mistaken for an abscess, as noticed  in the case by White, where the an-
eurism, being opened, discharged a pint of blood, and rendered it neces-
sary to place a ligature on the internal iliac.  The Journals mention a
recent case, (Ann. de la Chir. Franc, et  Strang., Mai, 1843, p. 116,)
where an eminent surgeon of London tied the primitive iliac in a patient 
 800            NEW ELEMENTS OF OPERATIVE SURGERY.

 who  was supposed to have gluteal aneurism; but in whom death, which
 took place eight months after, disclosed the fact that it was an eucepha-
 loid tumor.
   Manual of the Operation for tying the  Gluteal Artery.—Process of
 M. Bouisson.—After  repeated trials on  the dead body, the professor
 of Montpellier is satisfied that the method of Harrison (Surgical Anato-
 my of the Arteries, vol. IL, No. 93, Dublin, 1829, 2nd ed.,) that of
 making  the incision parallel  with  the  fibres of the  gluteus maximus
 muscle,  though hitherto  universally adopted, is defective, particular-
 ly in  fat persons with thick muscles, not  only because of the depth we
 are then obliged to go, and that their separation  by this kind of incision
 is, in consequence  of the retraction of the muscle exceedingly difficult,
 but also  because we are  more likely to wound not only the  gluteal vein
 but the branches of the gluteal and ischiatic arteries,  and the ramifica-
 tions  of  those arteries, inasmuch  as  their  general course is transverse
 to the  fibres of the  muscle  in  question.   A fortiori the  transverse
 incision  is infinitely preferable, enabling us to save those arterial bran-
 ches, and, moreover, the fibres thus divided tranversely, separate  wider
 apart, while modern surgery, especially the operations of M. Jules Gue-
 rin, have established indisputably that the thickest and widest muscles,
 divided  through and through, readily unite by the  fibro-plastic  mate-
 rial analogous to muscular tissue, deposited in the division, and soon re-
 acquire all their primitive functions.
   The surgeon  should  bear in mind the point of emergence of the glu-
 teal artery, which is at the  most elevated part of  the ischiatic notch at
 eleven centimeters from the antero-superior spinous process of the ilium,
 six centimeters from the posterior superior spinous process, and ten cen-
 timeters  from the most elevated part of the crest of that bone.  The
 patient being placed on his belly, the surgeon makes a transverse incision
 of 6 or 7 centimeters in extent, the middle of which corresponds  to the
point  of emergence of the  vessel.  This incision divides  the skin, cellular
tissue and gluteus  maximus, and lays bare the aponeurosis  in  a line
which is  tangent to the curve  of the  ischiatic notch.  The borders of
the wound  being kept  asunder, the aponeurosis is divided by a grooved
sound a little below the artery, whose pulsations are readily perceptible in
tracing the osseous border of  the ischiatic notch.   The surgeon, provided
with a grooved  sound  slightly curved and pierced  at its extremity with
an eye  through which the  ligature passes, cautiously  separates with it
 the cellular tissue which encloses the bundle of vessels, pushes the vein
or the veins, where there are  several, backwards, and the nerve inwards,
insinuates the beak of the sound  between  these organs and the artery,
and raises the last under the  osseous border of the ischiatic notch.  The
extremity of the sound  must be made to  go down sufficiently deep, in
 order to be  sure of seizing  the arterial trunk;  otherwise we may run
 the risk of including only one  of its divisions, (See a  case of this kind
 related by Malgaigne, Anat.  Chirurg., t. II., 1838,) and miss the trunk
 itself.  The transverse  incision, it will be  found, gives an infinite deal
 of facility  to these manipulations.   The  gluteal  is stated by  Muzel
 (Medicinische  und Chirurgische Wahrnehmungen, Berlin, 1754, 64  d
 72, in octavo,) to have been first tied by a surgeon in the middle  of the
 last century, and not again until by Jno. Bell, in 1808.
   Manual of the  Operation for Tying the Ischiatic  Artery.__Process 
ARTERIES OF THE ABDOMINAL LIMB.
801
of M.  Bouisson.—Though often wounded and the seat of aneurisms,
M. Bouisson  knows of no case in which  a ligature has been applied to
it; though this  can be done, he thinks, with even  more ease than upon
the gluteal.  Lizars and Harrison recommend an incision similar to that
for the gluteal, though  the latter remarks that it should be an inch and
a half  lower down.
  Chelius  attributes also to Zang  the  recommendation of a small in-
cision  parallel to the fibres of  the  gluteus maximus, but external to the
tuberosity  of  the ischium, by which we arrive at the external border of
the tubero-sacral  ligament and find the  ischiatic  arterj(|Dn the ischio-
sacral ligament.
   M. Bouisson has frequently  reached the ischiatic artery by means of
the same transverse incision, which he recommends for the gluteal.   The
ischiatic artery emerges from  under the pyriform muscle, precisely at
the  middle of a line drawn from  the postero-superior  spinous process
of the ilium to the tuberosity of the ischium.  A transverse incision of
six centimeters in extent should pass through the point indicated,  going
through the skin, cellular tissue and  gluteus  maximus.   The artery is
found'on the  inside of the  sciatic  nerve, and  the vein on its  posterior
and inner side, when the former is carefully separated  and raised up
in the  manner described for the gluteal.
   The same incision would answer for the internal pudic, which is situat-
ed at a few millimeters from the inner side of the ischiatic.

             Article XI.—The Primitive Iliac  Artery.

                           § I.—Anatomy.

   There are  two circumstances that cause a variation of length in the
common iliacs:  1, in place of  the fifth,  it is very often on the body of
the fourth lumbar vertebra that the aorta bifurcates ; 2, the trunk  of the
secondary iliacs may be found  much nearer than usual to the sacro-ver-
tebral angle ;  3, one of the primitive iliacs may be longer than the  other,
and that  because  the trunk, (i. e., the aorta,) from which they arise, is
not always found on the median line.  Their length, however, apart from
some exceptions that are sufficiently rare, hardly ever varies more than
from three or four lines to an inch.  They rest upon the side of the sa-
cro-lumbar angle, the  wings of the  sacrum, and against the inner side
of the psoas muscles.   On the right, the vein is outside and then behind;
on the left, on the contrary, it  lies  upon  the  inside, and does not arrive
there until after having passed under  the root  of the arterial trunk on
the opposite side.   The peritoneum alone covers them ; so that in thin
subjects it is still more easy to compress them than the  external  iliacs,
provided however we have  taken care to  separate the mass of  small in-
testines from them.
                          § II.—Indications.
   Bogros opened, in my presence, a subject  whose primitive iliac had
been wounded by a pistol-ball, thirty-six  hours  before  death.   M. Gib-
son relates a similar fact, and it is easy to conceive, that aneurisms may
extend from the two secondary iliacs, as far as to the common iliac, and
even attack the latter the first.
   Vol. I.                  101 
802            NEW elements of  operative SURGERY.   1

  It required no little  boldness to undertake  to  obliterate  an arterial
trunk of such size, approximated so near to the aorta, and so deeply si-
tuated.   Where the external iliac is wanting the blood  passes  into the
limb by the internal iliac ;  where one hypogastric is wanting the blood is
furnished by the other, but what can replace the common iliac ?   How
deprived an entire fifth of the  body of sanguineous circulation, without
causing its death ?  Many surgeons at first believed the thing  impossi-
ble.
  [Drs. Graves and Stokes have reported a case of very extensive arte-
ritis, affectingfche right common iliac artery and the arteries of the cor-
responding extremity.   Gangrenous action soon took place, speedily fol-
lowed by death.   The  right common  iliac was livid  and distended by a
clot, which stretched into the external and internal iliacs, and all their
branches downwards, as far as  they  could be traced.  (Vid. Stokes on
Diseases of Heart and Aorta, p. 115.)   G. C. B.]
  At present it is no longer a question ; practice has answered in the af-
firmative ; and if refrigerants, depletives, relaxants, and digitalis should
have failed, and if the aneurism should have ascended so high as to make
the ligature upon  the external iliac uncertain,  or insufficient, and forbid
the employment  of the method of Brasdor, then the ligature upon the
primitive iliac should be made trial of as a last resource.
  M. Gibson (Medical  Recorder, vol. III., p.  185) performed it unsuc-
cessfully for a wound in the  case I have mentioned above, but it quickly
terminated in death.   But the Professor V. Mott, (American Journal of
Medical Sciences, Nov. 1827,) who was the first to perform it according
to precise rules, on the 15th of March, 1827, for an aneurism of consid-
erable size, saved his patient; neither hemorrhage nor  gangrene super-
vened, and the  individual was enabled to resume his customary occupa-
tions.  In the year following, M.  Crampton, (Med.  and Phys. Journal,
January, 1831,) desirous  of imitating the skilful practitioner of New
York, was not so fortunate ; his patient died  from  hemorrhage on the
fourth day.  The case, nevertheless, was in effect one of very great im-
portance.  The circulation, heat, and sensibility, momentarily suspended,
had been completely re-established in  the limb ; every thing promised a
new triumph, when the  ligature appeared to have got displaced, and an
internal  hemorrhage came on, which destroyed these favorable anticipa-
tions ;  on opening the body, the  circumstances were such as to lead to
the belief, that the ligature of animal substance, which M. Crampton had
used, (Arch.  Gen. de  Med. t. XXV., p. 561,) had  been dissolved, or
ruptured, before having obliterated the artery.   The authenticity of these
two  operations is, moreover, sufficiently  guaranteed by the name alone
of the authors ; one enjoys  a reputation  and a celebrity justly appreci-
ated in  America and by all  Europe, the  other  is at the head of a public
establishment and hospital in England.  [Dublin, in Ireland.  T.J  In
addition to all which, many other repetitions of the operation since 1831,
the epoch when I wrote these  lines,  have made the ligature upon  the
primitive iliac artery a common occurrence, which is no  longer  looked
upon as extraordinary.  Though a wounded horse, on which M. Gedding
(Jour, des Conn. Med.-Chir., t. III.,  p. 428)  performed this operation,
died on the sixth day, of peritonitis;  a patient whom M. Leuret saw at
the hospital of  the Surgical Academy of St. Petersburg, aud the details 
ARTERIES  OF THE  ABDOMINAL LIMB.                 803
of which have been published by the operator, M. Salomon, {Gaz. Med.
de Paris, 1837, p. 598-650,) recovered perfectly.  A celebrated surgeon
of London, M. Guthrie, had  no hesitation in  performing  it.   Unfortu-
nately, the six lines that M. Hancock (Velpeau, Anat. Chir., Angl., p.
239) has devoted  to the description of  the case, though he says he at-
tended to the  progress of the case, do not explain, with sufficient clear-
ness, what was the result.

                [ Cases of Ligature of the  Common Iliac
                                                        C Peritoneal Inflammation
                                        Died on 13th day  < and secondary hemor-
                                                        £ rhage.
Gibson           1812  Gun-shot Wound

Mott            1827  Aneurism
Crampton        1828  Aneurism
                    C Secondary Hemor-'
Liston           1820 < rhage, after ampu-
                    i_ tation

                1833  Encephaloid Tumor
Guthrie—2

Alex'r H. Stevens

Salomon

Syme

Bushe




Deguise



Post


Peregoff




Peaoe
Hey
Stanley

Garviso
Garviso
Uhde
Wedderburn
1837

1838
1840
Aneurism

Aneurism
Aneurism by Anas-
tomosis of  left la-
bium
Recovered.
Died on 4th day

Died.
 Recovered.

 Died.

 Recovered.

 Died on 4th day.

■ Lived 5 weeks




 Recovered.
1840 \ Aneurism
                C Died from exhaus-
                (  tion in 24 hours.
f Secondary  hemor- "j
rhage after ligature v Died on mh d
of external iliac for
Hemorrhage.
C Died 5 months after the
< operation, from the dis-
£ ease.

(TDied  10  months after
< the operation, from ab-
C socss in the part.
( Sac was wounded, vee-
I  sel gave way under first
I  ligature,  and  femoral
■{  vein was wounded, in
  taking up femoral ar-
  tery to prevent second-
  ary hemorrhage.
Hemorrhage.
(. Aneurism
1842  Aneurism

1843

1837
1843
Bellingham
Aneurism
Medullary
Aneurism
Aneurism

Aneurism

Aneurism

Aneurism
Tumor
Recovered.
Recovered.
Died on 3d day.
Died in 4 hours.
Recovered.
Died.
Died.

Recovered.
f Several  months after-
 wards, a non-pulsating
 tumor reappeared, with
 mark3  of fluctuation.
 Hemorrhage  followed,
 and destroyed the pa-
 tient.

 Peritonitis.
C Peritoneal cavity open-
( ed in operation.
  Gangrene.
("Either trunk of com-
J mon  iliac tied, or  the
1 external  and  internal
[iliacs at their origin.
Lyons                Aneurism          Died.
Chassaignac      1850                    Died on 2d day.
Moore,  of Middle-
   sex Hospital.   1852  Supposed Aneurism  Died few days after  Tumor encephaloid.
  Thus we have 24 cases and 15 deaths.   G.  C.  B.] 
801
NEW ELEMENTS  OF OPERATIVE SURGERY.
                     § III.— Operative Process.

  As to the process to be followed, it is exactly the same for the com-
mon iliac  as for the external iliac.   M. Mott commenced his incision on
the outer  side of the  inguinal  ring, half an inch above Poupart's liga-
ment, and carried it to above the superior spinous  process of the ilium,
giving it a semicircular direction, and an extent of about eight inches.
That of M. Crampton, also, of a semi-circular  form, the concavity to-
wards the umbilicus, and  the length about seven inches, extended from
the last rib to the  antero  superior  portion of the  crest of the illium.
  Both  detached the peritoneum with the fingers, and nothing occurred
to lead  to the belief that  they  found any great difficulty in seizing or
tying the vessel.
  In these cases the  circulation of the blood  is re-established by the
anastomoses of  the internal  mammary, and of the epigastric, with the
lower lumbar  arteries, and the anterior iliac, or even  the ilio-lumbar,
and also the anastomoses  of the hypogastric artery and other branches
upon the  sound  side, with those of the diseased side.   [See Remarks
of Dr.  Mott, infra, on  Aneurisms, and also a note under the same, on
the ligature of the Primitive  Iliac.   T.]


                 Article  XII.—Abdominal  Aorta.

                          § I.—Anatomy.

  Situated in front of, and a little to the left of the bodies of the  ver-
tebrae, accompanied by the vena  cava, on the right, enveloped in a fibro-
cellular sheath,  crossed posteriorly by the lumbar veins, anteriorly by
the  pancreas, duodenum,  the splenic vein, or the trunk of  the  vena
portarum, and the left renal  vein,'surrounded by vessels and lymphatic
ganglions, and having in  front  of it the stomach, the transverse meso-
colon, and the root of the mesentery,—the  abdominal aorta, from its
passage through the pillars of the diaphragm, to its bifurcation in front
of the sacro-vertebral angle, furnishes a  great number of branches,
which it is important should be kept in view.  The coeliac, the emul-
gent, and  the great mesenteric, derive  their origin from its upper half,
that is to  say, they  are given  off from it above, or in the meso-colic  por-
tion of the mesentery.  A long  interval, therefore, separates them from
the inferior  mesenteric, which is given off from it at an inch and a half,
or two inches, above the  common iliacs.  In crossing the bodies of the
vertebrae  the lumbar  arteries are bound down  by small and extremely
strong fibrous arcades, and  thus  constitute so many fixed roots, which
prevent the aorta  from being  displaced more than a few lines, either
in this or  that direction, without almost inevitably causing their rupture.
It is evident, from  the ensemble of these relations, that by pushing the
small intestines  to the right, or keeping them aside, in  any  manner
whatever, the aorta may be easily compressed against the vertebrae  be-
tween the two mesenteries, or immediately above its bifurcation •  'that
these two points are  the only ones which present are opportunity for 
ARTERIES OF THE ABDOMINAL  LIMB.
805
surgical resources, and that it is  there that it  would be  necessary to
apply the thumb, through the walls of the abdomen, until  something
better could be done  if it became urgent to suspend a serious hemorrhage
in the lower arterial  system.

                         § II.—Indications.

   No artery  of the  splanchnic  cavities is more frequently the seat of
aneurism, from internal  causes, than the aorta; and in no artery does
either  aneurism, or the slightest traumatic lesion, present so many dan-
gers, or is more frequently followed by  death.   If it be that no wound,
or ulceration, nor any solution of  continuity in an artery, can be cured
without effecting  the obliteration  of the vessel, whicfr is the seat of it,
how can we conceive that such a termination, admitting that it may be
possible, in the aorta, would not, at the same time, be of necessity mor-
tal ?  Yet such, nevertheless, would seem to be the fact, from the seve-
ral cases which followed:
   1. Stenzel (De Steatomatib. Aorte) gives the case of two steatomatous
tumors in the substance  even of the walls  of the aorta, under its arch
(crosse ;) the arterial trunk was almost impermeable.  Nothing had led
to the suspicion  of  such an arrangement during life : 2 and 3. Meckel
(Acad, de Berlin, t. XII., p. 62) saw two dead bodies, with the abdom-
inal limbs well nourished, and the aorta considerably contracted under its
curvature ;  4. M. A. Severin, (De Recondit. Abscess.,  etc., lib. IV.,)
the  aorta under the eniulgents completely shut up by a solid concretion ;
5. Staerk, (Ann. Med., vol. I., p. 260, ou Barth, Press. Med., t. I.,) a
similar case to those of Meckel; 6. Paris, (Journal de Desault, t. IL, p.  ?
107,)  the aorta under the arch, reduced to the extent of some lines,to
so small  a calibre, that it was difficult to introduce a crow-quill into it;
7. Complete obliteration  at the same  point, seen  by Graham, (Trans.
Mid.-Chir., vol.  V., p. 287,) 8. Rainy, (Journal de Leroux, t. XXXIL,
p. 377,) saw a similar fact at the hospital of Glasgow, 1814; the speci-
men was given to M.  Monteith.  9.  Monro, (Journal des Progres, t. IV.,)
the  aorta obliterated,  in consequence  of the relics  of an old aneurism
immediately above the primitive iliacs ; 10. Goodisson, (Bulletin de la
Faculte, t. VI., p. 130, 138,) an obliteration extending to the two com-
mon iliacs ;  11. Reynaud, (Journal Hebdomad., 1.1., p. 161,) an extreme
contraction  of the  thoracic aorta.  12. M. A. Meckel, (Jour. Compt.
des. Se Med., t. XXX., p.  88,) the aorta so contracted under the arte-
rial canal, -that it was with difficulty a small straw could enter it.   M.
A.  Cooper, (CEuvres, etc., trad. Chassaignac et Richelot, p. 542,) com-
plete obliteration of the abdominal aorta.   M. Key, (Journ. des Pro-
gres, t. II., p. 19,) another in a paraplegic.
   To these  facts  we  may add those of Piorry, (Journal Universel des
 Sciences  Midicales, Mars, 1816,) the  aorta contracted near the arch ;
Baffos, (Archiv. Gin. de Med., t. XIV., p. 611,) the iliac  aorta  oblite-  ,
 rated; Nicod, (Archiv.  Gen. de Mid., t. VII. p. 466,) the same by con-
cretion;  Pailloux, (Bibliolh. Mid., 1829, t. L, p. 337,) the aorta below
obliterated  by concretion ;  Berton, (Rev.  Med., 1829, t. IL, p. 244,)
thoracic  aorta, aneurism, and concretion;  Schlesinger, Encyclop,  des
 Se Mid., 1836, p. 85,) abdominal aorta obliterated ; Legrand the same; 
806
NEW ELEMENTS OF  OPERATIVE SURGERY.
  (Rifncissem. de V Aorta Sec 1834 ;) also those of Spangcnberg, Ilervey,
  Laennec, Bright, and H. Berard,  (Diet,  de Med., 2e edit., t. III., p.
  400,) and  those  of Nixton, Andral,  Larcheus, Fontanus, Dell Anne,
  Morgagni, Jordan, Maisonneuve, collected by iii. Barth, (Presse Mid.,
  t. I., ou These No.  189, Paris, 1837.  An excellent  work of refer-
  ence.)
    In almost all these subjects, the state of the aorta was evidently the
  result of disease ; in all, the circulation had continued to go on above
  the strangulation ;  those  mentioned by M. Rainy  and M. Key were the
  only ones that  complained of an habitual weakness in the legs, or palsy.
  On the other hand, M. A. Cooper and Beclard have, it is asserted, often
  tied the  ventral aorta in dogs, without  causing gangrene in the hinder
  part of these animals.  In 1823,1 dissected a cat, upon which M. Pinel-
  Grandchamp had performed this  operation four  months before, and in
  which the abdominal aorta was transformed into a  fibro-cellular filament,
  from the superior mesenteric to  the origin of the primitive iliacs.   M.
  Scoutetten, (Archiv.  Gen. de Med., t. XIIL, p. 505,) who has  effected
  the  obliteration, in succession, of the  two femorals, the two carotids,
  and the two  subclavians, in the same animal, without  causing death,
  also tied the aorta in one of the  dogs  he had thus treated.  Though an
  acute peritonitis had supervened in this animal,  the day after the  ope-
  ration, he had  begun to walk, and  to recover his appetite,  when lacera-
  tion of the aorta above  the ligature suddenly caused his death, on the
  seventh day.
    If this  assemblage of facts  would not authorize us to conclude that
  we might tie the abdominal aorta  in man, without danger, they prove
  at least, and unanswerably, as it appears to me, that in spite of this
  ligature, the blood would  ultimately create for itself a channel to reach
  the  lower  limbs.   The  intercostals, and the superior lumbar arteries,
  the internal and external  mammaries, and the transverse and posterior
  cervicals, are large enough, in fact,  to carry the fluids below the strangu-
  lated point. If the  ligature was  placed between the two mesenteries,
  in place  of being applied below, we should have,  in addition, the great
  arcades formed by the union of the right and left colic, to re-establish
  the  circulation.  The human body  being, in reality, nothing  more  than
  a vast network, a great vascular circle, no  one, at  the present time, and
  much less  now than ever before,  can entertain any apprehension that
  we should  arrest  the course of  the fluids that circulate through it, by
  obliterating any one portion of it.
    Would then the ligature of the aorta be useful and practicable ?  That
  it is practicable we can  have no doubt, since MM. A. Cooper, James,
  and Murray, have performed it;  the first at London on the 25th of June
  1817 ; the second at Dublin in in 1829 ; the third at the Cape of Good
  Hope in  1834.  As to its utility it is  not near so well demonstrated.
:  I he patient of M. Cooper, (CEuvres, trad. Franc., p. 548,) died at the
    «n~  orty> hours; that of M-  James, (TAe  Lancet, 1829, Vol. IL,
  p. 60.,) survived  only  three hours; and I find that the  patient of M.
  Murray,  (JV. Amer. Archiv. of Med. and Surgical  Sciences, 1835, p.
  Wi,) died  at the expiration of twenty-three hours.  Aneurisms in one
  or both the common iliacs, or those which might develope themselves
  Delow the  inferior mesenteric, could alone  claim this operation • but 
ARTERIES OF THE ABDOMINAL LIMB.
807
the observations  of MM. Monro and Goodisson, and the cases of spon-
taneous  cure  of  aneurisms of the  aortic arch, as  related by MM. TV.
Darrach, Berton  and Calmiel, (Journal des Progres, le  serie,) show
what the system can do under  such circumstances.   But do not internal
treatment, cold  applications, and moxas, combined with the methods of
Valsalva,  Guerin, and M. Larrey, in fact,  offer in such cases, more
chances  of success than any operation that could be imagined ?   Would
not the  ligature  first  applied  to the external iliac upon  one side, and
then  upon that of the other,  according to the  method of Brasdor, be
preferable to  that upon the aorta ?   However, as it is possible that the
essay of the  English  Surgeon may be  repeated, I think it  proper to
point out the operative process.

                   § III.— The Operative Process.

   I do not deem the suggestion of penetrating into the left loin to reach
the aorta, without opening into the  peritoneum, as some modern writers
have recommended, of any value or worthy of being discussed. The
only  process  that prudence would  allow us to undertake, is the follow-
ing :—
   The patient being laid upon  his back,  ought to have the head, thighs,
and legs, moderately flexed, in order  to put the  walls of the belly into
a state of complete relaxation.   An incision of from three to four inches
long, is  then made upon the linea alba,  a little to the left, to avoid the
umbilicus, above  which it would as I  think,  be  advisable  to prolong a
little farther than below.   Having reached the peritoneum we  puncture
it, in  order to  divide it more freely with the blunt pointed bistoury guided
upon the finger; by this  opening the  forefinger pushes aside the intes-
tines, penetrates  to the spine,  recognises the  pulsations of the artery,
detaches the left layer of the mesentery and the subjacent cellular sheath
with  the nail,  and gently separates the aorta from the vena cava and the
vertebras, so as to isolate  it in  a proper manner.   If the subject  should
be thin, and the walls of the abdomen be brought very near to the verte-
bral  column;  if the eye in fine, could  follow the instrument up to that
point, a  sound would  advantageously replace the finger.   The ligature
is applied by means of the needle  of Deschamps, or the ordinary liga-
ture-holder, it is tightened by a double knot, while one of its ends is
cut near  the artery ; and the other is brought through the wound which
it is advisable  to unite by  some stitches of suture.  If the ligatures of
animal substance offered the same security as the others, this would be
a case for giving them the preference and leaving the knot at  the bot-
tom of the wound; but experience not having  yet decided upon these,
I dare not recommend  their employment  here.   M.  Cooper, placed his
ligature  at three  quarters of  an inch above the  primitive  iliacs.  It
would probably be better to place it above the lower mesenteric artery ;
the reason for this I  have given  above.  M.  James before  tying the
aorta at the Exeter Hospital, July 5th, 1829, had endeavoured to oblit-
erate  the external iliac by the  method of Brasdor, on the preceding 2d
of June,  without  obtaining  therefrom  any marked advantages.   At the
opening  of the dead body the external iliac artery was found divided
into  two trunks, which would  have sufficiently explained how the .first 
  808           NEW ELEMENTS OF OPERATIVE SURGERY.

  operation, which  was followed by a diminution in the pulsations of the
  tumor had not prevented them from soon after re-acquiring their former
  force.  The  process also of M. James is nearly the same as that of M.
  A. Cooper's.  " M. Murray, ( Gaz. Mid. de Paris, 1834, p. 502,) says, he
»  made  his incision to the left, in the direction of the aorta, and after
  the method of Guthrie, because he could  not operate to the right, owing
  to the size of the tumor which ascended very high in the belly.
    [Dr. Monteiro, of Rio Janeiro, operated in another case, in 1842.
  His patient  is said to have lived 15  days.   Sir Everard Home tied the
  femoral artery for aneurism of the external iliac, in 1825, without suc-
  cess, and  in  connection  witli this case, he observes, " it may be said,
  that I might  have taken up the aorta, but  I have  made up my mind to
  let those diseases that require tying the aorta which come under my care,
  take their course."   (Phil. Trans. 1828.)   The  unfortunate results in
  the four instances in which this operation has been performed, prove the
  wisdom of his decisions.   G. C. B.]
                          CHAPTER II.

                  ARTERIES OF THE THORACIC LIMB.

                Aeticle I.—Arteries of the  Rand.

                          §  I.—Anatomy.

  The Radial Palmar Arch,  extending in  the  form of a  segment of
a circle with its convexity forward, from the dorsal origin of the first
inter-osseous space, to the hypothenar eminence, where the ulnar artery
completes it; being embedded in the muscles, with the bones of the me-
tacarpus behind, and the flexors of the fingers and the other soft parts
in the palm  of the hand in front, is too  deeply situated  as  respects
aneurisms, to require any particular consideration.  The ulnar or super-
ficial arch, represents with sufficient exactness the shape of an arc, with
its convexity  downwards, of about  fifteen  lines  in depth, and the ex-
tremities of which would fall upon the projections of the pisiform bone,
and the  os  trapezium..   Covered near its  root by some  fibres of the
muscles of the little finger, by the palmar aponeurosis in its middle part,
and over that by the sub-cutaneous tissue in its whole extent, it furnishes
from its convex portion the collateral arteries of almost all the fingers.
The branches of the median nerve, the tendons of the sublimis, the pro-
fundus, and  lumbricales muscles, and a very loose synovial membane
separate it moreover  from the deep arch,  with which  it  is  made to
communicate, by  means  of the anterior branch of the radial  artery, a
collateral  of the thumb and the deep branch of the ulnar. 
ARTERIES OF THE THORACIC  LIMB.
809
                         § II.—Indications.

  We often  meet with wounds in the hand which may become alarming
from the hemorrhage which results  from them.  In a case mentioned
by Tinieus, (Bonet,  Corps de Med., part II., p. 188, Obs. 37,)  the loss
of blood by frequent repetitions ultimately caused the  death of the
patient.  Camper (Demonstr.  Anat.  Pathol., etc., 1760) says  the
arm had to be amputated to arrest the  hemorrhage in a case of wound
in the  deep palmar arch.  The hand is also sometimes the seat of
circumscribed  aneurisms.  Guattani  met with  one in  front of  the
thenar  eminence, which  was equal to the size of an orange.   Becket,
Fabricius of Hilden, and: the Gazette Medicate, (1837,  p. 524,) each
furnish another example of this kind.   In the case mentioned by Tulpi-
(us, Bonet,  Oper. Cit., t. IV., p. 40, Obs. 59,) it was situated  between
the thumb and index finger; and at the hypothenar eminence in that of
Somme. M. Champion writes me that he has seen  one in the  palm of
the  hand.   An  anlogous  case  was seen by M. Carrere (Gaz. Med de
Paris, 1834, p. 255.)
   The treatment of  such lesions is not free from embarrassment;  some-
times almost any thing will succeed, while at other  times  almost every
tiling  fails.  The patient of M. Champion had  received a cut from a
knife ; the compression was badly made ;  the hemorrhage  returned ; the
compression was applied better  ;" the  aneurism  was formed ; the patient
did nothing farther.   Like M. Carrere, I have seen the best applied com-
pression fail in a stout lad who had wounded the superficial palmar arch;
also in another in which the deep palmar arch had been wounded in open-
ing an abscess.  As with the cases of M. Quoy (Jour, des Conn.  Mid.-
 Chir., t. III.,  p. 269) and M. Pigeaux, (Arch. Gin. de Mid.,  2e serie,
t. X., p. 237,) I found in 1838, in a young man who had  thrust a knife
into the palm of his hand, that compression  answered perfectly  well.
The hemorrhage of which M. Dubreuil (Gaz. Med. de Paris, 1834,  p.
726) speaks, coming from the  palmar arch at the bottom  of an abscess,
at first  resisted  compression.   The  brachial  artery was tied, but the
blood reappeared.  A second compression was successful.   Compression
made in two other cases with an instrument of which  the  sugar-tongs
would convey a correct  idea, succeeded  very  well.  (Jour, des Conn.
Mid.-Chir., t. III., p. 10.)  M. Grisolle (Ibid.) also  cites  two cases,
where the compression no longer direct, but made upon  the radial or ul-
nar arteries, was attended with  complete success.  The red hot iron ap-
plied by Dupuytren cured the child that M. Carrere had treated by com-
pression.
   In other  respects the course to be observed is this: Is the case one
of hemorrhage and  recent diffused aneurism ?  I have then twice suc-
ceeded by tying the two ends of the artery at the bottom  of the wound.
To divide the palmar aponeurosis and the arterial arch itself as Camper
recommends, (Oper. Cit.,) would  be a means to be tried.  If the first
trials of compression made upon the palm of the  hand with  tampons,
agaric, and compresses and a bandage, or with the forceps of M. Gallias,
(Jour,  des  Conn. Med.-Chir., t. III., p. 10,) should not  succeed, it
should be made  in a third manner.   If the direct compression is power-
   Vol.  I.                   102 
810
NEW ELEMENTS OF  OPERATIVE SURGERY.
less or too uncomfortable to be borne, we must then have recourse to in-
direct compression upon the radial and ulnar above the wrist, as M. A.
Berard has done  (Gaz. Mid. de Paris, 1833, p. 706.)  Finally, if in
spite of these  means skilfully employed, the hemorrhage should return,
or inflammation and  swelling should threaten to attack the hand, there
would be no longer room to hesitate ; the ligature must be applied by the
method of Anel.   The ligature upon the radial only, aided by compres-
sion upon the ulnar, was sufficient in the case cited by M. Berard  or M.
Pigeaux, and in a patient of Duges,  (Jour, des Conn. Med.-Chir., t. I.,
p. 210.)   Sometimes  we succeed by  tying only the upper end  of the
wounded vessel; but as the two  arteries  of the  fore-arm communicate
freely with each other in the hand, it is more  secure and generally bet-
ter to surround each of them with a ligature, though only  one cf them
has been  opened.   In a  pork dealer  whose superficial palmar arch had
been divided, the bleeding came  on copiously  five times in succession in
spite of compression both direct  and indirect. I tied the ulnar and ra-
dial without waiting any longer,  and though a phlegmonous tumefaction
had already seized  the hand and fore-arm the cure was effected.  A young
butcher who had had the root of  the deep palmar arch and the collater-
als of the index finger opened, was exhausted in consequence of repeated
hemorrhages, when MM. Layraud and Viguereux  seut for me.   Com-
pression, astringents and cauterization  had been made trial of.   I  imme-
diately tied the two arteries of the fore-arm, and all the difficulties were
arrested.
   In the cases of circumscribed aneurism the  operation above is the one
we have to depend upon ; there would in fact be no choice ; the method
of Anel  only is applicable to these  cases.  By the  ancient method, or
the opening of the  sac, we should have to encounter too many difficul-
ties in laying bare  and especially in  seizing the artery.  The hazard in-
curred by M. Roux in a patient in whom he employed this method, and
by M. Manoury in  another, and the dangers of every kind to which we
are exposed in making incisions into the  palm of the hand, sufficiently
show that in such  cases the ligature to the radial or ulnar above  the
wrist  would be preferable;  it did not however prevent the boy upon
whom M. Roux (Gaz. Med. de Paris,  1837, p. 524) had made use of
it for  an aneurism at the thenar eminence, in  1836, at the  Hotel  Dieu,
from dying in consequence of repeated hemorrhages.
   [Prof.  Syme asserts  (Month.  Journ. April, 1851, p. 370) that  it has
always been an established principle with him, that the radial artery and
its branches at and below the wrist,  are  completely under the command
of pressure, provided it be  properly applied.   It should not be superfi-
cial, but lint or some other  suitable substance must be made to press di-
rectly upon the orifice of the vessel.   G.  C. B.]

                     §  III.— Operative Process.

   A.  We could nevertheless  reach without difficulty the superficial pal-
mar arch near its root, by commencing upon its radial or pisiform side,
an incision, which  should be prolonged forwards to the extent of about
an inch and in the  direction of the  last metacarpal space.   We should 
ARTERIES OF THE THORACIC LIMB.
811
have to divide in succession the skin and its cellulo-filamentous lining, a
sufficiently thin aponeurosis and some fleshy fibres.
  B. It would also be very easy to tie the origin of the deep arch upon
the back of the  hand: the  termination of the radial  is found there at
the bottom of the groove which separates  the  posterior extremity of the
two first metacarpal bones; a fibrous lamella separates it from the ten-
dons of the thumb, the cephalic vein and the skin.  The thumb and fore
finger should be extended and kept wide apart from each other, in order
that the surgeon may  not be incommoded  by the dorsal tendons of these
two fingers.  An oblique incision of an inch or an  inch and a half long
is then made at three lines from the ulnar side of the  artery and in the
direction of the long  extensor of the thumb.  Under the  skin  are seen
large veins of the metacarpus and one of the branches of the radial nerve.
If they were still in the way after pushing them aside they must  be divid-
ed ; the artery is still concealed by the aponeurosis, which must  not be
divided except upon the director.   Finally in isolating the vessel by the
point of the sound, it is important not to  lose sight of the neighborhood
of the carpo-metacarpal articulations.

              Article II.—Arteries  of the Fore-arm.

                           § I.—Anatomy.

   In the fore-arm, the posterior inter-osseous artery, distributed between
the two corresponding muscular layers, and the anterior inter-osseous,
accompanied by its nerve, and lying upon the ligament of the same name,
are of too  little size,  and too deeply situated to require the direct appli-
cation of the ligature.  It is, therefore, the radial and ulnar alone  which
the surgeon must look to under these circumstances.
   A.  In its lower  third, the radial artery, situated in the groove  which
separates the tendons of the flexor carpi radialis, and of the  supinator
radii longus, is covered only by a single aponeurotic layer, the  sub-cuta-
neous tissue and the skin ;   one  or two veins run by the  side of it; the
nerve is at some lines outside of it, and it lies almost naked on the ante-
rior face of the radius.  Elsewhere, its relations are  a little more com-
plicated.   Resting against the pronator radii  teres, or the radial portion
of the  flexor digitorum sublimis, where it is fastened by a fibrous lamella,
this artery, concealed also by the inner  border of the  supinator radii
longus, is, nevertheless, separated from the integuments in  the  same
manner as below, by  the anti-brachial  aponeurosis,  and by the superficial
layer,  in its whole extent.   Its course is indicated by  a line drawn from
the middle part of the elbow to the base of the styloid process, or by the
outer groove of the fore-arm.  It sometimes runs immediately under the
skin; more frequently it turns back upon the  outer surface of the radius
at the  middle of its length  ; While in other cases its principal branch lies
in  front, and goes to  form  almost entirely the superficial palmar arch.
   B.  The  ulnar, concealed above by the entire  thickness of the super-
ficial muscular tissue, is on that account only submitted to surgical oper-
ations in its three lower  fourths, where it is found  upon  the flexor digi-
torum profundus, between  the flexor  digitorum sublimis and the flexor
carpi  ulnaris;  the vein is outside, and the nerve on  the inner, that is, 
 812           NEW ELEMENTS OF OPERATIVE SURGERY.

 the ulnar side; at first, an aponeurosis, then the flexor carpi  ulnaris
 muscle, or its tendon, then another fibrous layer, and  afterwards the adi-
 pose tissue, separate it from the cutaneous  envelope  ; we may trace its
 course by means of a line drawn from the inner condyle of the humerus
 to the radial side of the pisiform bone, for its two lower thirds, and by
 a line drawn from the middle of the bend of the arm to the union of the"
 middle third with  the upper third of the ulna, for the upper third of its
 course.  Its anomalies of position are much more frequent than those of
 the radial;  I have often found it between  the aponeurosis and the skin,
 either in its whole or a part of its length ; I know many persons with
 this peculiarity.  At other times we find it between the aponeurosis and
 the muscles ; in certain cases it runs for a long distance near the axis of
 the limb, and does not approximate to the ulnar nerve  until when it is
 near the wrist.

                         § II.—Indications.

  There is no doubt but that an aneurism of the radial  near the wrist
 might yield to compression, nor is  there any that we ought  to  attempt
 this means in irritable, timid subjects, like  the one for example that A.
 Petit speaks of, and who died of spasms from a ligature upon the radial;
 it is equally certain also, as M. Pigeaux (Arch. Gen. de  Mid., 2e ser.,
 t. X., p. 337) says, that most of the hemorrhages of  the fore-arm could
 be arrested by compression properly made.
  A.  Compression.—The patient of Tulpius above referred to was cured
 of his aneurism by this mode.   A wound of the radial near  the carpus,
 was also cured by means of a  kind of tourniquet invented by Scultetus,
 (Arsenal de Chir.,  p. 335, obs. 89, pi. 19,  fig. 4.)  In  another  case
 Formi  (Bonet, Oper. Cit., t. I., p. 190)  succeeded equally well by plug-
 ging with tents, (tamponement,) and compression.  The patient treated
 by Favrie, also had a wound of the radial.   The arteries of the fore-arm
 are wounded ; the radial is tied ; the  hemorrhage reappears ;  which is
 the artery wounded ? they could not tell, says Dudaujon ;  (These, Paris,
 1803 ;)  in this doubt they attempt indirect compression with an apparatus
 expressly made for it; the patient got  well.  Compression proved in-
 sufficient, and it was necessary to come to the ligature  in  the  case  of
 Herin, (Pathol.  Chirurg., t. IL, p. 48,)  Mestivier, Martin, (Anc Journ.
 de Mid., t. XXX., p. 270—274,) Pelletan, (Clin. Chir.,  t. IL, p.  270,)
 and Ouvrart, (Obs. de Mid.  et de Chir.,  p.  253—255.)   Bourienne,
 (Journal de Horn, t. VII., p. 277,) who rejects the  ligature as useless,
and also strong compression,  employed with  success in  the case of a
wound of the inter-osseous artery, cauterization, aided by slight com-
pression.  But M.  Gouraud (Essai sur la  Formation des Os, These  de
Pans)  speaks of a similar lesion which could not be  cured by compres-
sion, and which obliged him to tie the trunk of the brachial.   A patient
ot whom Detharding (Planque, Bibl, t. XXVIL,  p. 40) speaks, was
more fortunate.  The artery of the wrist is opened.    The patient cannot
support the tourniquet.  They were about to amputate, when one of the
surgeons introduced a  plug of blue vitriol into the vessel, and stopped
ttie blood.   Plugging with tents, and compression, succeeded very well
in a case of wound of the ulnar, related by Leprince, Journ. de Horn 
ARTERIES OF THE THORACIC LIMB.
813
t. L, p. 398.)   M. Quoy (Journ. des. Conn. Med.-Chir., t. L,  p. 26,)
effectually arrested, by means of direct compression, a hemorrhage of the
arteries of the wrist, by deciding to make the compression  on the two
arteries separately.  M. B. Cooper (Presse Mid., t. L, p. 455) was not
less fortunate for a wound of the ulnar.  I have already remarked that
the hemorrhage did not return in one of my patients who had the ulnar
artery  divided, though compression was not made upon  the brachial
longer than twenty-four hours.
   B. All this does not prevent the ligature from being the most certain
remedy, and the one that may be employed with least  danger in lesions
of arteries of the fore-arm.   Compression and  the ligature, moreover,
are two resources which we must often in these cases  call to the aid of
each other.  Instead, for example, of tying those two arteries at the
same time for a wound in the hand, as the extensive anastomoses of the
palmar arches would  seem to require, we  may content ourselves with
placing a ligature on the principal, and with compressing the other.  At
and above the wrist, if the upper end of the artery which has been open-
ed has been tied, it will then be found sufficient, in order to prevent the
return of blood or the hemorrhage, to make compression upon its lower
end.
   Since I laid  down these rules, M. A. Berard, (Gaz. de Paris, 1833,
p. 706,) has confirmed them by \wo facts.   A case published by M. Quoy,
(Journ. des Conn. Med.-Chir., t. I., p. 269,) sustains them in the same
manner.  I may say  as much of that  of Duges, (Ibid., p. 210,) and of
some others. With M. H. Berard, (Arch. Gin. de Mid., 2e serie, t. VII.,
p. 448,) and M. Sedillot, ( Gaz. Med.  de Paris, 1834, p. 41,) the method
of Anel was found sufficient to  arrest a hemorrhage on the fourteenth
day from  a wound either of  the ulnar  or the brachial artery.  It would
be the same for circumscribed aneurisms; Somme, (Gaz. Mid. de Paris,
1833,  p. 695,) also cured his patient by tying the ulnar in the  middle
of the fore-arm.   It is nevertheless true, that in a patient who had had
the radial artery wounded, M. Dubreuil, (Ibid., 1834, p. 726,) after
having tried compression and the ligature upon the radial and then upon
the ulnar, was obliged  to  come  to the  ligature of the brachial artery
itself.
   If the wound whether traumatic or  spontaneous, were situated in the
dorsal branch of the ulnar artery, of which  MM. Fillet, (These No. 176,
Paris, 1827,) and Baretta, saw an instance at the Hospital of Lyon, or
in any other branch  in  the  same region, the  ligature which  is  attend-
ed with but little danger, and easy of application, and which should be
placed above and under the disease, by the ancient method, should be
preferred to any other mode.

                     § III.— Operative Process.         #

   Unless  the ligature is to  be made in the wound itself, it is to be ap-
plied immediately above the wrist, or  to the upper third of the fore-arm.
   A.  The Radial above the wrist.—When we wish  to tie  the radial
artery above the wrist, the hand should be  placed  in  supination.  The
surgeon seated outside, makes with  a straight or convex bistoury  an
incision into the integument of from one to two inches, in the direction 
814
NEW ELEMENTS  OF OPERATIVE SURGERY.
of the artery,  between  the flexor  carpi radialis  and  the  supinator
lona-us, taking care not to go too deeply at first.  Afterwards he divides
thermoneurosis which has  been previously raised up, in such  manner
that the bistoury passed along the groove of the sound cannot touch the
vessels.  As the nerve is  situated at a great  distance from it,  and the
collateral vein is of but little importance, it is a matter of indifference
whether the artery is seized by its inner or outward side;  only  that we
ought to avoid denuding it to too great an extent.
  B. The Ulnar above the icrist.—The hand and the fore-arm are placed
for  the ulnar as in the preceding case.  We give  the incision the same
extent and the same direction.   Nor should it  either descend to a line
with the  radio-carpal articulation ; also it is upon the radial border of
the  flexor carpi ulnaris, or in the inner groove of the fore-arm, that this
incision is to be made. After having divided the skin, the adipose tissue
and the thin fibrous layer which covers the tendon of the  flexor carpi
ulnaris, and  pushed this tendon inwardly, we perceive the artery through
a second  aponeurotic layer, situated on  the radial side of, and a little
anterior to, the ulnar nerve.
  C.  The Radial at the upper third of the fore-arm.—As we are obliged
to penetrate deeper in the upper third of the fore-arm than below, it is
advisable to give at least two inches of extent to the wound, which should
be a little oblique from within outward, in order not to go too far from
the  line of the track of the artery.   If ttien the superficial radial vein or
the  common medium should present themselves under the skin, they must
be pushed aside  with the sound.  It is better to fall some lines  without
than within  the border of the supinator longus  muscle ; at this outer side
the  aponeurosis has not yet  divided, and we find only a single layer of
it.   In the other, that is to say, on the border  of the muscle itself, a first
layer has to be first divided, and then the fleshy bundle is drawn to the
distance  of some lines outwardly ;  a second layer is  seen beneath, this is
divided upon the sound, and then the artery may easily be seized hold of.
  D. The Ulnar on  the middle third of the fore-arm.—The  ligature
upon the ulnar on its upper  third, or its middle portion, is  deemed  one
of the most difficult in the thoracic  extremity, which is owing probably
to the fact that most authors have given but very vague  rules  for per-
forming it.  Nevertheless, I have  not found  that  it required either on
the dead subject, or on the  living body, much more address than  the
radial, if we adopt the following mode :—
  Process of the Author.—We make an  incision  of from three to four
inches, which commences at three fingers width from the ulnar articula-
tion of the humerus, and descends to the middle of the fore-arm, in the
direction of the line  mentioned above.  When the  aponeurosis is  laid
bare, we seek for the interstice of the flexor carpi ulnaris and the flexor
of the little finger.   In order not to be deceived, it  is sufficient to draw
the  internal border of the wound  towards the ulnar side of the limb;
directing our attention then to  the median line, the first rather opaque
and yellowish or greyish  appearance that we meet is a certain mark of
the interstice sought for.   We then incise the aponeurosis  on the outer
border of this line to the same extent as the skin.   That being done, we
separate the flexor carpi ulnaris and flexor of  the little fino-er from each
other with the fore-finger, the handle of the scalpel, or the sound.   We 
ARTERIES OF THE THORACIC LIMB.
815
soon perceive, at the bottom of the wound, a large yellow or whitish cord,
which is the ulnar nerve, having the artery on its radial side.  To seize
this latter, it is not even necessary that we should see it, as we are cer-
tain to raise it up by directing the  extremity of the sound  between it
and the nerve.
  II. Process of M.  Guthrie.—If the  disease  was  situated higher up
upon the ulnar artery, inasmuch as it changes its direction and becomes
more and more difficult to cut down to, it would be evidently preferable
to tie the  brachial itself.  M. Guthrie, who has done this  once success-
fully, recommends that we should always proceed to search for the ulnar
itself in the part wounded, though it should be necessary to cut through
the muscles  transversely ; but this advice ought not to be followed, un-
less there already existed a wound of considerable size, with contusion
of the parts.

               Article III.—Arteries of the  Elbow.

                           § I.—Anatomy.

   At the bend of  the arm the humeral artery terminates, by giving ori-
gin to the radial and ulnar branches ; but in place of this occurring op-
posite to, or  below the coronoid process, its bifurcation sometimes takes
place in front of the articulation, or even much higher.  In descending,
it follows an oblique direction from within outwards, is situated upon the
inner bundle of the brachialis internus muscle, between the biceps flexor
cubiti, and pronator radii teres, and quite below, inclines to cross in the
same direction the anterior surface of the tendon  of the- biceps.   The
deep-seated vein, runs upon its radial side, and the median nerve, which
sometimes touches its ulnar border, is  not unfrequently separated from
it by a fasciculus of the brachialis internus muscle.  A cellular  sheath,
of greater or less  density, encloses it, as well as the vein.   Crossed, and
as if bridled  down by the fibrous bandelette of the  biceps, afterwards
covered by the  aponeurosis of that region, it has in front of it,  at  first
the trunk of the basilic vein, then the  corresponding median vein, the
branches  of the internal cutaneous nerve, and the cellulo-adipose tissue,
which organs  separate it to a  greater or less distance  from the skin.
When the bifurcation takes place higher up than usual, the nerve  lies,
in general, between the two arterial trunks, and it is then that the ulnar
is specially inclined to creep under the skin.

                          § II.—Indications.

   The bend of the arm is the part of the body where  aneurism  is most
frequently met with,  especially  false,  or traumatic  aneurism, whether
diffused,  circumscribed, or  varicose.   Spontaneous aneurism  may be
caused there, as in front of all the articulations, by a violent extension
of the  fore-arm, as happened, for example, in the innkeeper mentioned
by Saviard, (Observ.  Chirurg., &c, p. 22, 27.)   It is much more  rare
here, however, than in the ham, or even at the fold of the groin.  Apart
from those  which have  been  related  by Fordyce, Flajani, Paletta,
Lassus, Pelletan, and M. Roux, there are scarcely any instances of these 
816
NEW ELEMENTS OF  OPERATIVE SURGERY
aneurisms to be found in the most approved authors, and Scarpa himself
does not appear to have met with them.   As to varicose aneurism this is
pre-eminently its seat, whether it exists in its natural state, or is com-
plicated with a false circumscribed aneurism.  I have also seen a varicose
dilatation of all the arteries of the hand and  fore-arm, extending up as
high as the tendon of the biceps.  It was at the fold of the arm that an
aneurismal sac  was  seen  by Physic, (Dorsey, Elemen. de Chirurg., t.
IL, p.  268, pi. 24,) of the size of an egg, between the vein and artery,
with both of which it communicated.
  It is not only for aneurisms at  the bend of the arm, but also  for those
which occupy the  upper third of the fore-arm, that we apply the ligature
upon the brachial  artery, in this region.   At  the present day it is even
much more frequently for these last that we have recourse to it, than for
the first,  since, in  such cases, the method of Anel obliges us  to carry
the ligature  to a point situated at a greater or less  distance above tho
elbow.
  A. The cure spontaneously, or with the aid of compression,  of aneu-
risms at the bend  of the arm, has been so often observed, that it has now
become quite a common thing. D. Pormarest (Biblioth deBonnet, t. IV.,
p. 104) relates the case of a patient who never would submit to an oper-
ation, and in whom the aneurism ultimately burst, and thus got completely
well.   A hemlock plaster, aided by astringents, purgatives, and  compres-
sion, succeeded with  Fabricius, of Hilden, (Ibid., p. 96,) for an  aneurism
of the  size  of an egg. We find in Plater (Bonet, Corps de Med., t.
III., p. 24) the case  of an aneurism of this kind, in which nothing was
done.  Demarque (Oper.  Citat., p. 404) cured four of these aneurisms
by bandages, aided by topical astringents.   Mouteggia speaks of a man
seventy-six years  of  age, who had the artery opened during a bleeding,
and whom it was proposed to cure by a bandage.  The patient could not
support this treatment.  Different accidents, which at first seemed quite
alarming, ultimately  disappeared, and with them the aneurismal tumor.
Galen cured an aneurism at the elbow, in a young man, by regular com-
pression.  Genga appears to have succeeded  often by the aid of a ban-
dage, generally attributed  to Theden.  White, Desault, Foubert, and
Scarpa, have given examples in  favor of this method, which the Abbe
Bourdelot gave popularity to, more than a century since, by having  ap-
plied it successfully upon himself.  I have, myself, employed it  with suc-
cess in two cases of recent varicose  aueurisra.  It has succeeded three
times with Mothe, (Mel. de Med. et de Chir., p. 61 et 66,) who, on the
other hand states,  that in another  case, it produced gangrene.   Compres-
sion appears likewise  to have succeeded in two rather imperfectly de-
scribed cases, by M. Heustis, (Jour, des  Conn.  Mid., t. III., p. 72.)
A young woman who had had the fold of the arm wounded by the cut of
a knife, came into my department at La Pitie ; on applying compression
to the  hemorrhage  she was apparently cured.   At the end   of fifteen
days the blood reappeared, and obliged  me to tie the brachial  artery.
  B. On the other hand, the disease may be  slow in its  progress, and
scarcely incommode the patient who is the subject of it.  " There occur-
red," says Saviard, (Nouv.  Recueil d' Observ., p. 272, Obs. 61,)  " an
aneurism of the  size of a walnut, at the bend of the elbow, in a man,
after bleeding; he carried it with him during sixteen years, and with- 
ARTERIES OF THE THORACIC LIMB.
817
out ceasing to labour in the coal mines."  Patients have thus lived along
for thirty years, (Senert,) and even fifty (Preuss.  Helwich.)  M.  Ribes,
(Gaz. Med de Paris, 1835, p.  161,) who has collected these cases cites
one which  continued for twenty-eight years.  Nevertheless, as this an-
eurism, sooner or  later, with  a few rare exceptions, ultimately com-
promises the life of the patient, the surgeon  is not  to be  influenced  by
any of those considerations.  In ordinary cases, if compression should
not appear  to the  surgeon to answer the object, or if he has tried  it
without advantage, he would be censurable not to have recourse prompt-
ly to the ligature.
   C.  Operation.—It was for aneurisms at the elbow only that the meth-
ods of  Aetius and  Guillineau  were employed, until Keisler, and the
surgeons of Italy,  had ventured to treat in tho same manner the  aneu-
risms of the popliteal space.  It was in that region also that Anel cured
one of these tumors without  touching it,  confining himself to tying the
artery above it;  a  process which Mirault, Bulletin de la Faculti, t. III.,
p. 312,) of Angers, was the first among us to immitate, in 1787.
   I. Though it be  generally conceded, that the method of Anel suffices
here, the operation is sometimes performed by the method of Keisler,
in diffused aneurism, for example, also in  varicose and in  circumscribed
aneurism where the walls are  very much attenuated or  disorganized.
The reason given  for it  in the  first place is that by confining ourselves
to tying the upper  end, we incur the risk  of having the  hemorrhage re-
turn by the  lower end ;  that in  the  second place, by obliterating the ar-
tery above, the  blood  will nevertheless  continue to pass into the vein
by the  communicating aperture; in the  third, that in this  state it  is
impossible to obtain resolution of  the aneurismal sac ;  and that  is ne-
cessary to  open it and empty it of  its  clots, to prevent gangrene ; and
that in every case we preserve a greater number of anastomosing branches.
   II. These motives, in  reality, do not demonstrate the absolute  neces-
sity of  the ancient method in such cases.  If the  tumor  does not  shrink
upon itself after the operation, or threatens  to suppurate, nothing pre-
vents our treating it as  a purulent collection.   To put a stop to the he-
morrhage, supposing that it continues  after  the ligature above a  recent
traumatic aneurism, compression, even  though moderate,  rarely fails  to
succeed.  Though it be true, that in a patient operated upon by the new
method, at the Hotel Dieu, the  progress  of the aneurism did not yield
to the  opening of the sac and  the  ligature  upon the two ends  of the
vessel, it is not clear from the details of the operation, that the humeral
artery was actually included in the  ligature at the time of the first ope-
ration.   Nevertheless, M. Guthrie, though a warm partisan of the meth-
od of Keisler, relates a fact on this point which affords room for  reflec-
tion.   A man had the  artery punctured by a lancet.  It  is tied  above.
The hemorrhage reappears, and  it is tied higher  up.  The hemorrhage
takes place again.   Amputation is performed and the patient dies.   It
was necessary, says the  author, to have tied not only the brachial,
but also the origin of the radial and of the ulnar.
   III.  As to varicose aneurism it must be admitted that a certain num-
ber of facts seem to justify the recommendation of treating it by the an-
cient method.  In  the operative surgery of Sabatier, we find four cases
of Dupuytren in support of this opinion.  In the first, in spite  of the
   Vol. I.                  103 
818            NEW  ELEMENTS OF OPERATIVE SURGERY. .

ligature by the mode of Anel, it became necessary to have recourse to
amputation  of the limb ;  in the second  there  came on a stiffness and
false anchylosis of the fingers, with other accidents, which also rendered
amputation necessary ; in fine, in the third and fourth, the patients  were
ultimately  restored by a second operation, which  allowed of tying tho
artery above and below the wound.   In a patient, whose case is related
by  M. Alquie (Gaz.  Med. de Paris, 1837, p. 347,) it was tied above:
upon  hemorrhage recurring, a second ligature  was placed above ; the
hemorrhage returned, and compression  was used ; another hemorrhage
recurred  ; rest in bed, and compression, effected the cure.
  Nevertheless, a case has since been reported, where a ligature upon
the brachial alone  sufficed (Archiv. Gen. de Mid., 2e serie, t. VI., p.
576) to cure a varicose aneurism at  the bend of the arm.  But there is
a previous question to be solved here.   Is varicose aneurism, in itself, of
a nature  sufficiently serious to justify such operations ?   What I  have
said above,  and a  recent  case of M.  PI.  Portal, (Clin. Chir., t. I., p.
203,) and that of M. Browa,(Arch Gin de Bled., 2e serie, t. X., p. 370,)
may authorize us to doubt if it  is.   I would not, therefore, decide upon
this course,  unless  the functions of the limb  were  disturbed to so great
a degree as to expose the patient to imminent peril.
   [Dr. Pancoast has repeatedly tied the brachial with  success for trau-
matic  aneurism at the bend of  the arm.  Where  practicable, he ties it
just below  the condyles.   Mr. Critchett of the London Hospital, and
Petrunti  of  Italy have likewise  reported successful cases  from ligation
of the brachial alone.  In old  cases,  Dr. Pancoast opens the sac and
applies ligatures above and below.
  M. Malgaigne advocates, in the Revue Medico Chirurgicale of  March
1852, a method of treating varicose  aneurism which is detailed in the
following case.  A man  forty-two years of age had  been affected for
several months with varicose aneurism at the bend  of the elbow, and was
subjected by M. Malgaigne to the following operation :—An incision, about
one inch in length, was made below, and quite close to the tumor, and the
artery tied  after a very careful  and slow dissection, the patient  being
insensible with chloroform.   The vessel was then tied in the same manner
above the tumor and  the pulsations ceased  immediately both in the tu-
mor and  the radial and ulnar arteries.   The lips of the  two wounds
were  respectively  brought together, and the arm, bent almost at right
angles, put upon a  splint, the limb being half-pronated, and resting on a
high pillow.   As the arm was rather cold it  was wrapped in  hot cloths  :
no untoward symptom occurred, and the wounds healed by second inten-
tion.  On the  24th day the cure was complete, the  tumor having quite
disappeared.  M. Malgaigne  states  that this operation offers much less
difficulty than searching for the two ends of the artery in the  aneurismal
sac.  As to Anel's method of tying the main trunk, it is altogether to be
discarded.   M. Malgaigne  cannot say whether this method  will answer
in other cases, but his success in this instance induces him to think that
the two incisions will  be extremely useful in cases where no  counter in-
dication  to this mode of operating  lies in the way.
  The application of ligature above and below the sac is not always suf-
ficient to arrest the hemorrhage as in the case of which Mr. Alcock has
given some plates in his  lectures on Surgery.  This patient died after 
ARTERIES OF THE THORACIC LIMB.
819
submitting to ligature of the brachial and to amputation, after the for-
mer method had  failed.   Mr Hilton, at Guy's Hospital, for false aneu-
rism, tied both above and below the wound.   Hemorrhage still  contin-
ued  from a collateral branch,  which  was tied.  The  patient died  21
days afterwards from pneumonia or purulent absorption, abscesses having
formed near the wound.  We have  already referred to the fatal case in
the practice of M. Roux.   G.  C. B.]

                     § III.— Operative Process.

   When we have once decided upon  tying  the brachial artery at the
elbow, whatever be the motive  that influences us, the following is the
manner in which it is to be performed :—
   1. The fore-arm being extended, and  separated to a greater or less
distance from the body, is turned back upon its dorsal surface, and kept
in a state of supination.   An incision is made three inches long, parallel
to the radial, or upper border of  the pronator radii  teres muscle, com-
mencing at near an inch  above  the internal condyle, and terminating in
the middle of the bend of the arm.  Under the skin are found the super-
ficial veins, particularly the median-vasilic vein, and the branches of the
cutaneous nerve which  accompany it.  An  assistant  is  charged with
holding them aside  with a blunt hook, or the end of a curved  sound.
When some of their branches  incommode  too much, or cannot be con-
veniently kept out of the way,  we should divide them between two liga-
tures, or even without this precaution, when they are of small size ;  we
then  come  to the aponeurosis, which  we must divide upon a grooved
sound.  Even though we might preserve the  bandelette of the biceps, it
is better to sacrifice it;  we are then much more at our ease for the rest
of the operation.  After having freed the artery of the lamellar and adi-
pose tissue which surrounds it;  and after having isolated it from the vein,
or the deep veins, as well as from the median nerve, we pass between it
and this last cord, the extremity of  a sound, which  is then carried behind
it to raise it up, while with a nail of the other hand we prevent the veins
from accompanying it, or from  getting  on the  point of the instrument,
after which there remains nothing more to conclude  the operation, than
to apply the ligature and dress the  wound.
   II.  The course of the blood  though  temporarily  interrupted, is soon
established by two anastomosing  circles, which the internal and external
collateral arteries of the  brachial form  around the external and  the in-
ternal condyles, by uniting with the recurrent branches of the radial and
ulnar.   Thus it is by no means  indispensable, as has been long supposed,
 (Monro,  Med. de Chir., etc., 1826, p. 354,) in order to explain this phe-
nomenon, that the artery at the elbow should be divided into two trunks
above the point obliterated.   As this caprice of nature, however, happens
quite often, the surgeon ought  not to forget it.  A young man receives
a cut from a knife in the lower part of  the arm.  Having tied the two
 ends of a large artery, I  believe the operation to be terminated, and pre-
pare for dressing.   But the hemorrhage reappears.  A second arte}7
 of the same size as the first was found at the  distance of more than half
 an inch upon the outside  of it, and obliged me to tie also the  two ends
 of that. 
820
NEW ELEMENTS  OF OPERATIVE SURGERY.
     Article IV.—The  Brachial Artery, properly so called.

                          § I.—Anatomy.

  It is in the middle of the bicipital internal groove  that the  brachial
artery is situated ; its course is indicated by a line drawn from the  hol-
low  of the axilla to the  middle of the bend  of the  arm ;  the  median
nerve which runs along side of  its radial border above  soon covers its
outer (or cutaneous) face and  crosses it very obliquely in order to get
upon its ulnar border far below.  Two satellite veins  ordinarily  accom-
pany it, or sometimes  cover  it, and thus separate it from  the  median
nerve ; the ulnar nerve and the internal cutaneous nerve which approach
it above, separa-te themselves from it more and more as they descend to
reach the internal portion of the fore-arm.  Resting against the humer-
us between the coraco-brachialis muscle and the  tendon  of the latissi-
mus  dorsi  outside  of it, it soon arrives upon the brachialis internus
behind the biceps which it accompanies to its termination.   In thin  sub-
jects the aponeurosis is almost  contiguous to it.   The whole is covered
as elsewhere by the common integuments.  Its anomalies are so frequent
that  no one is ignorant of them.  I have seen it divide itself into  two
trunks near the bottom of the axilla, at some inches lower down, at the
middle of the arm, above the elbow—in a word, at all parts of the limb.
In one subject one of the branches bifurcated at two inches from the in-
ner condyle to form the ulnar and posterior inter-osseous.   In another
this last was independent of the radial and of the ulnar.  The two trunks
sometimes  lie side by side with  each  other down to the fore-arm; at
other times they cross each other once or several times ; it is not uncom-
mon  to see one of them, most usually the ulnar, pierce the aponeurosis and
place itself immediately under the skin, while  the other which then  fur-
nishes the radial and the inter-osseous, preserves its natural relations.
  [Mr. Richard Quain  states in his work on the Arteries, &c. &c.  that
he has seen the trunk of the brachial artery separated by a considerable
interval from the biceps muscle, and he has observed  the high division
of the vessel in 64 out of  481 cases.  Professor Otto cites  an instance
in which the radial  artery was  entirely  absent, while the inter-osseal
was  larger, and gave to the hand the branch which is naturally  sent to
the radial.   T.]

                         § II.—Indications.

  The brachial artery may become the seat  of aneurismal  affections at
every part of its extent almost  indifferently ; but it is infinitely less dis-
posed to them elsewhere  than at the bend of the arm.   As nothing in-
terferes with their development, the tumors, to which these diseases  give
rise, are generally regular, acquire great size in quite a short time, and
rest  frequently at their central  portion over the opening of the artery.
   [Mr. Todd has reported in the Dub.  Hasp.  Reports, vol. III., a  case
in which he tied the brachial  for a spontaneous aneurism in the posterior
part of  the right fore-arm ; and Mr. Liston once tied the same artery for
an aneurism at  the bend of  the  arm, in a ship-carpenter.   Sir  Astley 
ARTERIES OF THE THORACIC LIMB.              821
Cooper refers to an aneurism of the ulnar artery, and  Mr. Arnott has
tied the brachial for a tumor presenting all the  characters of aneurism,
situated in the upper third of the  ulnar artery  of the right fore-arm.
Mr. Crisp states that there is one of the lower part of the radial artery,
in the museum of the College of Surgeons, London.   Mr. Barnard Holt
tied the brachial, for spontaneous aneurism of the right radial artery, in
October, 1853.   Pressure had failed in consequence of  the impossibility
of fixing the compressing instruments.   Prof. Syme has cured a case of
spontaneous aneurism  of the  radial artery by compression, (Month.
Journ. Ap. 1851.)  G.  C. B.]
   A.  Before recurring to the  ligature it is sometimes  allowable  to at-
tempt compression  and  refrigerants ;  the humerus  here  offers a point
d'appui which  signally  favors the advantageous  application of these
means.   It was to a wound of the brachial artery at its upper third that
Chappe employed compression with success.  M. Lisfranc speaks of a
patient who has four areurisms in the arm, and  who, during  the  space
of a year, restricted their growth by means of a laced stocking.  The
Queen of Bavaria and another personage of  the north were cured of  an
aneurism of this  kind by M. Winter, by means of a compressing  band-
age.  Also it was not until lately that the practice was  determined upon
of tying  the brachial  artery, properly so called.   Cheselden  scarcely
believes the surgeons who told him they had done it.   It appears, how-
ever, that Lanfranc (Portal, Hist. Anat. et Chir., t.  I., p. 191) had
already  recommended it; Morel, (Jour, des Nouv. Decouv., t. III., p.
212,) going still farther, performed it in 1681, and  S.  Formi, (Riviere,
 Obs. de Med., p. 628,) as well as Tassin, (Chirurg. Milit., etc., p. 35,)
each relate a curious instance of it.   We should do wrong, however, to
deny the dangers of this ligature.   Palsy, says Schmucker, was the con-
sequence of it  in one case, though the nerve had been avoided.  In a
patient of M. Kraemer (Sprengel, t. VII., p.  348, 349)  it gave  rise to
tetanus.   A patient whom I operated upon at La Charite, in 1838, was
seised with paralysis at the  moment of the  operation; but it is  neces-
sary to remark that in him the wound had seriously implicated  the  soft
parts of the neighborhood.  M. Arbey, (Dissert.  Citee, Strasbourg,)
who, for a wound from  a ball, placed his ligature in the upper  third of
the arm, found gangrene supervene, and was obliged to amputate^
   B. It is nevertheless upon the humeral artery that  the operation for
 aneurism is most frequently performed, and upon which agopression, de-
vised by M. Giaccich, (Agopressure, Sec, Mai 1837,) might be made
trial of.   There the vessel is  superficial, easy to seize and surrounded
by parts that are sound  and not changed, while in front of the articulation
the presence of the aneurism  so masks  its  position that we sometimes
have much difficulty in  identifying it.  Nevertheless we ought, as a gen-
 eral  rule, to apply the  ligature here as low  down as the disease will
 permit.   No circumstance apparently, with the exception of a diffused
 aneurism and a fresh bleeding wound would justify a preference for  the
 ancient method.  If the aneurism  extended to high up we should decide
 rather upon tying the axillary in the hollow which bears its name, unless
 it should be judged advisable to put into practice the method of Brasdor.
   [Some two years since Dr. Van Buren thought proper to tie the subcla-
 vian for a rapidly increasing false aneurism  extending  from the arm into 
  822            NEW ELEMENTS OF .OPERATIVE SURGERY.

  the axilla.  It was caused by the thrust of a knife, " on  the inside of
  his right arm,  just above its internal condyle, and  passed upwards and
  forwards in the direction of the main vessels of the limb."  His reasons
  for deviating from the established rule in this case, were, that the position
  of the wound in the artery could not be  ascertained with  sufficient cer-
  tainty to warrant  a  search for it; and  that three weeks had elapsed
  since its  occurrence, and there was  the best evidence of the existence
  of a fluctuating pulsating  cavity,  of large size,  communicating with
  the  wound of the  artery.  The  successful  result in this  case,  Dr.
  B.  thinks,  shows  that  the ligature of the main  arterial trunk  was
  the appropriate remedy.  (Trans. Med. Soc. State of New York, 1853.)
  Mr.  Erichson remarks, (Science and Art of Surgery, p.  141) that he
  doubts whether there is a case on record of diffused traumatic aneurism
  treated on the Hunterian principle, that has not terminated in danger or
  death to the patient, and in disappointment to the surgeon.  In addition
  to the above case of Dr. Van Buren,  others may be found in the remarks
  of Dr. Mott on Aneurisms, infra.   G. C. B.]

                      § III.— Operative Process.

    A.  The limb being placed as before described, and  properly kept
  apart from the body, the operator  seeks for the groove of the biceps,
  carries the bistoury, in the direction of the arterial line from above down-
  wards, if it is the  right arm, and  from  below upwards if it is the left,
  and  makes an incision of from  two to three inches through the integu-
  ments.  Immediately after, he places his left fore-finger  in the wound,
  endeavors to feel the median nerve which presents itself under  the form
  of a rounded cord of considerable firmness, and to distinguish it from the
  artery which is  recognized by its pulsations ; afterwards  dividing suc-
  cessively upon the director, the aponeurosis and the sheath which  it give
  to the nerve, he tears, and always with  the  point of the  sound the cel-
  lulo-fibrous envelope of the  vessels ; isolates the artery from the veins
  which surround it, and  applies the  ligature.   This operation  can only
  become difficult in consequence of an anomaly or change in the relations
  of the parts which it is important not to confound.  The  median nerve
  is the first cord that presents  itself behind the biceps muscle ; I have
  but once seen it under the artery, between that and the brachialis internus
  muscle.  When we have once identified'it, we may be sure the vessels
  are not far off.
    B. Since in  a young man who came to La Charite, in 1837,  it was
  found sufficient to compress the  brachial  artery for the space of  twelve
  hours to avoid  the necessity of a ligature upon the ulnar which  had been
  wounded ; and since, in  the case of M. Wytheroeven, a strangulation of
  thirty-six hours produced the same  result after a lesion of the arteries
i  of the arm, we may understand  how the temporary ligature has in such
;  cases succeeded with M. Malago (Bull, de Firussac, t. XVIII., p.  82,)
  who removed it upon the fourth day ; with M. Bologna, (Jour,  des  Pro-
  gris,t. XVII., p.  248,) who left  it  on only three days;  and with M.
  Dolcini, (Bull,  de Firussac, IL,  p. 334,) who also removed  it  on the
  fourth day.
    C. Shall I add that  Formi used only the  indirect ligature  and that 
ARTERIES OF THE THORACIC  LIMB.
823
Buron (Tessin, Chir. Milit., p. 35) succeeded in the same manner with
the following case ?  In a sword-cut the artery was opened between the
two wounds, that is, at the middle part  of the arm.   It was  eight days
before it was perceived that the artery was wounded.   At the expiration
of this period, during a fit of passion of the patient, the artery bled afresh,
and all the remedies  proved unavailing.   Buron pierced the arm in the
belly of the biceps  near the  bone, with a carlet threaded with a double
ligature, which he  tied tightly upon compresses.  To prevent mortifica-
tion he slackened the ligature on the day  after, and so  on successively
ou  the following days.   The patient  was cured.
   Embarrassed by  the swelling of the limb, in a case  of gangrene suc-
ceeding to a wound  of the  brachial artery, M. Petrunti  (Gaz. Mid.,
1839, p. 186) tied  the vessel by passing a  riband through the arm, with
a seton-needle, and secured it by a knot on  the skin and a graduated com-
press.  The success was complete, and the  author says that his preceptor
succeeded in  the same manner with  a soldier.   A military surgeon, M.
Haspel, (Gaz. des Hopit., 1839, pp. 190,  191,) has seen, also,  wounds
of  the palmar arch, of the dorsalis pedis, &c, cured without the neces-
sity of ligature.
   D.—When  the   brachial  artery is obliterated, the circulation  is re-
established below it, by means of the muscular branches which  it gives
off throughout its whole length, by the great collateral or external col-
lateral artery, and by the  great  anastomosing branch, when it  has not
been sacrificed.
   [The following  diagrams, borrowed  from the Traite de  Pathologie
Externe, See, of M. Vidal,  may serve to remove some  of the confusion
arising from the different significations attached to the terms  aneurismal
varix, varicose aneurism, arterio-venous aneurism, &c.
  Fig. 1.—Aneurismal varix: a artery; v vein; o opening made by lancet in the  vein; the
white point opposite, is the opening of communication between the two vessels.  Fig. 2 —vari-
cose aneurism; artery and vein separated by an aneurismal sac, formed in the cellular tissue:
o opening in vein, directly opposite to that communicating between the vein and sac, beyond
which is another opening leading from the sac to the artery.  There is also a dilatation of the
vein.  There are, therefore, two tumors, seated one directly above  the other.   Fig. 3.—Late-
ral varicose aneurism; s sac on the side of the vessel, which have  been simultaneously punc-
tured; a artery, v vein.  The blood, instead  of dilating the vein,  forms  a cyst between the
vessels, as in Fig. 2. A remarkable variety is represented in Fig.  4, and described by M. A.
Berard, in his Memoir read before the Society of Surgery, 1843.  It is the subcutaneous vari-
cose aneurism.  The artery a, and the vein v, are completely united. The opening communi-
cating between them, has only the thickness of the consolidated walls.   On the opposite side
of the vein, between it and the integuments is the aneurismal sac  s, situated in the bend of
the elbow, having all the characters of a false consecutive aneurism. The above figures repre-
sent the principal varieties of this form of aneurism.  G. C. B.] 
*24
NEW ELEMENTS OF  OPERATIVE SURGERY.
   [Varicose Aneurism at the bend of the arm in bleeding, cured by pres-
sure.__Mr. Liston, (See his lectures, London Lancet, Dec. 21, 1844, p.
361,) says he has seen several cases of aneurism at the bend of the arm
from the operation of bleeding, [whether varicose  aneurism or aneuris-
mal  varix, or both, he does not specify.   T.] completely cured, if acted
upon immediately, and before the blood is much effused into the cellular
tissue.  This cure  consists in strong compression, beginning with the
roller bandage upon each finger separately, and passing around the hand,
in the palm of which  must be placed a compress.  You proceed  firmly
with the turns upwards, till you reach the wound, over which, after hav-
ing properly adjusted upon it, first a small, and then three or four other
compresses in order to obtain a proper elevation for them, you  twist the
remaining turns tightly over these, and in all probability, he says, you
will  prevent an aneurism.
   But when the aneurism is formed, it will do so speedily by the astonish-
ingly rapid condensation of the cellular tissue, by which means a regular
cyst is produced.   I have, says Mr. Liston, a preparation of an  aneurism
of two or three days' growth, with as regular and beautiful a cyst, as you
would wish to see in any aneurism.
   Cure by Pressure.—Mr. Liston believes that such aneurisms are some-
times cured by pressure ; which should be made by bandaging the lower
part of the limb, by which means  the patient will be enabled to bear the
pressure of a sort of ring-tourniquet on the  brachial artery, maintained
by a proper apparatus, which admits of being  regulated by the patient
himself.   In conformity with the  sound  views  of pathology adopted by
the Dublin surgeons, in the cure of aneurisms by compression, Mr. Lis-
ton says, it is only necessary to retard the flow of  blood into the tumor,
so as to favor coagulation of its  contents;  and this is to be effected  by
continued but not violent compression.
   Mr. Liston says, he has seen  more than  one aneurism disappear in
consequence of the application of pressure.   One was a case of brachial
aneurism, where the  pressure was made on the tumor itself.  Mr. Old-
know, according to Mr. Liston, (lb. loe. cit.) a surgeon of Nottingham
of extensive practice, had a similar case cured in the same way.
  There is no doubt, says Mr. Liston, that much is to be done for aneu-
rism, in some situations, by pressure well applied.
  Where  however, you have for  such accidents to resort  to ligature on
the brachial on the arm  above, be careful to ascertain, while the artery
is raised up from the edge of the biceps, that it is the trunk, which you
will  know by pressure upon it suspending pulsation in the tumor.   Oth-
erwise from the occasional high division of the brachial you may tie only
the ulnar.
  But where the tumor from the anastomosis being so strong is not di-
minished, the ligature on the trunk of the brachial itself will not answer,
and  we are then to cut down on the  tumor itself, and tie  both  ends of
the wounded vessel.   This M. Liston thinks the best plan in a recent
aneurism  in this part; also where pressure had been imperfectly made
on such  aneurism, or  ulceration had taken  place  over the tumor, pro-
ducing alarming hemorrhage.
   In wounds of the hand, laceration or evulsion of the thumb or one or
more fingers, where the  superficial  palmar  branch has been wounded 
ARTERIES OF THE THORACIC LIMB.
825
and pressure proves ineffectual in preventing extensive tumefaction of
the parts, inflammation, diffused aneurism, abscess, severe and repeated
hemorrhages, &c., from effusion and infiltration of blood from the wound,
M. Liston thinks, (London Lancet, Dec. 21,1844, p. 362—363,) the best
plan is to tie  the  brachial at once.   It will not do  to  tie the radial
or ulnar or both, for blood will still  be furnished from the  deep-seated
palmar arch, by means of the inter-osseous.
   The Brachial Artery Ruptured.—A case is related, (Lond. Med. Gaz.,
May 16, 1845, p. 130,) in which the brachial artery was found ruptured
and the upper  extremity  of the divided vessel retracted high up in the
axilla.  This accident occurred in a young  man aged  18, from fracture
of the head of the humerus  and glenoid cavity, with protrusion of this
extremity of the bone, caused by the  arm being caught  in machinery.
The patient was received into the infirmary of Newcastle-upon-Tyne,
and died of erysipelatous symptoms occasioned by the injury, without any
attempt being made to disarticulate  the bone  or to  place a ligature on
the upper extremity of the ruptured vessel.  T.]
                                    ■
                  Article V.—Axillary Arteries.

                          § I.—Anatomy.

   Under the name of axillary artery  I shall speak only of that  portion
of the arterial trunk, which extends from the clavicle to a level with the
lower border of the great pectoral muscle.  We may regard  it in two
points of view,  either  in the hollow, or on the anterior surface of the
axilla.
   A. In the first it is separated from  the skin, only by the two roots of
the median nerve, this nerve itself, the axillery vein, a cellular filament
ous and adipose layer of tissue, increasing in  thickness as we approach
the apex of the axilla, and by the aponeurosis and a second  cellular
layer.  The thoracic, sub-scapular, &c, cross it, and conceal it at differ-
ent points ;  the  other nerves of the brachial plexus, at first situated in
front of it, soon pass behind it to reach the ulnar side of the arm.   Out-
wardly it rests against the tendon of the sub-scapularis muscle, and the
scapulo-humeral articulation, the  head and neck of the humerus, between
the tendon of the teres major, which is behind, and the pectoralis minor,
or the coraco-brachialis, which are in  front.
   B. In its other portion, (i. e., on the anterior surface of the axilla,)
it is situated at a much greater distance from  the  skin ;  the  pectoralis
minor crosses it at two or three inches in  front of the  clavicle ;  a fibro-
cellular membrane, sometimes quite dense, conceals its position, and sep-
arates it from  the pectoralis  major muscle.   The vein  is situated upon
the inside, and  toward the chest, and the  anterior root of the median
nerve upon the outside and towards the shoulder, so that both, in part,
cover the artery, which is in the  interval, and a  little  behind ; an ar-
rangement nearly constant, and which may  prove of the  greatest assis-
tance in  the operation.   The  cephalic vein, as well as those which go
from the stump  of the shoulder, to empty themselves  into  the axillary
vein, below the  clavicle, are obliged to cross its anterior surface.   It is
the same with one or two thoracic branches of the nervous  plexus : the
   Vol. I.                    104 
826
NEW ELEMENTS OF OPERATIVE SURGERY.
axillary artery gives off the acromial artery, and the principal external
thoracic artery, before passing under the pectoralis minor muscle.
   C.  Lower down the median nerve is, in front, the ulnar outside, the
radial behind,  and the vein on  the inner side of the artery, so that it is
found almost completely surrounded by those parts, to which it is also
united by  a cellulo-fibrous sheath of considerable firmness.

                         § II.—Indications.

   Aneurisms and wounds of the axiliary artery claim the most  serious
attention.   Though less frequent than  at the ham, groin, and bend of
the arm, they are more so than on any other points of the limbs ; which
is  explained by the position and size  of the vessel, its relations with the
articulation, and  its proximity to the heart.   All kinds of aneurisms are
found on this  artery,  even  varicose aneurism has been seen here by M.
Larry, (Clin.  Chir., t. III., p.  142,)  Dupuytren,  and M. PI.  Portal,
(Op.  Cit.,n. 204.)  The  reaction which they  produce  on  the  nerves,
veins, and ganglions, and on the  articulation, and on all the surrounding
parts, make  aneurisms of  the axilla  a  serious disease, which has long
been a source  of  apprehension  to  surgeons, and was generally  looked
upon as beyond the resources of  art, until  at the conclusion of the last
century.
   A.—Van  Swieten,  (Comment., t.  I., § 161,)  however, had already
mentioned a traumatic aneurism in this region, which got well spontane-
ously, without necessitating the loss of the limb.   M. S. Cooper also
mentions a patient in St. Bartholomew's hospital, who was cured of an
aneurismal tumor in the axilla, without any assistance.   Sabatier effect-
ed the dispersion  of another by the method of Valsalva, and refrigerants.
But the patient was  less  fortunate  in  the  following case reported by
Chabert:  (Obs. de Chirurgie, p. 95; Obs.  41.  1724, in-12,) from the
cut of a sword a slight hemorrhage took place an hour after the wound;
a second hemorrhage on the eighth day, and a third on the eighteenth;
the treatment was incision, compression,  vitriol, &c.   On the twenty-fifth
day a fourth hemorrhage, to a considerable extent; on the twenty-ninth
day a fifth hemorrhage.  The jet of blood equalled the size of the thumb,
and was followed by instant death.   The artery being laid open length-
wise, was  found  dilated and engorged with coagulated blood up to the
first rib.
   Hall, about  the middle  of the last century, and Keate, in 1801, tied
the axillary artery with entire success.  This operation, which was then
thought new,  was not so.   A surgeon of La Charite, Morel, (Jour, des
Nouv. Dicouv., 1681, t. III., p. 70-75, Zodiac, Med., t. IL, p.  25,) of
whom  Saviard often speaks, had performed it with success for an  aneu-
rism,  before  1681.  Another surgeon, Baader,  (Portal, Anat. Med.,
t.  III., p.  233,)  according to  Portal, also  had  recourse to  it in the
last  century.   There is  also  a case of it in Formi, (Bonet, Corps, de
Mid., t. IV., p. 191,) who says that the  ligature  was required for a
wound.   But  in this  case  it was rather the brachial than the axillary,
to which  an indirect  ligature was  applied.   It is, therefore, no longer
allowable to think of amputation in the joint for this disease  as Gooch
still advises, and as was  the practice before the modern labors on this 
ARTERIES OF THE THORACIC LIMB.
827
subject, nor can I, in  reality, decide if it was more indispensable in the
case of  diffused aneurism, published in 1812, by M. Debaig, (These No.
144, Paris, 1812,) than in the case which was published by M. Auchin-
closs, (Edinburgh Medical and Surg. Journ., April,  1836,  p. 332,)
in 1836.
  The cures obtained through the aid of the system, the reducing treat-
ment, digitalis, purgatives, or cold topical  applications, are too uncer-
tain, as it seems  to me, and in too small  number to authorize us to de-
pend upon them.  The operation,  which is incomparably more  sure,
should be preferred as often as it is practicable.  White (J. Bell, Trait.
des Plaies, trad. Franq., p. 81) attempted it, it is true, without success.
The limb was attacked with gangrene, but the nervous plexus had been
included in the ligature.   Desault (CEuvres Chir.,t.  II., p.  52) met
with the same misfortune ; but he  embraced also, in a first ligature, the
whole brachial plexus.  In another case  he could not master a hemor-
rhage, which  soon terminated  fatally. In the case of Pelletan (Clin.
 Chir., t. II., p. 52) the whole thickness of the armpit was traversed by
a needle, and the artery was not secured.   Another attempt of Desault
is related, in which he was equally unsuccessful.   M. Roux says, that a
patient died at the hospital of Beaujon, in consequence of  a similar  at-
tempt.   Delpech, who thought it advisable to cut through the pectoralis
minor transversely, aud to  raise the whole axillary plexus  with the left
fore-finger, curved as a hook, in order  the  better  to isolate the artery,
was not more fortunate in  1814.   The  patient of M. Blasius (Arch.
 Gin. de Mid., 2e  serie., t. IV., p. 140) died at the expiration of two
hours, and the autopsy did not enable them  to  discover the arterial
branch, which gave place to such repeated hemorrhages. It was neces-
sary to have recourse to the Bonnafoux powder, and to  compression
above the  clavicle, to arrest a  hemorrhage, on the eighteenth  day, in
the case related  by M. Castanoso, (Lane Fr., t.  XII., p. 192.)   But
these unfortunate  cases prove nothing against the operation; the fault
is in  the. processes  employed, or in the unfavorable circumstances in
which the patients were  then placed  at the time.  To the  successful
cases mentioned above, we may add others which belong to M. Maunoir,
MM. Chamberlaine, Monteith, (The Lancet, t. I., p. 730,) Roux, (II.
Berard, Diet, de Med., 2d edit., p. 497)  and H. Berard.

                      § III.— Operative Process.

   A. Ancient Method, or by the Hollow of the Axilla.  If there should
remain  a free  space  above the tumor, or  that the  case should be one of
a simple wound in the apex of the  axilla, it would  be better, as M.  Hall,
M. Maunoir, M. Blandin, and  M. Berard, have done,  to seek  for  the
artery  in the hollow of the  axilla, than to  divide the  anterior wall of
this cavity.
   I. The patient being laid upon his back, and the limb held  apart from
the  body as far as possible, we make an incision of three inches in  ex-
tent, parallel to the vessels, and a little nearer  to the  anterior than to
the  posterior wall of the axilla ; fhe skin, a  cellular tissue, and  a
filamentous aponeurosis, present themselves successively, as in the arm.
The sound  performs the rest  of the operation;  its point pushes  the 
828
NEW  ELEMENTS OF OPERATIVE SURGERY.
  median nerve forward and outward, afterwards glides behind the artery,
  to separate it from  the  ulnar and  radial nerves, raises it up a little, to
  pass between it and the vein, which latter, the nail of the fore-finger,
  or thumb of the other hand, endeavors to push aside inwards and back-
  wards.
   II. The patient, of whom G. Bell speaks, had  received  a cut from
 a scythe, and was found in a  state of syncope, which had suspended
 the  hemorrhage.  Hall,  (Bell,  Oper. Citat., p. 82,) in consequence,
 confined himself to seizing and  tying the  upper end of the artery.   The
 patient  of Maunoir  had  received a sabre cut; the  wound was mere-
 ly dilated, and  the surgeon  applied one ligature above, and  then
 another  under  the wound of the vessel.   M. Blandin, (These de Con-
 cours, 1833, p. 5,) who  operated for a gun-shot wound  does not say
 what became of his patient; but a patient in whom the brachial artery
 divided  by a ball, gave rise to repeated hemorrhages and which compell-
 ed M. H. Berard (Archiv.  Gen. de  Mid. 2e serie, t. VII.,  p. 442) to tie
 the trunk  of the  axillary artery  by this process, recovered perfectly.
 Moreover, it  is  evident  that for an  aneurism, properly  so called, the
 method, by the opening  of the sac, would here be very dangerous, and
 too dangerous, in fact, in any case,  to be  resorted to.
  B.  The new method, or in front of the axilla.  When it is not possi-
 ble to  employ the process which I have  described, ought we to pene-
 trate in  front of  the  axilla?  Would it not be better, and more prudent,
 to endeavor to find the subclavian behind the clavicle, or 'would it not
 be as well to make trial of the method of Brasdor, by applying the liga-
 ture  below the tumor?   This  double question appears to me to be easy
 of solution.  If the  tumor occupies  the hollow of the  axilla, we must
 cut down at the supra-clavicular depression.  It would be  difficult to
 find a sound portion  of the artery in operating below the  clavicle.   If,
 on the contrary,  there remains a void above tho aneurism, it is by  the
 apex and hollow  of the axilla that we must arrive at the vessel, the same
 as if it was a case  of wound.  I come to  the  conclusion, therefore,  that
 the ligature upon the axillary  artery, through the anterior  wall of the
 axilla, is useless, and ought not  to be attempted.  If the  sac was  suf-
ficiently high up to allow  of placing the ligature between  its lower ex-
tremity and the origin of  the circumflex arteries, and the common scap-
ular artery, we might have every possible  chance of success, by adopt-
ing the process of Brasdor.  On the supposition, however, that the sur-
geon should decide on applying the ligature through the anterior wall of
the axilla; there are a number of processes by which this may be accom-
plished.
  I.  Process  of Desault.—Desault  incised the soft parts  within the
 coraco-deltoid line, and cut the pectoralis major upon the grooved sound ;
 in case of necessity, we  should divide the pectoralis minor itself, in or-
 der to lay bare  the  whole of  the  brachial plexus, to seize it  with the
 thumb and fore-finger of  the left hand, and to isolate the artery careful-
 ly from it as low down as possible.   It would not, it is true, be absolute-
 ly indispensable to adopt this process, made more exact in other respects
 by the new description which M. Marchal (Thise No. 156, p. 14, Paris,
 1837,) has given of  it, except we wished  to operate by opening the sac ;
 but if it was prudent or  possible to tic the axillary  artery above the tu- 
ARTERIES OF THE  THORACIC LIMB.
829
mor at this line, and that we should not wish to penetrate by the hollow
of the axilla, it might still be admissible.   Though adopted by Delpeau
in 1814, and though others have put it in practice  since, I  do not, how-
ever,  think we ought to consider this, or those that follow, in any other
light  than as cases of extreme necessity, or the  last  resource at our
command.
   II.  Process of Keate.—The incision of M. Keate was  directed ob-
liquely downwards and  outward ;  it included a part of the  pectoralis
major, without dividing it entirely through ;  but the first ligature was
applied too low  down, and it became necessary to have recourse to a
second one, quite near the clavicle,  which probably would not have hap-
pened, if, before passing a curved needle into the bottom of the wound,
M. Keate had taken the  precaution to isolate the artery with a grooved
sound.
   III. Process of M. Chamberlaine or of  Pelletan.—The course of M.
Chamberlaine, in other  respects conformable to the first proposition of
Pelletan, was more systematic and reasonable.  This  surgeon judged it
advisable, first, to make a transverse incision three inches long on the
fore  part of the  clavicle;  he then  made a second, of the same length,
parallel to the cellular line which separates the pectoralis major from the
deltoid, turned  down  the triangle circumscribed by this incision of an
L reversed, and  the artery, which he recognized by its pulsations, then
presented itself to view: an eyed-sound served for passing  the ligature.
This was the 17th of January 1815, and on  the 22d of February the cure
was completed.
   IV. Process of M.  Hodgson.—M. Hodgson rejected this double in-
cision.  According to him, (and M. S. Cooper adopts his opinion,) the
best method consists in cutting a semi-lunar flap,'with the convexity down-
wards and the  extremities of which, separated by an interval of three
inches, correspond  with the clavicle, near the sternum  inwardly and to
the acromion outwardly.  After having raised up this flap, which  com-
prises the whole thickness of the pectoralis major, the upper triangle of
the axilla remains free, and the artery may  be easily isolated and seized
between the clavicle and  the pectoralis minor muscle.  Nevertheless, we
may reproach M. Hodgson, as well  as M.  Chamberlaine, with uselessly
sacrificing a great portion of the  pectoral and deltoid muscles ;  so that
in France a process has been specially recommended, which is nearly sim-
ilar to that which M.  Ch. Bell  describes  and figures, being the same
nearly as that of  Keate.
   V.  Ordinary Process.—The limb is first slightly held apart from the
trunk, and  the shoulder thrown downwards (dejetee) and a little back-
wards.
   a.  First Stage.—The surgeon, placed between the chest and the arm,
commences the incision at two fingers' width outside of  the sterno-clav-
icular artciculation, and prolongs  it to below the coracoid process, in the
direction of the  fibrous bundles of  the  pectoralis major muscle, taking
care to stop at some lines from  the deltoid insterstice.   If any small ar-
tery should show itself under the skin, the ligature should be immedi-
ately  applied to it; the  fleshy  fibres  should be gradually separated by
the bistoury, rather than divided  by it; a yellowish layer is then very
distinctly seen, which shows that the muscle has been divided, the fibres 
830            NEW ELEMENTS  OF OPERATIVE SURGERY.
of which  are  then relaxed by depressing the limb a little, in order the
more easily to keep  apart, or cause to be kept apart, the  lips of the
wound.
  b. Second Stage.—However little  danger there may be of wounding
any vessels, the sound should be made to replace the cutting instrument.
With its extremity we tear the adipose or cellular layer and the coraco-
clavicular aponeurosis, while the left fore-finger, curved as a hook, de-
presses and forcibly  pushes  down the upper  border of the pectoralis
minor.  The eye soon sees either the vein, which is recognised by its
size  and its blueish aspect, or the first nervous branch of the  brachial
plexus.
  e Third Stage.—In order to find the artery  which is between and
behind these two cords, [i. e.,the vein aud nerve above.  T.] the sound
is carried to the outer  side of the vein, which is to be pushed a  little
towards the thorax ; then, by movements forwards  and backwards, we
make the extremity of the instrument  penetrate perpendicularly to the
depth of four to six lines, so that in elevating it from behind forwards
and from within outwards, it does not fail to bring up the arterial trunk,
from which we then separate the nerve with the finger or the point of
another sound.
  d. This process, which appears so simple on the dead  body, and which
I have considered the best, is nevertheless the most difficult  of all  upon
living man. Convinced, as we are at the present time, of the little dan-
ger there is in wounds of  the  muscles, I should not hesitate to prefer,
instead of this process, that, of MM. Hodgson, Chamberlaine, Manec, or
Marchal, if I were obliged to apply a ligature in this region to the truuk
of the axillary artery.
  VI.  With these precautions, the secondary  vessels and the nervous
filaments, on the dead body at least, are easily avoided, and the axillary
artery reached with  certainty.  By placing  the ligature immediately
below  the cephalic vein, we are almost  sure  of encircling  the  axillary
artery between the  acromials  which we leave above, and the  external
thoracic which are found  below.  The  supplemental branches, charged
with keeping up the circulation in the limb after this operation, are, the
acromial, the sub-scapulary, the transverse cervical, the internal mam-
mary,  and  some others less  important, which all anastomose with  the
circumflex, the common scapulary, and the internal  mammary.
  [Ligature on the Axillary  Artery or Axillary Portion of the  Sub-
clavian.—Instead of tying the subclavian for wounds of the  axillary
portion of this artery, Mr. Liston prefers tying both the divided ends
of this last portion, (Lond. Lancet, Dec. 21, 1844, p.  361,) if  called in
time.  You can tie immediately under the clavicle in the first  part of
its course, or low down.  In the middle portion, he considers it difficult,
from the nerves interlacing it.  You reach the vessel by dividing freely
the fibres of the pectoralis major in the direction of their  course.  If
the artery is wounded in the lower third, you cut down under the border
of the pectoral, by which you  may tie it pretty nigh up in the axilla,
without interfering at all  with the muscular fibres.
   Ligature on the Axillary Artery below the  Clavicle.—The right axil-
lary artery was  tied in Sept., 1842, (Ann. de la Chir. F. et E.,  Jan.,
1843, aud Cormack's  London  Se  Edinb.  Month.  Jour.,  May  1843, 
ARTERIES OF THE THORACIC LIMB.
831
p. 473,) at Messina, (island of Sicily,) by Dr. Catanoso, in a peasant aged
33, who in falling from a tree, had lacerated the  vessel by receiving a
wound in the axilla from the pointed  branch  of a limb,  causing  consid-
erable hemorrhage, which was controled at first by ice and other appli-
cations ;  but recurring afterwards, it  was thought  advisable to perform
the operation, which was effected on  the  11th  day  from the accident.
The incision was carried from the inner edge of the clavicle, to within
about an inch of the sterno-clavicular articulation.   The upper edge of
the pectoralis  minor was now seen, and immediately above this the artery
was found  pulsating.   Finally it was isolated, and secured by  means
of  a fine*silk ligature, which was cut  off  close  to the knot.  On tight-
ening the ligature, the brachial and radial arteries  ceased to beat, and
the whole  extremity became cold.  It was rolled tightly  in  flannel.
Next day the limb was found warmer ; but after a continuance of favor-
able symptoms till the 19th day  after the operation, secondary hemor-
hao-e ensued, which was arrested by compression upon  the  subclavian;
this hemorrhage having occurred while the dressings were being removed
from the wound, at the bottom of which the blood was  seen jetting out
from a hole of  about  the size of a  goose-quill.  Plugging  ultimately,
 completely arrested the hemorrhage,  but the wound healed slowly, and
 the arm, for along time after the cure, remained somewhat atrophied and
 impaired in its movements.   T.]


               Article VI.—The Subclavian Artery.

                            § I.  Anatomy.

    Many authors have described the axillary artery as composed of  two
 portions : the one, that which I have just examined, situated under the
 clavicle ; the other, between this  bone and  the scaleni  muscles.   Noth-
 ing can justify such an abuse of anatomical language, which I regret to
 find still sanctioned in an excellent article of M. H. Berard, (Diet, de
  Mid., t. IV., art. Axillaire, 2d edit.)  The  arterial trunk  of the  arm
  ought not to take the name of axillary  until it enters  into  the  axilla ;
  up to that point the proper name  for  it is the subclavian artery.  I  see,
  with pleasure, that M. Cruveilhier has  adopted this opinion, any other
  than which leads, in fact, to error and confusion.
    K.—Within  the scaleni  muscles, the subclavian artery, which is ex-
  tremely short on the right  side because  of the  brachiocephalic trunk,
  has on its posterior surface some  filaments of the great symphatic, then
  the pneumo-gastric, the nhrenic and  the branch  of the  pneumo-gastne
  which connects the second  with the third cervical ganglion, cross its an-
  terior surface—all which organs are  then covered by the  sterno-thyroid
  and sterno-hyoid muscles, various cellular lamellae, the internal border of
  the sterno-mastoid, the aponeurotic layers of the neck, and the common in-
  teguments.  Below, the recurrent nerve embraces it, while its concavity is
  separated from the lung only by the pleura or cellular tissue.  It is in this
  Short space that it gives off the vertebral, the internal mammary, the thy-
  roid, the transverse  cervical, the ascending cervical, the deep cervical,
  and the superior intercostal.  On the left side, the subclavian within the 
832
NEW ELEMENTS  OF OPERATIVE  SURGERY.
 scaleni ascends almost vertically from the arch of the aorta to the bor-
 der of the first rib, separating itself by degrees from the corresponding
 carotid.   The pneumo-gastric nerve descends on its inner side ;  the  re-
 current nerve does not cross it behind, because it is not until after it has
 embraced the arch of the aorta, that it ascends upwards  towards the
 trachea.  The thoracic duct lies very near its posterior surface, and or-
 dinarily bridles it above, before emptying itself into the left  subclavian
 voin.   This vein, which is separated from it by a very considerable space,
 crosses it  at a great distance, while on the right side the  artery is  prin-
 cipally covered by the termination of the internal jugular.
  In all these and other aneurisms, Mr. Liston says  he has  found the
 common aneurism needle, like that of Weiss, quite sufficient, as he has
 put a ligature with it on  all the vessels  of the neck and all those of the
 extremities, (lb. ib., p. 308,) but considers  those of Gibson, Mott, &c,
 complicated.  (Ib. ib.)   T.]
  B.—Having become horizontal, the subclavian presents the same rela-
 tions on both sides, and lies naked  ou the first rib ;  the  lower  attach-
 ment of the anterior scalenus muscle separates it from the vein, and this
 latter separates it from the sternal portion of the sterno-mastoid muscle;
 all the nerves of the brachial plexus are above and behind, so as to form,
 in prolonging themselves on the anterior surface of the posterior scale-
 nal muscle, a kind of net-work, of which the artery  constitutes the first
 radius.
  C.— Outside on the scaleni muscles, the subclavian artery corresponds
 to the supra-clavicular depression, and rests against the first intercostal
 space, the second rib, and the first bundle of the serratus magnus muscle.
 The vein which approaches it and covers it while descending a little to-
 wards the clavicle, receives there the sub-scapular vein, the external ju-
 gular, and  sometimes the acromial veins.   It is accompanied on its supe-
 rior border by the united  branches of the last  cervical pair  of nerves,
 and of the first dorsal;  then, a little farther on by the other branches
 of the brachial plexus, which soon  pass behind ; so that it is constantly
found in the triangular space formed by the omo-hyoideus muscle  upon
the outside, the clavicle  below, and the anterior scalenus muscle on the
inside.
  D.  Anomalies.—I should remark that we sometimes find the vein with
the artery between trie scaleni muscles and the artery, occasionally tak-
ing the place of  the vein, and  that I have myself observed these two
anomalies ; when the  little scalenus muscle exists, it may, as Robert re-
marks, while attaching itself upon the rib, separate the two inferior cer-
vical nerves from the superior  branches, incline tbem forward and push
them towards the vessels ; at other times it completely isolates the artery
from all the nerves.   The vein may be higher up than usual above the
clavicle, or double, as Morgagni has seen it, and entirely conceal the ar-
tery, which latter is found moreover in certain cases, though rarely, sur-
rounded on all sides by the brachial  nerves; the presence of  a  small
muscle attached by its two extremities upon the clavicle, the insertion
of the sterno-hyoid muscle on the inside of the sterno-mastoid, the inser-
tion upon  the clavicle of  a second root, or of the  inferior widened bor-
 der sent off, from the  omo-hyoid muscle to the  clavicle, are also anoma-
 lies which the surgeon ought to be aware of. 
ARTERIES OF THE THORACIC LIMB.               833
                         § II.—Indications.

  The subclavian artery being protected by the clavicle, and partly en-
closed in the chest, or at least sheltered by the walls of this cavity, is but
little  exposed to external agents.  Exempted also from those alterna-
tions of flexion and extension which the axillary and popliteal are obliged
to assume, this artery is consequently  disembarrassed of a frequent oc-
casional cause of spontaneous aneurisms.  It is nevertheless, not invul-
nerable, and the diseases to which the  other arteries are exposed have
often  affected this.  M. Larrey, (Clin. Chir.,t. III., p. 142,) relates
many examples of its  wounds from swords, &c.;  he has even seen two
cases where they were followed by a varicose aneurism,  (Bulletin de la
Facufte,  t. III., p. 27.)  The subclavian artery however is tied not so
much for the  diseases that  are proper to it, as for those  of  the axillary
artery.  Should, for example, an aneurismal tumor be developed in  the
supra-clavicular depression, though it may augment ever so  little in vol-
ume,  it will not be long before it will be impossible to  place a ligature
on the trunk  which produces  it, between this tumor and the heart: let
an aneurism on the contrary in the hollow of the axilla, enlarge in size
and increase  upwards to such extent as to raise up the shoulder, and the
ligature must be applied above the clavicle.
   [To Dr. J. Mason Warren  of Boston, we  believe is due the credit  of
having perfomed the first successful operation  for tying  the subclavian
artery for an aneurismal tumor situated above the clavicle.  Owing to
a remarkable deviation of the vessel he was enabled to  apply the liga-
ture on the outside of the scaleni muscles, the operation on the inside
having been invariably followed by fatal results.
   In  his  work on " Anomalies Arterielfes," &c, &c, M.  Dubreuil refers
to but a  single subject in  which  as in the case of Dr. Warren, the sub-
clavian passed in front of the scalenus anticus,  and in this case the same
deviation existed on both sides (p. 109.)  Mr. Fergusson has particular-
ly referred  to this irregularity (op. cit., p. 634,) having  himself met
with one example.  He states, also, that Mr. Lizars, in  operating out-
side that  muscle, discovered  the vessel lying in front.   This case was
reported  in the Lond.  Lancet, for August, 1834.  G. C.  B.]
   A.   Spontaneous Cure.—Aneurisms which a ligature upon the subcla-
vian may cure, may like others disappear spontaneously in certain cases,
as has been shown by a case published by M. Bermardin, (Archiv. Gen.
de Mid., t. VI., p. 511.)   The  method of Valsalva, refrigerants, &c,
would also, without doubt,  arrest some of them.  M. Richarme  cites in
his thesis an  example of a cure obtained in this manner.   A case is also
mentioned (Jour, de Med. et Chir. Pratique, September, 1830, t. I., p.
268,) of  an arterial hemorrhage, from a sabre  wound above the clavicle
which was arrested by pledgets of lint, dipped in  Binelli water.  But
as it is dangerous  to  let them take  their course, and as the utility  of
these means  is  always problematical, the wisest plan is to operate as
soon as possible.
   B.  Method of Brasdor.—The ancient method is not applicable in these
cases. If it should  not be practicable to  employ the method of Anel,
that of Brasdor is the only one that could be  used in its  stead.   In that
   Vol. I.                    105 
834
NEW ELEMENTS OF OPERATIVE SURGERY.
case, for a supra-clavicular aneurism it would not  be upon the subcla-
vian, that we would apply a ligature, but upon the axillary.  Dupuytren
is  the first who attempted  it upon living man.   The  patient it is true
died at the expiration of nine days, on  the 20th of July, 1829 ; but in
the place of increasing in size as it was apprehended it would have done,
the tumor had on the contrary, diminished in volume,  and in a great
measure lost its pulsations ; finally, repeated hemorrhages and one from
a supplementary branch, and which was at first attributed to the division
of the principal artery, seem, much more than the operation itself, to have
been the  cause of death.  The patient of M. Laugier, operated  upon in
the same way, lived a much longer time, and seems to have been the vic-
tim to accidents equally disconnected with the operation.
   It must, however, be  conceded that the axillary is one  of  those  the
least adapted to the  method in question.  The numerous branches that
are given off from it constitute so many [collateral T.] channels, through
which the blood will continue to flow, and which will prevent the aneur-
ism from  being consolidated, unless  they should have been previously
obliterated by depositions  of fibrine, or the progress  of  the  disease.
[The  author  doubtless  means here, as one of the  most frequent causes
of such obliteration of the collaterals, the pressure of the increased size
of the  aneurismal  sac itself on those collaterals.  T.]   The  branches
which the subclavian gives off within  the scalenus, will constitute an ob-
stacle not less formidable to the success of this mode of operating, so
often as the disease shall have extended to that part.  But as it is prac-
ticable to apply the ligature very near the sac ; as it is possible that the
internal concretions of the aneurism may have diminished, or even closed
up the calibre of these arteries, and as the least resistance sometimes to
the course of the  blood  suffices to produce coagulation  in the sac, I  am
of opinion, that we ought to make  trial again of what Dupuytren  has
done.
   C. Method of Anel.—In following out the principles of Anel,  the lig-
ature upon the subclavian has been applied at three different points of its
course, within the scaleni, between the scaleni and on the outer  side of
these muscles.

                     §  III.— Operative  Process.

   A.  Within  the  Scaleni.  I.  Process of  Colles.—M.  Colles, (Rev.
Med., 1834, t. I., p. 4-58.—Gaz. Med., 1834, p. 119,) M. Mott, (Gaz.
Mid de Paris, 1838, p. 600,)  and M. Liston, are the  only persons to
my knowledge who have ventured to  lay bare the subclavian artery  be-
tween the trachea and the anterior scalenus  muscle.  A great difficulty
was experienced in placing the ligature around the  vessel, and it was
supposed in one case that the pluera  had been slightly wounded.   Be-
fore the thread was tied, the respiration  became laborious, and  the  pa-
tient complained of a feeling of compression near the heart.   These
symptoms became  so  alarming in the patient of M. Colles, that it was
notthought advisable to tighten the ligature before the fourth day.  The
patient did very well up to the ninth day; at this epoch he again expe-
rienced strangulation and an acute pain in the cardiac region ;  delirium
supervened and death took place nine hours after the commencement of 
ARTERIES OF THE  THORACIC LIMB.
835
these symptoms.  On opening the  body the aorta as well as the whole
extent  of the subclavian were found diseased.  The case of M. Liston
did well up to the ninth day, though at the  time  of the operation a li-
gature  had been placed also, upon the corresponding primitive  carotid,
after an unsuccessful attempt at electro-puncture.
  II. Process of the Author.—To arrive upon the arterial trunk, if we
should not wish to follow the process of M. King, {These No. 15,Paris,
1828,) it would  be  necessary to cut  transversly  upon the sound, the  .
root of the sterno-mastoid muscle, to depress the  internal jugular vein
towardsthe trachea, the subclavian vein downwards and forwards upon
the clavicle, and also to push back the  carotid, the phrenic nerve  and
the pneumo-gastric.   On the left, moreover, we should run the risk of
wounding the  thoracic duct, and should be obliged to penetrate much
deeper; but it would not be impossible to place the ligature between the
origin of the  mammary and vertebral arteries, &c,  and the heart, while
on the  right,  the proximity  of the brachio-cephalic trunk would render
such an attempt one of the greatest danger.
  [As  the late  Dr. J. Kearny Rodgers was the first who ever tied the
left subclavian within the scaleni muscles,  we insert in this place the ac-
count of the operation, which was published in the New-York Journal of
Medicine, March, 1846.  The patient,  set. 42, was admitted, Sept. 13,
1845, into tin New-York Hospital.  The aneurismal tumor was situated
above the clavicle, was about as large as a  small sized hen's egg, and ex-
tended externally to the outer third of the bono, being covered internally
by the  outer  edge  of  the sterno-mastoid  muscle.  Dr. Rodgers,  after
a consultation with  the other  surgeons  of the  Hospital, resolved to at-
tempt the operation.  The patient having been placed on a low bed with
his head and shoulders raised, and his face turned to the right side, so
that the light from the dome could shine directly on the part to be oper-
ated on, an incision three inches and a  half long was made on the inner
edge of the sterno-mastoid, so as to terminate at the sternum, aud divide
the integuments and playtysma-myoides.  This was then met by another
incision, which extended  along the sternal extremity  of the clavicle,
about two and  a half inches, and divided  a plexus  of varicose  veins
which were in the integuments covering the clavicle, and communicated
with the subclavian  vein.  To check the free bleeding  which occurred
from their cut extremities, it became necessary to  tie them.  The flap
of the  integuments and platysma-myoides being now dissected up, and
the lower end  of the sterno-cleido-mastoid laid  bare, a director was
passed  under  this muscle, and the  sternal as well as half of the clavicu-
lar origin divided by a bistoury.   This  muscle being now turned up, the
sterno-hyoid and omo-hvoid muscles, as well as the  deep-seated jugular
vein, were seen covered by the deep cervical fascia.
  On turning up the sterno-mastoid, a portion of the aneurismal sac was
seen strongly pulsating and overlapping  about half the  width of the
scalenus, so as to form the outer half of the track  through which it was
necessary that the operator should pass, showing fearfully one of the dan-
gers of the operation, but one which Dr. Rogers had anticipated.  The
deep fascia being then  divided by  the handle of the scalpel and the fin-
gers, the dissection  was continued in contact with the outer side of the
deep jugular  vein to the inner edge of  the scalenus anticus muscle, for 
836
NEW ELEMENTS OF OPERATIVE SURGERY.
 the purpose of reaching this muscle fully half an inch above the rib, in-
 stead of at its insertion, in order to guard against any injury of the tho-
 racic duct.  The phrenic nerve could  now  be distinctly felt running
 down on the anterior surface of the scalenus, and was of course avoided,
 until, by pressing the  finger downwards, the rib was discovered, when
 after some little search the position of the artery was recognized.  By
 pressing the vessel against the rib, all  pulsation  in  the tumor ceased ;
 whilst, on removing the finger, the pulsation returned.   In order to avoid
 any injury to the pleura and thoracic duct in detaching the artery, Dr.
 Parrish's needle was  employed after that of Sir  Philip Crampton had
 been tried, the point of the former being introduced under the artery,
 and directed upwards so as to avoid the pleura.   The  needle being de-
 tached from the  shaft of the instrument, the ligature was drawn upwards
 so as to  surround the artery, and  then  tightened with the  forefingers  at
 the bottom of the wound, all pulsation ceasing immediately in the tumor,
 and also in the arteries of the extremity.  Warmth was subsequently ap-
 plied to  the limb, and the usual treatment pursued.   On the thirteenth
 day, the  patient  on changing his position from the right side of his back,
was attacked with hemorrhage, of which he died two  days  subsequently,
or fifteen days after  the application of the ligature.  A post-mortem ex-
amination,  after detailing other points, established the inaccuracy of one
fact which  has been  previously urged as an argument against the opera-
tion, viz. the risk of hemorrhage  from the want  of sufficient adhesions
in  the artery.   In  this  case  there was a perfect  coagulum  found  in
the vessels, the hemorrhage had come from the distal end  of the artery
 in  consequence of the  free communication of the internal carotid at the
base of the brain with the vertebral, the latter vessel having been given
 off from  the subclavian just beyond the point where Dr. Rogers had ap-
plied his ligature.   Decidedly the greatest danger in  the operation, ^as
thought by the operator to be the risk of wounding the pleura and thora-
 cic duct.
  Although the fact is not mentioned  in this report,  we have been in-
 formed by  a most  competent judge, who examined  the  parts, that the
 pleura in this instance was extensively  lacerated.
  Shortly after  the fatal termination of this  case, Dr. Rogers  remarked
 to the writer, that if he  should ever have an opportunity of  repeating
 this formidable operation, he should at the same time apply a ligature  to
 the vertebral.   G. C.  B.]
   [I regret for the  honor of American surgery, that this first  attempt
 of a ligature on the  left subclavian within the scaleni, was not crowned
 with success.
   At  a  full  consultation of all the surgeons  and consulting surgeons
 of the hospital, (myself  included among the latter,) it was concluded,
 after a free expression of opinion, to leave the case to the discretion and
 judgment  of the surgeon, (Dr. Rodgers,) under whose care the  patient
 came.
   I may observe, however, that at consultation  mentioned, I  gave it as
 fay opinion, that  although the artery in question,  could undoubtedly
 be tied by a careful and well informed surgeon, 1 nevertheless, consid-
  ered that it was improper so to do.  I founded my opinion in  this case :
  1st upon the relative anatomy of the left subcalavion artery in the whole 
ARTERIES OF THE THORACIC LIMB.               837
of its course  within the  scaleni muscles, and its intimate association
with the internal jugular vein and the thoracic duct;  2nd, upon the re-
sult of all the operations which had been performed upon the right sub-
clavian  within the  sacleni muscles; this latter operation having been
performed four times, and  all the cases having  terminated fatally by
secondary hemorrhage.
  A fortiori, it was my  opinion that the ligature on the left subclavian
from  the anatomical relations stated, would make this operation  still
more  hazardous.   Insomuch that I remarked then, and still reiterate the
assertion as my belief, that I do not think it a justifiable operation, and
would not perform it myself.
  This  case of Dr. Rodgers, the only one in which a ligature has ever
been applied to the left subclavian within the scaleni, terminated fatally
by secondary hemorrhage ;  the ligature having been applied, as we under-
stand, just below the origin of the vertebral artery.  V. M.]
  III. In whatever  manner  performed, the ligature  of the subclavian
between the anterior scalenus muscle and the trachea, will be a labori-
ous and formidable  operation.  As on the other  hand we can scarcely
conceive that it would suffice, when carried farther outward it should
have  offered no chance of success, I cannot see what could authorize its
application.

    [Ligature of Subclavian on Tracheal side of  Scaleni Muscles.
No.	Surgeon. 1		Result.	Cause of Death.
T	Colles	Died on 4th day		Hemorrhage
2	Mott	u	18th day	Hemorrhage
3	Hayden	ii	12th day	Hemorrhage
4	O'Reilly	a	13th day	Hemorrhage
5	Partridge	a	4th dav	Pericarditis and Pleurisy
6	Liston	a	13th day	Hemorrhage
7	Liston	a	36th day	Hemorrhage
8	Auvert	it	22d day	Hemorrhage
9	Auvert	a	11th day	Hemorrhage
10	J. Kearny Rodgers	a	15th day	Hemorrhage
  Ten operations, and all fatal!   In one instance only was the left sub-
clavian tied and that was the case of Dr. J. Kearny Rodgers.  In view
of the almost constant  failures of the ligature of the subclavian artery
for aneurisms seated above the  clavicle, Mr. Fergusson has proposed
amputation at the shoulder joint in  these desperate cases.  Ligature
of the axillary  artery on the face of the stump, would bear some  re-
semblance to  Brasdor's operation, but there would be this important dif-
ference ;  after the removal of the limb, the same quantity of blood  not
being required in this  direction, the tumor would be much more under
the influence of pressure.   The value of this suggestion we believe  yet
remains  to be tested.   The axillary or subclavian  might first be tied
under the clavicle, and  then if the aneurism still increased, amputation
might  be performed. (Practical  Surgery, 3 Lond. ed. p. 626.)  In  the
winter of 1846, 47, we  heard Mr. Fergusson  in his lectures propose a
new method  of treating aneurisms at the root of the neck, viz. by caus- 
838            NEW ELEMENTS OF OPERATIVE SURGERY.
ing a displacement of the layers of fibrin in an aneurismal sac, so as to
brino* about a consolidation of the  contents of the  sac.  In  February,
1S52, he applied this method in a case of aneurism between the scaleni,
the tumor being about the size of a hen's egg.  By  some rough squeez-
ing with the flat end of the thumb he displaced  sufficient of the fibrin
to cause pulsation in the axillary, and all the branches below to cease.
Four months afterwards strong hopes were entertained of a cure. ( Op.
cit. p. 638.)
  From a notice in  the London  Medical Times and Gazette, for Feb.
1854, p. 117, we perceive  that Mr. F. has adopted this  plan in a case
of carotid  aneurism.  The result on the tumor is not stated, the only
fact mentioned, being that hemiplegia immediately followed.   G. C. B.]
  B.  Between  the Scaleni Muscles.—Nor  should it ever be performed
between these two muscles, unless the  state  of the parts should abso-
lutely forbid  our applying  the ligature outside of them.  It is not that
it3  execution is very difficult or  that it might  not succeed, but that
the advantages  it procures may be otherwise obtained and that the sec-
tion of the scalenus in itself an inconvenience, exposes us besides to the
risk of  wounding the internal jugular, or the subclavian vein itself, as
well as  the two nerves of respiration.
  The  ligature  applied upon  the axillary artery, in the hollow of the
axilla, and according to the method of Brasdor, would offer more prospect
of success, less danger, and infinitely  fewer difficulties.
  I. Process of Dupuytren.—This is the manner in which  we would
reach the  trunk of the  subclavian  between the scaleni, in following the
process  of Dupuytren.   We make at the base of the neck a transverse
incision, which extends  from  the anterior border of the trapezius mus-
cle, to the inner border of the sterno-mastoid, and which is prolonged
even a short distance upon the outer side  of this last muscle.   After hav-
ing satisfied ourselves that we have come down to the anterior scalenus,
we  insinuate between its posterior surface and the artery the extremity
of a grooved sound, upon which we divide the muscle.  By this section
alone the  artery  is b.id  bare  and completely isolated.  The posterior
scalenus serves  as a guide to the eyed probe which bears the liga-
ture.
  C.  Outside the Scaleni.—It is in the  omo-clavicular triangle, or on
the outside of the scaleni muscles, that the subclavian artery should be
and has more especially been tied.
  I.  Process of Ramsden.—A transverse incision  an inch and a half
long, is  first made above the clavicle ; a second is then made two inches
long, parallel to the outer  border  of the  sterno-mastoid muscle,  and
which falls  at  a right  angle  upon the  first;  after having  depressed
the shoulder, M. Ramsden  continues the dissection of the  tissues in
order to lay bare the border of the anterior scalenus ; the artery is then
easy to reach.  Having isolated it with the nail ho wished to pass a liga-
ture around it; numerous difficulties presented themselves ;  it was found
necessary  to resort to a variety  of movements; and  it was  not until
after a  very  great number of trials  and a considerable lapse of time,
that he  succeeded in  terminating this operation, which had been beo-un
so auspiciously ; the patient died on the sixth day.
  II.  Another Process.—IL T. Blizzard  made an incision three  inches 
ARTERIES OF THE THORACIC LIMB.
839
long, parallel to the external jugular vein, at the lower part of the neck
and towards the acromion.  Post  commencing his incision at the outer
border of the sterno-mastoid, divided the tissues in the direction of a
line slightly oblique in relation to the clavicle.   M. Porter made a hori-
zontal incision above the clavicle, then 'a vertical incision  outside the
sterno-mastoid muscle, and turned  back the triangular flap thus form-
ed.   M. Dubled on the  contrary proposes that the incision of  the skin
should be  directed,  obliquely from  above downwards and from without
inwards, to make it  terminate near the  sterno-clavicular articulation.
According to M. Hodgson the wound should be altogether transversal,
and it is this last precept which  unquestionably offers the greatest num-
ber of advantages.  I do  not  think that the advice  formerly given by
a member of the Academy of  Surgery, to include in the same ligature
both  the artery and the  clavicle, should ever be followed.  I have diffi-
culty also in  comprehending what reasons could have  induced  M. Cru-
veilhier  (Etud. Anatom., t.  II., p. 609) to say, that  it would  be  ad-
vantageous to  saw this bone in order to tie the subclavian with greater
security.
  III. The Process to be followed.—The patient should be placed upon
his back, with  his chest  a  little elevated; his head and neck should be
turned to the  sound side, while an  assistant depresses  the shoulder as
much as the aneurism will  permit, by raising the arm from the body.
  A. First Stage.—The integuments are then divided in a  transverse
direction at an inch  above the clavicle, and from  the  anterior surface
of  the sterno-mastoid muscle down to the trapezius;  we divide in the
same  direction the cellular  tissue, the fibres of the platisma myoides,
and the  external jugular itself, after  having tied it above and below,
if we cannot keep it out of the way by pushing it by  means of a blunt
erigne, either forwards or backwards ; we soon arrive  at the aponeuro-
sis  which in its turn is also cut;  then the fore-finger may feel the border
of  the scalenus immediately below and  on the inside of the sterno-
mastoid.
  B.  Second Stage.—After having torn apart or separated the cellular
tissue, and the lamellae,  filaments, and  ganglions, at the  bottom of the
wound, with  the extremity of the  sound  or a good dissecting  forceps,
we  apply the finger near the root of the scalenus to identify the tuber-
cle  of  the first rib.   This tubercle is a sure guide here,  so much so, that
if the pulp of  the  fore-fiDger without being taken off from it is carried
a little outward and backwards, it almost constantly falls upon the ves-
sel.  Being once found  the  eye is  no longer indispensable.  The nail
applied against its posterior and outer side serves as a director to  the
curved sound or to the needle we are using.
  [In the third part of Lisfranc's Precis de Med, Operatoire, p. 65, we
find the following assertion of this distinguished surgeon :   J'ai indique
le premier,  voyez le Manuel des operationes chirurgicales, par M. Coster,
1823, un fait anatomiquc  extremement important et qui facilite beaucoup
la manoeuvre  pour  mettre l'artere a decouvert:  c'est le tubercle de  la
premiere cote en dehors duquel immediatcment  ce vaisseau."   He then
expresses his indignation that  M. Cruveilhier  should  have  neglected,
even in the second  edition of  his  Traite  d'Anatomic  descriptive,  to
give to himself the credit  of first pointing out this important guide, 
840
NEW ELEMENTS  OF OPERATIVE SURGERY.
 and reminds him of the moral principle which would render unto Caesar
 the things that are  Caesar's.   Now upon this same  principle, we would
 take the  liberty of inserting in this place the  following  extract  from
 a paper by Dr. Parrish in the Eclectic Repertory, vol. iii.  1813, p. 239.
 After stating that the operator need not  bring the edge of the scalenus
 anticus into view, as commonly advised, he proceeds:  "He has another
 and more certain guide to conduct him to the precise point for securing
 the artery.   To fix this point was a subject of considerable importance,
 that required and received very deliberate  attention, and was decided
 for the  superior edge of the first rib.
   In addition to this, the operator has a guide to conduct him precisely
 to the part he is seeking for, which it is believed had  never been noticed
 by any  preceding surgeon.  Just at the insertion of the anterior scale-
 nus muscle  into the upper edge of the first rib there is a roughness, or
 rather process of the bone which is very perceptible to the touch, being
 in the generality of subjects so clearly defined that it cannot be mistaken.
 Now, instead of the  operator depending on his vision, he may get at
 the exact spot  that he is in  search of by a reliance on  the  sense of
 touch."
   Dr. J. Mason Warren met with a case in which, while  seeking for the
 first rib, to  his surprise he discovered both the first and a part of the
 second rib passing obliquely  across  the neck above the clavicle.   At
 length he  detected  the insertion of the  scalenus anticus, but, the tuber-
 cle was not  sufficiently developed to be manifest to the touch.  In this
 patient, the  whole  osseous  system seemed to have undergone  a partial
 displacement.  The spine and ribs attached had been carried upwards,
 whilst the sternum had.been moved in an opposite direction (Am. Journ.
 Med. Sciences, Jan. 1849, p.  14).   G.  C. B.]
   C.  Third Stage.—By making the point  of one of these  instruments
 pass from  before backward, and slightly from without inward, you  soon
 get it under the artery which you raise up, at the same time that the fin-
 ger placed between it and the first fasciculus of the  brachial plexus,  as-
 sists in  supporting the vessel,  and preventing its escape.
  When the shoulder is not too much deformed, or too much raised up
by the tumor, or when it is possible to depress it without inconvenience,
any person possessed of tolerably accurate anatomical knowledge may
succeed in applying this ligature with much less difficulty than is sup-
posed.
  IV. The section of the omo-hyoideus muscle proposed by some  per-
sons, and of the external border of the sterno-mastoid, as still practised
by M. Mayo  and M. Liston, is altogether  useless.   The assistance of
the sound  which should be preferred after  the division of the  aponeu-
rosis, enables us to avoid the  plexus formed by the  confluence of the
small veins of the shoulder and neck when they empty into  the subcla-
vian.  To avoid also at the same  time this latter  vein nothing more is
ever required than to pass the end of the director under it and near to
the scalenus before directing the point of the instrument backward with
the view of hooking up the artery.   Fnally, inasmuch as the subclavian
 artery in the normal arrangement of the parts is constantly  the  first
 moveable  cord that is felt by  the  finger on leaving  the  tubercle of the
 rib, and that the nerves moreover  are  distinguishable  from it by their 
ARTERIES OF THE  THORACIC .LIMB.
841
 rounded form  and their solidity, we cannot  see  what can lead to any
 mistake on the part of the operator.
   D.  Method of Brasdor.—M. Wardrop has tied the subcalvian artery,
 by the method of Brasdor, for an aneurism of the brachio-cephalic trunk,
 in a patient whose corresponding carotid obliterated by the tumor soon
 after recovered its permeability.  The success at first appeared complete,
 but after a certain time the  aneurism  began to enlarge again, and Ma-
 dame Desmarest, who was the patient, died on the 13th of September,
 1829.  I will return to this case a little further on, and will confine my-
 self to remarking, that it would be better  in  the event of our  wishing
 to treat a lesion of the  subclavian by this method, to place the ligature
 upon the artery immediately under than above the clavicle.
   E.  Consequences of the Operation.—The mortification of the limb which
 seems to be dreaded so much after the  obliteration of the subclavian, is
 a circumstance  that rarely occurs.   In the  patients of MM. Ramsden,
 Colles, Blizzard and  Mayo, the phenomena noticed were suffocation,
 delirium, symptoms of cerebral affection, and implication of the  heart
 or its envelope.   After death there were found traces of pericarditis,
 diseased  condition of the aorta or heart, and inflammation of the brain,
 but no gangrene.   In some cases the circulation is re-established even
 with a remarkable rapidity ; in the  patient of M. Roux the pulsations
 reappeared in the radial and ulnar arteries two days after the operation.
 The blood is brought back into the axillary or the brachial, by the anasto-
 moses of the internal  mammary with the thoracic  and the circumflex,
 and of the  acromial and common scapular  with  the posterior  cervical
 and  supra-scapular.   If the ligature was placed within the  scaleni be-
 yond  the vertebral and mammary arteries, the fluids could  not  arrive in
 the diseased side but  by the communication of its vessels  with those of
 the sound side.
   F.  History and Appreciation.—M. Ramsden, who performed his op-
 eration in November, 1809, appears  to have been the first who  actually  g_v ,\>
 tied the subclavian artery.  Some time before him, M7A7 Cooper had
 tried, but in vain,  to seize this vascular trunk; he tied a nerve  instead
 of it, and the patient soon died of hemorrhage.  The same  misfortune
 happened afterwards, under another form, to  M. Lallemand,  (Dubreuil,
 Gaz.  Mid. de  Paris, 1837, p. 563.)   To relieve a hemorrhage of the
 axilla, this  professor wished to tie the subclavian artery, but  could  not
 succeed ; the patient  died on the   day after.  The vein which was be-
 tween the scaleni  was at the  distance  of nine lines below the artery.
 In the month of April or May, 1810, a woman, aged about sixty years, was
 admitted  into the Hotel Dieu of Paris,  for an enormous aneurism in the
 axilla. Dupuytren believed that the  operation of the ligature  of the sub-
 clavian could and ought to be performed ; Pelletan (Dubreuil,  Gaz. Mid.
 de Paris, 1827, p. 563) was of an opposite opinion, and  the patient died
 after the lapse of a few days without having been operated upon ;  a suf-
 ficiently long  time, however, after  the attempts  of MM.  Cooper and
 Ramsden, to prevent our making any claim to priority in this matter.
r   A very aged and debilitated subject, operated upon in  1811, by M. W.
 Blizzard, also died on the fourth or fifth day.   The same happened with
 the  patient of  M.  Galtiein 1814.  M. Th.  Blizzard and M. Colles were
 were not more  fortunate in 1815.   But complete success   attended  the
   vol. i.                          106 
842
NEW ELEMENTS OF OPERATIVE SURGERY.
operation  of Post  in  1817, and  afterwards  these  of Dupuytren, MM.
Liston, Bullen, Green,  Gibbs, Key, Roux, Langenback, Mott, Porter, &c.
  Cases of ligature upon the subclavian artery have been published by
M.  Syme, (Edinb. Med. and  Surg. Jour., vol. cxxxvii., p. 338,) who
was obliged afterwards, in one case, to amputate at the shoulder-joint.
M. Woodroffe informs me that he has met with entire success in this op-
eration.  In a case related by N. Neret, (Archiv. de Med. Juin,  1838 ;
L'Expirience, t. iii., p. 106,) an aneurism of the left subclavian  artery
extended into the chest and penetrated the lung.  A ligature upon the
subclavian, for a wound in the axilla, caused gangrene of the limb, rend-
ered necessary amputation at the shoulder, and was followed by  death, in
a patient of M. Haspel,  (Gaz. des H5pit., 1839, p. 186.)
  Moreover, the ligature upon the subclavian artery is  one of those
which most frequently jeopardize  the life of the patient.  In about sixty
cases which have come to my knowledge, I find at least twenty-five cases
of deaths, and as  many of cure.   Here is the list  of the  greater part
of them :—
1.	A. Cooper	Dead
2.	Ramsden	Id.
3.	Colles	Id.
4.	Th. Blizzard— Gang.-delir.	| Id. 8th day
5.	W. Blizzard	Id. 4th day
6.	Rigaud	Id.
7.	Segond	Cured
8.	Gibbs	Id.
9.	Monteith	Id.
10.	Ferguson	Cured
11.	Liston	Id.
12.	Liston	Dead
13.	Gal tie	Id.
14.	Seutin	Id.
15.	Roux	Id. transf.
16.	Montanini	Cured
17.	Lallemand	Dead
18.	Langenbeck	Cured
19.	Baker	Dead
20.	Grossing or Crossing	j Cured
21.	Mayo	Id.
22.	Bullen	Id.
23.	Key	Id.
24.	Green	Id.
25.	Buchanan, after amputation	j Dead
26.	Lallemand	Cured
27.	Travers	Dead
28.	-----	Ib.
S. Cooper, Diet, de Ch.
Edin. Med. Se Sur. 1815, p. 1.
Boyer, 2.  245.
Hodgson, p. 133.

Boyer 2. 244.
These No. 106, Paris, 1836.
J. Hebdom, 1835, t. I., p. 33.
B. d. f.  8-83, Arch., 8-595.
Lancet, 28—266, t. I.
Ed. Jour., 1831, Arch.
Ed.  Jour.  V.,  XVI.,  Arch.
    Gin., t. XXVIIL, p. 26$
Ed. Jour., ib., 348.
Delp. Clin., t. I., p. 18.
Bull. Be/g., Sept., 1834.
These No. 218, 1834.
Gaz., 1837, 285.
lb., 562.
Lancet, 1828, 1. 249.
lb. 1829, 2. 210.

Arch., 2e ser.,  1. 543-541.

Ibid, 455,-546.
 The Lancet.
Ibid.
lb.

Trans.  Med., 1835.

Arch.  Gin.  de Mid., 2. 9. t.
    VII., p. 474
Lond. Gaz., 1827, p. 333.
Trans. Med. Ch.,  1829, 314. 
ARTERIES OF THE THORACIC LIMB.
843
29. Arendt	Cured
30. B. Cooper	Dead
31. Post	Cured
32. Mott	Id.
33. Brodie	Dead
34. Porter	Cured
35. Nichols	Id.
36. Roux	Id.
37. Dupuytren	Id.
38. Colles	Dead 11th day
39. Post	Cured
40. Dupuytren	Id.
41. Mayo	Dead
42. Roux	Cured
43. Brodie	Dead
44. Mott	Cured
45. Auchingloss	Dead
46. Alison	Id.
47. Mantault	Id.
48. Baroni	Cured
49. Liston	Id.
50. Fearn	Id.
                                     Med. G., 1827, 502.
                                     Lane, 1828, v. I., p. 448.
                                     Med. Gaz., 9. 185.
                                     Arch.   Gin.,  t.  XXVIL,  p.
                                          259.
                                     Med. G., 1827,  p. 504.
                                     Med. G.,1.
                                     Med. G., 2—241.
                                     Boyer, 2—234.
                                     Lee, 4—524.
                                     Boyer, 2—246.
                                     Boyer, 2—246.
                                     Rev., 1821, 9—221
                                     Med. Chir., 12, p. 12.—Arch.
                                        G., 2e ser., t. I., p. 546.
                                     Bib. 1825,  8—156.
                                     Med. Gaz., 9—430.
                                     Med. G., t. VIIL, p. 106.
                                     Ed.   Med.,   April,  1836,  p.
                                          324.
                                     Arch.  G., 2e.  s. t. VII. p.  388.
                                     Gaz. Med., 1836, p. 585.
                                     lb. 1835, p. 695.
                                     lb. 1823, p. 600
                                     Gaz. Med., 1838, p. 601.

   [The subclavian  has  now  been tied in at least 104 instances.   In
 1845, Dr. Norris published (Amer. Journ. Med. Science, vol. X.    )
 his statistics of 69 cases which he had then collected, and of  these  36
 recovered and  33 died.  Dr. Van Buren  has published  an account of a
 successful case of ligature of this  artery  ( Trans.  Med.  Society, State
 of New York, 1853) and in this he states  that he has collected 101 cases
 of this operation, 8 of which were within the scaleni.   Add  to these
 the  three cases reported by Auvert in his magnificent  work ("Selecta
 Praxis" &c. &c., Paris and Moscow, 1850) and we have as before stated
 104 operations.  Two  of these by Auvert were within  the scaleni (right
 side) and like all the others performed in this region, they were fatal.
 Of these 104 operations, 45 died.  Availing ourselves of the labors  of
 Drs. Norris and Van Buren, we subjoin the following details, which are
 but little modified by the cases of Auvert to which  we have alluded.
   Of the 104 cases, the operation on the  external portion of the artery
 comprises 87 ; of which 54 were successful,  and 33 died.
i   Of 10, within the scaleni muscles, 9  on the right and  one on the left
 side, all were fatal.
   Of 3, between the scaleni muscles, only one died.
   Of 4, below the clavicle, but one died.
   Of 87, upon  the external portion of  the artery, 54 recovered, and  33
 died.  Of these, 39 were performed for true aneurisms ;  26 were cured,
 and 13 were fatal.   In 12, there was traumatic  aneurism ; in these 9 re-
 covered and 3 died.   In  14, the axillary was wounded ; 7 recovered,
 and 7  died.   In 5 cases, the distal operation was performed ; 2 recover- 
844
NEW  ELEMENTS OF OPERATIVE SURGERY.
ed and 3 died.   In 3, mistake in diagnosis; of these 2 died.  In 14, dis-
ease and injuries unknown.
   Causes of Death.—Dr. Van Buren gives the following :   In 33, of
the operations for spontaneous aneurisms, 12 (14 with those of Auvert)
died from hemorrhage ;  6 from gangrene ; 4, inflammation within cavity
of chest; 3, exhaustion from supparation in sac;  1, hospital gangrene ;
1, dyspnoea; 1, from irritation caused by inflammation of phrenic nerve ;
1, exhaustion from repeated hemorrhages  and operations ; 1, encepha-
loid tumor of axilla ; 2, cause unknown.  In 6 other cases, hemorrhage
contributed to without directly causing fatal result.  It also occurred to
a greater  or less extent in 8  of  those  which  recovered, making in
all  26 cases of  hemorrhage.  Of the  101 cases  collected by Dr. Van
Buren, 21 belonged to American surgeons, and 6 of the 21 were fatal, a
mortality below  the general average.   For other  interesting details we
must refer to the paper  itself.   G. C.  B.]
                         CHAPTER III.

                       ARTERIES OF THE HEAD.

  There is scarcely a branch of any importance, whether in the  face or
the cranium, which may not be wounded by external agents, or  become
the seat of one of these spontaneous aneurisms which are qualified with
the name of  mixed or true.
             Article I.—Arteries of the Exterior.

  Two aneurisms, one on the head and the other on the jaw, were not
ascertained till after death,owing, says Barbette, (Chirurgie, ch. 16, 2e
part, liv. I., p. 218,) to their being without any pulsations during life.
Paletta cites one example, and Scarpa (Obs. sur I'Aneurisme, etc.) two,
of aneurism of the temporal artery.
  M. Green (The  Lancet, 1828, t. IL, p. 381; et Fletcher,  These No.
267, Paris, 1836)  has made known a fourth.   Klaving  mentions one
which occupied the left posterior  auricular in a young  man of twenty-
five years, and M. Renzi (Velpeau, Med.  Oper., trad. Ital., p. 182) re-
lates a  case analagous to that of M. Nanulla.  Dehaen  has seen  the
same thing on the dorsal artery of the uose.  M. Godichon has describ- (
ed  an aneurismal pedunculated tumor on the forehead larger than  the
thumb; he has noticed another in front of the right parietal protuberance.
   [Dr. Pancoast has tied the stylo-mastoid artery  for  traumatic  aneu-
rism.  G.  C. B.]
   We find in the Actes of Leipzig, the case of an aneurism of the fron-
tal artery, and I have also met with one  example  of  it.  In a similar
 case, M. Brodie (The Lancet, 1829, vol. IL,  p. 259) operated by the
 ancient method with success.  MM. Gaste, Merat, and Stone, (Journal 
ARTERIES of the  head.
845
des Progres, 2e serie, t.  II.,  p.  215,) also  speak of aneurisms in the
temple.  M. Gams has cured one which existed near the commissure of
the lips.   M. Begin cites one which occupied the middle meningeal, and
which caused the death of the patient, after having perforated the tem-
poral fossa.   M. Krimer (Jour, des Prog., t. X., p. 237) relates a similar
fact, if it is not the same.  Pelletan mentions an aneurismal, or erectile
tumor, in the  eyelid, in a young  boy; another on the conjunctiva of a
second patient, and in a third  a similar disease in the upper part of the
fore-head.  He has also seen, in two different cases, almost all the branch-
es of the occiptal, or temporal, and even of the external carotid,  dilated
and hypertrophied, as if they were varicose.  The same thing took place
in a patient of M. McLachlan, (Encyclog.  Med.,  1836, p. 131.)  A pa-
tient, of  whom M. Kuhl speaks, (Glasgow Bled.  Jour., 1828), had the
cranium  covered with aneurisms.  M. de Noter,  (Bullet, de la  Soc de
 Gand, 1836, p. 192,) relating a similar fact, gives a figure which shows
that his patient had all  the external arteries of the cranium  transform-
ed into enormous  varices, (Bull, de  la Soc. de  Gand, 1836, p.  192, et
Encycloped.  Med., 1836, p.  131.)   The  palatine artery itself is not
exempt from these aneurismal dilations, as  appears by an observation of
 M. Delabarre.
                            Article II.

   As to  the arteries of the  interior of the cranium,  they  may,  though
less frequently, be the seat  of lesions of the same kind as those of the
exterior.  Examples  of varicose aneurisms, or of aneurism by  anasto-
mosis of the eyelids, or of the orbit, have been published by MM. War-
drop, Travers, and Arendt.   M. A. Cooper has noticed a small aneuris-
mal sac  on the central  artery of the retina.  MM. Serre, Lebert, and
Bright (The Lancet, 1839,  vol. IL, p. 727) have  described  another as
large as a walnut, which was seated in a basilar artery, and M. Hodgson
 describes a case in which a small sac, formed by the anterior cerebral ar-
 tery, was completely filled with a solid clot of blood, which did  not  en-
 ter into the cavity of the vessel.   Other examples of the same character
 have been collected by M. Nebel, (Dissertatio Inaugur., &c., Heidelb.,
 1834,) who also gives the figure of an aneurism, developed upon the sella
 turcica,  at the expense  of the artery of the corpus callosum.
    [Unquestionably, the most remarkable case of intra-cranial aneurism
 on record, which  has  been  subjected to treatment, is that reported by
 Prof.  Dudley in  the 3d  volume of the Trans. Am. Med. Association,
 1850.   The eye protruded from the socket, and the transverse suture at
 the corner of the eye was separated so as to admit the end of the finger.
 A large  portion of the  frontal  and temporal bones, together with  the
 temporal plate of  the sphenoid bone, and  a part of  the parietal bone,
 were disjoined and elevated some lines above  their proper level by an
 aneurism of the internal carotid.   The functions both of the eye  and ear
 were  destroyed.  The treatment consisted in the use of evacuants, ap-
 propriate food, and the application of a ligature to the carotid.  In two
 weeks, the  disunited portions of the  cranial bones  had united, the eye
 and ear  regained  their proper functions, and the patient, a blacksmith,
 had returned to his work.  Dr. Pfeufer has reported  another  case of
 basilar  aneurism, the  details of which may be found in the  Archives,
 Gen. de Med., July, 1844. 
 846           NEW elements  of operative surgery.

   Durino* the  past  summer, Dr. Van Buren tied the carotid of one side
 for an intra-cranial  aneurism.   The pulsations for a trine diminished, but
 at length returned with their former strength.  We believe that it is pro-
 posed to tie the other carotid, in this case.   G.  C. B.]

                     Article  III.—Indications.

   Of two  things one  must happen: nothing, for  example, can lead us
 to suspect  the  existence of the aneurism when it is shut up  within the
 cranium, and the aid of surgery, therefore,  cannot be appealed  to ;  or
 the disease is seen externally, and in that case we  must proceed as for
 aneurisms of the  limbs.  The patient of M. Krimer died of a frightful
 hemorrhage, because mistaking his aneurism for encysted tumor, it was
 extirpated.  That of M. Stone got well without assistance.  Percy men-
 tions  that he saw Lombard, who tells it himself, mistake an aneurism of
 the occipital artery  for an abscess, and compelled to come to the ligature.
 The simple operation succeeded with M. Syme (The Lancet, 1829, vol.
 I., p.  598)  in the case of an aneurism of the auriculo-mastoidean.   M.
 Green, who operated  for a varicose aneurism, tied the artery below and
 above the tumor.  M. Carswell  has since reported the history of another
 varicose aneurism in the temple, caused by scarification in this region.
 After having tied the arterial trunk below, it was found  necessary to
 make the  division of the branches above.   M.  Larrey {Clin. Chir.,t.
 I., p.  189)  himself succeeded with cauterization, in the case of a wound
 of the middle meningeal artery.
  We thus see that  all kinds of aneurisms, and all kinds of treatment
 that are practised for those diseases, apply to those of the cranium as to
 those of other regions.  Also, the great number  of anastomoses makes
it requisite, in these cases, even more so than in the foot that  we should
 tie or compress both below and  above.  Aneurisms which are  the conse-
 quence of temporal arteriotomy, are also much  more common in Eng-
land than in France.   M. A. Cooper (Led., Sec, vol: II.)  operated for
 one of them by  the ancient method  successfully.  That which Burns
 (Surg. Anat., p. 342)  mentions,  was a varicose  aneurism.  M. Bush
 (The Lancet, 1828, vol. II., p.  413-456) speaks of three cases where
he was obliged to extirpate the  tumor; and  M. Desruelles has described
this  disease in detail.  If  compression  should not answer,  the  open-
ing of the sac should be  attempted.  M.  Cisset did it once with suc-
cess for the occipital  artery ; in other cases the  ligature of the carotid
itself  is preferred to that of the artery, which is  the seat of the disease.
  [Mr. Andrew  Ellis, of the Jervis-Street  Hospital, Dublin, seems to
have had an extensive experience in the treatment  of  traumatic aneu-
risms of the temporal artery, and we therefore subjoin the following ex-
tract from his " Lectures and Observations on Clinical Surgery," Dublin,
 1846.                                                °  J
  " Temporal aneurisms.—What I have  already stated relative to the
 pathology  of traumatic brachial  aneurism, is strictly applicable to the
 aneurisms  produced by  wounds  of the temporal arteries.  I will not
 therefore delay you with a superfluous  description of phenomena, with
 which you are already acquainted, but at once proceed to inquire in what
 state may a surgeon find a temporal aneurism ?   He may  be  called on 
arteries of the head.
847
to treat such a case in any one of the three following stages : First, when
the tumor presents all the characteristic symptoms of aneurism, but un-
accompanied  with inflammation.  Secondly, the surgeon may see the
case for the first time, when, in addition to the symptoms I have alluded
to, there will be considerable redness, heat, and pain in the tumor and
its vicinity. _ Thirdly, the surgeon  may not be called on until the integu-
ments have in  part been destroyed by sloughing and ulcerative absorp-
tion, so that hemorrhage has actually taken place.   I will now suppose
that a case of the first form of  the disease  has  been submitted for our
consideration, and ask what is  the best  method of treating it ?   Sur-
geons have not as yet agreed upon  any fixed  plan of treating such a case:
you may therefore expect to see one practitioner employ pressure, a se-
cond would prefer tying the artery at the  cardiac side of the  tumor,
leaving the latter unopened ; whilst a third would cut down at once into
the sac, turn out the coagulum, tie the artery both above and below the
aneurismal opening, then divide it between  the ligatures, and dress the
wound.
  ;' Experience has  convinced me that  all the  methods of treatment
which I have enumerated are liable to objection, and in the great major-
ity of instances fail to accomplish the object  in view.   In the first  place,
I never could succeed in curing a case by  compression, although I have
often tried to do so.   I always found that  the  degree of compression
necessary to effect a cure produced inflammation in the part, so that the
second form of the disease became established, and if the pressure were
still persevered in, the third stage ensued,  characterized by ulceration,
sloughing, and haemorrhage.  The plan of treatment by applying a liga-
ture on the artery at the  cardiac side of the tumour is objectionable for
the following reasons : A ligature  so applied will not necessarily cut off
the supply of blood from the tumor  in such a manner as to accomplish
a cure, inasmuch as the free anastomoses which exist between the branch-
es of the temporal  arteries of opposite  sides will furnish an abundant
supply  of  blood, which will flow into the sac at the distal side, in this
way render the operation ineffectual,  whilst the wound, irritated by the
ligature left in it, might give rise  to  erysipelas.  My  objection  to the
third method applies solely to the employment of ligatures, which  I con-
sider worse than useless, by acting  as foreign bodies.   The plan of treat-
ment which I have found successful in all  cases  of temporal aneurism,
no matter what may be the state of the parts at the time, is to open the
tumor freely, so as to completely divide the artery, sponge out the  blood,
and dress the wound from the bottom  with graduated compresses of lint,
previously  dipped in spirits of turpentine.   These should be kept on by
a roller applied with a moderate degree  of  tightness, and not removed
sooner  than the fourth day after the operation, when the wound will usu-
ally be found suppurating kindly.   The  case should now be treated in
every respect in the manner I have described, when  speaking of  obsti-
nate cases  of primary haemorrhage."
  A case has been reported, by M. Barrier of Lyons, of a temporal an-
eurism   arising  from a blow.  The  tumor extended from the ear  to the
angle of the eye, and although  compression  of the  temporal artery to-
wards its origin arrested its pulsations M.  Barrier thought proper to tie
the primitive carotid, which produced  some difficulty of swallowing and
speech,  after which, matters progressed favourably.   G. C. B.] 
848            new  elements of  operative surgery.
                 Article IV.—Operative Process.

  There is hardly any rule to be given here in relation to the operation,
except for the trunk of the facial, occipital, and temporal, that is, in those
cases where we do not act upon the seat of the lesion itself.

                     §  I.— Temporal  Artery.

  We easily find the temporal at three lines, in front of the ear, a little
above,  and on a line with the zygomatic arch ; an incision an inch long
is sufficient to arrive at it in the  deep  lamellae  of the  cellular  tissue by
which it is enveloped.  [See note  above.  T.]
  The  aneurisms  of the  cranium,  moreover, having  no fixed position,
it is  necessary, in order  to treat them by the  method of Anel, that we
should leave ourselves to be guided much more by the pulsations of the
artery, than by any anatomical relations laid down in advance.  Another
indication to be recollected is this, that whether we follow the  ancient
method, or operate  without opening the tumor, the  ligature  should be
placed very near the aneurism, both  above and below, and  on  all the
branches which go into or come out from it.

                      §  II.— Occipital Artery.

  The  occipital artery is  to be sought  for in the neck.  But it is so much
concealed in this  part, that be  the case what it may, we should  make a
direct application of the ligature upon the artery, or do it at the opening
of the  vessel, seizing it at the point where it is wounded rather  than to
attempt the method of Anel.
   [Dr. Neil of Philadelphia has recently tied both occipital arteries for a
pulsating tumor of the occiput.   G. C. B.]

                      § III.—Facial  Artery.

  The facial at its arrival upon the lower maxilla, would not be more
difficult to cut down to, than the temporal. By cautiously^ dividing the
skin on the edge of this  bone, and in a horizontal direction, from  the
anterior border of the masseter  to the triangular muscle of the lips, we
would  be sure of coming down upon it immediately.  We  may  also
reach it, by dividing the  parts which cover it, to the extent of an inch,
or an inch and a half, obliquely from  above downwards, and from before
backwards, quite close to the masseter muscle; its satellite vein is the
only organ which it is important to avoid, and even that might be wound-
ed or included in the ligature without any serious inconveniences result-
ing from it.   Like the temporal the facial artery ought also in general
to be tied both above and below the  sac, or at its two ends, in order to
give the operation every possible chance of success.  Siebold says, he
has tied it successfully for an intermittent hemorrhage of the gums. 
ARTERIES OF THE  NECK.
849
                          CHAPTER  IV.

                      ARTERIES OF  THE NECK.

  The arteries which we may be required to tie in the neck are the max-
illary, lingual, pharyngeal, thyroid, vertebral,  carotid, and trunk of the
arteria innominata.

             Article I.—External Maxillary Artery.

  To lay bare the  maxillary artery in the neck,  we should make an in-
cision two inches long, parallel to the inner margin of the sterno-mastoid,
and the middle part of which should correspond to the great cornu of
the thyroid cartilage.   After having divided the skin, the platisma myoi-
des,  and the cervical aponeurosis, then pushed  aside the  muscles and
brought the carotid itself into view, it is  necessary to tear open by means
of the grooved sound, the sheath of this vessel upon its anterior side,
up to the  os hyoides.   Here  we find the origin of  the facial  artery,
which  runs obliquely inward  and upward to reach the sub-maxillary
gland, and lower border of the jaw.
   Another process also, which I described in  1825, (Anat.  Chir., t. L,
p. 179,) consists in dividing  the tissues  from the great horn of the os
hyoides to the border of the sterno-mastoid muscle; in order to  seek for
the artery between the sub-maxillary gland and the digastric muscle.

                    Art. II.—Lingual Artery.

   Many practitioners have felt the necessity of obliterating the lingual
artery, and some  of them have even pointed out the mode  of  doing it.
For  in addition to the fact that the wounds of this artery would become
too dangerous, if in order to arrest  their hemorrhage, we were forced
to tie  the carotid artery,  they might also have this inconvenience that
the blood would probably continue to flow by  the upper end, by means
of the anastomoses of the  face, and perhaps, also, from the lower end by
the return of the circulation through the internal and external carotids.
   On the  other  hand, the lingual  artery may be the seat of aneurisms.
Colomb, (Obs. de  Mid. et de  Chir., p.  451,)  relates an example of it
which he cured by opening into the sac, and by the ligature.  But it is
for the purpose more especially of arresting the  progress of certain
erectile, fungous  and cancerous tumors of the  tongue, that after the
example of Beclard this operation  has been proposed, which would also
be a valuable resource if it could be performed before  carrying the
bistoury to the tongue itself, when  we are obliged to amputate a certain
portion of that organ.
   Beclard appears to have been the first who  gave a correct description
of the process by which the lingual artery may be reached  with preci-
sion ; but this process has never been published.
   Vol. I.                    107 
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NEW ELEMENTS OF  OPERATIVE SURGERY.
                                §1.

  The process which I have pointed out above for the maxillary artery
equally applies to the lingual, which is a little deeper, and at first courses
horizontally, before  taking a vertical  direction, between  the os hyoides
and the muscles of the tongue.

                   § II.—Process of the  Author.

  The following is the one  which I have elsewhere recommended, (Anat.
Chirurg., t. I., p. 180, 1825 ; et t. I., p. 424,  1833.)  We make an in-
cision in the supra-hyoidean region, which should approach a little more
to a horizontal than to a vertical line, in order that its anterior extrem-
ity may extend towards the chin.   Penetrating thus at some lines under
the submaxillary gland, we may seize the artery  of  the  tongue behind
the hyo-glossal muscle  by pushing  aside  the nerve  that crosses it, or
what is as well, under this muscle itself, by dividing those of its fibres
wliich form a thin layer upon the vessel.  It must also be observed, that
the facial artery  passes above  and on the  inside of the submaxillary
gland, while the lingual lies lower down.

                  § ILL—Process of Bl.  Blandin.

  (Anat. Topog., p. 194.)  A  small incision  parallel to the os hyoides
which is easily felt, enables M.  Blandin to cut in this  manner, through
the skin and plastima myoides, and then to raise the digastric and stylo-
hyoid muscles.  The hyo-glossus  muscle would be involved (See a few
lines above,) and the  artery being laid bare  could easily be seised by
means of a grooved sound.  We  must  not go too far from the  great
horn of the os hyoides for fear  of wounding the hypo-glossal nerve.
  This process which scarcely  differs from that  which precedes it, is
neither better apparently nor worse.   Both permit of our reaching the
artery, but the operation is not easy  either  with the one or the other.

                               § IY.

  M. Mirault, (Mem. de  l'Acad.  de Med., t. IV.,  p.  35,) also, who
could not succeed in tying the lingual artery by the ordinary processes,
endeavoured to devise a new  one.  Having carefully studied the ano-
malies of this artery, on thirty-eight dead bodies, he saw that in twenty-
one  it  originated on a level with the os hyoides ;  that in fourteen its
root was found from one to eight lines above, and in three only at three
lines below ; from whence he concludes, as I  had also myself ascertain-
ed, that it is above this bone that we must seek for the lingual artery.
   In place of  dividing the parts obliquely from below upwards and from
behind forwards, as if to  cross the submaxillary gland, M.  Mirault pro-
 ceeds in the following manner:—The patient having his head  thrown
 backwards and  his chin  turned towards  the sound side,  the surgeon,
 grasping the upper region of the neck with  the  thumb  and fore-finger
 of the left hand, divides the tissues in the direction of a line which ex- 
ARTERIES OF THE NECK.
851
tends from the upper border and anterior part of the great  horn of the
os hyoides, to the  anterior margin of the sterno-mastoid muscle, on a
level with or a little above the angle of the jaw.   After having thus di-
vided the skin,  the sub-cutaneous fascia and the platisma  myoides, he
reaches the external jugular vein which ne pushes  aside or  ties, and di-
vides in order  to cut immediately  through the  cervical fascia, and to
lay bare the submaxillary gland, which  he detaches and gently  turns
back from below; upwards.  After having divided the deep  layer of the
aponeurosis  which then presents  itself,  we come to the  Dharyngeal
and  lingual  veins, which  it may  be  advisable to tie and  to cut in or-
der to  lay bare the great hypo-glossal nerve.   The artery is found
between this nerve and the lower border of the stylo-hyoid  muscle  near
the great horn  of the os hyoides.   Nothing more then remains to be
done  but to isolate the  vessel by means  of a grooved  sound, or by a
curved needle, and to surround it with a ligature.

                                §  V.

   M. Flaubert,  who appears to have once tied the lingual artery, in 1835,
recounts the kind of difficulties that he met with; so that the rules for
the operative process may be established now upon trials  and facts fur-
nished from the dead body as well as from living man.   It is  impossible
at the present time to say what might be obtained from this ligature in
operations to be performed upon the tongue or in organic  disease of this
body.   M. Flaubert, (Voranger, These No. 85, Paris, 1836,) who makes
his incision from the point of union of the small and great horn of the
os hyoides, outwardly and upwards, towards the angle of the jaw, found
the operation very simple ; it was in order to remove with less danger a
tumor of the tongue, and I have already said, that M. Mirault, not being
able to find the artery, had in a case of this kind tied  the tongue itself.
   I am not aware that these processes which upon the  dead body  have
not appeared to me perceptibly more simple than my own, would render
the operation much more  easy  on living man.  It is evident, also, that
if it was a case of recent wound with  hemorrhage, it would be neces-
sary to  dilate the wound and to seek for the artery in the midst of the
wounded tissues.   Colomb, also, having operated by the ancient method,
found himself under the necessity  of being guided  much  more by the
seat of  the tumor than by any rules previously traced out.

                 Article III.—Thyroid Arteries.

   The thyroid  arteries  have already been tied by numerous  practition-
ers,  and especially by  MM. Graefe, Hedenus, (Journal de  Graefe et
 Walther, t. IL,  p.  242, et Gaz.  MM., p. 169,)  Coates, (Medico-Chirm-
gical Trans., vol. X., p. 318,)  and  Langenbeck, (Bulletin de Firussac,
t. X., p. 363,) to allow of the extirpation  of the  thyroid body or to
cause its atrophy, in cases of scirrhous degeneration or goitre.  M. Walth-
er, (Soc. de Mid. de Marseille, Comte Rendu, 1818, p. 34;  Journal de
 Graefe  et  W.,  t. XIII., p. 203,) M.  Earle, (Bull, de Ferussac, t.  X.,
p. 289,) M.  Blizzard, (Ibid.,  288,) M. Brodie, (S. Cooper, trad., p.
244,) and Carlisle, (Gaz. Mid. de Paris, 1833, p. 657, have also had 
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NEW ELEMENTS  OF OPERATIVE SURGERY.
recourse to it, to effect this last mentioned purpose.   It is also in order
to avoid the danger of coming in contact with the thyroid arteries that
the trunk of the  carotid itself  has sometimes been tied ;  as, for example,
in the case of M. Boileau.  This ligature would probably have prevent-
ed suffocation in the patient mentioned by Heime, and in whom the thy-
roid artery had been opened.
   [We  have  tied  the superior thyroid after ligating the external  caro-
tid to suppress a hemorrhage from its branches, caused by carcinomatous
ulceration.   Our object in  ligating the superior thyroid  was to prevent
secondary  hemorrhage from this source, and to afford greater space for
the formation of a coagulum in the trunk of the external carotid.
                                                        G. C. B.] '
                    §  I.— The Superior Thyroid.

  The incision is made in the same manner as far as the external maxil-
lary ; as soon as the sterno-mastoid muscle  is pushed  aside  from the
larynx,  we see in the omo-hyoid space the jugular vein and the primitive
carotid.  After having torn apart the fibro-cellular lamellae which cover
and unite  these  vessels, the thyroid artery, though deeply situated, pre-
sents itself naked between them and the corresponding lobe of the thy-
roid gland.  Some  small veins occasionally  conceal it, but it is always
easy to  isolate  it with the grooved sound, and the  more so as we ap-
proach nearer to the trunk  that gives origin to it.

                    §  II.— The Inferior Thyroid.

  The incision  should  be made here in the same manor  as for the liga-
ture upon  the  carotid at  the  lower part of the neck.  The thyroid
arising  from the subclavian,  passes  behind  the internal jugular,  the
pneumo-gastric nerve, and the  carotid artery itself; in order afterwards
to ascend  obliquely upon  the posterior surface of the corresponding
lobe of  the thyroid  gland; the upper portion of the omo-hyoid muscle
ordinarily conceals it.   It is necessary to divide or to depress this mus-
cle in order to  seize the artery behind it, between the trachea or oesop-
hagus and the  trunk  of the  carotid,  taking  care  in the meantime to
avoid the  recurrent nerve  and the descending branch of the great hy-
po-glossal  nerve.   We find it  between the longus colli muscles and the
anterior scalenus, outside  the jugular, and accompanied by the phrenic
nerve ;  we might therefore cut down to  it by means  of the process
which M. Sedillot recommends for the ligature upon the  carotid.

              Article IV.—The Vertebral Artery.

  The vertebral artery concealed in the canal of the transverse processes
of the cervical  vertebrae, seems up to the present time to have  been
placed out of the reach of  all surgical solicitude.

                          §  I.—Anatomy.

   Nevertheless, if we  remark with M. Ippolito, that this  artery, as I
•myself have also ascertained, in the place of always passing into its canal 
ARTERIES OF THE NECK.
853
by the foramen of the sixth or seventh cervical vertebra, frequently does
not enter it until it has reached the  fifth, and quite often even that of
the fourth, sometimes also that of the second or first, we may under-
stand how external violence  of  every kind may affect it with almost as
much facility as the carotid.   Admitting, even, that the vertebral artery
runs through the entire canal formed by the succession of the transverse
processes, it is easy to see  that sharp-pointed or cutting instruments and
fractures in the  cervical region are also of a nature calculated to wound
it.  At the  point where it turns round  upon the postero-external sur-
face of the atlas to enter the cranium by the occipital foramen, the loops
that it forms exposes it in  a special manner to wounds and aneurisms.

                           §  II.—Indications.

   Spontaneous  aneurisms  of the basilar artery, which I have spoken of
above, are additional motives  for the surgeon to interest himself in the
operations which it might be possible to perform upon the vertebral artery.
   [Lisfranc  has commented  with  much severity upon the remarks of
our author  respecting  spontaneous  aneurisms of the basilar artery as
constituting one of the indications for the ligature of the vertebral artery.
(Bled. Operatoire, tome troriseme, p.  101.)   We must confess  that we
share in his incredulity as to the possibility of forming a clear diagnosis
of this affection, though Dr. Samuel S. Whitney of Dedham,  Mass., who
  as devoted considerable  attention to cerebral auscultation, claims that
  e has succeeded in thus detecting an unequivocal aneurism of  the bas
ilar artery ;  (Vid. Amer.  Journ. Med. Sciences, Oct. 1843.)  Dr. Wm
 S. Bowen has reported a case of aneurism of the basilar artery, (N. Y.
Journ. of Bled. Sf  Collat.  Sciences, Nov. 1849, p. 345) and has attempt-
 ed to show the  possibility of diagnosticating intercranial aneurisms.  His
 remarks  are  based upon  an  analysis of twelve cases of cerebral aneu-
 rism, of which seven were of the basilar artery.  Our limited space pre-
 vents us from giving a  summary of his arguments.  G. C. B.]
   Should I not add that the  trunk of the carotid has been tied by mis-
 take in a case  where  the vertebral  artery  alone had been wounded ?
 Fabricius already, in 1746, relates the case of an individual who perish-
 ed from a wound of this artery between the atlas and the occipital.
   A man twenty-eight years  of age was wounded below the left angle
 of the lower jaw  by a sharp-pointed instrument.  A false  consecutive
 aneurism resulted from it, having its seat under the mastoid  process.
 The professors of the hospital of Naples, consulting together, decided that
 recourse  should be had to a ligature  upon the primitive carotid artery,
 which was  performed  on the 18th of July, 1829, by Professor Chiari.
 (Archivi di Chirurg.  e Bled.,  an.  2, No. 19.)  The patient  died on
 the ninth day,  and the autopsy showed  that the  aneurism occupied the
 vertebral artery, between the transverse processes of the two first cervi-
 cal vertebrae!
    Bl. Ramaglia (Filiatre Sebezzio, ann.  3, fasc. 2) relates a fact some-
 what analogous.   A man, aged thirty-nine years, received a wound from
 a sharp-pointed and cutting instrument under the left ear ; the aneurism
 which resulted  from it left the surgeon in doubt which was the  wounded
 artery.   M. Rispoli  proposed to tie  the  vertebral artery, but the other
 
854
NEW ELEMENTS OF OPERATIVE SURGERY.
professors  were opposed to it; it was decided to obliterate the carotid.
Seeing  that the strangulation  of this last did not arrest the pulsations
in the tumor, the operator withdrew  the  ligature ; various symptoms
supervened, which, after a certain time, caused the death of tho patient.
The  examination of the dead body here also showed  that the aneurism
originated  from the vertebral artery.  These observations having been
communicated to the  academy of Naples, MM.  Castelacci and  Grillo.
(Rev. Med., 1836, t.  111., p. 399)  were induced to undertake a series
of researches, the result of which has not yet been published.

                     § III.— Operative Process.

  Being a witness to the facts,M. N. Ippolito (Sulla Ligatura dell' Ar-
teria Vertebrate,  1834,) has examined  in what manner the vertebral ar-
tery could be cut down to, and surrounded with a ligature.
  A.—The  process which  M. Ippolito determines  upon, is as follows:
The patient should be laid horizontally, with his  head a little turned to-
wards the sound side.  The surgeon, placed on the opposite side, makes
an incision two \nches long upon the external border of the sterno-mas-
toid muscle, and thus  penetrates  gradually down to the side of the an-
terior scalenus muscle.  Afterwards, making use of the sound, he gently
tears away the cellular tissue, finds the  artery, separates it from the vein,
and surrounds it with a ligature, by passing around it from without in-
wards.
  I was, perhaps, the first (Anat. Chir., t.  L, 1835,) to point out the
practicability and the manner of cutting down upon the vertebral artery.
In 1833,1 felt myself justified in recommending an incision which should
pass between the two  roots of the sterno-cleido-mastoid muscle ; that is,
by the process which M. Sedillot recommends for the ligature upon the
primitive carotid.
  B.  The Process that should be adopted.—At the present day, it would
be easy  to arrive at the vertebral artery by taking for our guide the ca-
rotid tubercle, pointed out by M. Chassaignac.   Making part of the an-
terior surface of the  transverse process of the  sixth cervical vertebra,
this tubercle, which is generally felt without any great difficulty through
the skin, is found at some lines within, or at some liues above the trunk
of the vertebral  artery; but as the width of the sterno-mastoid muscle
is extremely variable, and that also of the upper notch of the sternum,
I do not think that the incision of the integuments  should always  be
made upon the same  part of the neck.  Whether, after the manner  of
M. Ippolito, we make it on the outside, or find it more convenient to car-
ry it upon  the inside, or prefer that it  should fall between the two roots
of the sterno-mastoid muscle, it would nevertheless be necessary to  di-
vide the tissues successively and with caution until the vertebral tuber-
cle could be felt  with the finger.   Then the grooved sound being substi-
tuted for the bistoury, will place it in  our  power, after dividing the cel-
lular tissue a little below, and with the finger pushing back the  jugular
vein and the carotid  artery to the inside, to isolate the vertebral artery
without any very great difficulty.  A curved needle, sufficiently short,
and made after the pattern of that of Deschamps, would render the pas-
sage of the ligature  less painful than if we depended upon the flexible
probe. 
ARTERIES OF THE  NECK.
855
    This operation never having haen performed upon living man, it is un-
  necessary to describe it more at length in this place.   Now that surgeons
  are aware  of its practicability, and that they  know the cases that may
  require it, we must wait until experience  has put it in our power to ap-
  preciate its difficulties.
    [The vertebral artery was tied by MM.  Maisonneuve and Favrot, of
  Pans, on the evening of the  20th of February, 1852.  This was done
  to arresta serious hemorrhage produced by a gun-shot wound in the cer-
  vical region. ^ We copy the following  account  of the process  adopted,
  from the  Union Medicate, March 20th, 1852, p. 142.   An incision of
  about 15 centimetres was made along the anterior border of the sterno-
  mastoid  muscle, a little external to the opening made by the  entrance
  of the ball.  This exposed the carotid artery and the internal jugular
  vein intact.  It was  easy through this large  opening to discover^ 1st,
  the cricoid cartilage, the left side  of which had been grazed;  2nd, the
  upper rings of the trachea and the  oesophagus which  had been exposed,
  but not wounded by the ball.   In  exploring the  bottom of the wound
  for the vessel which furnished the hemorrhage, the ball was discovered
  in the body of the sixth cervical vertebra, and was immediatelv extract-
  ed.   The  hemorrhage at once became violent and appeared to proceed
  from  the vertebral artery, which had been  wounded in the canal of th3
  transverse  processes  of the vertebrae.  At length the wounded vessel
  was discovered, and was seized with a spring forceps.  The facility with
  which this was done, led them to suppose that they had been deceived, and
  that,  instead of having secured the vertebral artery, they had found only
  some  branch of the inferior thyroid.  An armed needle, with a very short
  curve, was  passed around the  vessel, which was tied above and below
  the wound.   The hemorrhage was immediately and completely arrested.
   Another  vessel, more superficial, which was proved to be the inferior
 thyroid, was afterwards tied without difficulty, as were several others of
 minor importance.  Matters progressed favorably and on the 29th of Feb.
 the ligatures came away.   On the fifth  of March, fever suddenly mani-
 fested itself with violent  mental disturbance. On the 9th of March, at
 2 o'clock, P. M. whilst making his  toilette, the  patient was seized  with
 severe pain in the cervical region, uttered a cry, and  instantly fell in a
 profound coma, which lasted until 9 o'clock in the evening, when he died.
 At the autopsy, the vertebral artery, for an inch  above  and below the
 wound, was found filled with a solid coagulum.  The body of the verte-
 bra was hollowed by a deep canal, the extremity of which communicated
 with the spinal canal, by a small  opening evidently produced in  the last
 moments of life.   The spongy  tissue of the bone was infiltrated with
 pus, and a sero-purulent  exudation  existed in the spinal canal, both in
 the external cellular tissue and in the sub-serous tissue of the envelopes
 of the spinal marrow.   No  other  serious lesion was discovered in any
 of the other organs.
  The primitive carotid has several  times been tied through mistake, for
 aneurism of the vertebral  artery.   Mr. South, in his edition of Chelius,
 refers to an  instance which occurred at the  Northern  Infirmary, Liver-
 pool.   The tumor increased after the application of the ligature, and the
patient died on the fourteenth day.   M. Fraeya, published an article in
Journ.  Bled, et de Pharm. 1849-50, p. 183, in  which he  attempts to 
856
NEW ELEMENTS OF  OPERATIVE SURGERY.
 point out a means of diagnosis in these cases.  This consists in compres-
 sing the carotid immediately above  the carotid tubercle, avoiding the
 space below.  The circulation continues through the vertebral, but it
 is arrested in the carotid.   The effect upon the aneurismal tumor will of
 rourse vary according to the vessel which is the seat of the disease.
       '    '         °                                  G> C. B.]
               Article V.—The  Pharyngeal  Artery.

   If the operation of the ligature upon the carotid artery has  been so
 frequently performed, this has  happened as much so, perhaps, because,
 in a great  number of cases the arterial branch actually wounded did not
 seem accessible, as  because of the diseases proper to the common carotid
 itself.  A  hemorrhage from the facial, laryngeal, occipital, or lingual ar-
 tery, and from the different branches of the external or internal maxil-
 lary, have, without doubt, been often treated by  a ligature upon the pri-
 mitive carotid.   The danger, in fact, from wounds of any of these arte-
 ries is sufficiently great to  justify important expedients, since a  patient
 of whom  Saucerotte speaks, and who had a wound of the laryngeal ar-
 tery, died  in consequence of being suffocated  from blood ; that a lesion
 of the thyroid artery produced the same result in a patient mentioned by
 Heime ; and that the same thing  would have happened from a hemor-
 rhage from the gums, alveoli, and vault  of the palate, if Sicbold had not
 taken the  resolution to tie the facial artery, or that M. Duval  and M.
 Delabarre, in a similar case, had not found means of arresting  the blood
 by compression.
   The inferior pharyngeal  artery, besides being quite small, is so deeply
 situated that we have scarcely anything to fear from its wounds.   Since
 in the patient of M. Mayo, who had a hemorrhage from the throat—in
 another of M.  Syme, that  lost blood from the  mouth and ear—and in
 those of M. Luke and M. Duffin and some others—the wound, in all of
 them, was  situated upon the branches rather than upon the trunk  of tho
 carotid—is it not evident  that the ligature upon  the  wounded  branch
 would have been more efficacious, and  especially less dangerous, than
 that on the common carotid, which in reality was the artery tied ?  The
 misfortune  here is, that it is sometimes difficult to determine the seat of
 the arterial division.  Admitting, however, that we should be enabled to
 ascertain it, and the thing appears to me  practicable in the greatest num-
 ber of cases, I would be disposed to lay down this law:  In hemorrhages
 from the neck,  mouth, throat, ear, or cranium, vje should do all  in our
power to reach the  arterial branch that is wounded, rather than tie the
 carotid artery itself.
   As to the inferior pharyngeal, properly so called, we could reach  it
 by cutting down as we do  to lay bare the upper extermity of the common
 carotid.  By separating, with the  extremity  of a sound, the lamellae
 which unite the internal and external carotid, we should find  its trunk
 lying between these branches, in such manner as  to enable us then to
 pass a ligature  around it without difficulty.  We should know  if  it  was
 this artery  which kept up  the  hemorrhage, by taking the precaution,
 before finally tying it, of alternately compressing it with the finger  and
 then leaving it free.  The search for  the pharyngeal, moreover, would
 not expose  us to any inconvenience, since the same incision would suffice, 
ARTERIES OF THE NECK.
857
should it become necessary for the ligature upon either  carotid, for  the
lingual artery, or for the external maxillary or superior thyroid artery—
all which should be seized hold of in succession, in order to be certain
which is the one which is really divided.

          Article VI.—The Secondary Carotid Arteries.

  It may readily be supposed that surgeons formerly must  have found
it more convenient and secure  to  tie the  common carotid  for all  the
arterial diseases of the cranium or head, than to  endeavour in certain
cases to tie the secondary carotids  or  their branches; but  that is no
longer admissible  at  the present  time.  There  is a class of diseases
especially which in this respect seems imperiously to demand a modifi-
cation in surgical practice ;  I refer  particularly to varicose aneurisms,
aneurisms by anastomosis and erectile tumors.  When in fact we have
tied the common carotid  for one of these diseases, the blood of the  op-
posite side, returning by the  internal carotid, re-enters from below  up-
wards into the external carotid, at the same time that it returns into  this
latter by its own appropriate anastomoses.  Thus Pelletan, Dupuytren,
MM. Wardrop, Kuhl, and De Noter, operating for varicose aneurisms,
failed  by tying  the [common] carotid  only, and it was  remarked  that
the erectile tumors of  certain regions of the head, yielded  much  more
readily to this ligature than others  did.  These tumors, when having
their seat in  the temporal region have resisted  the  ligature upon  the
(common) carotid in the hands of MM. Willaume, Mussey, Roux,  and
many  others, while the same  operation has generally succeeded with simi-
lar tumors developed  in the orbit or in  the  substance  of  the  eyelids.
The ligature upon the external carotid  would  put a period to this diffi-
culty for all  tumors of the face and  the exterior of the  cranium, and it
would be necessary to tie the internal carotid for the aneurisms or arte-
rial diseases of  the orbit.

                                 §  I.

   M.  Mayo  having anticipated  this  indication, asks if it  would not be
better for hemorrhages or aneurisms of the head, to  tie separately  the
external and internal carotid, in place of acting upon the common caro-
tid.  M. H.  Berard, (Diet, de Bled., 2e edit., t. VI., p. 414,) who has
demonstrated the inutility of thus tying the two carotids for the diseases
of  one only,  proposes to tie at first the  primitive  carotid, then to place
another ligature upon one of the two secondary carotids it is immaterial
which, under the expectation that it would be difficult  for  the circula-
tion to re-establish itself in the external carotid artery, if it is   that
which has been tied, by means of the anastomoses of  the  internal caro-
tid, and difficult also in the contrary case in this  last by means of the
external carotid.  The reasoning of M. Berard  in this  case  does  not
appear to me to be well founded.  I have not found that it  was difficult
as this author believes it is, to .distinguish the two secondary carotids
from one another, and it  appears  to me altogether  rational when we
wish to tie only  one of them, to tie that which is diseased in preference
to that which is  not so.
   Vol. I.                    108 
858
NEW ELEMENTS OF OPERATIVE SURGERY.
                               §11.

   This operation I have performed in still another  manner.  A young
man aged sixteen had at the lower part of the temple a tumor accompa-
nied with pulsations.  This youth who was seen by a great  number of
surgeons of the capital, and "exhibited by me to the Royal  Academy of
Medicine, appeared to be affected with an  aneurism, or an erectile tu-
mor of the pterygo-temporal fossa.  The bruit of the vessels, the visible
heaving up and pulsation of the tumor, and the manner in  which it had
been developed, united in establishing this  diagnosis. Having laid bare
the carotid upon the side of the os hyoides, in the omo-hyoid triangle, I
isolated its bifurcation and  was only incommoded in that  part by some
lymphatic ganglions.  After having tied the common trunk of this artery,
I proceeded to the  ligature upon its  internal  branch, which as it always
is, was within and a little behind.
  The tumor which immediately  ceased to pulsate, rapidly diminished
in volume.  Repeated hemorrhages, soon followed by a complete hemi-
plegia, caused the death of the  patient upon the sixteenth day.  The
blood came from the external carotid and escaped by the upper  end of
the common  carotid.  The tumor also was hard, and rather fibrous than
erectile.   Placed over the external maxillary artery which was  double
its natural size, and which passed above the external pterygoid  muscle,
in place of traversing the  space  which separates the  muscle from the
internal pterygoid, the tumor was raised up in such manner as to present
the characters of a  true aneurism.   Perhaps also it had been contracted
and indurated at this point after the operation, and in consequence of the
exhaustion of the patient.  The common carotid having been closed,  I
had hoped to place  an impediment against the return of blood by tying
the internal  carotid.  I did not wish to tie both the secondary carotids,
for  fear of seeing the circulation kept up in the common carotid up  to
its bifurcation.  Does the result prove that I was wrong V

                                §  III.

  For the Operative Process, we should  proceed in every particular as
if it was for the primitive carotid artery,  with this difference however,
that the  incision should be  prolonged upward to  above the level of the
angle of the jaw, and that it would  be important to turn aside and forci-
bly raise up the chin  towards the sound side.  We commence  then by
laying bare the common carotid.   Ascending afterwards  with caution
we  soon arrive upon the bifurcation of this trunk and the root of its two
branches.  The lymphatic ganglions, veins, and nervous filaments must
be carefully  pushed aside ; the  two  carotids being  laid bare we may be
sure that the external is  most superficial and nearest to the larynx.  We
recognize it moreover by  the branches of the third order which originate
from it to go to the face and the rest of the neck.   It would be important
also to place the ligature above and below the whole groupe of  arteries
which the external carotid gives off near its origin, and to  take measures
against the dangers of the  collateral circulation. 
ARTERIES OF THE  NECK.
859
              Article VII.-—The Primitive Carotid.

                          § I.—Anatomy.

 _ A.  On leaving the chest the carotid artery soon places itself on the
side of the passages of respiration and deglutition, where it continues up
to the moment of its bifurcation which generally takes place opposite
the thyro-hyoid space.  The internal jugular vein lies upon its outer sur-
face and conceals even a part of its anterior surface during life.   On the
inside, elastic and resistant cellular lamellae, branches of the recurrent
nerve^ and inferior  thyroid artery, separate it from the  larynx, trachea
and oesophagus.  The cardiac nerves  of the pneumo-gastric, and the
internal filaments of the great sympathetic, cross more or less obliquely
its posterior surface, along the entire length of the outer border of which
moreover, run  the trisplanchnic and the pneumo-gastric themselves.   A
yellowish solid sheath, difficult to be torn, unites it to the vein and ner-
vous cords, and to the descending branch of the great hypo-glossal which
usually follows its antero-external  portion.   Resting moreover  against
the  front  portions of  the cervical vertebrae, and covered near its origin
by the sterno-mastoid muscle, which soon  separates from it so far as to
leave it free upon its whole inner margin, covered also by the outer border
of the sterno-hyoid and sterno-thyroid muscles,  then by the correspond-
ing lobe  of the thyroid  gland, and  by veins which are sometimes of
considerable size, and which empty into the internal jugular, it is as it
were  divided into two portions by the omo-hyoid region.
  This  little muscle in fact transforms the side of the neck into two
very  regular triangular  spaces.  In  the inferior  or omo tracheal tri-
angle, bounded by the trachea, clavicle and muscular bundle in question,
the artery concealed by the inner  root of the  sterno-mastoid, does  not
present other than very simple relations  except that in this situation it
lies very deep  ; in the other or the omo-hyoid triangle, which is  circum-
scribed by the border of the sterno-mastoid outwardly, the transverse line
which limits the sub-hyoid region above, and the omo-hyoideus muscle
below, it  is much more superficial; but it is in  this place that we fre-
quently find a venous plexus covering its anterior surface.
  Nevertheless, the right carotid which is shorter, as is known, than
the left carotid, because of the trunk of the innominata, and being also
perceptibly nearer the median  line and  more superficial, owing to  the
trachea which  raises it up near the sternum, is for that reason, almost as
easy to reach in  the omo-tracheal space, as in the  omo-hyoid triangle.
  B.  Anomalies.—Among the varieties which the  carotid arteries pre-
sent, there are some that may occur, which the surgeon ought not to lose
sight of.   That of the right side may come directly from the aorta.  At
other times, the trunk of the innominata ascending higher than usual, of
which M.  Harrison cites an example, the carotid is thus found shortened
to the same degree.  Zagorsky has seen  the left carotid and subclavian
arise from a common trunk, while upon  the right  they were separate.   I
have seen, as have also A. Monro,  Scarpa, A. Burns, Goodman, Meckel,
&c,  the  two  carotids arise from the  trunk of the innominata, also
originating by a common trunk from the aorta, distinct  from  the two 
860
NEW ELEMENTS OF  OPERATIVE SURGERY.
subclavians ; but it is rare that they separate into external and internal
carotid at the lower part of the neck, as Burns and some others have
noticed.  M.  Langenbeck has seen the primitive  carotid divided into
internal carotid and superior thyroid, and without giving off any exter-
nal carotid ; and Burns cites examples where the cephalic trunk did not
bifurcate until  at a level with the angle of the jaw.

                        § II.—Indications.

  The primitive carotid has been the seat of every kind of aneurism.
Too often does it happen that we find it wounded by pointed or cutting
instruments, giving rise  to hemorrhage  which  speedily terminates in
death.  The patient who, after receiving a sword thrust in the ear died
of hemorrhage, in the arms of Ravaton (Chirurg. d'Armee, p. 467, Obs.
4,) in spite of topical applications, tents and  compression, had  been
wounded in the carotid artery.   It was the same with  one in whom a
fatal hemorrhage took place, while a tumor  was being extirpated  from
the neck, (Cammere Litter. Nuremb. 1733.)   Sometimes,however, the
only result of such  wounds is an aneurism, which, from being at first
diffused,  ultimately becomes circumscribed.  Harder mentions  a case of
this kind in a soldier, whose carotid had been punctured by the point of
a sword.  M.  Reid  relates  the case of a patient, (Gaz. Blid., 1838, p.
282,) who having swallowed a fish bone, wounded the carotid and died
at the  end of ten days with vomiting of blood.   At other times, aneu-
rism is caused by violent movements ; Rumler saw it produced in this
manner in a man who wishing to raise a heavy burden, threw  his head
violently backwards.  Scarpa was witness to a similar fact in a soldier,
who having been thrown from the top of a wall at Mantua, experienced a
torsion and violent  traction of the neck.  Aneurism of the carotid may
also arise without any  appreciable cause, of which at  the  present  day
we  possess numerous examples.
  M. Larrey, (Clin. Chir.,t. III., p. 149—154,) M. Willaume, (Allge-
meine Bled Zeit., Avril, 1838.—Arch Gin de Med., 2e serie, t. IV., p.
135,)and Desparanches, have seen varicose aneurism in this artery.   We
also have at the present  time very remarkable examples of this kind.
A student in philosophy receives a sword thrust in his neck.   The first
symptoms are subdued and are succeeded by a varicose aneurism, (Saba-
tier, t. III., p.  187.)   Au  inhabitant of Martinique, receives  a wound
in the neck from a sharp pointed instrument.   From that time he has a
pulsating tumor in the carotid region.   (Communique par M. Rutz, Mars
1838.)  A wound from fire-arms proves fatal in fifteen days ; the autopsy
discloses  a  communication  between the internal jugular vein and the
carotid.  The  ball  was underneath and in the jugular vein itself.  I
have seen the  specimen, (Commun.  par M. Joret,  medecin  a Valines,
1838.)  The  lesions of arteries  of such large size, and which are the
only ones which nourish the exterior of the head and the greater portion
of the brain, must have  necessarily created uneasiness in the mind of
the surgeon when  the  conviction  presented itself before him, that the
cure could only be effected  by proceeding at once to the obliteration of
the wounded vessel.
   Wounds of the  Carotid causing Aneurismal Varix and Varicose Aneu- 
ARTERIES OF THE  NECK.
861
rism.—Veterinary surgery again comes to the aid of our art in relation to
some new pathological results  noticed  by M.  Rey, Professor at the
Royal  Veterinary School of Lyon, (See Jour, des  Connaiss. Medico-
Chir., Paris, Janvier, 1843, p. 20, et seq.,) in puncturing the carotid
while opening the jugular vein for bleeding.  Two cases have  fallen
under  his observation, the lancet in  both  having been used instead of
the  fleam.  1. In the  first a  mule  aged  15 years, the  carotid alone
owing to  a sudden movement of the  animal was  punctured.  The pro-
fessor  immediately  applied to it the twisted suture  with three pins; a
large tumor formed  immediately afterwards, which, in  confirmation of
the present revived mode of healing aneurisms by compression, and also
wounds  of the  brachial  artery in   the human subject in  bleeding,
was entirely  dispersed, and a perfect  cure effected in two  days by a
containing  bandage, vigorous compression, acidulated lotions and diet;
2. In the  second  case the aneurism which the application of a liga-
ture to the vessel could not prevent [the ligature must have been on the
distal side of the artery, we  presume.  T.]  was cured  by refrige-
rants.  Both the cases were probably aneurismal varix of the artery.
   In another case which is the most important of all, arteriotomy (i. o.,
of the  carotid) was  performed as an experiment, and was  followed by
no unpleasant result, though the animal was left to himself.  T.]
   B.—Galen  and Valsalva, it is true, had already  remarked  that the
ligature upon  the  carotid in dogs, is not  attended with danger ; but
little was it then thought that this fact could be applied to man.  To
create  confidence in the minds of observers  on this point, other facts
were necessary.  Petit (Acad, des Sciene, 1765) found the right caro-
tid completely obliterated.   In dissecting  the dead body of a woman,
Haller met with the same thing in the left carotid ; Bailie (S. Cooper,
 Oper. Cit., p. 155) found  one of them entirely  shut up and  the other
considcraly contracted.  Pelletan (Clin. Chir., t. I., p. 68,) and M. A.
Cooper, have each related a similar fact.  If we may believe Koberwein,
M. Jadelot saw this obliteration in both carotids at the same time.  These
examples, to which at the present day we might add many others, and
especially that which I had occasion  to observe in 1831, ia a dead body
delivered for dissection at the School  of Practice,  prove two  things :
first, that one of the carotids  or even both may be closed, without in-
volving the death of the individual, or preventing the blood from reach-
ing the brain ; secondly, the aneurism on either of those vessels, left to
itself, may in certain cases disappear spontaneously.
   C.—The cure also of  wounds and aneurisms  of the carotid  region
had been attempted by various methods.   We  already find in Verduc
(Pathol.  Chir., p.  147) a compressing bandage devised for this purpose.
Compression exercised with agaric,  a  bandage  and the hand, cured a
wound  of the external carotid, in a case mentioned by Caestrick, ( Ga-
zette Salut., 1767, No. 46.)  Anel, V.  Horn and M. Larrey, cite simi-
lar  facts, (Mim. de  Chir. Milit., t.  I., p. 309.)   The method  of Val-
salva  and refrigerants, employed in our time with  some success by M.
Larrey, {Clin. Chir., t. III., p. 150,) has not been less efficacious in the
hands of Delpech, (Rev. Med., 1824.)   Attention was especially drawn
to the ligature in cases of aneurism,  because it did not appear possible
 to establish in the neck, between the heart  and the aneurism, a sufficient 
862
NEW ELEMENTS  OF OPERATIVE SURGERY.
degree  of compression  to allow of the sac being opened  with the re-
quisite  degree  of security.   The surgeons of La Charite who, accord
ing to  Harder, (Boyer, Malad. Chirurg.,  t. II., ou Apiar., Observat.,
Obs. 86,) were bold enough to undertake it, saw the patients perish un-
der their hands.   According to Hebenstreit, cited by M. S. Cooper, the
carotid  had nevertheless, been tied with success for a wound made during
the extirpation of a scirrhous  tumor from the neck, and also by Aber-
nethey with  success, for a traumatic lesion of the external and internal
carotids.  In 1803, M. Fleming was not less fortunate in a marine who
had attempted to  commit suicide.   We find in the journal of Sedillot, a
fourth example of this operation, for a wound in the neck.   The patient
died on tho  ninth day.  M. Brown relates a fifth, which  resulted in a
cure.   M. Collier furnishes  a sixth, to which M. S. Cooper was a wit-
ness,  and the treatise of M. Hodgson supplies a seventh.
  D.—Be this  as it may, it  was in  November, 1805, that an aneurism
of this artery was for the first time treated by the method of Anel.   The
patient  died  on the twentieth day.  M. A. Cooper  had  recourse  to it
again in the month of June, 1808 ; and this time with perfect success.
In the month of September following, a patient operated upon by M. Cline,
died on the fourth day.  It was not until this epoch that the trials which
had been made at London were known at Paris.   In the year 1804,
Dubois had every thing prepared for a similar operation, which did not
take place, because the patient died suddenly the evening preceding the
day upon which it had  been  arranged to perform  it.   I will  add, also,
that the operation had been formally proposed by Deschamps, the son,
and by  Horeau, (Prix de la Soc de Mid.  de Paris, an X., inedit,) in
1800  or in 1801.   At present, it has been performed  altogether, more
than one hundred and fifty times, and to fulfil  indications  that are es-
sentially different also from  each other.  More than  forty of those ope-
rated upon have  died, while eighty at least have survived ; but it would
be difficult at present to give the exact proportion of cures and failures.
  E.—These operations have been performed, 1st, to remedy hemorrhage
which was caused by wounds of the mouth, pharynx, face, cranium, ear,
parotid region, and all other parts  of the  neck ; 2nd, to effect  the  ab-
sorption, or cure of erectile  tumors in the  same regions, (See Erectile
Tumors) and to arrest the development of  certain fungous or cancerous
tumors ; 3rd,  to  facilitate the  extirpation  of parotid, pharyngeal, and
thyroidal tumors,  (See the Parotid, and Tonsils) ; 4th, to enable us to
remove the lower jaw, (See Exsection  of the Jaw, infra) ; 5th, to cure
certain  diseases of the brain, or of the nerves which arise from it;  6th,
for aneurisms of  the  neck and  head, (See  Compression  of Arteries;)
7th, for certain aneurisms of  the trunk of the innominata or of the aorta
itself.
  [Sir Benjamin  Brodie tied  the primitive carotid to arrest the hemor-
rhage following the extraction of a tooth.  The operation was not  suc-
cessful and the patient lost his life.   The  hemorrhage  was temporarily
checked, but soon returned, the general oozing from  the part being pro-
fuse.  (Med. Chir. Trans.,\ol. viii., p.  225.)  G. C. B.]
  F.—We may thus explain  how the  carotid artery  has been tied so
great a number of times in less  than forty years.   Here is the list of
the cases which I have been  enabled to collect. 
ARTERIES OF THE NECK.
863
Dupuytren

Chiari

Porter

Molina
Vincent
Clellan, 3
cured

dead
cured
Id
dead
cured
Chaumet	Id.
A. Robertson	Id.
Warren, 15	Id.
A. Cooper, 3	2. c. 1. d.
Coates	dead
Hodgson	cured
Lyford	Id.
Macauley	Id.
Jon	
Key	dead
Cline	Id.
Walther	cured
Dehaen	Id.
Gaunit orGonnet Id.
Marschal        dead
Mott            cured
Post            Id.
Dupont         Id.
r. ,           (for  an.  of
Liston        j   subclav.
        Total, 43—cured 34
I. For Aneurisms.

       Bull, de la Faculte, t.  IV., p. 46,
         Rev. Med., 1828., t. IV.
       N.  Ippolito, Lig.  dell'art. Verteb.,
          1837.
      Dub. Hasp. Repts. vol. V., p. 211.
       Arch.  Gin.  de Mid.,  t. XVIIL,
          p. 569.
       The Lane, Vol. IL, p. 570.
       The  Lancet, 1828, Vol. I., p. 715,
          Journ. Hebd., t. II., p.  7.
       Comm. by the Author, 1837.
       The Lane, t. I., 1838.
       Private  Communication.
       Med.  Chir.  Transact., 1806, 1809,
           CEuv. Ch., p. 450.
       Med. Chir. Tr., Vol. XL,  p. 277.
       T. IL, p. 18.
       Med. Chir. Tr., Vol. II.. p. 97
       Ed. Med. Se Surg. Jour., t. X., p. 178.
       Lisfranc, These, p.  130.
       The Lancet, Vol. I., p. 190.
       Lon. Med. Rev. Vol. II., p. 96
       Hodgson, t. IL, p. 83.
       Med. Gaz., Vol. X., p. 34.
       Berard, Diet., t. VI., p. 420.
       Jour. Hebd., 1835, t. IV.,  p. 271.
       Hodg. t. IL, p. 36.
       Mem. Biograph., p. 18.
       Vanderhagen,  Th., 1815.
       Gaz. Med. de Paris, 1838, p. 600.

    dead 7.
II.  For Wounds, Ulcers and Hemorrhage.
Guthrie
Duffin
Michon
Roux
Larrey

Mayo

Syme

Sisco
dead
Id.
cured
cured
cured

cured

cured

 cured
Op.  Cit., London, 1830.
The Lane, Vol. I., p. 587,1829,
   Vol. II., p. 638.
Lane Jr., t. XII., p. 475.
Wounded of July, 1830.
Clin. Chir., t. IL, p. 120—130.
Bull,  de Ferussac,  t. XXL, p.  123.
   Arch.  Gen., de Med.,  t. XXIL,
   p. 117. Gaz. Mid.,  1827, p.  329.
Ed.   Med.  Sf  Surg.  Jour., 1833.
   Arch.  G., 2e serie., t. IL, p. 108.
Annal.  Univ. de  Med., 1829. Bull.
   de Ferussac, t. XXIL, p. 446. 
864
NEW ELEMENTS OF OPERATIVE SURGERY.
Forner

Boileau
Tyerman
Flemming
Miller

Hebenstreit
Luke
Brown

Dacrux
Garrey
Colliei

Abernethey
Bedor
Dupuytren
Maurin
Marjolin
Travers
Giroux
Cheyne
                       American Jour,  of Bled.  Sciences,
                          1832; Arch.  Gen., 2e ser., t. I.,
                          p. 572.
                       Arch. Gen. de Mid., t. VIIL, p. 45
                       Rev. Bled., 1836, t. IL, p. 423.
                       Bled.  Chir. Trans., Vol. III., p. 2.
                       West  Journal Bled. Sf Surg.,Yo\. I.,
                           p. 425.
                       Hodgson, t. III., p. 25.
                       Guthrie, p. 326.
                       Ed. Bled. $ Surg. Jour.  t.  XIV.,
                          p.  106.
                       Jour. Hebd., t. III., p. 451.
                       Trans. Bled., 1833, p. 360.
                       Bled.   Chir.   Trans.,   Vol.  VII.,
                          p.  107
                       Surg.  Obs. Jour., p. 115. '
                       Presse Med., t. I., p. 73.
                       Hodgson, t. II., p. 39.
                       Jour. Hebd.,  t. II., p. 7.
                       Hodgson, t. II. p. 44.
                       Bull, de  Firus., t. X., p. 286.
                       Hodgson, t. II., p. 45.
                       Arch., 2e ser., t.  IL, p. 108.
Total, 27—Cured, 21—Dead, 6.
cured

cured
cured
cured
cured
cured
cured
cured
cured
cured
cured
dead
cured
dead
cured
dead
cured
dead
cured
Dalrymple

Mussey

Walther
Velpeau
Willaume
Wardrop
Pattison
Clellan
Kuhl

Delpech

Travers

Bernard
Hall

Rogers
Mayo
Arendt
III.—For Erectile Tumors.   Fungus

 Cured
dead

dead
dead
unsuccessful
unsuccessful
cured
cured
dead
unsuccessful
cured
cured
cured
cured
dead
cured
Hodsrson, t. IL,  p.  15, Med.  Ch.
    Trans., vol. VI.
Jour, des  Prog.,  2e ser., t.  II.,  p.
    262.
Tarral. Arch.  G.,  2e ser., t.  VII.,
    p. 22.
Unpublished, 1835.
Jour. Hebd. Univ., t. II., p. 117.
Hodgson, t. II., p. 82.
Burns, Surg. Anat., p. 465-476.
The Lancet, 1828, vol. I., p. 715.
2 cas, a 3 m. de  dist.,  Ency.  Med.
    1836, p. 131.
Tarral. Arch. Gen., 2e ser., t. VI.
Med. CAir.Tr., vol. I., p. 222, or vol.
    II.
Rev. Med., 1833, t.  III., p. 26.
Tarral, Op. Cit.; Burns, Op. Cit., p.
    485.
Amer. Jour, of Med. Se, 1833.
Quarterly Rev. Jour., 1834, p. 411.
The Lancet, vol. XV., p. 116. 
ARTERIES OF THE NECK.
865
Dupuytren	unsuccessful
Busk	cured
Bushe	cured
Davidge	dead
Maunoir	unsuccessful
Roux	cured
Peyrogoff, in- | fant 9 mos.	dead
Zeis, infant of	
15 months j	• dead
Jameson	unsuccessful
Machlachlan	dead
                       Sec. Oral. Rep. a"Anat. etPh., t.VL,
                         p. 232.
                      Bled. Chir. Rev., April, 1836, p. 184.
                       The Lancet, 1828, vol. IL, p. 413.
                      Burns, p. 481.
                      S. Cooper, Art. Aneur.
                      Berard, Diet., t. VI., p. 422.
                       Ann. der  Ch. de Dorpat, 1837, Rev.
                         Med., 1838, t. III., p. 422.
                       Rev. Med., 1838. t. III., p. 404.
                      Burns, Surg. Anat., p. 480
                      Glasgow Med. Jour., 1828.

Total, 26—Cured, 11—Dead, 9—Unsuccessful, 8 ?

     IV.—For the Removal of Tumors, SfC
Langenbeck     dead
Fouilloy
Gibson

Flaubert

Goadlad
Magendie
Palmi
Kuhl
Baravero
Lisfranc
Gensoul
Fricke
Graefe
Mott
Mott
Mayo
  Vol. I.
cured
Mayer Stedman	cured cured
Awl	cured
Eckstrum	unsuccessful
Beclard	dead
Warren Scott Tarie	cured dead cured
 cured

 cured

 cured
 unsuccessful
 dead
 dead
 unsuccessful
 dead
 dead
 dead
cured
cured
 dead
unsuccessful
Arch. Gin. de Med.,t. XIX., p. 118,
    Diet, de Rust., t. II., p. 11.
Arch. Gin.  de Blid., t. XXVIII., p.
    599.
The Lancet, vol. XIV., p. 174.
Gaz. Mid., 1832, p. 529.
West. Med. Se Surg. Jour., vol. I., p.
    423.
Bullet, de Ferussac, t. VIIL, p. 204.
Arch.  Gen., t.  IV., p.  62,  Berard,
    Diet. t. VI., p. 434.
On Tumors,  p. 292.
Lond. Med. Gaz., vol. IX., p. 951.
lb., p. 374.
Amer. Jour, of Med. Sc,v. XXVI.,
    p. 505.
Voranger, These, No. 85, Paris, 1836,
   Arch. Gen. 2e ser., t. XII., p. 343.
Med.-Chir.
  p. 112.
Trans., vol. VII., p. 1.,
   Bull, de Feruss., t. XII., p. 253.
   Kock, Dessert., &c, 1831.
   Peters, These, Leipsic, 1836.
   Bull, de Feruss., t. XII., p. 234.
   Arch.  Gen. de Med., t. XIV. p. 112-
      114, Rev. Bled. These, 1834.
   Lett. Chir., Ac, 1833.
   The Lancet, vol. II., p.  670.
   Mag. de Rust, et These, de Koch.
   Arch. Gen. de Med., t. XXVII. p. 246.
   New York Med. Se Phys. Jour., v. II.,
      p. 401.
   Lond. Med. Jour., 1827, Nov., p. 408.
109 
866
NEW ELEMENTS OF OPERATIVE SURGERY.
Seutin          cured         j Jou[^[Bf £ Nat' de Bruxell'*> Nov.
Widmer         cured          L'Exper., t. II., p. 336.
         Total, 26—Cured, 12—Dead, 10—Unsuccessful, 4.

                  V.—For Diseases of the Head.

Preston         1, 2            Gaz. Mid., 1833, p. 76.
Liston          unsuccessful   "j Ed' M«|- and Surg. Jour., v. XVI.,
                             (   p. 73.
         Total, 3.
VI.—Method of Brasdor.
Wardrop
Busch
2 cured
  cured
Montgomery     dead
Fearn
Morrison
Rigen
Tillanus
Lembert
Evans
cured
dead
dead
dead
dead
cured
Mott
Key
Mott
Graefe
Bland
Hall
Kuhl
Lizars
       dead
       dead
Total, 12—Cured, 4-
 1 M. Vilardebo, Thhe, 1831.
   The Lancet, 1828, No. 2, p. 149.
  ( Berard, Diet. 6, p. 418,  The Lancet,
  j    June, 1833, p. 421.
   Arch.  Gin., 3e ser., t.  II.,  p.  364,
      recid. 1838.
   Arch. Ibid., p. 369.
   Lettre Privee de M. Kerst.
   Ibid.
   Arch.  Gen. de Med., t. XV., p. 441.
   The Lancet, 1828, vol. L,  et Vilar-
      debo, t. IV., p. 58.
   Amer. Jour, of Med. Se, 1830, Jour.
      des Progres, t. IL, p. 262, 2eser.
   Lond. Med.  Gaz., July, 1830.
-Dead, 8.
VII.— The Arteria Innominata.
dead
dead
dead
dead
dead
dead
Burns, Surg. Anat., edit., 1823.
Jour, de Graefe et W., t. III., et IV.
Amer. J. of the Med. Se, 1833, p. 509.
Arch. Gen., 2e ser., t. VI., p.  267,
  Baltimore Med. Jour. vol. I. p. 125.
Peters,  Dissert., &c. 1836.
The Lancet, June, 1837, p. 600.
        Total, 6—Dead, 6.
n Gu?f,aln Tota1'  143—Cured>  82—Dead,  46—Unsuccessful, 13-
Doubtful, 2. 
ARTERIES OF THE NECK.
867
[Ligature of Both  Primitive  Carotids.
1 Macgill 2 Mussey	20	C Fungous Tumor of or-l bit (Cirsoid Aneurism of i scalp C Cirsoid Aneurism on ( Scalp and Ear
3 Mussey 4 Mott and Eve	28	
5 Mott 6 Mott 7 Hamilton 8 J. Kearny Rodgers and Van Buren 9 Preston 10 Preston	(Malignant disease of ( Parotid Gland Malignant Polypus 18 Epilepsy } ^ung girl {<*«£*, A—ism 0f 51 Epilepsy adult Epilepsy	
11 Preston	24	Epilepsy
12 Moller	4J years	Erectile Tumor in nose
13 Kuhl	53	S Aneurismal tumor of i occiput
14 Ellis	21	C Hemorrhage from gun-t shot wound of neck r
15 J. Mason Warren	23	J Erectile tumor of face mouth and neck I
16 Robert 17 Blackman	young girl 14	Cirsoid Aneurism (Malignant disease of \ antrum
18 Willard Parker	42	) Malignant disease of j nose and orbit
1 month	Recovered
12 days	Recovered.
28 days	Recovered
1 year	Recovered
15 minutes	Died in 24 hours
several mos.	Recovered
6 months	Recovered
several years	i Recovered
11 weeks	Recovered
1 month	Recovered
i	f Recovered — felt
5 weeks	every weak after
	(_ operation
147 days	Recovered
	r Recov'd,—slight
73 days	< convulsions after
	£ each operation
4£ days	Recovered
	f Recov' d,—slight
32 days	J faintness after i operation and
	^drowsiness
8 months	Recovered
21 days	Recovered
	f Died about 5
32 days	1 months after op-
	( eration
  The case last mentioned, we attended until the death of the patient.
During the five months which he survived, he was almost constantly un-
der our observation.   For several weeks after the last operation, the pa-
tient assured us that he was not aware of any unusual feeling in his head,
and his intellect was undisturbed.   At length, with the extension of his
disease, his mind  began to wander, and at times he would lose the con-
trol of the muscles of his lower  extremities.  For 36 hours before his
death he became comatose, and from the whole aspect of the case, for a
month previously, I suspected ramollisement of the brain.   In our own
case, immediately after the application of the last ligature, vision on that
side was destroyed.   In the course  of  half an hour it returned, and  no
unpleasant symptoms afterwards appeared.   His memory, however, was.
for  some months,  impaired, but is  now good.  Seven years have elapsed
since  the operation and nis health is perfect.
  In the child upon which Moller operated, paralysis of the right arm
followed the first ligature, and slight somnolency and  pectoral distur-
bance the second.
  The two patients under  the care of Professor Mussey exhibited  no
symptoms indicating a deficient supply of  blood,  and some months after
the operation, in his first case, the opposite state  seems to hare existed,
as the patient had a flushed face accompanied with head-ache, which was 
868            NEW ELEMENTS  OF OPERATIVE  SURGERY.
 relieved  by venesection.  In the first recorded case we have been ablo
 to find, viz. that in  which Macgill operated, it is stated that " some in-
 teresting  phenomena were  observed "  but of their nature no mention
 is made.   Kuhl's patient, the  oldest on the list, had pallor of counte-
 nance, a  shivering sensation, cephalea on the third day, and paralysis of
 the right arm.   Intellect was unimpaired.
    Professor Porta, of Pavia, in his  magnificient work  entitled " Delle
 Alterazioni Patologiche delle  Arterie  Arc, Milan, 1845, p. 293, states
 that Bunger of Marsburg is reported in  Froriep's Notizcn, 1832, B. 36,
 P. 173, to have tied both primitive carotids on the same patient, but the
 result is  unknown.
    Langenbeck is eroneously included on the list of the surgeons who
 have performed this operation.   Dr.  Xorris is  guilty of the same mistake
 in his  valuable statistical  paper on the  ligatures of the carotid arteries
 published in the American Journal of Bledical Sciences, for July, 1847,
 and the same observation  applies to Mr. Erichsen (Science and Art of
 Surgery, Lond.  Ed. p. 530.)
    By referring to the Archives Generaels, torn.  XIX., p. 118, it appears
 that Langenbeck tied the right superior thyroid to arrest the growth of a
 pulsating goitre, and that in consequence of secondary hemorrhage from
 the  seat  of ligature on the eleventh day, he tied  the primitive carotid of
 the same side.   The patient immediately sank into a comatose state  and
 died thirty four hours after the last operation.   Dr. Crosse, of Norwich,
 Eng. was called upon to tie one carotid, the other having been  secured
 for the purpose of arresting the hemorrhage produced by the extirpation
 of a parotid tumor, but as compression  produced unpleasant effects, he
 did  not venture to apply a ligature.  He refers to this case in his Relro-
: speclive  Address before  the Prov.  Bled, and Surg. Association, July,
 1836, (Vid. Transactions of that body,  Vol. 5th, 1837, p. 67) and states
 that the  patient fell a victim to the  undertaking which he was  made to
 believe necessary to preserve his life.  We have no positive information
 as to the application of a  ligature to the other artery.
    Of the 18 cases, therefore,  which we have  collected, we find but 2
 deaths, and these occurred in the practice of Professors Mott and Par-
 ker of this city.  Professor Parker's operation was performed in May
 and June of the present year, (1854) and during the intense heat of
 July and August, the patient became greatly  prostrated, and continued
 to sink until he  died.  Perhaps his death  should rather be attributed
 to the exhaustion ordinarily following malignant disease, than to ramol-
 lissement of the brain.  Thus  we have but  one death in 18  cases,
 after the ligature  of both  primitive carotid  arteries, an extraordinary
 result  when contrasted with that shown  by the  statistics of Dr. Xorris,
 of the ligature of one carotid, viz. 1 death in  4i70 cases.  G. C.  B.]

                      § III.— Operative Process.

    The ligature upon the trunk  of the carotid is generally of easy execu-
 tion, and the mode of doing it varies but little.
    A.  Ordinary Process.—The patient should  be laid upon his back,
 with his cfcest slightly  elevated, the neck a little extended, and his face
  turned towards the healthy side. 
ARTERIES OF THE  NECK.
869
  I. First Stage.—The surgeon, placed on the diseased side, first seeks
for  the anterior border of the sterno-mastoid muscle, which is indicated
to him by a slight depression, and then makes, in the  direction of this
border,  an incision of about three inches in extent, which commences on
a line with the  cricoid cartilage, and  terminates near the sternum, pro-
vided we wish to lay bare the artery in the omo-tracheal triangle.  This
incision, on the contrary, is prolonged a little higher, and not quite so low,
when the  disease admits  of our applying the ligature  in the omo-hyoid
triangle.   A second cut of the bistoury  divides the platisma myoides,
and the cervical aponeurosis, and lays bare the fibres of the sterno-mas-
toid muscle.   The assistant  draws the inner lip of the wound towards
the median line.  The operator having drawn  its external and muscular
lip  to the outside, by means of the left  fore  and  middle finger, omits
the extension, inclination, or throwing back of the head, and then divides
the fibro-cellular layer, which extends from the sterno-hyoid and thyroid
muscles, to the posterior  surface of the  sterno-mastoid, and upon the
fore part of the vessels.
  II. Second Stage—The omo-hoideus  muscle is now seen under the
form of a reddish bandelette ; if it interferes  too much with  the action
of the instruments, we divide it upon the  director; but we can general-
ly save  it by drawing it out of its place to one side or the other ; above
and below are seen the vein and the artery, enveloped in their  common
sheath,  whose anterior wall encloses the descending branch of the  ninth
pair.  This sheath should be first perforated opposite to the artery, and not
the vien, by means of the point of the director, then divided upon the same
instrument with the bistoury, to the extent of an  inch or two.  When
the jugular swells so much during the inspirations as to conceal a  part
of the carotid, and  to embarrass  the operator, we compress it  near the
upper angle of the wound, and it immediately shrinks.
   III.  Third Stage.—The sound, held as a writing-pen, is then passed
between the two vessels ;  one or two fingers of the other hand  hold the
artery fast and prevent it from slipping towards the trachea,  while by
gentle movements forwards  and  backwards, while  making pressure on
the point of the instrument, we reach its posterior surface, in such man-
ner as to raise  it without  effort, and without being  obliged  to touch
either the pneumo-gastric nerve,  the great sympathetic, or any of their
branches.
   B.  Remarks.—If we were to strike at first within the sterno-mastoid
muscle, we should run  the risk of confounding this fleshy bundle with
the sterno-hyoid, and of being thus led astray ; it is therefore  better to
cut upon its outer surface, and at the distance of some lines outside  of its
border, which latter it is always easy to bring afterwards upon a line with
the wound of the integuments.  If unfortunately, the jugular vein should
happen  to  be opened, I do not know whether it would be better to tie it
or to stop the hemorrhage by tents.  MM.  Simmons and Miller ( Western
Med. SfSurg. Jour., vol. I., p. 425,) have it is true,applied the ligature
to it without difficulty, and the tents would oblige us to leave the wound
open ; nor had M. Gibson, in 1830, M. Stevens in 1832, nor M. Dugas
(Gaz Bled de Paris, 1837, p. 298) since, any fear in surrounding it with
a double ligature.  The ligature has also been applied to it by  M.  War-
ren (Communicated by the Author,) and by M. Widmer, (Experience, t. 
370            NEW  ELEMENTS OF OPERATIVE SURGERY.

II.. p. 336,) without difficulty.   But to say nothing of phlebitis, which
in  this case is the most formidable  consequence to apprehend,  who
would not hesitate in suddenly obliterating so large a vein at the same
time with the principal artery of the head ?   If the wound were small,
it would be prudent to pinch it with the forceps, and to bring its lips
together and secure them with a  ligature laterally, in  such manner  as
not to shut up  the calibre of the  vessel.  The patient upon  whom M.
Guthrie (Oper.  Cit., p.  328,) operated in this  manner, died in conse-
quence of a ligature which it was afterwards found  necessary to  place
upon  the carotid,
  C.  Process of Bl. Sedillot.—In  order to come down perpendicularly
upon  the artery, and to have  a wound  more neat and of less depth, and
which will  give a more easy egress to the discharges, M. Sedillot (Nouv.
Bibliot. Blvd., 1829, t. II., p. 63,) has  proposed a new process for tying
the carotid at the lower part of the neck.   This  incision, carried much
further outwardly than in the ordinary mode, falls upon the  outer side
of the sterno-mastoid muscle, the whole substance of which, between its
two roots must be divided; the lips of  this wound being held apart with
the fingers  by  intelligent assistants, or by hooks, we come immediately
in front of  the vein and artery, which we have nothing more to do than to
isolate.  This process is  practicable and ingenious ; but it would be, if
I do not deceive myself, less easy and less sure than the preceding.  Con-
sequently I do  not think it  should be  exclusively adopted, but that it
Bhould be reserved only for particular cases.
  D.  Consequences of the Operation.—When the carotid is obliterated,
the circulation is soon fully re-established in the corresponding side of
the neck and head ; the voluminous and almost innumerable anastomoses
which it contracts in the brain, with the vertebral  and internal carotid
of the opposite  side ;  those  which are  established by the  temporals,
occipitals, supra-orbitars, facials, Unguals, thyroids, superior and inferi-
or ; in a word, by all the  branches of the external  carotids,—form  too
vast a net-work  to  allow  of  our having the  least uneasiness  on this
subject.  We should rather have to fear that these resources, so valuable
and for so long a time  overlooked, might not jeopardize our success, by
bringing too much blood into  the tumor after the operation.   This  is, in
fact, an inconvenience which  we meet with ; we have seen the pulsations
in the aneurism at first diminish, and soon after reappear and be kept up
for  several  weeks.  In the patient operated upon  by M. Walther, for
aneurism of the external carotid, they  continued for two months.  We
should, indeed, have difficulty in comprehending, if observation had not
demonstrated the fact, how the ligature upon the primitive carotid could
cure aneurismal affections as  remote as those, for example, of the  orbit,
the face, and exterior of the  cranium ; but it is proved to-day that this
reflux does not  always hinder the tumor from being  dispersed—that
refrigerant applications and  compression, moreover, co-operate in pro-
moting this resolution, or, at least, in accelerating it when it is too tardy.
The successful  results enumerated in the  preceding  table  sufficiently
establish this point.
  We are not,  however, to conclude, therefore, that the obliteration  of
the carotid  artery involves no danger.   If M. Tuson, in advancing the pro-
position that it ought in some sort  to be proscribed in sound surgery, has 
ARTERIES OF THE NECK.                   871
  extravagantly exaggerated its  danger, we  must also admit that most
  surgeons impute too little importance to it.  The patient of M. Gonnet
  was attacked with serious accidents before being cured.   That of Aber-
  nethey died in  delirium and  convulsions.   One  of those of Dupuytren
  died  from prostration, probably from purulent infection, like one of
  mine.   Inflammation of the sac, caused the death of those of  Cline, A.
  Cooper, and  if. Key.  Another, operated upon by M. Key, and one of
  the patients of il. Langenbeck, died in less  than two  days  from the
  destruction of  the functions of the brain.  Incipient paralysis took place
  in the cases of  MM. Mayo, Sisco, Molina, and Zeis.   The patient of M.
  Horner was seized with aphonia.   An actual  and complete  hemiplegia
  took place in at least five cases, (Magendie, A. Cooper,  Baravero, Vin-
  cent, and Macauley,) and one of the patients  operated upon by me  was
  also attacked with it.  Abscesses and hemorrhages from the upper end,
  as in the case of M. Lisfranc and in one of mine; phlebitis, inflamma-
  tion of the air passages and the viscera of the chest, are also among the
  consequences calculated to make the ligatnre  upon the carotid  a serious
  operation.

   Article  IV.—Ligature upon The  Trunk  of  the  Carotid, ac-
              cording TO THE NATURE  OF THE DISEASE.

                    § I.— Wounds.—Hemorrhages.

   In cases of wounds the ligature of the carotid cannot in respect to the
 mode of  operation be subjected to fixed rules.  The operation should
 then be performed after the method of Keisler, or according to the rules
 laid down in the chapter on diffused aneurism  and arterial wounds in
 general. It is consequently upon the bottom of the wound itself  or oppo-
 site to the wounded  point of the artery, that we are to operate  in order
 to seize the  vessel, and not upon the  region where it would be most easy
 to  reach it.  Another  peculiarity of wounds of the carotid  and its
 branches is, that unless it is found wholly impracticable to do so, there
 must be a ligature placed both below and above the division.   Otherwise
 the hemorrhage in fact might be kept up, by means of anastomoses from
 the upper end of the artery ; under this  point  of view wounds of  the
 carotid may be compared to those of arteries of the  hand or fore-arm
 and of the foot or leg.  Because a single ligature has sufficed  for  the
 cure in certain cases, we are not therefore to conclude that it is generally
 unnecessary to apply two.
   [Mr. Fearn, of  Derby, E. reported in the  Prov.  Med. and  Surg.
 Journal, Sept.  8th, 1847,) a case of wound of the internal carotid artery,
 and  division of the par vagum, in which the common  carotid was tied
 and notwithstanding  the injury to the par vagum, life was prolonged
 beyond the eleventh week, and Mr. Fearn believes that the  operation may
 fairly be regarded, in a surgical point  of view, as  successful.  The
 details of this very  interesting case may likewise  be  found in the
 American Journal of Bledical Sciences, January, 1848, p. 266.  Mr. F.
remarks that he has been unable to meet with more  than  one recorded
instance in which the internal carotid was  proved to have been injured 
872
NEW ELEMENTS OF OPERATIVE SURGERY
 and in which the common carotid  was tied.   This case is related  in
 Cooper's Surgical Dictionary, and was under the care of Andersch.
    *                                                    G. C. B.]
                          §  II.—Aneurisms.

   If the aneurism which renders a ligature upon the carotid necessary,
 should be situated in the neighborhood of the parotid region, the opera-
 tive process which I have described above  is applicable  to  it in every
 particular.  But whenever it  is of large  size  or descends down to a
 level with the larynx, the manipulation can no longer be  so  simple.   In
 that case we are obliged to commence the incision lower down  and  to
 prolong it to near the sternum or even upon the anterior surface of that
 bone.  M. Mayo in fact in one of  his patients  was obliged to  divide
 the inner portion of the sterno-mastoid muscle, in order to arrive at the
 trunk  of  the carotid artery.   In such cases also the larynx  or the mus-
 cles are displaced to such extent as to change in part the relations which
 I have pointed out above.  We cannot expect to find therefore in such
 cases any other guide than that which is to be obtained from a profound
 knowledge of the anatomy of the region, and from the carotid tubercle
 of the sixth vertebra.

                     §  III.— Varicose Aneurism.

  The examples of varicose aneurism observed by M.  Larrey,  (Clin.
 Chir., t. III., p. 149, 154,) M. Willaume  and M. de  Xoter (Blem. de
 la Soc de Blid. de Gand., p. 192,) and lastly  by M. Kuhl,  (Encyclog.
 Mid.,  1836, p. 131,) M. Jorret, (Private communication,  183S,) and M.
 Rufz, (Private letter,  March, 1838,) prove  that the  carotid  like  all
 other arteries  is liable to  this disease.  Only  that the  position  of the
 head appears to me to render varicose aneurism in this region less incon-
 venient even than upon the limbs.  In other respects, if it  should produce
 symptoms so alarming as to oblige us to attempt a radical cure, it would
 be proper as in those of the arm, to tie the  artery both above and below
 the point of communication, if the operation  should not be found too
 difficult.   In the contrary case there  would  be room  to hope  that  a
 single  ligature below would in most instances suffice.

                      \  IV.—Erectile Tumors.

  When a ligature is to be placed upon the primitive carotid artery for
erectile tumors of the head, we may proceed exactly in conformity to the
rules laid  down for the operative process.   As all the organic  tissues
of the  carotid region retain in that  case  their natural position, we are
enabled to make choice of the place  where  the artery  can be reached
with the  greatest ease.   But then the question may often arise whether
we should rather tie the primitive or the external or tho internal carotid.
^ hether in place of tying one of  the common carotids, it would  not be-
come necessary after the example of MM. Mussey, Kuhl and Laugenbeck,
to tie both.  As these questions in no  respect change tho operative pro-
cess itself, I shall not discuss  them until I come to the chapter upon
erectile tumors. 
ARTERIES OF THE  NECK.
873
                       § V.— Various Tumors.

   The preceding remarks are applicable also to the various tifmors which
 have been thought to require a ligature upon the carotid trunks.  It is
 in fact readily perceived that these tumors when situated upon the head,
 leave  the sub-hyoid region perfectly free, and in no  manner  interfere
 with the manual of the operation.   On the supposition that they should
 exist in the neck, in the body of the thyroid or parotid gland for exam-
 ple, they  would require the  same precautions as for an aneurism in those
 regions.  I cannot however understand how a ligature upon  the carotid
 should be had recourse to with the view of arresting the develoDmedt or
 nutrition  of a fungus, or of any cancerous tumor whatever.
   [We have had some experience on this point proving most incontestably
 that a ligature upon the carotid may arrest the  development or nutrition
 of malignant tumors on the  head and neck.  We reported a case, in  the
 American Journal of the Bledical  Sciences,  October, 1845, p. 331, iu
 which the above effect  was most decidedly produced,  although the ter-
 mination, from other circumstances, was  fatal.  Sometime  afterwards
 we tied the external carotid to check the  progress of a malignant ulcer
 on the face, which was endangering the  patient's  life, by involving  the
 temporal, and facial arteries.   Previous to the  application of the liga-
 ture, the patient had suffered severely from the lancinating pain, but this
 disappeared after the operation, the whole aspect of the  ulcer  became
 changed for the better, but  the  patient died five months subsequently
 from hemorrhage  at the  seat  of ligature.  In  the  American  Journal
 of Medical Sciences, Jan. 1848, p, 357, is the report of another case in
 which we  tied  both primitive carotids to arrest the progress of  a very vas-
 cular and malignant growth in the antrum.   The first operation was per-
 formed August 24th, 1847, the second, three weeks afterwards,  and this
 patient  is now (Nov. 1854) in  the  enjoyment of perfect health.   Dr.
 Mott saw this  case before the  arteries  were tied, and had no doubt of
 the malignant  character of the disease.  This case will be  referred to
 under the head of diseases of  the  antrum.  Other cases have  been  re-
 ported in  which the result was equally  fortunate ; indeed, Dr. Mott him-
 self, has recently ligated both primitive carotids in a  similar case, and at
 last report the patient was doing well.   Even in the cases,  where pa-
 tients have died from cerebral or pulmonary trouble,  following the oper-
 ation, the effect of the ligature was to  arrest the growth of the  tumor.
                                                        G. C. B.]

               § VI.— Operations on the Face or Neck.

  When the carotid has been tied in operations upon the face, the paro-
tid region or the thyroid body, we have been governed by the rules which
belong to  two  different conditions of the parts.
  If, as happened to Beclard and M. Warren, the artery has been una-
voidably wounded during the operation, we  must proceed as  in the cir-
cumstances for wounds in general, that is, while an assistant makes com-
pression  between  the  wound and the  heart, we must immediately  seek
for the lower end and then the upper end of the divided  vessel, and in
this manner apply the two ligatures. 
874
NEW ELMENTS OF  OPERATIVE SURGERY.
    Upon the supposition on the contrary that we wish to tie the artery
 previously, as I have done in a case where I had to remove an enormous
 cancerous tonsil, as MM. Graefe, Palmi, Mott, Awl, and a great number
 of other prSctitioners have done, before extirpating the thyroid, disarti-
 culating the lower jaw, or removing parotid tumors, the operation would
 be quite simple, and would be regulated by the rules of the general oper-
 ative process.

                         § VII.—Neuralgia.

   Supposing that any one were disposed to  follow the suggestion of M.
 Pres'ton or M. Liston, and tie the carotid for  nervous affections  of the
 head, it would be a case where the operation  evidently  would  present
 the greatest degree of simplicity ; but as hemiplegia not unfrequently re-
 sults from the operation itself, we cannot comprehend why M. Preston
 should  have tied the carotid for the cure of  hemiplegia.  The  patient
 operated upon by M. Bolieau, and who was epileptic, continued never-
 theless  to have paroxysms after the obliteration of  the vessel.   Here
 was a fact ascertained which should have deterred M. Preston from un-
 necessarily exposing the life of an  epileptic, in whom  he vainly attempt-
 ed to effect a cure by a ligature upon the carotid.   The failure of M.
 Liston,  also, shows how irrational  it was to place a ligature upon the ca-
 rotid for the purpose of relieving a simple neuralgia

                    § VIII.—Blethod of  Brasdor.

   If, in place of applying the ligature upon the carotid by the method
 of Anel or by the ancient mode, we should choose that of Brasdor, this
 process has nothing in addition peculiar in its  manipulation, except that
 the incisions should be made a little higher up than  in the preceding
 cases, and that we must lay bare the artery in the omo-hyoid triangle, and
 in the neighborhood of the great horn of the os hyoides.   We shall see,
 moreover, in the  following articles, what  we have to  expect from this
 method  when applied to aneurisms at the apex of the chest, and at the
 lower part of the neck.

           Article IX.—The Trunk of the Innominata.

   When aneurisms are situated upon the lower part of the carotid, it i3
no longer  practicable to treat them by the  method  of Anel, unless by
placing  the ligature  upon the trunk of the innominata; and  should this
last-mentioned trunk itself be affected, it would  seem at first  that the
disease  was beyond the resources of art.  When, on  the other hand we
consider that in a great number  of cases, the  precise  seat of the aneu-
rismal tumors in the lower part of  the neck, and in the supra-clavicular
region, and  at the apex of the thorax, is exceedingly  difficult to deter-
mine, it  is easy to conceive what must be the embarrassment of surgeons
uuder such  circumstances, when  the question comes  up of applying a
ligature  upon the artery which is diseased.
   As a  remedy, in part, for  these difficulties, the method  of Brasdor
has been, at the present  day, often had recourse to upon the neck.  It 
arteries of the  neck.                    875
is a method also which numbers now a sufficient number of trials to re-
quire that it should  be examined with  care.  Though all the surgeons
who have made trial of it have done so, upon the supposition that it was
for  an  aneurism at the  origin  of the  carotid;  they  have frequently
found, however, that they had to do with quite a different affair.  Thu3,
one  of  the  patients  of M. Wardrop had  an aneurism of the brachio-
cephalic trunk, and  this  surgeon, not perceiving the pulsations of the
carotid, placed the ligature  upon  the subclavian.  There  is reason to
believe, also, that  the arteria innominata  was the seat of aneurism, in
the  cases of M. Evans, M. Key, and M. Mott.   M. Montgomery,  who
supposed he was operating for an aneurism of the carotid, was enabled
to ascertain, four months  later,  that the disease was seated in the arch
of the aorta.   We may  add, that in  another  case, where M. Wardrop
had  supposed that he had embraced the carotid in a ligature of the in-
testine  of a silk-worm, this  artery, at the  end  of three months,  was
found perfectly free, without its being possible to say exactly what had
become of the aneurism.  Nevertheless, one of  the cases of M. Ward-
rop, that of M. Evans, and also that of M.  Bushe, demonstrate, unques-
tionably, that certain aneurisms, at the apex of the thorax, may be cured
in this manner.
  It might  seem a priori  that the ligature in the hyoid region might
suffice whenever the  aneurism is situated  upon  the  carotid only ;  but
that it  would  be necessary to combine with it  the  ligature upon  the
subclavian  also where the trunk of the innominata itself is affected.   But
M. Kerst of Utrecht has  communicated to me  two facts  which, with
those of MM. Evans (Vilardebo, These, etc.,  p. 58)  and Montgomery,
prove indisputably that the ligature upon the carotid alone may not only
arrest the development of aneurisms upon the trunk of the arteria innom-
inata, but also those of the arch of  the aorta.
  A man was received into the Civil Hospital of Amsterdam with an
aneurism which projected above  the sternum.  M. Tillanus supposing it
an aneurism of the left carotid, tied this artery a little higher up.   The
patient got well.  Five months after he suddenly  died.  The aneurism,
which was seated upon the arch of the aorta itself, was completely filled
with a white coagulum.   The specimen is preserved in the  cabinet of
pathological  anatomy  at Amsterdam.  In  the  other case the aneu-
rism which was on the point of bursting was found in the same situation.
Believing also that it was  an aneurism of the left  carotid, M. FJgen of
Amsterdam tied this artery at some  inches  higher up, on  the 21st of
February, 1829.   The  dangerous symptoms disappeared, and the size
of the tumor diminished considerably.   It became necessary to operate
upon this man  for a strangulated hernia on the  9th  of May following ;
but  he  died on the 13th  of June  with symptoms of spasm or asthma.
The autopsy showed that  the  aneurismal sac occupied the  arch of the
aorta between  the left carotid and the trunk of the  innominata.  As in
the case of M. Tillanos, it was filled with a white coagulum  and consid-
erably diminished.
  We  see  therefore that  the ligature upon the carotid  artery, by the
method  of Brasdor, deserves  to be tried even in cases where the aneu-
rism appears to have extended to the aorta.   Nevertheless the question
constantly presents itself to my  mind whether the  chances of success 
876
NEW  ELEMENTS OF OPERATIVE SURGERY.
would not be greatly increased by the simultaneous  or subsequent liga-
ture  upon  the  subclavian  artery.   Only  that  there  remains  a  doubt
whether the internal mammary, the vertebral and inferior thyroid arte-
ry, <fcc, might  not be sufficient to keep up the circulation in the root of
this vessel and thus destroy all the effect of the  ligature in reference to
the aneurismal sac.
  [Aneurisms of Innominata treated by  Ligature of  Subclavian only.

Dupuytren  <  Died on ninth day.
Exhaustion,  following i
cough and secondary he-
morrhage.
Laugier
Wardrop
Died, month after ope-
ration.

Died two years  after
operation.
Blaokman  4  Died on eighth day.
                        Aneurism of subclavian dil-
                        atation of innominata, and
                        aorta.
                        Aneurism of innominata, dil-
^ Asphyxia.            Z atation of aorta, and oblite-
)                     (ration of right carotid.
}                     C Size of tumor and pulsations
> Exhaustion.          < diminished,  respiration im-
)                     (_ proved.
                      )( Tubular aneurism of innomi-
  Hemorrhage caused by]  nata and arch of aorta. Left
  jumping out of bed.   j  carotid and subclavian ob-
                      literated.
Aneurisms of Innominata treated by Ligature of Carotid only.
Evans


Mott
Mott
Recovered.


Died about a year af-
ter operation.
Died.
                                                        (Tumor existed with pulsa-
                                                        tion, at the end of a year.
                                                        Its  progress  arrested,  not
                                                        cured.
                                                       C After death, no tumor exter-
                                                       < nally, but internally, large
                                                       (asa double fist.
                                                       C Aneurism of innominata, and
                                                       < arch of aorta.  Occlusion of
                                                       (left carotid.
                                                       C Tumor nearly filled with firm
                                                       I coagulum, carotid previous.
                                                        'Aneurism of innominata  and
                                                        carotid.   Arch of aorta dis-
                                                        eased.  Right carotid dilat-
                                                        ed to seat of ligature, and
                                                        plugged by firm coagulum.
                                                        'Tumor diminished.  Aneu-
                                                        rism of innominata and arch
                                                        of aorta.   Dilatation of de-
                                                        scending aorta  as far aa di-
                                                        aphragm.
                                                        ' Tumor diminished.   After
                                                        death,  filled  with  purulent
                                                       ! matter, and grumous blood.
                                                       [ Firm  coagula in right caro-
                                                       ls tid and subclavian.

Aneurism of Innominata treated by Ligature of Carotid  Se Subclavian.
     Aston Key ! Died shortly after ope- S
             J j ration.              i

     Fergusson < Died on seventh day.  <


k    Morrison   { ^If  twen|7  months -
                 after operation.
Campbell
Died on nineteenth day < Pneumonia.
Asphyxia.
Hemorrhage.
Vertebral arteries dim-
inished in size, deficient
supply of blood to brain.

Pneumonia.
Cause unknown.
Hutton    \  Died on   sixty-sixth .
           |  day.

           I
Bronchitis.inflammation
and suppuration of sac,
opening into trachea.
Fearn
Wickham
Rossi
Carotid, Aug.   30th
1836, subclavian, Aug.
2d, 1838.

Carotid,  Sept. 25th,
1839, Subclavian, Dec.
3d 1839.
Carotid and subclavian
simultaneously.
Died three  weeks after
last   operation,  from
pleurisy.

Died 2£  months after
first bursting of sac, and
5 months after first lig-
ature.
Died in six days.
 Tumor filled with firm coagu-
 lum, a channel size of artery,
 previous.
'After ligature of carotid tu-
 mor  diminished, and  dys-
 pnoea  ceased for a while.
 Tumor  increased after  liga-
ture of subclavian.
 (Obliteration  of left  carotid
 and right vertebral brain
 supplied  by left  vertebral
 only. 
ARTERIES OF  THE NECK.
877
Aneurisms of Root of Carotid, treated by Brasdor's Operation.
Wardrop   J Recovered.
Lambert
Bush

Colton Dr.
    Noyou

Lane
Died.
Recovered.
Recovered.
\ Hemorrhage from up-
1 per part of artery.
Died on eighth or tenth
day
 Inflammation  and  en-
' largement of sac, thora-
 cic inflammation.
  (Tumor diminished until fifth
  day, then suppurated and
  burst. Patient alive  three
  years after operation.
f Tumor diminished after ope-
< ration. Ulceration above lig-
( ature.
C Tumor rapidly diminished
< after operation. Patient alive
(three years after operation.
( Alive and well three  years
( afterwards.
                                                          G.  C.  B.]
      §  II.— The Ligature upon the Brachio-Cephalic Trunk itself.

   A. Anatomy.—The trunk of the innominata, which is about two inches
 in length, and which reaches from the right antero-superior portion of
 the arch of  the  aorta to the level of the sterno-clavicular  articulation,
 where  it bifurcates to give  origin to the right subclavian and carotid,
 takes a direction slightly oblique from below upwards, from within out-
 wards  and  from before  backwards.   The pleura  covers its outer side;
 behind  it rests  against the front and right side of the trachea ; its an-
 terior face is crossed above by the left subclavian  vein, and lower down
 by the  vena  cava descendens, which is parallel to it and separates itself
 more and more  from it, as it approaches the right auricle.  It is after-
 wards  covered  only  by  the cellular tissue, the root of the hyoid and
 sterno-thyroid muscles, the upper  portion of the right side of the ster-
 num  and  then to a small extent by the sterno-clavicular  articulation
 upon the same side,
  Anomaly.—This remarkable  artery  presents numerous varieties ; it
 may be  wanting  altogether  or be found on the left, side; be longer or
 much shorter; give off at the same time both the right and left carotid  ;
 or it may originate from  the left  side of the  aorta, cross the whole
 breadth of the trachea and nevertheless pass to the right side.  I have
 once  seen it, and two similar cases were shown to me in the pavilions
 of the  School of Practice, pass to  the left,  across  the trachea, turn
 round this canal from before backwards, and crossing the posterior sur-
 face  of  the  oesophagus and the  vertebral column, reach the line of the
 first  rib, and then divide as usual.   (Anat. Chir, t. I., Reg. Sous-hyoid:
 Sommet de la Poitrine ; region sous-claviculaire.)
  B.  Indications.—Aneurisms of  the brachio-cephalic  trunk have been
 observed in a great number of instances.  Sharp, A. Burns, MM.  Mott,
 Graefe, Wardrop, Devergie, Vosseur, &c.,have published several exam-
 ples  of them.  Spontaneous aneurism either by dilatation or by rupture
 of the  internal and  middle  coats, is, nevertheless, almost the only one
 which is to be met with in this artery.  It was an aneurism of the trunk
 of the  innominata, which, opening into the trachea, strangled the indi-
vidual mentioned by Malouet, (Bibl. de Planque, in 4to., t. V., p. 278.)
The  case that M. Focke  (Dissertatio Med., etc., 1835,) published, in 
878
NEW ELEMENTS OF OPERATIVE SURGERY.
 eluded also  the arch  of the aorta.   M. Genest, (Arch. Gen. de Bled.,
 t. XXYL, p. 205,) describes one which extended up as high as the chin.
 In a patient of M. Martin Solon, (Arch. Gen., Mars, 1836.— Gaz. Blid.
 de Paris, 1836, p. 357,) an aneurism of  the  aorta  had obliterated the
 brachio-cephalic trunk as well as the vena cava; yet the circulation, not-
 withstanding, continued in the arm.
   [Mr. Guthrie in alluding to the errors which have been committed in the
 diagnosis of aneurisms at the root of the  neck, asserts ( Commentaries
 on Surgery, p. 278) that  mistakes of this kind are not likely to occur
 at the  present day, as the stethoscope will always point out the true na-
 ture of the case—in fact, that " the stethescope will remove all doubt."
 No one will question the authority of Dr. Stokes in matters connected with
 the physical diagnosis of thoracic diseases, and to those who are inclined to
 credit the above assertion  of Mr. Guthrie, we would recommend the pe-
 rusal of the recently published work, on the Diseases of the Heart and
 Aorta, of the above named physician.  If any doubts still remain as to
 the fallacious character of the physical signs so commonly relied on, let
 him also consult the paper of Mr. Fuller of St. George's Hospital, London,
 which  may be found in the Lon. Med. Times and Gazette, November,
 1853, p. 489.  We might adduce abundant evidence to show the  utter
 impossibility  of forming a correct  diagnosis in these  cases, but as Dr.
 Mott has fully noticed  this point in his remarks on aneurisms, we must
 refer the reader  to that part  of the  work.  Dr.  Holland of Cork, has
 devoted much attention to the  study  of aneurisms of the innominata,
 and has probably succeeded as well, if not better  than any other writer,
 in his attempt to establish the differential diagnosis of aneurisms of the
 innominata and arch of the aorta.   His valuable essay is published in
 the Dublin Quarterly Journal of Medical Science, and we here insert his
 conclusions.

  Aneurisms of the  Innominata.      Aneurisms of  Transverse  Por-
             J                             tion of the Arch.

   " 1st.  External tumor is a fre-    " 1st. External  tumor   occurs
 quent and early sign, situated gen-  comparatively rarer and later situ-
 erally above  the inner third of the  ated generally at the left side of, or
 right clavicle.                     under the sternum.
   "2.  Arteries in the right arm,    "2. Arteries in left arm, and on
and on the right  side of neck and  the left side of neck and head, gen-
head, generally pulsate weaker than  erally pulsate weaker than those on
those on the left.                   the right.
   "3.  Stridulous respiration,cough    "3. Stridulous respiration,cough,
 dysphagin, alteration in the voice,  dysphagin, alteration in the  voice,
and  dyspnoea, are  comparatively  and   dyspnoea  are  comparatively
rare.                              frequent.
   " 4.  Pain,  adema, and  enlarge-    " 4. Pain, oedema, and enlarge-
ment  of tho  veins, begin  in right  ment  of the veins, begin in left arm
arm or the right  side of neck and  or the left side of neck and head,
head ;  they may  finally extend to  they may finally extend to the right
the left side.                       side. 
ARTERIES OF THE  NECK.                   879
   " 5.  Partial  loss  of  motion or    " 5.  Partial  loss  of  motion or
 sensation in the right arm is a com-  sensation of the right arm is a com-
 paratively frequent symptom.       paratively rare symptom.
   "6.  Dislocation of the clavicle,    "6.  Dislocation of the clavicle,
 trachea or larynx, a comparatively  trachea or  larynx,  very  seldom
 frequent occurence.                occurs.
   " 7.  Alteration  in the intensity    " 7.  Alteration in the intensity
 of the  respiratory  murmur occur  of the respiratory murmur occurs
 but very  rarely,  and  then  it  is  very frequently, and then it is gen-
 weaker in the right lung.           erally weaker in the left lung.
                                     " 8.  Abnormal arterial murmurs
   " 8.  Abnormal  arterial murmurs  loudest in left carotid or subclavian;
 in the right carotid or subclavian,   heard also along the spinal  column
                                   posteriorly.
   " 9.  Pressure on the right caro-     " 9.  Pressure on the carotid and
 tid  and subclavian diminishes or   subclavian, on  either side, has but
 stops the pulsations of the tumor.    little effect on the pulsations of the
                                   tumor.   G. C. B.]

   A case of Pelletan, in which it is seen that the subclavian, the right
 carotid, and the termination of the arteria innominata were obliterated
 during  life without causing any serious symptoms ;  the case related by
 M. W.  Darrach, in which it is seen that the trunk of the innominata
 and the left carotid had completely closed, prove  that  the circulation
 may be  kept up in the upper limb, though the  brachio-cephalic artery
 has ceased to be permeable  to the blood.  Surgeons have been embold-
 ened by this to attempt a ligature upon it when the aneurisms of the  neck
 are situated too low down to allow of its application to the carotid itself.
  C. Appreciaton.—M. Mott, (A. Burns' Surgical Anatomy, edit.  Pat-
 tison, 1823, p. 433-456,) who was the  first to perform it, in the  case
 of a man aged  27 years, ou the 11th  of May,  1818, for a moment in-
 dulged the hope  of seeing the operation crowned  with complete success.
 Death did not occur till the twenty-sixth day.  The circulation had re-
 established itself in the limb.  On the twentieth day the patient was so
 well that he was enabled to walk in the garden of the hospital; but on
 the twenty-third day, repeated  hemorrhages ensued, and the man  died
 in a state of extreme  exhaustion.   There was neither inflammation in
 the aorta, the lungs, nor the  pleura;  a firm and adherent coagulum filled
 a part of the trunk of the innominata below the ligature ; an ulceration,
 situated upon the other side  of the  artery,  was the cause of the acci-
 dents.   In 1822, M. Graefe, (Edinburg Medical Se Surgical Journal,
 vol.  XLIX.,  p.  m.—Jour. de Graefe et  Walther, t. III., c. IV.—
 Dictionnarie de  Chirurgie, de Rust, t. IL,  p. 81,)  repeated the opera-
 tion of the Professor of New York; his patient lived sixty-eight days,
 and died only from his having made imprudent efforts which gave place
 to an abundant hemorrhage; the  ligature came away on the fourteenth
 day.  Though not conclusive, these two results nevertheless demonstra-
 ted that the  ligature upon the trunk of the  innominata presents some
 chance of success, and that it might be made trial of, if art possessed no
other resources, in cases  where the  patient seemed  doomed to an inevi-
table death.   Thus has a been repeated at least four times since; the issue 
880
NEW ELEMENTS  OF OPERATIVE SURGERY.
has been unfortunate ; the four patients died.  That of M. Bland, (The
Lancet, January, 1837, p. 607,) died of  secondary hemorrhage, ou tho
eighteenth day, and the aneurism was situated upon the right subclavian
artery !   In the case of M. Hall, (American Journal of Bled.  Sciences,
No. 22, p. 509,) death took place on the sixth day, and was  preceded
by dyspnoea, acute pains and an issue of black blood from the wound ;
that of M. Lizars, (Baltimore  Medical Journal, Yol.  I., p. 125.—Arch.
Gen. de Med., 2e serie, t. VI., p. 267,) operated upon the 31st of May,
1S37, died on  the 21st of June, in consequence of  hemorrhage.  There
were twenty ounces of blood  in the chest, and  the  subclavian artery,
which was the seat of the aneurism, might have been tied between the
tumor and the carotid!  In the sixth example, in the case of a cancerous
tumor in the neck, the roots of the carotid and subclavian were tied to-
gether, on the 26th of September 1836, at the Hospital of Leipeic, under
the impression that the carotid alone was  tied.  The case is too remark-
able to omit giving the account of it in this place.
  The patient, who was forty-three  years of  age, having been properly
seated in an elevated chair, the head inclined to the  left side, and held
by assistants, M. Kuhl (E.  0.  Peters, Dissert. Inaug., in the  appendix
at the end.  Leipsic, 1836) made his first incision on the anterior bor-
der of the  sterno-cleido-mastoid muscle, from the cricoid cartilage to
the sternal portion of the clavicle.  After having divided the  skin, pla
tismamyoides and fascia of the neck, he perceived the sterno-cleido-mas-
toid muscle ; the external  jugular vein  was wounded  and tied.  The
lips of the  wound being kept apart by  Arnault's hooks, the operator
readily reached the bottom to separate, by means of the finger, the parts
in the  neighbourhood of the  artery, to wit:  the internal jugular vein,
the par vagum, the descending  branch of the hypo-glossal nerve, and the
omo-hyoideus  muscle.  After  all these difficulties,  we were astonished,
says M. Kuhl, not to find the division of the common carotid near the
larynx ; I found it, finally, near  the  clavicle, where I tied it.   The pa-
tient died on the third day.
   Half of the arteria innominata, a portion of the carotid, and a portion
of the subclavian artery, were  surrounded with a layer of plastic lymph.
We found the right carotid and  subclavian tied together at three lines
above their origin from the trunk of the innominata ; their coats were
ruptured, and their canal in part obstructed.
   Six trials, by six different surgeons, of  different countries, have ended
in six fatal  results!   Is it not enough to enable us to pronounce an  in-
exorable verdict upon such an operation ?  At the  present day therefore
I do not hesitate formally to proscribe it  not only because of the dangers
which accompany it, but  also  because the aneurism which requires it is
often-of a difficult diagnosis, and especially because, as I have said above,
the ligature beyond the tumor  and  by the method of Brasdor, presents at
the same time less difficulty and more prospect of success.  This however
is the mode of operating. 
ARTERIES OF THE NECK.                   881
[ Total number of cases of Ligature of the Innominata, up to 1854.
Operators
Mott
Graefe
Bland
Hall
Kuhl
Lizars

Arendt
Disease
Bujalski
Hutin
Subclavian Aneurism
Subclavian Aneurism
Subclavian Aneurism
Subclavian Aneurism

Subclavian Aneurism

Subclavian Aneurism
           Hemorrhage afterLig-
             ature of Subclavian
Dupuytren
Norman
Martin
         Total, 12—All Fatal.
Result
Died on 26th day
Died on 67th day
Died on 18th day
Died on 5th day
Died
Died on 21st day

Died on 8th day

Died

Died on 8th day

Died
Died
Died
Cause of Death
Hemorrhage
Hemorrhage
Hemorrhage
Hemorrhage

Hemorrhage
Inflammation of
Lung, pleura and
aneurismal sac


Hemorrhage

Cases referred to
by writers
  The artery has been exposed in 3 instances, and the operation aban-
doned in consequence of disease of its coats.   This occurred to Messrs.
Porter, Hoffman and Key.   G. C. B.]

                     § III.— Operative Process.

  A. Process of M. Mott.—M. Mott made an incision above three inches
above the  clavicle, and which extended from  the outer part  of  the
sterno-mastoid  muscle, to the fore part of the trachea;  then another of
the same length upon the  inner border of the sterno-mastoid muscle,
making it fall upon  the inner extremity of the first.   He  afterwards
divided all the sternal portion, and a great part of the clavicular attach-
ment of the same muscle, in order to turn it back outwards and upwards.
After having separated with the handle of the scalpel, the jugular  and
subclavian veins and several small veins, together with the surrounding
nerves, M. Mott laid bare the carotid;  observing  that it appeared dis-
eased, he proceeded down to the brachio-cephalic  trunk, around which
he passed and tied a simple ligature of  silk.
  B.—M. Graefe proceeded nearly in the same manner, with this differ-
ence, however, that he left in the wound an artery compressor to tighten
the knot.  This, moreover, was the course that M. Porter thought proper
to follow at Dublin in 1829, to tie the carotid very  low  down, in a man
who recovered perfectly.
  C.—Others have thought, I  do not  know for what reason, that we
should succeed better by trephining the  sternum; but the best process,
and that which is performed with the most ease on the  dead body, is
the following, which differs, however, but very  little from the method
proposed by M.  O'Connell of Liverpool, and which M. King has describ-
ed in his Thesis.                   •
  D.  Combined Process of the author.—I.—First  Stage.—The  opera-
  Vol.  I.                    HI 
882
NEW ELEMENTS  OF OPERATIVE  SURGERY.
tor being placed  on the  left, makes in the supra-sternal  depression of
about three inches upon  the inner border of the left sterno-cleido-mas-
toid muscle, obliquely from left to right; he thus divides  successively
the skin and sub-cutaneous  tissues, the superficial layer of the fascia
cervicalis, the adipose cellular tissue, and a second fibrous layer.  En-
countering behind, the sterno-thyroid muscle, the thyroid plexus, and
the thyroid artery of Neubauer, when it exists, he separates these vessels
or causes them to be pushed  aside by an assistant; or even applies the
ligature  to  them, if he cannot  avoid them, and thus arrives at  the
trachea.
  II. Second Stage.—Then  are seen the left subclavian vein and the
right internal jugular, which must be carefully turned aside to the right
and upwards by means of the  director.   The surgeon causes his patient
to bend his head a little, endeavours to identify the artery between  the
trachea and the right sterno-hyoid muscle ; he first  isolates its concave
part by  inserting from before backwards, between it and the superior
cava vein, the point of a slightly curved director; and isolates it in the
manner on the side of the trachea, in order to  separate  its posterior
surface and to raise it up.
  III.  Third Stage.—Increasing a little  the curve of the director which
serves to guide the ligature probe, whether he introduces  it from before
backwards, and from right to left, or from behind forwards, and from
left to right, he takes care during all this manipulation to avoid tearing
the pleura, or touching the nerve of the par vagum, which he leaves on
the right, or drawing too much on the  subclavian vein, which  perhaps,
it would be more convenient on the living subject to raise up or depress,
in order to pass the director between it and the trachea, than to push it
aside (que de la retirer)  as I have just mentioned.
  IV.—This process, unquestionably, more simple and less dangerous
than any other, has  moreover, this advantage, that the same  incision
would admirably serve for either of the subclavians within the scaleni,
or for either of the carotids near their origin.
   V.  Consequences  of  the Operation.—After the obliteration of the
brachio-cephalic trunk, the blood is returned  first by the  ramifications
and branches of the  carotids and left  subclavians, which  pour it into
the corresponding vessels on the  left side ; afterwards, these, that is,
the thyroids, cervicals, &c, transmit it to the supra-scapulary, external
thoracics, acromial, common scapulary and circumflex, and consequently,
to the whole upper limb,  which also receive  some through the medium
of the intercostals and the internal mammary.  Thus, it is not the want
of circulation which we have most to fear, as a consequence of such an
operation ; but the section and the ulceration of the artery, rendered
almost unavoidable  by the  proximity of the heart and the size of the
vessel;  and the effusions into the pleura, the  inflammation of  the aorta,
of the pericardium and even of the cavities of the heart.
  VI.—On the supposition that the trunk of the innominata itself is dis-
eased, no one would think of  surrounding it with a ligature ;  the opera-
tion beyond  the tumor, is then the only resource that can be attempted,
and when the disease is  confined^ to the carotid, however  low  down it
may be, this last operation seem'to suffice.  Therefore, I see only two
conditions  that can  make the ligature upon the  brachio-cephalic  trunk 
ARTERIES OF THE  NECK.
883
justifiable : 1, when an aneurismal tumor sufficiently developed to cover
the secondary carotids up to their origin, nevertheless leaves space enough
above  the sternum to enable us to reach them, and that without being
dilated, this trunk is diseased nearly up to  the aorta; 2, when  the sub-
clavian alone being  affected, the alteration of its coats extends too far
toward its root to  venture to surround it  with a ligature, inasmuch  as
the method of Brasdor would then probably fail.   The ligature then
upon the trunk of the innominata, is an operation, in fact, which should
rarely  be  put  in practice, if in truth it is ever indispensable.
   Aneurism of  the  Brachio- Cephalic Trunk or Arteria Innominata.—
M. P.  E.^ V. Guettet, in a late thesis,  (Determiner si Vonpeut  tenter la
cure de I'aneurisme du Tronc Brachio- Ciphalique, avecquelques chances
de succes.   La  Ligature du  Tronc Brachio- Ciphalique, est-elle prac-
ticable ?  These supported, Dec. 31st, 1844, before the Faculty of Medi-
cine of Paris.  See  Gaz.  Med.  de Paris, Mai 3, 1845, tome XIII., p.
286, &c.) attempts to revive the now  generally rejected method of Val-
salva for the treatment of aneurisms,  by applyingit to those of the bra-
chio-cephalic trunk, upon principles more minutely rigid as to regimen,
rest, food and exercise, &c, than those adopted by the Italian  surgeon;
That debilitating and exhausting plan we may repeat en passant, is now
generally  considered obsolete and at war with the more sound pathologi-
cal and physiological views which should govern the therapeutics of such
affections.   It has been well  remarked  by MM. Syme, Henderson, and
others, that such an enervating and exsanguinating process by abundant
bleedings, low refrigerating regimen, diet, &c, must necessarily deprive
the blood  of its essential elements, and defeat the very object  in view by
depriving it of the power of furnishing the quantity of fibro-plastic  lymph
requisite to establish an adherent permanent clot in the sac; which ver-
dict has been fully confirmed by the more or less  opposite  course of
treatment adopted in the extraordinary  cures by compression recently
effected by the surgeons of Dublin,  and by M. Liston and others who
have imitated  the process of the Irish practitioners.
  M. Guettet, in sweeping terms, reiterates the perhaps too unmeasured
denunciation or  proscription which has been  fulminated chiefly at Paris,
against the method of Anel in aneurisms of the brachio-cephalic trunk,
which question will be found fully considered and discussed  in the Re-
marks  of Dr. Mott, infra, whose opinions, coming as they do  from the
first person that ever tied this trunk, may  be thought to be  entitled to
some weight.
  In according,  where a surgical operation should be resorted to, an un-
qualified preference  to the method of Brasdor  over that of Anel, M.
Guettet proposes a new or retrograde revolution in  the modification to
which the minds of the Brasdorean partisans  seem now tending: to wit,
he is not for tying both the  subclavian  and carotid, either simultaneously
or at any time, but only one of these two trunks, as the most efficacious
in the cure, and the most sound  in principle.  Thus, suppose for exam-
ple, the inferior  aortic orifice of the innominata is dilated to such extent
by an aneurism as to receive more blood than the upper orifice can give
egress  to;  then  the  innominata would  become a sort of funnel with a
wide mouth, whose walls will share in the pressure and distension  which
are experienced by the aorta,  and will also be more exposed than any 
884
NEW ELEMENTS  OF OPERATIVE SURGERY.
other part to the action of the sanguineous current coming from the heart.
In consequence therefore of the relative narrowness of calibre of the up-
per extremity, the column of blood will exercise its greatest percussion
upon the walls of this infundibulura ; making the vessel in fact in itself
a sort of infundibuliform aneurism of the  aorta.   These  aneurisms
therefore at the cardiac extremity of the innominata, would be aggravat-
ed by a ligature on the two  branches, because the force of the impulsion
would be vastly augmented by the total occlusion of the trunk, and lead
to the inevitable destruction or expulsion of the clot.
  But even the method of Brasdor must be abandoned where the aneu-
rismal dilatation is at the  cardiac extremity of the innominata.  If how-
ever, the dilatation is at the middle part,  and one of the branches is tied
and both its extremities through which  the  passage of the blood contin-
ues to be made, be supposed to be of like calibre, the actual median posi-
tion of the aneurism between those narrow  openings under such circum-
Btances must favor the stagnation of the blood, and the deposit  and for-
mation of the clot.
  Of the two branches he  prefers, (and upon the presumed data we sup-
pose, which we have just given,) the carotid to the  subclavian ; the liga-
ture on this latter, after that on the carotid, having in his view hastened
the death of the cases of  Fearn  and Wickham.
  At  the  sitting of the  Academy of Medicine  of  Paris, Sept.  8, 1810,
the illustrious Larrey took occasion to give as his opinion, (Gaz. Med.
de Paris, No. 37, p.  589,) that the method  of Brasdor should be totally
rejected in any case whatever.   M. Diday, in taking opposite ground and
to illustrate the preference of this method in supra-clavicular aneurisms,
indulges in a latitude of expression  which is  not wholly justified.  He
goes so far as to say, (See his memoir on this method, and on the  liga-
ture upon  the  Brachio-cephalic trunk and the  origin  of its branches,
Gazette  Medicale, Feb. 22, 1845, p. 116,  Ac.,) that " if there is  any
principle in Operative Surgery established irrevocably, it is the absolute
prohibition of  a ligature on the arteria innominata  for aneurisms of  this
artery." (See on this subject the general remarks of Dr. Mott on aneu-
risms, infra.)   The  resource by the method of Brasdor, M. Diday also
deems perilous and uncertain, but the only  one  there is between the pa-
tient aud certain death from  the disease.   And moreover, contrary to
the opposite opinion  of Mr. Wickham,  an English  surgeon, (Gaz. Med.
1841, p. 365,) he deems this method more positively indicated in the class
of aneurisms of which this memoir above mentioned treats, than in those
of any other region.  He considers this method based on physiological
principles  that are  incontrovertible, though  not as easy of application
as other methods.   The  little success however which has  attended it
shows, as M. Diday very properly remarks, that it requires revision and
modification, (See remarks of Dr. Mott, infra.)  M. Diday considers it
impossible that any aneurism involving the  brachio-cephalic can ever be
radically cured except by the  obliteration,  either by surgical means or
spontaneously, both  of the  subclavian and primitive  carotid.   At the
time that the memoir of this surgeon first appeared, viz., in 1842, (Read
before the  Academy of  Medicine of  Paris, Sept. 13, 1842 ;  but not
published until in the  Gaz. Med., Fev.  22,  1845, p. 115,) the method
of Brasdor for aneurisms in  the supra-clavicular space had been  per- 
ARTERES OF  THE NECK.
885
formed, he says, seventeen times, not one of which he contends militates
against the truth of the foregoing proposition.
  M. Diday and most other surgeons would scarcely think it prudent to
tie, unless under very peculiar circumstances as stated by Dr. Mott, (see
infra,) both arteries at one operation.
  The subclavian, according to M. Diday, should be tied as near the tu-
mor as possible ;  because, in proportion  as the  ligature should be more
remote, the greater, naturally, would be the number of, and the greater
certainly the chance of obliterating, branches  that might be given off in
this interval between the ligature and tumor; and therefore to the same
extent would there  be more danger of  producing  mortification of
the arm, the more the collateral circulation would be deprived of the
branches which  were gradually to re-establish the course of the blood
between the branches of the right subclavian and those  of the  left caro-
tid  and left subclavian.   [See Dr. Mott's remarks below, wherein it will
be seen that he entertains an opinion the reverse of that of M.  Diday, as
respects the point on the subclavian to be selected for a ligature.]
  Although the  surgeon, says M. Diday, might feel greater confidence
of success if he found one of the  two  great branches of the innominata
already spontaneously obliterated to his hands, and might therefore sup-
pose that the ligature on the other would certainly complete the cure ; yet
that this is not  always so ; for it has  been found  (in proof  of which he
gives the cases of MM. Wardrop, Mott and Wickham) that the operation
of the ligature then is to have in some cases the disastrous effect of re-
opening a large passage for the blood through the interior of the sac, and
thus to give a new impulse and greater activity to the disease, showing
that the obliteration which had been supposed  to be permanent was only
temporary.  In the examples  cited, M. Diday appears to have supposed
that the operators labored under a misconception of this kind.
  Surgeons, therefore, should not, according to M. Diday, to  conclude,
because no pulsation may be felt in the carotid for example, that that artery
is obligated.  We believe there are none  possessing any knowledge of
the subject who have ever allowed themselves to  be deceived by any such
illusion.   Suppose in such a case this cessation of pulsation  in the caro-
tid  had been owing, as he thinks it might be, to the size and  pressure of
the aneurismal  sac itself upon the artery,  this latter, on tying the sub-
clavian would immediately diminish and the blood return to  the carotid.
  Thus, also, in the case above cited of Mr. Wickham, (Loe. Cit., supra,)
the carotid was tied first and the tumor diminished, but then augmented
in volume and prolonged itself  in a  new direction outwardly and along
the clavicle, because, no  doubt,  according to M. Diday, tho  pressure of
the  tumor being at first taken off  from  the subclavian as we arc to sup-
pose, the latter vessel was as it were re-opened, and in this manner gave
vent to  the then pent-up blood of the aneurism and  actually augmented
its volume—all of which reasoning, as it appears to us, is somewhat con-
tradictory upon the principle  laid down by M. Diday that the augmen-
tation of the volume or size of the sac has just produced a temporary sus-
pension of the pulsation, i.  e., an  apparent obliteration of the calibre of
the  carotid subclavian.
  Notwithstanding which obscurity, M. Diday thinks we may overcome
the difficulty of the diagnosis on  this point of  permanent or temporary
obliteration by attending to the following rules:— 
886            NEW ELEMENTS OF OPERATIVE SURGERV.
   1. To ascertain if the vessel in question corresponds at its origin or
at its middle portion only, to the most prominent point of the aneurismal
tumor;  in the first case there would be more probability of obliteration ;
in the second, of compression.
   2. To ascertain if the movements made in the shoulder, arm and head
do not cause some pulsation in the branches of one of the two trunks in
question—thus in the radials or  temporals for example.
   3. To ascertain if these same pulsations may not be made to re-appear,
by displacing the aneurismal tumor with the fingers, and endeavoring to
shift it  from off  the  arterial trunk which we may suppose to be com-
pressed by it.
   4. To mark the dilatation which  is  sometimes noticed in the veins con-
tiguous to the tumor; we may, from this sign, conclude that the tumor
presses forcibly on the neighboring  parts, which will  be  an additional
reason for  supposing that the cessation of the pulsations in one of the
arterial trunks is attributable only to  the pressure made upon it at its
origin.
   M. Diday considers it a law, positive and incontrovertible, that when-
ever one of the two  great trunks of the innominata is either totally ob-
literated or has undergone an organic contraction (or diminution) in its
calibre, the ligature must first be applied to the other trunk.
   Among the minor points which become enhanced in importance where
both  trunks are  found permeable, are:—the  direction of the  great
axis of the tumor, and that  in which it  appears to make the most rapid
progress; that in which its  pulsations  act with the greatest force, and
the changes produced in the size of the sac  by making  alternate com-
pression upon one or the other of the  two trunks in  question ; all of
which may be of service in determining the surgeon upon which artery
he should first apply the ligature.
   The last test is the best, but not decisive, for in  a case in which War-
drop (These de Villardebo; 3e  serie, 1 observ.) found compression on
the subclavian  produced no change in the tumor, he  nevertheless tied
that vessel,  and found that immediately after the operation the  size and
pulsations of the sac disappeared ; and the respiration became more free.
So in the case of M. Morrison, (Gaz. Mid.,1831,p. 583,) the tumor did
not sensibly diminish  in volume, though pressure  was made with great
force upon the carotid ; jet  he tied this vessel  and the  tumor disappear-
ed entirely,  so  that the patient  continued well for more  than sixteen
months.
   Where there are no indications to guide us it is best, M. Diday thinks,
to commence with the ligature upon  the carotid.  He considers Wardrop
to have established the fact that the constriction of  this vessel diminishes
to a much greater degree the blood which  traverses  the sac than that
of the subclavian  possibly can do.   So, also, are the dangers of the op-
eration  incomparably less;  on which  account, doubtless, it is  that all
the surgeons who have tied  the two branches have begun with the caro-
tid.   The statistical results  also fully  confirm  the correctness of this de-
cision.
   Up to the present time, surgeons  have not proceeded to a ligature on
the remaining trunk, until that on the other has been found to have failed
in effecting  a cure.   Though it is  an established truth, that whatever 
ARTERIES OF THE  NECK.
887
branch has been  tied, the  sac has, without a single exception, says M..
Diday, experienced  a certain diminution  in  its volume and pulsations,
yet a preference has perhaps been given to the ligature on the carotid
first, from the impossibility of distinguishing  with certainty an aneurism
of the innominata from one  at  the  origin of  the carotid.   This has led
to the hope of a cure by tying this  artery only, and thus, by procrasti-
nating the period of tying the subclavian,  the aneurismal tumor has been
permitted to obtain a new growth.   To this circumstance M. Diday im-
putes many of the failures.
  The second operation should be performed, he thinks, as soon as it is
ascertained that  the tumor  no longer decreases, and especially if the
pulsations which have been temporarily suspended by the first operation,
begin to reappear.   Thus, in the case'of  M.  Wickham, (Loe.  Cit.,) the
tumor, by the ligature on the carotid, had at first diminished ; but,  at
the end of a month, it had acquired its primitive volume.   The patient
resisted the operation on the subclavian  for  another  month,  when the
tumor having now acquired  an enormous size, the ligature on this vessel
resulted soon after in rupture of the sac and  death.  One motive for re-
tarding the second  operation, should that  be on the subclavian, un-
doubtedly has been  the fear that the  circulation might not be re-estab-
lished  in  that vessel, because of the anastomosing branches to it from
the carotid being now cut off.   This M. Diday thinks an inadequate rea-
son for  delay; moreover, it is  possible, he  thinks, to  establish, by  the
pulsations in the temporal and facial arteries, and even by those of  the
tumor, that the circulation of the carotid  is restored, and therefore that
there is no danger  in proceeding to the  subclavian.  Montgomery has
seen the pulsations  of the  temporal  and  facial arteries reappear in  ten
days after a ligature on the carotid.  Until the  second ligature is  de-
cided upon, gentle and moderate compression should be made on the sac.
This we think one of the  most important suggestions of the author, espe-
cially after the remarkable success which has resulted at Dublin from
treating  aneurism by compressing moderately the trunk of  the vessel
above the sac; (see note on the subject above ;) also, by direct pressure
upon the  sac itself, (see Mr. Luke's case, note above.)   Could com-
pression to the tumor r_nd its neighboring connecting trunks be efficiently
applied, and conjointly with a ligature on one of the great branches, so
as to affect a cure, it would  indeed  be another masterly and  bloodless
triumph for surgery.  This  compression, says M. Diday, in the interval
mentioned, would become indispensable where it is the size of the  sac
whose pressure has suspended  the  pulsations in a neighboring artery.
We thus, in taking off the pressure on the artery and applying it to the
sac, aid its natural contraction.
  In regard to the place to  be selected for a ligature, it is to be remark-
ed that all the hemorrhages which have followed the ligature on the caro-
tid by the method of Brasdor, have come  from the upper, i. e., the peri-
pheric end of the vessel,  in  both the  cases published, viz., that of Lam-
bert and that of Montgomery, (Vilardebo, ut  sup.)  M. Diday considers
that such hemorrhages are owing to surgeons not paying sufficient atten-
tion to a point of surgical anatomy which  he  deems of great importance,
viz.: to  tie the trunk at a sufficient distance above a collateral, provided
that collateral be of a large size, and  goes off  in a retrograde direction 
888
NEW ELEMENTS OF OPERATIVE  SURGERY.
from, and at an acute angle with, the main trunk, i. e., has  its sinus
turned toward the capillaries, for, in that case, the column of contained
blood in the collateral, though diminished by passing through the capil-
lary, circulation may still have so much force as to break up the clot
above the ligature.   To this cause, viz., an ulceration of the peripheric
end of the artery, he imputes the hemorrhage which proved fatal to Dr.
Mott's case of ligature on the innominata, 1818, and that of M. Crampton
on the primitive iliac, 1828.   He cites also a case he saw at the Hospital
of St. Louis, Paris, in 1839, in which fatal hemorrhages supervened from
the lower end, in a patient in whom  the femoral had been tied a little
above the origin of the profunda, (Gaz.  Mid., 1839, p. 681.)
  M.  Diday considers that all these  conditions of hemorrhage from the
peripheric extremity, exist to a greater degree in the  primitive carotid
than elsewhere, to wit, the proximity, size, and retrograde direction  of
the collaterals; for, in the only two  cases where hemorrhage took place
in this vessel from the peripheric end, the ligature was placed  too high
up on the artery ; thus diminishing not only the  length of the contained
clot, but its power of resistance to the reflux current of blood.  Thus
Montgomery, in his case, remarks that the ligature was placed very near
the bifurcation of the carotid.  In that of Lambert, he  states that the
ligature was placed above the point where the  artery is crossed by the
omo-hyoid muscle.
  Therefore, says M. Diday, tie the  carotid  as far as  possible from its
bifurcation ;  only that, in  thus approximating nearer to the tumor, we
run the greater risk of constricting a  diseased portion of the vessel. Pru-
dence and judgment must decide upon the proper place, though M. Di-
day would, in a case of doubt, prefer  approaching the tumor  than the
capillaries.   He instances the great number of cures and infrequency of
hemorrhages in the  ligature on the external iliac for spontaneous aneur-
isms, and in which it has to be placed very near the tumor.  The danger,
therefore, of this method, which was that of Kesleyre, he thinks, has
been greatly exaggerated  by Jno. Hunter.
  At the bifurcation of the carotid, there is,  according to Hodgson, the
additional danger that depots of calcareous matter and simple dilatation
are more common here than in any other part of its trunk.
  We  have  given  a more  detailed  abrege  of the useful  paper of  M.
Diday, because of its historical details on most of the operations which
have been performed on  the brachio-cephalic trunks for  aneurisms, by
the method of Brasdor.  This method  has of late years attracted much
attention on the Continent, and M. Diday, a zealous  champion of it, has,
as we should think, exerted himself  with all the ability that could be
brought to bear in its favour.  Consequently, it will be seen that his analy-
ses of several of the fatal cases  are made to correspond in favour of his
views.   We (speaking for  ourselves individually) are no partisans  of
the Brasdor plan ; least of all, in giving it a preference over that of Anel,
where that is at all  practicable.   The paper of M. Diday will be service-
able, at least, as a reference for those who are investigating this subject,
and  wish to treat it with  exactitude, as always should be our rule  in
all matters of science.  T.] 
ARTERIES OF THE NECK.
889
  Article X.—Arteries of  the third or fourth  Order, which may
                  also require the  Aid of Surgery.

     Some arteries, which have not yet been spoken of, may nevertheless
  become the seat of aneurisms, and require the aid of operative surgery
  when they are wounded.

                                  §  I.

     The arteries of the shoulder and those of the thorax have chiefly at-
  tracted attention under  this point  of view.  A fact taken from  the
  practice of Desault is related, where it appears that this surgeon, sup-
  posing that he was opening an abscess, plunged the bistoury into an an-
  eurism of the  thoracic arteries.  Pelletan (Cliniq.  Chir., t. IL, p. 10)
  says he saw,  on the apex  of the shoulder, a tumor  which he took  for
  an aneurism of the acromial artery.  M. Liston {Edinburg Med. Se Surg.
  Journ., vol. XVI., p.  66)  speaks of a bloody sac whose Vails were ossi-
  fied, and which he considers  as an example of aneurism of the sub-scap-
  ular artery.   On the other hand, it may be conceived that the sub-scap-
  ular artery, the  acromial  artery, and the circumflex arteries, might, if
  wounded, give rise to  a serious hemorrhage.  But of two  things one
  must take place: either the wound or the tumor is within the reach of
  the bistoury, and in this case  it is necessary to attack the vessel  directly
  upon the diseased  part—or  the  aneurismal  affection is too  deep to be
  treated by direct means, and then we can only  effect our purpose by
  having recourse to  the  axillary artery.   Though I had  elsewhere
  (Anat Chir., 1.1., p. 319,1825—p. 446, t. IL, 1833—p. 380, t. IL, 1837)
  given  the method  to  be adopted to  tie  the sub-scapular artery at its
  entrance into the sub-spinous fossa, I do not think it  necessary to repeat
  it in this place.
                      § II.—Intercostal  Arteries.

    Cases of wound  or aneurism  of the intercostal  arteries  have been
  related by various authors.  Ruysch, A. Petit, Walter, (Ancien Jour, de
  Med., t. LXV., p. 313,) Delmas, (Questions Chirurgicates pour  Con-
  cours,  Montpellier, 1811, p. 7,) and Briot, give examples  of them.   M.
  Floret, ( These No. 6, Paris, 1836, p. 20—Arch. Gen. de Blid., 2c serie,
  t.  XII., p. 337,) in fact, relates the case of an individual who had  the four
  first intercostal arteries covered with true aneurisms.  But the operations
  to  be  performed in a case  like this will be found under the head of the
  article on Empyema.

                §  lll.—^The Internal  Mammary  Artery.

    ^he internal mammary artery, besides being of sufficient size to give
( rise to spontaneous aneurisms, is  also very much exposed to wounds.
'  Chopart succeeded in  arresting  a hemorrhage  from it in a  child, by
 means of  compression.  Bonet relates a  case where a wound  of this
 artery caused the death of  the patient.  M. Demontegre (Thise No. 14,
 Paris,  1826, p. 6) gives the history of a man seventy-six years  of age,
    Vol. I.                    112 
890
NEW ELEMENTS OF OPERATIVE SURGERY.
who died five weeks after receiving a wound from a sabre, and in whom
an aneurism two inches long was found in the internal mammary artery.
It is also certain that wounds of this artery have quite frequently occa-
sioned death, as in the case of Bonet.   It would be important, then, to
possess a process by which we might be enabled to lay bare  this vessel
and tie it.  Here is the one which I was the first to point out near fifteen
years since.
  As the mammary artery crosses the cartilages of the ribs  behind, at
two, three, or four lines on the outer side of the  sternum, we may cut
down to it by dividing the tissues  to the extent of two or three inches,
in a direction parallel with the border  of the bone, and by  preference
upon the third intercostal space, which in truth is the  largest  of all.
After the integuments, we should have to divide the sub-cutaneous fascia,
the  fibres of the pectoralis major,  the internal extremity of the intercos-
tal muscle, and some cellular lamellae.   The thickness of the cartilages
would show the depth it would be proper to penetrate.  The needle of
Deschamps, passed from without inwards and brought out from behind
forwards, would answer for applying the ligature to the artery without
wounding the pleura.
  Since I recommended this operation, the ligature upon the internal
mammary artery has been proposed or practised by means  of processes
somewhat different from that of which I have just spoken, by M. Goyrand,
of Aix and by a surgeon  of the army of Africa, whose name has escaped
me.

                § IV.— The Arteries of the Penis.

  If Albinus,  (Heuztault,  These, Paris,  1811,  p. 17,)  sustained by
Gavard,  (Splanchnologie, etc., p. 498,)  had not related a  case  of a
bloody or aneurismal tumor of the corpora cavernosa, no one  would have
thought of diseases of arteries of  the  penis, of which, in fact, I shall
not speak,  except  under the head  of  the  operations indicated for the
diseases of this organ.

                               § V.

  The epigastric artery is also exposed to certain wounds ;  but I shall
have an opportunity  of  describing the ligature upon this vessel when
speaking of the operation for hernia. 
DR. MOTT ON ANEURISMS.
891
                  REMARKS ON  ANEURISMS.

                         BY  V. mott, m. d.

  The pathology of aneurism  is now sufficiently well established not to
require any particular detail in this place, after the full and erudite ac-
count by our learned author, M. Velpeau.   We deem it more important
to confine our remarks  to those of a practical nature.  More difficulty
attends the diagnosis of aneurisms throughout the chest and lower part
of the neck, than practitioners who are merely theoretically acquainted
with the  subject can possibly be aware of.   All the additional light that
has been thrown on the subject by auscultation, will be  admitted by all
practical men, to be as yet an insufficient guide.  Many cases are clear
and obvious ; others,- on the contrary, are obscure, and remain unknown
until autopsic examinations discloie the truth, when it is too late for the
interposition of therapeutic means.   All men of experience must acknow-
ledge this fact.  The appearance of a tumor in a very remote part  from
its origin, is calculated  to  mislead the  most  sagacious and  observing
practitioner.   And what adds  to the  obscurity, is often the  positive his-
tory derived from the patient,  and  the  practitioner who has been in at-
tendance from the earliest  period of  the case.   We have seen instances
in the chest as well as in the extremities, in which we have  been posi-
tively assured  that there was no aneurismal character  belonging to the
case in the early stage, when usually its most striking features are mani-
fested.   When now submitted  to our inspection, the advanced stage pre-
sented fewer of the features by which we are  to recognize  this disease.
Thus for example, we have seen an aneurism of the arch of aorta, pre-
sent its tumor above the clavicle in the situation  of one  which might be
thought to have proceeded from the acromial or scapular side of the sub-
clavian artery of the right shoulder.  This was its first appearance, and
was  positively  stated to have  been unaccompanied with  any pulsatory
movement of the aneurismal character.  The first appearance of tumor,
was stated to have entirely  passed away; then to have reappeared and
advanced forward to the clavicle, and continued to increase and finally
encroached upon the  trachea  and  larynx, involving and destroying the
clavicle.   One of these tumors  finally attained the dimensions and shape
of a half-loaf of bread.   The practitioners  and surgeons who saw it be-
fore me,  differed in opinion as to its nature.   A  surgeon of eminence,
first  thought it aneurismal, then he altered his mind and determined to
puncture it, and went, as  he thought,  prepared to  do it; but  upon
searching his  pocket, found that he  had left his  exploring needle at
home.   Shortly after this, he again thought it to be aneurism.  I was
now called to see the case and, without knowing the opinions  which had
been  entertained, deemed it, after a  careful examination, not to be an-
eurism.   The  surgeon in attendance,  now gave me  his views of the
case, and stated that he now  thought it  aneurismal.   It had a general
pulsatory motion, though not the swell and general growth in the pulsa-
tion  which I consider the chief diagnostic mark of aneurism.  It was
soft and  apparently fluid  throughout, destitute  entirely of all thrill or 
892
NEW ELEMENTS  OF OPERATIVE SURGERY.
bruit de soufflet, and  was stated by a practised stethoscopist, who had
repeatedly examined it, to have been devoid of the bruit in question, at
all his examinations.  The incredible quantity of muco-purulent material
which the patient  constantly expectorated, amounting sometimes to a
quart in a short period of time, and which he could always  apparently,
force into the trachea by  pressing his finger on that  part of the tumor
which encroached on  this passage, and which, as he stated in my pres-
ence, and as I several times  saw him do, gave great relief to the  tension
of the tumor, necessarily threw great obscurity on the case.
  Such was the distressing and imminently dangerous state in which the
patient  was placed,  and the great uncertainty of the aneurismal charac-
ter of his disease, that I advised with the approbation of the attending
surgeon and at the urgent wish of the patient,  that the nature of the tu-
mor  should be tested by the  exploring  needle.  This was accordingly
done, and upon introducing a probe into the aperture made by the needle,
it was admitted to the depth of a few inches with the same partial resis-
tance that all  practical  men know bekmgs to a malignant tumor.  A se-
cond puncture was made and the same results were obtained.  Only the
most trifling quantity of dark grumous blood issued from the punctures,
and the same appearances were seen upon the probe.  My colleague now
thought the disease  a malignant tumor, as I myself also did.   The aper-
tures were now closed by a strip of  adhesive plaster.-  The patient con-
tinued in a most suffering condition  for a few days and then expired.
Great interest was naturally excited to determine the nature of the case,
by a post mortem examination.
  This inspection proved that the case was in reality, an  aneurism of the
arch  of the aorta only, just below the origin of the innominata.  The
aperture at the aorta, was  the  smallest and seemed to be the most
natural  and healthily organized opening that I ever saw in any case.  To
the smallness of the opening and the remote distance of the tumor from
this aperture, may be ascribed the difficulty which existed of forming a
correct diagnosis.
  If this tumor had originally presented the true aneurismal character,
it would naturally from  its location, have led a surgeon to the question
of tying the innominata, upon  the  cardiac  principle of treating  aneu-
risms ; as no other artery in this case could have  offered as many  advan-
tages to the patient.
  We believe that tying the  subclavian  of the right shoulder within the
scaleni  muscles offers in fact in all cases, less chance of success  in con-
sequence'of the proximity of the origin of the  several branches which it
ordinarily  gives off.  In  two of the operations which have been per-
formed upon the subclavian at this  point, one by Dr. Colles of Dublin,
and the other by myself, the patients in both cases perished from se-
condary hemorrhage.   In the two remaining and recent instances, which
were those of  Mr. Liston and Mr. Partridge, the same result ensued.
  If an aneurism of the aorta can first present  itself at so great a dis-
tance from its origin, and when it is considered  at the same time that it
much more frequently happens that it presents itself nearer its origin,
how  cautious ought  we to  be in our diagnosis and  determination to op-
erate, when we find aneurismal tumors situated at the lower part of the
neck and about tho  clavicles. 
DR. MOTT ON ANEURISMS.
893
     All  surgeons,  whose  opinions are of any value, will readily excuse
  mistakes that are made by even those who have had the greatest expe-
  rience, because, notwithstanding  all the light  afforded by pathological
  investigations and stethoscopic examinations, it will we think, be gen-
  erally admitted by the profession, that  no subject  is more difficult and
  obscure than that of sub-sternal and thoracic aneurism.
     Certainly when aneurisms show themselves as they ordinarily do near
  their origin, destroying  the  super-imposed tissues, soft and hard, and
  presenting a pulsating tumor to  the eye and touch, the true nature of
  the case is almost self evident.  But when they sprout out  to a great
  distance  from the trunk  on which they have originated, in the form of a
  long tube or neck, developing their true character at a remote point, the
  diagnosis must necessarily always be exceedingly difficult.
    It is in most of  these aneurismal tumors, which appear about the lower
  part of the neck  and shoulders,  that  the  distal operation is most fre-
  quently thought of as the only one which is practicable.
    From the  uncertainty therefore of the  origin of aneurismal tumors
  which appear about the upper part of the sternum and clavicles, we can
  readily understand why  the distal  operation must  frequently be of no
  avail.   For it is  well known that, when  an aneurismal  tumor shows
  itself above the upper bone of the sternum, it happens as often that it
  proceeds from the aorta as from the innominata.  Therefore after tying
  the carotid  upon  the  distal  principle,  though  the  artery should  heal
  kindly, there will  be  no diminution of the disease.  So also if we tie
  the subclavian beyond the scaleni muscles for a supposed aneurism within
 those muscles, the operation is equally useless; as in both cases the
 aneurism may proceed from the  aorta itself.
   If, fortunately, however, as  has been our  lot,  in a case of aneurismal
 tumor above the sternum, it has been proved to  be situated in the inno-
 minata itself, we believe and know that the tying of the primitive  carotid
 has caused the entire  disappearance  of the tumor.
   We know also that when the innominata is aneurismal itself, that na-
 ture makes an effort to cure the disease by plugging up, or  obliterating,
 one of its two great branches ; either the subclavian or the common caro-
 tid.  We have thus seen several cases in which either one or the other of
 those two great trunks, spontaneously ceased  to convey blood to their
 branches.  In'two  instances in which we  have operated for an  aneurism
 of the innominata on the distal principle, no pulsation  could be discov-
 ered in the subclavian, axillary, brachial  or cubital arteries of the right
 thoracic extremity; but the pulsation of the  primitive carotid continued
 with even  more force than natural.   Ought not such  facts as these lead
 every reflecting surgeon to adopt and practice the distal operation upon
 the  only pervious trunk adjacent  to  the aneurism ?   Thus, in the two
 cases above mentioned, I  tied  the  primitive carotid  because the subcla-
 vian appeared, so to speak, to have been spontaneously plugged up.
  In all such cases, therefore, the surgeon ought  to be governed by this
 principle, and thus  co-operate with  the salutary efforts of nature.  If the
 subclavian  should be the pervious trunk, that should be tied without the
scaleni muscles, and never within, under this or any other circumstances,
as we have already stated.
  If the carotid be  the pervious trunk, that should be the one to tie.  If
both be pervious, both should be tied  at the same time. 
894
NEW ELEMENTS  OF OPERATIVE SURGERY.
    We have verified occasionally the excellent and practical diagnosis of
  these aneurisms as laid down by Mr. Wardrop of London ; but we never-
  theless believe it to be insufficient in the majority of cases to enable us
  to arrive at a correct  opinion.   We know very well, as before stated,
  that sub-sternal and thoracic aneurisms will sometimes be first manifested
  in the several situations pointed out by Mr. Wardrop; but we know also
  that a tumor which shows itself above the first bone of the sternum, and
  the tumor that appears between the origins of  the sterno-cleido mastoid
  muscle and upon the outer edge of the clavicular portion of that muscle,
  instead of denoting an aneurism of the arteria innominata, common caro-
  tid or subclavian, as he would  infer, may be in either of these several
  situations in fact an aneurism  of the  aorta.   An  operation, therefore,
  which may be performed upon the distal principle, of tying  the carotid
  or subclavian, must ever in such cases  be fruitless and unavailing.
    The Arteria Innominata.—In all cases, therefore, in which it may be
 proposed to tie the innominata upon the cardiac principle, more or less
 of doubt must remain in the mind of every enlightened and experienced
 surgeon.  For notwithstanding all the aid of auscultation or other means,
 the aneurism-for which the innominata shall be tied may prove to be sub-
 sternal or thoracic, and nevertheless present a tumor in the situation of
 an aneurism of the  subclavian itself.
   Fortunately for ourselves, in the operation which we projected and first
 executed upon the arteria innominata, the disease proved to be connect-
 ed with the subclavian  only, and the operation was  truly  on the cardiac
 principle; and we believe  such has been the  case in all the subsequent
 operations upon this great arterial trunk, which, as will  be seen by the
 text of M. Velpeau,  amount to  five besides my own, and which, as far
 as  my information  reaches, are all that we possess any authentic ac-
 count of.
   Although this great and  difficult operation has never yet succeeded in
 effecting a permanent cure, still the spontaneous separation of the liga-
 ture at the usual period, satisfactorily proves that when this artery is in
 a sound state, as it always should be when we attempt to tie it, it will,
 though a great trunk and so near the heart, heal  by adhesive inflamation.
 In my case, as will be seen hereafter, the ligature separated on the four-
 teenth day, and the healing process had nearly completed the  closure of
 the wound before an ill-conditioned ulcerative action had commenced;
 showing as I think conclusively that but for the  vitiated habit of my pa-
 tient the operation would have resulted  in a  perfect triumph.
  This man was sufficiently recovered to walk in the  grounds adjacent
 to the house for some days previous to the commencement of  the ulcer-
 ation which ended in fatal secondary hemorrhage.   No  inconvenience
 was experienced by  the patient, either in the  functions of the heart, lungs
 or brain, or in  perfect exercise of  all the functions of the  right superior
 extremity ; proving conclusively in our mind that the tying of the innom-
inata on this principle,  is not only a practicable but proper operation.
The close proximity of  the disease in the subclavian within the scaleni
muscles in this case, was an untoward circumstance perhaps fort, favor-
able result.  This was seen during the operation, and forbade the appli-
cation  of the  ligature  to that vessel, and left  no  alternative but the
brachio-cephalic trunk.   I  felt  emboldened  to  take this step,  which 
DR. MOTT ON ANEURISMS.
895
up to that time had as is well known never been ventured upon in the liv-
ing^pody by any one, by  the solitary fact stated by Allau Burns, that in
making an injection in the dead  body after applying a ligature to the in-
nominata he found some of the injection had passed into the right superior
extremity.   Knowing this  fact, I had been in the  habit for several years,
in my surgical lectures, of showing the practicability of applying a lig-
ature to this artery, without wounding the pleura, and thereby opening the
right cavity of the chest.  I had therefore no doubt in my mind as to the
possibility of accomplishing this operation upon the vessel if proper care
was  observed ; but I confess, notwithstanding  the fact of Burns, I had
many misgivings  as to the preservation of the right superior extremity.
I said to myself that if injection can by this circuitous  channel find ita
way  into the  arm, the  blood  would  with much  more certainty do the
same.  And I was delighted with the result, that this  member suffered
no more  inconvenience for the want of nourishment than if the brachial
only had been tied.
  I am aware that many  surgeons  will still doubt the  propriety of at-
tempting any future  operations upon this artery, as all the cases have
terminated fatally.   Yet I am free to say,  that  if ever a case should
present itself  to me again,  I should tie the primitive carotid at the same
time that I tied the innominata, as both can readily be done  through the
same incision.  I am very  well aware that this would be objected to by
some as inflicting an extent of operation new and untried ; yet it seems
to me, that by thus intercepting the retrograde current through the prim-
itive carotid, there would be less chance of any reflux  hemorrhage in the
event of a  phagedenic  ulceration being set  up in the wound.  This is,
however, a most momentous question for a surgeon to decide upon, and
must ever be left to his own judgment and discretion.
  Until my operation was performed, no surgeon had ever ventured  thu3
to rob the brain of  at least half its blood.  This  alone  was certainly a
hazardous experiment, but  we  were gratified in  the  result, and subse-
quent experience has  extended this principle even still farther than any
one would have anticipated.  For we now know  that the full functions
of the brain have been performed for six days by one  vertebral artery
alone, (See case of M. Rossi in the list  above.)  In all the  cases in
which both the carotids have been tied, an interval of some months has
generally been allowed to elapse.   In one of my two cases twelve months
passed away before it became  necessary to tie the remaining carotid.
This young man did not experience  the  least inconvenience when the
circulation  was  interrupted through  the  last carotid, and he recovered
perfectly.
  In the other case, which I have never yet published, the imminently
hazardous and formidable  character of it was such as to justify, in my
opinion, the tying of both carotids at the same time, with an interval of
only  about fifteen  minutes.   Coma  and stupor  in the  course of  a few
hours supervened, and he died within forty-eight hours.
  If the primitive iliac, when tied, will heal, and we by this operation,
save the patient's life, why may we not with perfect propriety yet hope,
that  some one is destined, in the brilliant march  of surgical triumphs,
to obtain the like happy result from a ligature on  the innominata ?   The
force of the circulation must be  as great and as  direct  in the primitive 
896
NEW ELEMENTS  OF OPERATIVE SURGERY.
 iliac, from its proximity to the aorta, as it  is in the  brachio-cephalic
 trunk.   My hopes are not at all dampened by the hitherto repeated#iil-
 ures of this operation; and I fondly anticipate that tho day may come
 when some one of my countrymen may yet be heralded as the success-
 ful operator.
   The  Subclavian Artery  within the Scaleni Muscles.—The  relative
 anatomy of the right and  left  subclavian arteries, within the scaleni
 muscles, compels us to believe that the right only can  ever be  thought
 of as proper for a ligature.  The deep origin of  the left as a primitive
 trunk, from the arch of the aorta, and its  associations with the deep
 jugular,  and the thoracic duct, should forbid in our opinion, any attempt
 ever  being made to put a  ligature  upon it.  The right, from  its high
 origin from the brachio-cephalic trunk, makes it more  readily  accessi-
 ble in a surgical operation.   It was  first tied by Dr. Colles, of Dublin ;
 he unfortunately  lacerated the pleura, by which the cavity of the chest
 was opened, and his patient died in a short time, before the ligature had
 an opportunity of becoming separated.
  In  a case, which was the second, and performed under the most favor-
 able  circumstances, as to health and moderate extent of disease, full
 time was allowed for the spontaneous separation of the ligature.  But,
 unfortuntely, while  separating, arterial blood  showed  itself, which,  as
 can be readily imagined, was a humiliating and appalling event.  This
 discharge  was repeated from time  to time, through an opening barely
 large enough to admit the passage of the ligature, showing, conclusively,
 that the ulcerative rather than the adhesive process, had been produced
 by  it.  This  amounted by degrees to an actual hemorrhage, which,  in
 a few days, wasted the energies  of my patient, and ended in death.
  From  the  number of large arterial branches which are given off by
 the right subclavian in its  course from  its origin to the  inner edge of
 the scalenus anticus muscle, we very much doubt whether a ligature will
 ever be applied successfully to it.   The distance between the origin of
 these  branches is so small, that an opportunity, in our judgment, is not
 given for the adhesive process ever to be accomplished.
  This is, at  present, the  apprehension we entertain ; but we shall be
 happy to find hereafter that our fears shall have proved groundless.  In
truth, if  we are warranted  in expressing an opinion, we think  there is
less to be  hoped for, in the application  of a ligature here, owing  to
the  fact  of these several branches  coming off within  so short a dis-
tance  of each  other, than there would'be in tying  the arteria innomina-
ta itself.
  Ligature in the  Middle  or Scalenus portion of the  Subclavian.—
We do not see any reason to doubt but that a ligature may be success-
fully placed on the middle  or scalenus portion of the subclavian, for it
appears to us  to be sufficiently distant from any considerable branch  to
allow of complete adhesion of its  walls to take place.  Dupuytren is
said to have tied it in this situation: we have repeatedly  done it on the
dead  subject, ana believe it a proper and practicable operation.  Great
care must  be taken by the operator  that he does not injure the phrenic
nerve, as it runs directly over  the anterior surface of  the scalenus an-
ticus muscle.
  The Subclavian without the Scaleni Muscles.—The subclavian in this 
t
                       DR.  MOTT ON  ANEURISMS.                  897

part can  be tied in a surgical operation with equal  facility on  both
shoulders.   Since the time  of Mr. Ramsden, who  first  tied this artery-
above  the clavicle, it has been performed in different countries by vari-
ous persons.  It is due to our  country, aud to our  distinguished citizen,
the late Dr. Wright Post, to state  that he has the honor of having first
performed  this  operation successfully.   I had the pleasure of assisting
him in it, being united with him in the case.   Since that period, it has
fallen to my lot to have tied this artery four times for aneurism, all of
which  cases resulted in complete  success.   Several of the cases have
been published in the journals of our  country.
  This  operation must always be viewed as one of great importance;
but with the knowledge of anatomical relation, which has added so much
lustre and precision to modern surgery, it can be accomplished by a care-
ful  operator with great  satisfaction to himself, and great  benefit to his
patient.
   The Left Subclavian  within the Scaleni Muscles.—The deep origin
of this  artery  as a primary branch from the  arch  of the aorta,  and its
consequent more intimate relations with the deep jugular, pneumo-gastric
nerve and transverse vein, and lastly, more important still, the thoracic
duct, would  we repeat make an attempt to place a ligature upon it too
hazardous, in our judgment.   We saw the first, and perhaps only attempt
that ever  was made, to tie this artery.  This  was by my illustrious and
revered preceptor, Sir  Astley Cooper.  After working indefatigably
with all his  eminent skill and superlative  tact  for an hour and a half, he
abandoned the operation as  hopeless.   The patient died in the course of
a few days.
   The  Primitive Carotid.—Since  the first attempt, and unsuccessful
attempt, by  Sir Astley  Cooper, to cure an aneurism  of the carotid on
the cardiac  principle,  a great number  of  surgeons  in different countries
have tied this artery for that and other affections.
  We were  present at Sir  Astley  Cooper's  second attempt to tie this
artery, and  the issue was fortunate.   Dr.  Wright Post was also the first
who succeeded in this operation in this country.   I have tied the primi-
tive carotid  for aneurism, and for various  other purposes, twenty-three
times, most  of which, all in fact, but  two, have terminated favorably.
Two of these cases were for navi materni, i.  e., aneurism by anastomo-
sis, one an  infant  of three, and the  other of six months, and in both
radical cure of the disease  was effected.
  There is the  best ground for hope that the ligature on the common
carotid  upon the cardiac principle, will continue to be a very successful
operation, in consequence of its giving off no  branch whatever through-
out the  whole length  of its trunk,  a most curious, interesting and im-
portant  fact.  Although we  have ourselves tied the  external carotid as a
preparatory  step to the exsection of the parotid gland, we nevertheless
believe that it is preferable  in such cases to tie the primitive trunk.  Our
reason is that it is much more accessible, and the operation much more
easy, and' that it does not, in our judgment, in the least degree, augment
the dano-er.   On the  contrary, the ligature being more remote from any
arterial ^branches than it would be on the external carotid, makes the ope-
ration more safe to the patient.
   The Anti-Cardial, Distal, or Brasdoreal Operation.—My opinion is,
   Vol. I                       H3 
898            NEW elememts of opeartive  surgery.

that  it is tne duty  of the surgeon to make trial of this method rather
than  leave his patient to perish.  Although the instances of success are
very  few, yet  in  our view they  are  sufficient to justifiy the operation.
Deschamps and  Sir  Astley Cooper first availed themselves of this pro-
cess, which was only recommended,  but  never had been  performed by
Brasdor, whose name it bears.   These cases were for femoral aneurism,
So high up that the femoral artery could not be tied below Poupart's lig-
ament ;  and as no  one  yet had ventured to tie the external iliac, these
two surgeous tied the femoral below the disease.   Both these patients,
however, unfortunately  died.   The  surgical world is  more indebted to
Mr. Wardrop  than to any other person, for having revived  this practice
and applied it to the great arteries of  the neck and shoulders.  A num-
ber of attempts have now been made upon the carotid and subclavians,
upon this principle, and  some successes have crowned these  efforts.   The
carotid has been successfully treated in this way.   AVe have tied the ca-
rotid twice on this principle for aneurism of the arteria innominata.   In
one  case, secondary hemorrhage after  the ligature had separated, led
to a  fatal result.  In the other case, which was my first, I feel author-
ized  in saying, that it  was successful.   The ligature separated kindly,
and  the  wound healed.  The tumor above the sternum, which had been
near the size of  the fist, entirely disappeared.  My patient returned to
the country, and died  at  the  expiration of about a year from the time
of the operation ; but no tumor had ever reappeared above the sternum.
He rigidly persevered in the most abstemious and starving diet, contrary
to my express injunctions, and became  frightfully emaciated.  Cough
then  supervened, with  difficulty  of breathing, with which  he gradually
perished.  The post-mortem, which we shall annex with the description
of the case, shows that* the aneurism  of the innominata had shrunk to a
solid and extremely indurated mass, having almost a stony  hardness, the
pressure  of which on the bronchi, led to the pulmonic difficulties which
have been stated.   My firm belief is, that if he had used  a reasonably
nutritious diet, his strength would have been sustained, the resources of
art  aided, the tumor perhaps  absorbed, and  his life saved.  We  think
there  cannot be a better established  principle than that the energies of
the  system  frequently  require aid,  in  order to  enable it to  remove
surgical diseases. ' The extravagant, depletory, and starving system of
Valsalva, in aneurisms, and  of other practitioners  for other diseases,
deserve  to  fall, as they are  doing  rapidly, into disrepute.  My patient
may emphatically be said to have died while he was being  cured.
   Arteries  of the Superior  Extremity.—The axillary artery, from its
origin at the first rib, untill its termination opposite the lower border of
the  axilla, we have tied in a number of instances ;  and where it can be
done for au aneurism of the brachial  artery, it is much more simple  and
proper than the tying of the subclavian above the clavicle.  The parts
to be encountered are much more simple, and  the operation more readily
accomplished if the surgeon be fully posted up in the anatomy of rela-
tion.  Keeping close to the  inner fold of the  axilla, and arriving  at the
Coracoid process of the scapula, the artery can be readily followed up to
the  lower margin of the first rib, at  which point this vessel commences.
We would reprobate  here the practice which has been recommended,
and followed by some,  of  cutting through the thick part of the pectora-
lis major, by an incision just below the clavicle.   The numerous branch- 
DR. MOTT ON ANEURISMS.
899
es of veins which are always  encountered here before arriving at the
trunk of the axillary vein, makes it a much more hazardous and difficult
operation than some may imagine who are not familiar with the anatomy
of the parts.   And when the trunk of the vein is reached, the operator
must search for the artery higher up, and either go above, or below, the
great venous trunk in order  to find it, and apply his ligature.
  This operation, like many others in surgery, is too loosely  and care-
lessly described ; showing clearly, to a practical operator and one versed
in relative structure, that all  who  describe  operations are not more
familiar with the parts they  describe than many are whom  we see cut in-
to them.  It is one thing to  describe, and quite a different thing to per-
form, an operation.
  The brachial or humeral,  from its  superficial course, first along the
inner edge of the coraco-brachialis, and then the inner edge of  the biceps,
makes a ligature upon it an  easy operation to a very ordinary surgeon.
He must only be careful not to tie the median nerve, which is associated
with it differently, in different parts of its course.
   We may, with great propriety, emphasize upon this nerve, for we have
known a distinguished surgeon pass the  aneurismal needle through its
centre, besides including the brachial vein along with it; which proced-
ure, as might be expected, ended in the death of the patient.
   We have had  some experience also in wounds of the brachial artery
in venesection.  We are happy to say that in our long career of practice,
we have never had the misfortune to wound this artery with the lancet,
but we have several times had occasion to serve  our  neighbors in this
calamity.  The  first and paramount thing to be recollected whenever
this accident should befall any person, is  to compress the brachial artery
somewhere in its course above the wound, and never to  attempt compres-
sion at Me point ivounded.   For no compression that can be made by an
ordinary person will prevent the extravasation of blood.
 .  I have seen in less than an hour after the accident, where this attempt
had been made, and as it had been thought, effectually, the whole superior
extremity from the shoulder to the ends of the fingers  injected  with ar-
terial blood, forming thus an enormous diffused  false  aneurism, so that
the limb looked  like everything but natural, and  was, in fact, frightful
to behold.
   In this case, however, we made a careful dissection at the bend of the
arm, going through from one to two inches of  coagulated blood diffused
through  all the tissues,  then carefully tied the artery  above  and below
the wound, and  the patient recovered.  Under ordinary  circumstances
the artery  can easily be found at the bend of the arm,  running between
the median nerve and the tendon of the biceps, and may be tied by the
least experienced  operator.   Two ligatures in these cases should always
be put upon the artery, one  above and the other below the wound.
   In all recent cases, therefore, we would advise the process above des-
cribed.
   If a false aneurism  shall have formed simply between the artery and
the vein, our practice always would be, to tie the brachial  somewhere in
it3 course above, and leave the aneurismal tumor untouched.   If the vein
be involved with the circumscribed aneurism, the more secure  practice
certainly is, to tie the brachial artery above and below  the aneurism, and 
900            NEW ELEMENTS OF OPERATIVE SURGERY.
exsect the sac ; but in every case I would prefer the more simple prac-
tice of tying the brachial  somewhere above, and leaving the diseased
parts  untouched;  hoping that the  resources of nature would  lead to a
successful result.   If they did not, the former or more severe operation
must be resorted to.
  If the artery should be  ivounded, and transmit its blood directly into
the vein, the former vessel healing securely and firmly to the under sur-
face of the vein, and only pouring a small quantity of blood directly in-
to it, and thereby distending it an inch or two above and below the cica-
trix in the vein, our  observation and  experience  lead  us to say, that
nothing is to be done.
  We  have  not observed even any weakness in such arms ; and persons
accustomed to laborious employments may be assured that generally  no
such consequence results from it.
  We have seen one  true aneurism on the ulnar artery in its lower third.
Wherever an aneurism shall  be seated in either of the  arteries of the
fore-arm, the radial or ulnar ought always to be tied below  the elbow
if there is room enough.   If not, the brachial must be resorted to.
  We have known of several instances of aneurisms in the palm  of the
hand from punctured wounds.  The first and very natural step for a sur-
geon to take, is to compress the arteries at the wrist, one after the other,
to determine from which  palmar  arch  the  aneurism proceeds.   Most
generally it will be from the superficial  palmar; and therefore on com-
pressing the trunk of the  ulnar, the pulsation in the aneurismal tumor
will cease.   We would recommend, however, that both radial and ulnar
arteries be tied in every such case, in order to render the cure certain.
  It will not be amiss in this place to state that in all wounds in the palm
of the hand in which the branches divided cannot readily be discovered
and tied, it is better in all cases  to tie both arteries at the wrist, rather
than be satisfied with the one only whose compression at  the wrist shall
appear to stop the hemorrhage.   We have, in a number of instances from
our own  experience, seen the hemorrhage return after a number of days;
indeed even when the wound was granulating, say nine or ten days after
the accident, making it then necessary to resort at last to  the second ar-
tery of  the wrist where only one at first had been tied.
  In one instance in  a gentleman, now living in this city, who received
a small punctured wound from a pen-knife, between the thumb and fore-
finger, the surgeon first tried compression, not being able to discover the
branch wounded.   The bleeding however continuing, he  tied the radial
artery, which commanded the hemorrhage.   Some days afterwards, the
bleeding returned and he  very  properly  resorted to a ligature upon the
ulnar.  Some days more elapsed and the hemorrhage again reappeared.
Such was then his alarm that he sought  my assistance.  The patient,
from  the extent  of  hemorrhage, being already exceedingly exhausted,
there was  no  alternative  left in  my  mind but to secure the brachial,
which the patient requested that I should do myself. From the time it
was tied, no hemorrhage  ever returned.   A number of years have now
elapsed since this occurred, and but a few days since the patient called
to consult me about another matter, and told me he had never  experi-
enced any inconvenience in the arm.
   My reason for  urging that both arteries should  be tied at once, even 
DR. MOTT ON ANEURISMS.
901
though one should command the hemorrhage, is this, that by tying both
simultaneously, you give time for  the  wounded  artery to heal before a
free inosculation can be established in the hand, and thereby revive the
hemorrhage.
  By tying one after the other with an interval of some days between,
you do not diminish sufficiently the inosculating  circulation, to prevent
the recurrence of hemorrhage.
  It may not be amiss for me to connect with this important surgical sub-
ject, the fact that I have  succeeded with compressed  sponge  in these
wounds, where I formerly was in the habit  of  tying  the arteries.  The
sponge ought always to be cut into small pieces, as it is in this way more
readily introduced into the bottom of the wound, and by successive pieces
makes more  complete  pressure in all  parts of it, and  possesses in an
eminent degree the great advantage, afterwards, of being  gradually re-
moved, asthe suppurating  process comes on, without doing violence to,
or lacerating the  newly united vessels.  For when a single large piece
only is introduced, a very considerable force is afterwards  necessary to
detach it, which thereby endangers a return of the hemorrhage.  (See
our remarks on this subject more fully, under the Dorsalis Pedis, above.)
   The Abdominal Aorta.—We presume that surgeons of the  present
day, and of all time to come, will confine their attention to the propriety,
not the practicability, of tying the abdominal aorta.
  This bold and original idea was  first conceived by that great master
of practical surgery, Sir Astley Cooper.  It required a giant, with repu-
tation such as he justly possessed, to give the least sanction to this great
step in operative surgery.  It is probable that, had this  step been taken
by any other  surgeon, it would have been condemned as  rash and unpro-  ■■
fessional.   It was  in an extremity such as surgeons occasionally  witness,
that this original and bold operation of tying  the abdominal aorta was
conceived and  executed.  Projected and  accomplished by so  great a
practical surgeon,  it deserves the serious attention of all operators.
  It is easy to censure what we have never done  ourselves, and nothing
is more common, under such  circumstances, than  to  find  persons who
reproach our  best efforts and  most justifiable procedures.  Those who
criticise and condemn the most, are those, who, reasoning from the natu-
ral  structure of parts,  are totally unacquainted  with the changes that
are produced by disease, and the extraordinary exigencies that such con-
ditions call for.  Thus, for example, it was easy to say that the danger
of his operation was greatly enhanced by cutting through the peritoneum
and mesentery ;  and some thought it remarkable  that he did not search
for the artery by getting under the peritoneum from the left side.   We
presume, however, that he  was tfie best judge, from the peculiar nature
of the  case.  In  the natural state of parts, it is certainly more easy,
and would appear  to be more surgical,  to get under the bag of the peri
toneum from the left side, by making the incision on the left side, as we
shall presently explain.  But  the circumstances of his case may have
precluded the possibility of performing the operation in that way.  He
was emboldened, in this great undertaking, by a number of facts, which
are recorded, of obstructions having taken place  in various ways in the
abdominal aorta, as related by different pathologists.  His own experi-
ments, too, I think, on the aorta of dogs, seem to have strengthened the
pathological facts  that had been recorded. 
 902            NEW ELEMENTS OF OPERATIVE SURGERY.

   The aneurism in his case had nearly arrived at the point of bursting,
 and we think he was fully justified in resorting to the great  experiment
 which he  did, of tying  the abdominal aorta, to prolong  or save the
 patient's life.
   The case was a most unpromising one in its character, and terminated
 fatally  some  hours  after the artery  was tied.   The  mere fact of the
 patient's  death, is no argument whatever against the propriety of the
 operation ;  for  every surgeon knows that several of the first operations
 upon other large arteries have been  attended with the same unfortunate
 result.  It  may therefore, for all we know—and we hope it most earn-
 estly—be  reserved for some one yet to have the honor of achieving so
 great a triumph as this will be for operative surgery.
   We are  far from joining in the clamor of denunciation against all these
 noble  attempts to extend the dominion of our art.  We frankly confess
 that our  fears are, that this great and primitive  channel of the arterial
 system will never be  tied  successfully.  To be enabled to  interrupt
 suddenly, by  a  ligature, so vast a current of blood, and thus to subject
 the heart to all  the impatience necessarily thereby produced, seems to us
 more than can reasonably be expected.  The  pathological  facts,  on
 record, would seem to  us to inculcate the propriety of gradually closing
 the  artery by some contrivance, by which the heart shall be saved  from
 any inordinate  action and distress.   All the cases in morbid anatomy,
 which have been recorded, of complete obliteration of the aorta,  must
 have taken place gradually ; and we think we have derived from  those
 facts a basis for this, as it seems to us, important suggestion.
   If it were to  fall to our lot to meet  with a case in which we deemed
 it proper  to obstruct this great channel, we would therefore, if possible,
 do it gradatim; that is, by closing the tube one third say to-day, another
 third to-morrow, and the last third on the following day.  This would
 be imitating, to a certain extent, the process of nature herself,  who ought
 always to be strictly and carefully watched. It will perhaps be recollect-
 ed, by some, that this idea occurred to me in  fact so long ago as when I
 tied  the arteria innominata.  In that case I  drew the ligature but  par-
 tially at first, which  gave me time to  observe the effect this had on the
 brain, heart, and respiration.  Finding these not  in the least  affected, I
 was emboldened to close the trunk entirely.
   We fully believe, that  the best mode  of  getting at  the aorta, if the
natuae  of  the case permitted, would be on the left side, by an incision
extending from the last ribs to the posterior spine of the ilium.  By care-
fully dividing the parts and  exposing the peritoneum, the latter can very
readily be detached from over the left kidney, after which, by continuing
cautiously to raise the peritoneum, the aorta can  be arrived at as it runs
on the left side of the spine.  This method must be attended with less ha-
zard to the life of the patient, as the peritoneal bag will remain unopened.
Besides the greater facility of getting at the artery in this way, it should
 always be recollected that the ligature upon the aorta ought to be placed
 as distant as possible from the inferior or superior mesenteric arteries.
  The aorta has been now tied four times :—
  1. By Sir Astley Cooper ;
   2. By Mr. James, of Exeter, (England,) July  25, 1829; 
DR. MOTT ON ANEURISMS.
903
  3. By M. White, (Encyolograph, des Sciences Med., Oct., 1837;)
  4. By Dr. Candido Borges Monteiro, at Rio Janeiro, (Brazils,) July
5, 1842 : The patient lived to the fifteenth day ! (See London Lancet,
Nov., 1842.)
  The  Primitive  Iliac—Until my operation  upon the primitive iliac
March the  15th, in  the  year  1827, (vid. below,) no  one had ever at-
tempted to tie this great trunk for aneurism.   The enormous size of  the
tumor in my case, reaching from Poupart's ligament to nearly on aline
with the umbilicus, induced me to commence the operation in the safe way
of getting under the peritoneum from the internal abdominal ring.  And
although I had to encounter the adhesion of the peritoneum to the tumor,
and  the delicate  and  difficult separation of it from that attachment, I
nevertheless, deemed it  most prudent to adopt this course, not knowing
but  that I might  be able to tie the external iliac.  But finding that the
tumor reached up  to the division of the primitive trunk into the external
and  internal iliacs, there was left for me no other resource than to apply
the ligature to the primitive iliac itself above its middle.
  In any  future  case, I would adopt the same, and what I deem a pru-
dent course, rather  than cut down directly in a line with the track of
the artery  upon the peritoneum itself.   For I consider that one very great
danger  in all these operations about the peritoneum where great arteries
are to be tied, consists in wounding this membrane.   I had been in the
habit for many  years  before  I met  with this  case, of showing in my
lectures the practicability of the operation by pursuing the course which
I have just pointed out.  All this is  very easy upon the dead  subject
where no  disease exists.   But  on living man with a formidable tumor
before you the case is far otherwise.
  My patient recovered without an  untoward circumstance, and  was
still alive and in the enjoyment of excellent heath, in April  1841, when
ne  paid me a visit soon  after my return from Europe, furnishing thus
another triumph of our  art.
  Some years after the above operation, Sir Phillip Crampton of Dublin,
also performed it.  His patient died of secondary hemorrhage.
  Mr. Salomon's case (St. Petersburg, Russia,) was I believe the next,
and  his patient recovered.
  Mr. Guthrie of London,  also performed this operation for a supposed
aneurism.   Sir Astley Cooper and other distinguished surgeons were in
the consultation.   After death the disease was found to be a malignant
tumor, and not aneurism.
  Mr. Syme of Edinburg, also tied the primitive iliac, and his  patient
died.
  Dr. Peace of Philadelphia, has also recently, within two or three years
performed this operation with success.
   Some months after the apparent recovery of this case, the tumor re-
turned, and the patient died.
  To those who have criticised my mode of tying this artery, by saying
that the incision  terminated where it should have  begun,  I reply  that
such persons would  do well to reflect that those who see a case are gener-
ally the best able to  judge  what ought to be done.  Such commentators,
should  they be so fortunate as to live long enough, would find themselves
becoming more and more modest as they had more and  more experience. 
904
NEW ELEMENTS OF OPERATIVE SURGERY.
   The Internal Iliac  or Hypo-gastric—This important vessel was first
secured in a ligature by Dr. William Stevens, of the Island of St. Croix,
West Indies ;  for an aneurism in tho gluteal region, in a negress.  The
patient recovered, and lived many years, and died of another affection.
The parts  were removed, aud  I  saw the preparation on  board ship
at this port (New York,) in possession of the  operator on  his way to
London.   My belief, from an examination of the specimen was, that the
internal iliac  had truly been  tied.   Some doubts have since been ex-
pressed on this point at London ; but these were  entirely removed by a
committee of the Royal College of Surgeons, who carefully inspected the
preparation, and  found  the internal iliac completely obliterated above
the point where the ligature had been applied.
  It may not be amiss to remark in this place, that we have also known
instances in which anatomists and surgeons have pronounced the sentence
that an artery had not been tied, because on making a superficial exam-
ination of the  specimen, there  appeared to be at first sight a continuous
trunk of artery.   From our observation in these cases, although the lig-
ature has as we know actually made its way through the  artery by the
process'of ulceration, and necessarily therefore  divided it, the granula-
tory process follows so rapidly upon the ulcerative, that the solidification
in this place has the appearance  externally of an uninterrupted trunk.
   [In confirmation of these remarks, we may quote the following obser-
vations of Mr. Porter, of Dublin, unquestionably a high authority on the
subject of aneurisms.  In describing the appearances  in a case where a
patient had died seven years after tho ligature of  the carotid artery, he
observes:
  " The remnant  of  the  artery exhibited one  continuous and unbroken
cord from the  bifurcation of the innominata to  the division into internal
and external carotids, so that, although the vessel  must  have been di-
vided by the  separation  of the  ligature, it had  united  again, and the
exact spot at which it had been tied could  not be ascertained.  (Dublin
Hasp. Reports, Vol. V.)   G. C. B.]
  This we have noticed several times in our dissections ; and the decep-
tion has occasionally led to illiberal and ill-natured remarks, which how-
ever have always  ultimately recoiled upon those who have made them,
and justly stamped the authors as both ignorant and presumptuous.
  Mr. Atkinson, of York  in England, afterwards  performed this opera-
tion, and his patient died.
  The third operation was by Dr. S. P. White, of Hudson, in the state
of New York.   His patient recovered.
  The next and last, as far as we  know, was  performed by myself, at
New York, on the 29th of December, 1834.  The result was completely
successful.  The patient still lives, in perfect health, and frequently calls
to see me.
  When aneurism exists  in the gluteal region, we believe it utterly im-
possible for any surgeon to say whether the disease is seated in the glu-
teal or ischiatic artery.
  These arteries emerge from  the pelvis so near together, that, a priori,
the identification of an aneurism in one or the other is totally impossible.
Those persons who have suggested the practicability of tying the trunk
of either of those arteries on the cardiac principle, can never have seen an 
DR. MOTT ON ANEURISMS.
905
 aneurism in this situation.  Like many other great operators upon paper,
 they have formed their ideas in favor of, or against, an operation, merely
 by the dissection of the dead body. These are generally the most vindictive
 and censorious critics, and  the most ignorant and dangerous surgeons.
 It must always be recollected that they predicate their conclusions  as
 to  the  practicability of surgical operations  on  the  living body by the
 beautiful delineations of normal structure.   Those who choose to  retro-
 grade to the ancient practice of opening the aneurismal sac  by an inci-
 sion afoot or two long, and reach for the.artery at arm's length,  in the
 midst of a gal/on or two of coagulated blood and the gushing and roar-
 ing of the vital torrent,  are at liberty to do so if they please.
   For our part, we prefer the more genteel method of tying the primitive
 trunk itself within the pelvis.   It is only in all recent wounds of the re-
 gion of the trunk of the  gluteal or ischiatic arteries, that we should use
 all commendable industry and care in endeavoring to secure and tie the
 bleeding vessel, or  to  command the  hemorrhage by the mode we have
 already pointed out, with small pieces of sponge  and  pressure.
    The External  Iliac—The honor of first tying this artery belongs to
 John Abernethy.  He was,  in  fact,  the first person  ever known who
 ventured  to put a ligature in living man  above  Poupart's ligament and
 under the peritoneum.  The case terminated successfully.  Mr.  Freer
 and Mr. Tomlinson, of Birmingham, in England, followed next; and
 after them,  Sir Astley Cooper, in a case which I had  the satisfaction of
 witnessing while I was his pupil.  The operation  has since  been repeated
 by  a great number of surgeons, in various parts  of Europe, in America,
 and also in India.
   In  our country, the  external iliac was first  tied by Dr. Dorsey, of
 Philadelphia.  (See his Surgery.)  It was  next performed in  our city,
 by  Dr. Wright Post, in the New York  Hospital.  Afterwards by Dr.
 Smith of New Haven,  Dr.  Jamison of  Baltimore, Dr. Whitbridge, Dr.
 A.  H. Stevens, Dr. David L. Rogers, and others.
   I have tied this artery six times; four of the  patients  recovered per-
 fectly.  One died  from  peritoneal inflammation,  in consequence  of im-
 prudence in spirituous drink;  the other, from secondary hemorrhage.
   In  tying the external  iliac artery, we have always pursued  the plan
. last recommended by Sir Astley Cooper ; and-we have no hesitation in
 saving that, in our opinion,  it ought always to be followed as the safest
 and best method.  It is obvious that the great danger in the operation is the
 wounding of the peritoneum; and whoever cuts  directly upon this mem-
 brane, must always incur considerable hazard, either from his own un-
 steadiness or  the  motion of his patient.   By the method  recommended
 by  Cooper, we commence the incision just above  the external abdominal
 ring,  and carry it a little above Poupart's ligament, to within a small
 distance of  the anterior superior spinous process of  the  ilium.  After
 cutting through the integuments, the superficial fascia, and tendon of the
 external oblique muscle, we expose the muscular fibres of the internal
 oblique.  Upon detaching a few of these from the upper and inner edge
1 of Poupart's ligament, we lay bare the spermatic cord.  Pinching  up the
 cylindrical process of the cord, and dividing it with the knife transversely,
 the finger is readily passed  up the inguinal or abdominal  canal, and ar-
 rives at the internal abdominal ring.  We now know that the finger," by
    Vol. I                       HI 
906           NEW ELEMENTS OF OPERATIVE  SURGERY.

being passed into the internal abdominal ring, is certainly below the pe-
ritoneum, and that this membrane, with gentleness and care, can readily
be pushed upwards, and may be detached to any distance above and be-
low, so as to expose the artery as high up as may be  necessary for the
ligature.  It ought always to be recollected, by an operator, that imme-
diately behind  and below this internal ring, the external  iliac is  to be
felt.  This mode of operating has always appeared to me  to  be by far
the most safe on this account: that you are sure of getting below the pe-
ritoneum—and it has, in our judgment,  a decided  preference over the
methods  of Abernethy, and others who  followed him, by cutting down
upon the peritoneum, by means of a longitudinal  incision, more or less
in a line with the linea alba.
  In all our  operations on  the iliac arteries, we have  invariably adopt-
ed the kind of incision we have  above described for the external  iliac.
Our object previously has been to be sure of getting below the peritoneum.
This being accomplished,  by going through the internal ring, we  then,
by  continuing to push up  this membrane, may divide the super-imposed
parts in any direction and  to any extent we think proner, to enable  us to
reach either the primitive or the internal iliac ;  always taking care to
keep the peritoneum well pushed up before dividing the parietes.  Re-
collecting always, however, that when the finger is in at the internal  ring,
the epigastric artery must  always be on the inner side of the finger, and
that cutting in that direction is therefore to be carefully avoided.
  In one of the cases in which we tied the external  iliac, there  were
some peculiar features which make it deserving of particular mention.
  A man aged about 35 years, of a vitiated habit, presented himself to
me with a true popliteal aneurism on the right leg, and an inguinal aneu-
rism on the left.  Both were  circumscribed,  and each about the size of
the fist when he called upon  me.  I urged him to submit to surgical op-
erations for their cure.   He  however preferred to postpone any surgical
interference until it should be  more  urgently called for. About a year
from the time of my first seeing him, he sent  for me to relieve him,  say-
ing that  he  feared  he had deferred the matter too  long.   I found
his popliteal aneurism now increased  nearly to the size of a man's head,
blue, cracked, and oozing a  sanious  fluid from  the surface, and in the
most imminent danger possible of bursting  every moment.   I immedi-
ately tied the artery in the lower part of the upper third of the thigh.  In
a few days  an extensive  surface of the aneurism  gave way, and dis-
charged a hatfull of coagula.  Nevertheless, when all these latter had
escaped, suppuration and  granulation kindly took place, and  the whole
of this immense ulcer healed up, leaving him only with a little contraction
about the knee joint, and shortening of the limb, not so much, however,
but that he could still bring about half the plantar surface of his foot to
the ground.
  About a weeK after I had applied the  ligature to the femoral artery,
he sent for me in great haste.   Having visited him on the same morning,
and found him doing well,  I was somewhat surprised at  receiving an
urgent message that he was  suffering  intolerable torture, and  labouring
under the greatest anxiety and alarm.   This condition, on arriving, at
the house, I found  arose from a sudden  sensation of something giving
way in the inguinal aneurism on the other side, which was, in the morn- 
DR. MOTT ON ANEURISMS.
907
ing, a little larger than an ordinary sized fist, but now I found had at-
tained more than double this volume.   The tumor extended upwards and
downwards—reaching  upwards considerably above Poupart's ligament.
In  truth, this circumscribed true aneurism had  suddenly become dif-
fused.
  No time was now to  be lost.   I immediately, therefore, tied  the ex-
ternal iliac ; every thing went  on well, and the patient perfectly recov-
ered of both aneurisms, and is now, near  twenty years since  the opera-
tion was performed, enjoying much  more robust  health than formerly,
and with  very little impediment in walking ;  requiring only  the heel of
his boot on the limb which had been affected with the popliteal aneurism,
to be made a  little higher than the other.  This curious case has never
before been published.
   The Femoral  Artery.—This artery may be  tied in  any  part  of itst
course.  We always prefer, when we have  a  choice, the lower part of'
the upper  third,  as recommended  by Scarpa, and now called  by Pro-
fessor Velpeau and others, Scarpa's space.  The artery here is most su-
perficial, lies directly below the inner edge of the  sartorius muscle, and
requires that this muscle should be but very little  disturbed  in order to
get at the vessel.   We have, in  our  practice, tied the femoral artery
forty-nine times.
  [Since  this chapter  was prepared, Dr. Mott has tied this artery in
3 other instances, making the whole number up to the present time, (1854)
fifty-three.   G. C. B.]
  Some surgeons have doubted the propriety of tying the artery between
the going  off of the profunda and  the  origin of the epigastric.  We
have, however, several  times put a ligature here,  and in every instance
'with success.
  In one instance we have  tied the popliteal successfully.  We have, in
a number  of  instances,  tied the anterior and posterior tibial  arteries, in
different parts of their course.  In one case, an aneurism of the anterior
tibial on the dorsum of the foot, where  it is called the dorsalis pedis,
we  found  it necessary  to tie, not only the anterior tibial, but also the
posterior.
  In tying the anterior  first, it seemed for a while to promise a  cure of
the aneurism; but the tumor, after some time, began to increase in size.
We then tied the posterior tibial artery, and the case resulted in a per-
fect cure.
  In  wounds of the  dorsalis pedis,  as we have  mentioned in a note
above, it oujrht to be recollected that we  are always to tie both ends of
the wounded arterv.
  In  wounds of the plantar arteries in  the bottom of the foot, or  in
a wound between the great toe and the one adjoining, when the wounded
branches cannot  be readily found, the  best  practice  is to tie both the
anterior and  posterior tibial arteries at once, on the same principle, and
for  the  same  reasons  that  we have  recommended the  arteries  of the
wrist to be tied in wounds  of the palm of the hand.
  On the   Method  of tying Arteries, and on Ligatures, Dressing, See
__We would advise all  who tie large arteries, to bear in mind, that after
the edge of a muscle is  laid bare, which is the anatomical guide or land-
mark for the relative situation of the artery, that very little use should
be made of the knife. 
908
NEW ELEMENTS OF OPERATIVE  SURGERY.
  With his fingers, or the handle of the scalpel, the surgeon can readily
separate the parts, so as fully to expose the artery.   In this way he will
be much less troubled with the oozing of blood, from cutting the small
vessels, and thereby  better  enabled to  see the principal trunk more
distinctly.
  With  the parts held asunder  with curved spatulas, the surgeon now
seizes the filamentous structure with the forceps, and raises it from the
artery.   He then  cautiously  divides the structure perpendicularly, and
upon the anterior surface of the artery only, and should never dissect
or use the edge of the knife on the sides of the artery, but introduce the
handle of the knife, and separate  the structure from  the artery on each
side, only denuding the  vessel to  an extent barely sufficient to allow the
hook to be passed around it.
  This  rule we believe  most  important, as by  using  the edge  of the
knife on the sides of  the artery we endanger frequently the division of
branches; as  most of these  are  given off  laterally ; and the  flow of
blood where they are  divided, obscures and interferes very much with
the beauty and the neatness of the operation.
  Denuding the artery, also, to any considerable extent of its filament-
ous structure must,  by robbing  the vessel  of its  connecting  media,
always  be adverse to the  salutary  changes which  we expect from the
ligature.
  For  passing the ligature,  we have always  used the American aneu-
rismal  hook,  which  we  consider the best  that has  ever been in-
vented*
  To use this most prudently, we  always introduce it from the vein.
  We prefer the small, strong round ligatures of silk or flax, and we
only use one around  the vessel.   We have come to the conclusion long*
since that one ligature is quite sufficient.   Formerly, in many instances,
we used two ligatures, about an  inch distant .from each other.   Then,
in other cases, we divided the vessel in the interspace ; again, we adopt-
ed the   expedient  of  passing the ligature through the artery, above and
below  where it was tied, tying it again, and then dividing it in the in-
terspace. In another case we used two  remarkably delicate ligatures
of raw  or flossed silk, each ligature not weighing over the sixteenth or
twentieth of a grain, and  we divided here also the artery in the inter-
space, and then cut both ends of each ligature close to the vessel.  We
then healed the wound by the first intention, the first dressing being the
only one required.  This  all seemed very beautiful; but the sequel re-
mains to be told.  Some  six  weeks after the patient had got about, in-
flammation and suppuration took place  opposite the points of the two
little ligatures, and they were discharged.
  We have  also  used animal ligatures of different kinds, as catgut, the
raw hide, &c.; but we have  long since come to the  conclusion that the
plain simple ligature is the best, and one only.
  In all my experience for the last forty years in tying arterie.i, I have
only lost one  patient from mortification of the inferior extremity.   This
was a case  in which  the femoral  artery was tied higher up than usual;
there being a femoral as  well as popliteal aneurism in the same limb.

  * This  aneurismal hook  or needle was invented by Drs. Parish, Hartshorne and Ilewson,
of Philadelphia, many years ago. 
DR. MOTT ON ANEURISMS.
909
  The popliteal aneurism, for some days before the operation, had be-
come  diffused  from above the knee to the toes, distending the parts to a
very  painful degree.  This inordinate distention of the lower part of
the limb, no doubt effectually prevented the inosculating channels from
conveying a sufficient amount of blood to preserve its vitality.  Should
I ever meet with another case of this kind, I would  amputate the thigh
above the femoral aneurism at once.
  In the case of an old man, partial mortification, to a slight extent in
the smaller toes, took place ; but it was arrested, and he recovered.
  My mode of dressing the wound after tying  the femoral artery, is
to pass a single stitch through the integuments in the centre of the wound.
Short straps  of adhesive plaster then answer to bring the remainder of
the lips  into contact.
  I then wrap the whole limb in wadding or wool; place the patient in
bed, with the limb a little flexed and turned a little outward, with a pil-
low under the ham.
  No bandage of any sort is to be applied on any account whatever.   We
even  avoid long pieces  of adhesive plaster, for fear that  by their com-
pression the inosculating circulation might  be interrupted.
  Nothing is more dangerous than the application of a tight bandago to
an aneurismal limb after the artery is tied; as everything that interferes
with the collateral circulation must be to the greatest degree hazardous.
  In  order that those wishing to refer to our labors, in regard to the sub-
ject of  aneurisms and  ligatures upon the great arterial trunks, may
have  embodied before them an authentic and correct  abstract of what we
have  done in these matters, and of what we consider as our own sur-
gical  property, we have prepared and revised  the various publications
that have Wen made of our operations in this department, as they are
found scattered in different medical periodicals  of our country, over the
space of the last twenty-seven years.   We  have arranged them consecu-
tively in chronological order.
  The account of  the attempt to place a ligature upon the left subclavi-
an, by Sir Astley Cooper, referred to by me above, and in which I had
the honor to assist that eminent surgeop, is as follows:—

Case of Subclavian Aneurism, which occurred in Guy's Hospital, Lon-
  don ; communicated to Dr. Miller, by  Valentine  Mott, M. D., Cor-
  responding  Member  of the  Medical Society  of  London,  Sec  (See
  New York Medical  Repository, edited  by  Drs.  Samuel L. Mitchell
  and Edward Miller, 3d Hexade, Vol. I., New York, 1810, p. 331-334.)

  On the 20th of August 1809, a man, aged 40, came into Guy's Hospi-
tal, in London, with a tumor, occupying the whole of the  left shoulder,
the greatest part of the clavicle, and extending under the pectoralis
major muscle.  It was not red upon the surface, but very hard, and with-
out any distinct pulsatory motion : it was of about six months' duration,
and, when very small, A. Cooper said he saw it, and  there  was no dis-
tinct  pulsatory motion to be discovered ; at least, only such a motion as
the subclavian artery beneath  might communicate  to a tumor situated
immediately over it.  The tumor, however, A. C.  fully believed to be an 
910
NEW ELEMENTS OF OPERATIVE SURGERY.
 aneurism of the subclavian artery;  and when, upon examination, an an-
 eurism was discovered in the femoral artery, just below Poupart's  liga-
 ment,  the smallest  doubt did not remain, in the mind  of any person
 present,  as to the nature of the  tumor in  the shoulder, and that it was
 an aneurism of the subclavian artery.
   The situation of the man being truly painful, and it being evident that
 the disease must prove, in a short time, fatal, if no operation were  to be
 performed, A. C. was determined to make an attempt to take up the sub-
 clavian artery, just after it had passed  betwixt the first and second sca-
 lenus muscle.
   Though this would appear to many to be a cruel and  unwarrantable
 attempt to save life, yet, as A. C. very  properly observed to me, it could
 only shorten his days a little to attempt the operation, and it was pos-
 sible it might succeed, though it had never before been performed.
   The man was willing to  submit to anything that might be thought
 proper for the relief of his  distresses.  A. C. then pointed out to him
 the uncertainty of the operation, and promised if he would submit  to it,
 that nothing should be done but what was perfectly proper  and safe ;
 Baying, that if, in  the course of the  operation, he should find it not safe
 to proceed, he would give it up.  The man consented, and was laid  upon
 the table in the theatre, with his shoulders a little elevated.  The oper-
 ation was then begun, in the presence  of G. W. Young, Esq., Surgeon,
 B. Travers, Demonstrator of Anatomy, and a number of other surgeons.
 The incision was commenced at the outer and lower edge  of the  sterno-
 cleido-mastoideus  muscle,  close to the clavicle,  and  carried,  straight
 outwards and  backwards, about three inches.  The most careful dissec-
 tion was now necessary, and by  means of tho edge, and sometimes the
 handle of the  scalpel, the muscles were separated, till the n%ves, going
 to form the axillary  plexus, were laid  bare.  The  opening between the
 muscles was very  small and so deep,  (A. C.  remarked that it vms like
 looking down a well,) that the fore finger could but just reach the nerves.
 The subclavian artery was  felt beating very feebly, immediately under
 one of the large nerves going to the axilla; it could not be felt at all by
 several that were  present, and by none constantly; A. C. was convinced
 that he felt it at times, and I was certain that I  perceived  it  also.  A
 curved probe was  now passed under the artery, and repeated trials  were
 made to draw  it from under the nerve, so as to pass a ligature around
 it; but these  were all  unsuccessful.   Every time  the nerve  was put
 upon the  stretch, with this view, the patient complained of the most ex-
 cruciating torture, not only in the shoulder and neck, but extending
 throughout the whole arm.   It was not one or two trials, but many, that
 were made, before A. C. could be satisfied to relinquish the operation.
 After, however, keeping the man on the table an hour and fifty minutes,
 he desisted from any  further attempts ; saying it was impossible to ac-
complish  it, and even if it  were then possible, after so much violence
 had been done, and the patient so much exhausted, it would not be  safe,
 as it was  most probable that it  would almost immediately prove fatal.
 A. C. remarked to me, that the operation, though not difficult in a small
 aneurism, cannot  be  performed in one  of a very large size.   The man
 did not lose an ounce of blood in the attempt.
   The wound  was now  brought  together by sutures and plasters ; the 
DR. MOTT ON ANEURISMS.
911
 patient put to bed and a large opiate given him.  He complained of ex-
 treme pain all  over his shoulder and arm, occasioned, no doubt by the
 violence done to the large nerves, going to form the axillary plexus. _ A
 considerable degree  of fever ensued the  day after the operation, which
 very much increased ; attended with high delirium, though venesection,
 purging, and  sudorifics  were assiduously used; and  on  the sixth day
 from  the operation he died.
   Upon examining the body after death, the two  first ribs were found
 to be  destroyed, and a portion of the upper  lobe  of the left lung was
 adhering to the  aneurismal  sac; the sac was  large, and contained large
 coagula  of blood, which  had thrust the  clavicle  very  much upwards.
 A. C. took out  the part, very carefully preserving all the vessels  con-
 nected with it.
   Would any but  a  great mind, conscious of its own  powers, and the
 rectitude  of  its  intentions, make the following remarks ?—He  said to
 me, " I am  suspicious  that, in  this operation, the thoracic  duct must
 have  been divided, as it was on  the left  side;  though I did not think
 of it at the time of the operation,  nor  before it."   I could not learn
 that any person present had thought any thing about the  danger of in-
 juring this vessel; no doubt  from its being a vessel  which we have never
 been accustomed to think of  in any  operation.  I regret  that it  is not
 in my  power, at present, to  satisfy the curious on this point, as A. C.
 had not ascertained the fact when I left London.
   We are not to despair, though  this first attempt* has been unsuccessful,
 when  we consider the great and splended chirurgical achievements of
 the last three years in the British metropolis.   The first  operation for
 carotid aneurism  was performed by that eminent and  accomplished,
 surgeon, A Cooper, and was unsuccessful; this, however, did  not deter
 him from a second attempt,  in the  summer of 1808, which completely
 succeeded.
   After this the carotid was  taken up by an eminent surgeon of Stock-
 holm, M.  Bierken  ; but, from some  unfavourable circumstances  of the
 case, it failed, as I am informed in a letter from my learned  friend Dr.
 Wegell, Physician  to  the late King of Sweden, who assisted at the oper-
 ation, and  accompanied me,  when in London, to A. C.'s second opera-
 tion.
   In  the winter  of 1809,  Henry Cline, sen., of St. Thomas' Hospital,
 tookup the carotid for  an aneurism of a very large size, involving the pos-
 terior angle of the lower jaw, and extending down towards the shoulder.
 The artery  was secured'in the  usual way,  by that great surgeon, and
 without any kind of difficulty.  The man,  in the course of the following
 night,  drank very freely of spirits, and became  in some measure inebria-
 ted, and he died  the next day.  The parts were  examined  after death,
 and there was nothing unusual about the aneurism, but the brain and its
 membranes showed  signs of inflammation.  This state  of  the brain, no
 doubt, was induced by the excessive stimulation,  and caused his death;
 as the brain then from its altered circulation, was more predisposed to
 inflammation.

  * Keate, the Surgeon-General of the British army, and one of the Surgeons of  St. George's
Hospital, is t»aid to have  taken up this artery, below the clavicle, in a wounded  soldier, who
recovered. 
912
NEW ELEMENTS  OF OPERATIVE SURGERY.
  The carotid was again tied in the spring of 1809, by B. Travers,
Demonstrator of Anatomy at Guy's Hospital, for an aneurism by anas-
tomosis,  situated in the left orbit, which had  protruded the eye a little
from its  socket.   He used two small round ligatures, but did not divide
the artery  between, and secure the ligatures by passing them  through
the artery, as was done in the other cases, except A. C.'s first.   The lig-
atures came away in about twenty days, and no hemorrhage ensued, nor
did the brain suffer the least injury.  The  pulsation  in the tumor was
diminished by the operation; there was, however, but little alteration in
its size three months after.  Though this operation did not succeed in
removing the disease for which it was performed, it is a valuable fact, and
proves, with A. C.'s case, that the artery may be tied with perfect safety
as to the functions of the brain.*
  Abernethy's operations upon the external iliac, and A. Cooper's upon
the carotid and subclavian, must be admitted by every one to be master-
strokes of  scientific surgery.  These, most  undoubtedly, are proud days
for London, and particularly when we  know that they have never been
the subjects, even of dream or speculation, in the capital of France.
  Are we not to expect, from  these and similar examples, that the lives
of many valuable individuals  may be protracted far  beyond the period
in which their diseases have hitherto proved fatal?   They may, indeed,
be protracted to a very late age, if we are allowed to judge from similar
cases,  in which the  whole system has not become  affected from the dis-
ease of a part.

  No.  I.—May 11,1818.  Ligature on the Arteria Innominata.

  The first publication of this operation, was made in a periodical pub-
lished  in New York, and entitled  " The Medical and Surgical Register,
consisting chiefly of cases in the N. Y. Hospital, by John Watts, M. D.,
and  Alexander H.  Stevens,  M.  D.,  New York,  printed  and  pub-
lished  by Collins &  Co., No. 189  Pearl-street, 1818."  Part I., vol. I.,
p. 9 to 56 inclusive.  Also two plates, illustrative of the  same with ex-
planations, on the 4th page from the title of the work.  The case  is as
follows:—

  Reflections on securing in a Ligature the Arteria Innominata.  To
which  is  added a case in which this artery was tied by a Surgical ope-
ration.   By Valentine Mott, M. D., Professor  of Surgery in the Uni-
versity of New York, Sfc.

  Since the publication of Allan  Burns's invaluable work on the  surgi-
cal anatomy of the  head and neck, I have been in the habit of showing
in my  surgical lectures, the practicability  of securing in a ligature the
arteria innominata ; and I have had no hesitation in remarking that it was
my opinion, that this artery might be taken up for some condition of aneu-
risms ; and that a surgeon, with a steady hand and a correct knowledge of
the parts, would be justified in doing it.  I felt myself warranted in this,
from the singular success which this celebrated anatomist informs us atten-

  *The case of Mr. Travers was ultimately successful.  See Medico-Chirurg. Trans., London. 
                      DR. MOTT ON ANEURISMS.                  **■&

ded his injections, and from my own investigations  of this subject. ^  If
the right arm, and the right side of the neck, can be filled with injection,
after interrupting its passage through the innominata, as we believe they
can, who can doubt the possibility of the blood to find its way there also, as
it will pass through thousands of channels, which art could not penetrate
even by the finest injections ?   The well know anastomoses of arteries,
and the great resources of the  system in cases of aneurism, encouraged
me to believe, that this  operation might be performed with  reasonable
prospects of success.   With  all  this sanction, and the analogy of the
other great operations for aneurism, I could not for a moment  hesitate
in recommending and performing the operation.
  The following operation, as  the steps of  it will show, was performed
with the two-fold intention: 1st, of tying the subclavian  artery before
it passes through the scaleni muscles, if it should be found in a fit state;
and 2dly, to tie the arteria innominata in  case the  former should be
diseased or too much encroached upon by the aneurismal tumor.
   Michael Bateman, aged 57 years, was born in  Salem, Massachusetts,
and by occupation a seaman.  He was admitted into the New-York hos-
pital on the 1st of March, 1818, for a catarrhal affection, having at the
same  time his right arm and shoulder much swollen.   At th^ time of his
admission the catarrh being thought the  most  considerable disease of
the two, he was  received as a medical patient, and placed under the care
of the physician then in attendance.  During  the three first weeks of
his residence in the house, the  catarrh had  greatly yielded to the reme-
dies prescribed.   The inflammation, which had produced an enlargement
of the whole superior extremity, extending itself to  the muscles of the
neck on the right side, was also gradually subsiding.
   A tumefaction, however, situated above and  posterior to the clavicle,
at first involved in the general swelling, and  not to be  distinguished
from it, began to show itself.   This resisted the  remedies which were
effectual in relieving the other, and  became more distinct  and  circum-
scribed as the latter subsided, at length assuming the form of an irreg-
'ular tumor.
  The history which he gave of the case is  as follows :—He said, about
a week before he entered the hospital, while at work on  ship-board, his feet
accidentally slipped from under him, and he fell upon his right arm, shoul-
der, and the back part of his head ; that he  felt but little  inconvenience
from the fall, and after a short time returned to his duty. Two days subse-
quent to this, however, he felt  pain in the shoulder, and the succeeding
night was unable to lie upon it in bed.  The whole arm and shoulder then
began to swell, and became so  painful that he was unable any longer to
perform his duty as a seaman.   The ship having arrived in  New-York,
he was admitted into the hospital.
  For some time after  the general swelling had subsided, leaving the
tumor distinct and circumscribed, no circumstance occurred  which gave
rise to a suspicion of its being aneurismal.  The enlargement was thought
to be a common indolent tumor, and was repeatedly blistered, with a view
to discuss it.  The tumor gradually diminished under this treatment;
though  a considerable time elapsed before any very striking  change
took place.
  At  length a faint and obscure pulsation was perceived;  still it was a
  Vol. I.                 115 
914
NEW ELEMENTS  OF OPERATIVE SURGERY.
 matter of doubt whether the tumor was aneurismal, or whether the pul-
 satory motion was communicated to it by  the subclavian artery, imme-
 diately over which it was situated.   From its firm unyielding nature upon
 pressure, the latter was considered as  the most probable, and the blis-
 ters were  continued as before.   During  the whole  of this time the
 patient had worn his arm in a sling, the motions of it being very limi-
 ted, and always attended with pain.
  The patient remained in this state for several days, without any marked
 change either  in his feelings or in the  appearance of the tumor.
  On the 3d of May, at 6 o'clock in the  afternoon, the patient com-
 plained that he " felt something give way in the tumor," that his shoul-
 der was very painful, and that he was able to raise it only a  few inches
 from his side.  The tumor at this time suddenly increased about one
 third, and a pulsation was distinctly perceptible.  Its most  prominent
 part was below the clavicle ; at which place the pulsation was most dis-
tinct.   The portion above the clavicle was  also much  enlarged; it  still
 however had its usual firmness, except in one point near its centre.
  May 4th.—The tumor is evidently increased, that portion of it more
 particularly which is below the  clavicle ; it is not as firm and resisting
 as it has be<|n.  Pulsation  is not so distinct as yesterday but appears
to be more diffused.
  He was this day transferred to the surgical  side  of the house, and be-
 came my patient.   The cough having become  comparatively  slight, the
 tumor  appeared to be  the'most urgent disease, and, in my opinion, to
 call for prompt attention.   The arm is now perfectly  useless, and any
motion at the  shoulder joint  gives him severe pain.   The  patient is
naturally of a spare habit, and  from the nature of  his disease,  and the
 confinement to which he has been  subjected,  has become much  reduced
in strength.
  May 5th and 6th.—The tumor is still progressing, and the pain in the
 shoulder is also more severe.   During the  three last days his medicines
have been discontinued, except that he is allowed to rub the parts about
 the  clavicle with volatile liniment.
  On the 7th I directed a consultation of my colleagues to be called, con-
 sisting of Drs. W. Post, Kissam and Stevens.   I now stated  to them
 that I wished to perform an operation  which would enable me to pass a
 ligature around the subclavian artery, before it passes through the scaleni
 muscles, or the arteria innominata, if the size of the tumor should pre-
 vent the accomplishment of the  former.   This I was  permitted to do,
 provided the patient should assent, after a candid and fair representation
 was made to him of the probable termination of his disease; and that
 the  operation, though uncertain, gave  him  some  chance, and,  as we
 thought, the only one of his life.
  Dr. Post, at my request, communicated with him privately on this
 subject, and after a full explanation of the nature of the case, my patient
 requested to have any operation performed  which promised him a chance
 for  his life, saying that in his present  state he was truly wretched.
  May 8th, 9th, and  10th.—The tumor is acknowledged by all to be in-
 creasing, and it is thought proper not  to defer the operation any longer.
 I therefore requested  that  preparation be made  for performing it to-
 morrow. 
DR. MOTT ON ANEURISMS.
915
  It is difficult to give an idea of the size of a tumor so irregular in its
form, and so peculiarly situated.  A thread passed over it, from the lower
part of that portion of it which is below the clavicle, extending upward
obliquely across the clavicle toward the back of the neck, will measure
five  and  a  quarter inches.   Another  crossing this at right angles one
inch above the clavicle, will measure four inches ;  two and a half inches
of the thread are on the sternal side of the former, and one and a half
on the acromial.   It rises fully an inch above the clavicle, which added
to the depression below the clavicle on the opposite shoulder, will make
the size of the swelling above the natural surface about two inches.
  May 11th.—One hour before the time assigned for the  operation, the
patient appeared  perfectly composed, and  apparently pleased with the
idea that the  operation afforded  him  a prospect  of some  relief.  He
was directed to  take of Tinct. Opii. 70 drops."
  No difference  can be perceived in the pulsation of the  arteries in the
two extremities  ; his pulses are uniform and regular, each beating 69 in
a minute.
  He  was placed  upon a table of the ordinary height, in a recumbent
posture,  a little  inclining to the left side, so that the light fell obliquely
upon the upper part of the thorax and neck.  Seating myself on a bench
of a  convenient height, I commenced  my incision upon the tumor, just
above the clavicle, and carried it close to this bone  aud the upper end of
the  sternum,  and terminated it immediately over  the trachea;  making
it in extent about three inches.  Another incision about the same length,
extended from  the termination of the  first along the inner  edge of the
sterno-cleido-mastoid muscle.   The integuments were then dissected from
the platisma myoides, beginning at the lower angle of the incisions, and
turned over upon the tumor and side of the neck.
  Cutting through the platisma myoides, I cautiously divided the sternal
part of the mastoid muscle, in the direction of the first incision, and as
much of tho clavicular portion as the size of the swelling would permit,
and reflected  it over  upon  the  tumor.  The internal jugular vein was
encroached upon by the swelling, which made this part of the operation
of the utmost delicacy, from  the morbid  adhesion of that part of the
clavicular portion of the muscle to it, which was detached.  I separated
this portion of  the muscle to as great an extent,  however, as the case
would possibly allow, to make room for the  subsequent steps of the ope-
ration : only a part of the vein was exposed.  The sterno hyoid muscle
was next divided, and then  the  sterno-thyroid, and turned upon tho
opposite side of the wound, over the trachea.  This exposed the sheath
containing the carotid  artery, par  vagum, and internal jugular vein.  A
little above the sternum, I exposed the carotid artery, and separated the
par vagum from  it; then drawing the nerve and vein to the  outside, and
the artery towards the  trachea, I  readily laid bare the subclavian about
half an inch from its origin.   In doing this, the handle of a  scalpel was
principally used, nothing more being required but to separate the cellu-
lar  membrane, as  it covers  the artery. ^  I judged  it would  be very im-
prudent to introduce a common scalpel into so narrow and  deep a wound>
especially as  it  would be  placed  between two such important vessels or
parts, as the carotid  and par vagum, and where the least motion of tho
patient might  cause a  wound  of one or the other of them.   The proper 
916           NEW ELEMENTS OF OPERATIVE SURGERY.

instrument, in  my opinion, for this part of the operation, is a knife, the
size of a small scalpel, with  a rounded  point, and  cutting  only at the
extremity ; this was used, and found to be very convenient for this stage
of the operation.   It can be introduced into a deep and narrow wound,
among important  parts, without the hazard of dividing any but such as
are intended to be cut.  This knife is contained in a set of instruments
admirably calculated for this and other operations on arteries deeply seat-
ed, and which I shall mention more particularly hereafter.
  On arriving  at the subclavian artery, it appeared to be considerably
larger than  common, and of an unhealthy  colour ;  and when I exposed
it to the extent of about half an inch from its origin, which was all that
the tumor would permit, to ascertain this circumstance more satisfactori-
ly, my friends concurred with me in opinion, that  it would be highly
injudicious to pass  a ligature  around it.   The close contiguity of the
tumor would of itself have been a sufficient objection to the  application
of the ligature in this situation, independent of the apparently altered
state of the artery.  Art in  this case  could not anticipate any thing like
the  institution of the healthy process of adhesive  inflammation in an
artery in the immediate vicinity of so  much disease.   The Pathology of
arteries has long since  taught us, that ulcerative inflammation, and  all
its train  of consequences, would have been the inevitable result.   This
was  the fate of the only case, in  which  a ligature  has been applied to
the artery in this  situation.   The operation was performed by that emi-
nent Surgeon of Dublin,  Dr. Colles.
  While separating the cellular substance  from the lower surface of the
artery, with the smooth handle of an  ivory scalpel, a branch of artery
was  lacerated, which  yielded for a few minutes a  very  smart hemor-
rhage, so as to fill the  wound perhaps six or  eight times.   It was about
half an inch distant from the innominata, and from  the stream emitted,
was  about  the  size of a crow-quill.   It stopped with a little pressure.
I can scarcely believe  this to  have  been the internal mammary, from
the hemorrhage ceasing so quickly ; though,  from its situation, it would
appear so, and if  from some irregularity it were not the superior inter-
costal, it must have proceeded from an anomalous branch.
  With this appearance of  disease in the subclavian artery, it only re-
mained for me either to pass the ligature around the arteria innominata,
or abandon my patient.  Although I very well knew, that this  artery
had  never been taken up for  any condition  of aneurisms, and never in
fact tied as a surgical operation, yet with the approbation of  my friends,
and  reposing great confidence in the resources of the system, when aided
by the noblest efforts of  scientific surgery, I resolved upon the operation.
  The bifurcation of the innominata being now in view, it only remained
to prosecute the dissection a little lower behind the sternum.  This was
done mostly with the round  edged knife, taking care to keep  directly
over and along the upper surface of the artery.  After fairly denuding
the artery upon its upper surface, I very cautiously, with  the  handle of
a scalpel, separated the cellular substance from the sides  of  it, so as to
avoid wounding the pleura.   A round silken  ligature was now readily
passed around it, and the artery was tied about half an inch below the
bifurcation.  The recurrent and phrenic nerves were not disturbed in
this part of the operation. 
DR. MOTT ON ANEURISMS.
917
 ^  As most surgeons who have performed operations upon large arteries,
 m deep and narrow wounds, complain of the embarrassment which has
 attended the application of the ligature, I am happy in the present op-
 portunity to have it in my  power to recommend a set of instruments, con-
 trived for the purpose, which, in my opinion, are calculated to surmount
 all difficulties.  This set of instruments consists of several  needles of
 different sizes and curvatures, with sharp and  blunt  points, and having
 in each two eyes.  The needles screw into a strong handle or shank of
 steel:  there are  also two strong instruments in handles, with a ring or
 eye in the extremity similar to a tonsil  iron, and perhaps  they  may be
 called  ligature irons : a small knife rounded at the extremity like a lan-
 cet for scarifying the eyes, and a small hook at the extremity of a steel
 shank, also fixed in a strong handle.  These instruments are the inven-
 tion of Drs. Parish, Hartshorne, and Hewson, of Philadelphia.   They
 are the result  of  investigations made upon the dead body, as  to the best
 mode and place for tying the subclavian artery on the acromial  side of
 the scaleni muscles.*
  With the ligature introduced into the eye of one of the smallest  blunt
 needles, which was nearest the shank of the instrument, I  pressed  down
 the cellular substance and pleura with the convex part, and very  care-
 fully insinuated it from below upwards, under the artery.   The point of
 the needle appearing on the opposite side of  the artery, I introduced the
 hook into  the other eye of it; then unscrewing the  shank, the needle
 was drawn through with the utmost facility,  leaving the ligature under-
 neath the artery.
  In the application  of the ligature to this artery, I would  invite the
 attention of those who perform it, to a circumstance which, in my opinion,
 is somewhat important: it  is to pass the ligature from below upwards,
 in order  to prevent the pleura from being wounded.   From the use of
 these instruments repeatedly, I would also recommend that the hook be
 fixed in the eye of the needle before the shank is unscrewed, otherwise
 very considerable difficulty will be experienced in finding it, and  even
 when felt, not easily introduced, from the want  of firmness  which the
 handle part of  the instrument would afford.
  I now made a knot in the ligature, and with my forefingers carried it
 down to the artery, and drew it a little so as partly to close its diameter
 and arrest  the column of blood gradually.  This was continued  for a
 few seconds to observe the  effect produced upon the  heart and lungs ;
 when no change taking place, it was drawn so as to stop the circulation
 entirely, as was shown by the  radial  artery of the  right  arm, and the
 right temporal  immediately ceasing to pulsate.  The knot was drawn
 more firmly by the ligature irons, and a  second knot applied in the  same
 manner.
  In no instance did I ever view the countenance of man with more fluc-
tuations of hope and fear, than in drawing the ligature upon this artery.
To intercept suddenly one  fourth  of the  quantity of blood, so near to
the heart, without producing some  unpleasant effect, no surgeon, a priori
would have believed possible.  I therefore drew the ligature  gradually,
 and with my eyes fixed  upon his face ; I was determined to remove it

               *  See Dr. Parish's Paper, Eclectic Rep., vol. III., p. 229 
918
NEW ELEMENTS OF OPERATIVE SURGERY.
  instantly if any alarming symptoms had appeared.  But, instead of this,
  when  he showed no change  of feature oi\ agitation of body, my gratifi-
  cation was of the highest kind.
    Dr. Post now asked him if he felt auy unpleasant sensation about his
  head,  breast, or arm, or felt any way  different from common, to which
  he replied, that he  did not.
    Immediately after the ligature  was drawn tight, the tumor was  re-
  duced in size about one third, and the course  of the  clavicle could be
  distinctly felt.
    The parts were  now  brought into  coaptation, and the  integuments
  drawn  together by three interrupted sutures and straps of adhesive
  plas^r; a little lint and additional  straps completed the dressing.  Three
  small arteries were tied in the  course  of  the  operation : the first was
  under the sternum, and divided with  the  sternal part  of the mastoid
  muscle,  and  from its course  may have  been a branch  of the internal
  mammary reflected  upwards ;  the  second, in raising the inner edge of
  the mastoid muscle, about the upper angle of the longitudinal incision,
  and must have been the most descending branch of the superior thyroid;
  and the  third, wa3  a branch of the inferior thyroid, and  cut while rais-
  ing the  sterno thyroid  muscle.  The  patient lost  perhaps from two to
  four ounces of blood,  most of which came from the ruptured branch  of
  the subclavian.  The  operation occupied about one hour.
    The curved spatulas recommended by Dr. Colles, I found of great  use
  in the operation.  I provided three for this  purpose, two broad and one
  narrow, bent at  right  angles, and  sufficiently  firm.   After raising 'the
  muscles  they were  of the greatest advantage in  keeping separated  the
  carotid artery and  par  vagum, as  likewise  the  divided muscles ; they
  served also  another  very useful  purpose, that  of preventing by  their
  equable  pressure the constant oozing from the smaller  vessels ;  and
  the little room  taken up in a small  and  deep wound, will give them a
  great superiority over the fingers introduced.
    Ten minutes after the operation  the pulse  is regular, and not the least
  variation can be perceived ;  it beats 69 strokes in a minute ; the patient
  says he is perfectly comfortable, and has no new or unnatural sensation,
  except a little  stiffness of the muscles of the neck, which he thinks is
  owing to the position in which his head was placed during the operation ;
  the temperature of the  right  arm is a little cooler than  the left;  his
  breathing has not been the least affected by the operation, but is perfectly
  free and natural.
    2 o'clock, P. M.—Patient  expresses a desire to eat, and is directed a
  little thin soup and bread ; the temperature of both arms is very nearly
  the same; breathing perfectly natural; pulse as before.
    3 o'clock, P. M.—There is still  a trifling  difference in the temperature
  of the  two arms ;  ordered the right to be  wrapped in cotton wadding;
■  not the least unpleasant symptom has as yet made its appearance.
8    6 o'clock, P. M.—Complains of a little pain in his head, not more on
  one side, however,  than the other; describes it as a  common head-ache:
  the pain of the shoulder and arm much less than  before  the operation:
  no difference can now be perceived in the  temperature of the two arms;
  pulse a little accelerated, and perhaps a little full.
    9 P. M.—Patient complains of head-ache ;  skin is rather hotter than 
DR. MOTT ON ANEURISMS.
919
natural; pulse strong and full, and beats 75 in a minute; the carotid on
the left side of the neck is observed to be much dilated and in strong ac-
tion ; tongue moist and clean.
   9| P. M.—Symptoms continuing the same,  directed  him to be bled
from the left arm to § xvj.   After  bleeding the pulse fell 7 beats, and
was less full.   Complains of some thirst; let him drink common tea.
   12 P. M.—Patient has  slept a little ; is free from pain ; pulse full and
less frequent, beats 60 ; skin moist and of a natural temperature.
   Second day,  2 o'clock A. M.—Patient enjoys a natural  and undis-
turbed sleep ; respiration free, and performed without the least difficulty.
   5 A.  M.—He has  rested  well  the last  three hours.   Says he has a
slight head-ache, and a little pain in the right  elbow ; the latter he at-
tributes  to the  position in which his arm has lain  during sleep;  pulse
full, but not so tense as before the venesection ; skin natural and moist;
temperature  of both arms the same.  He states that he can now incline
more upon the shoulder than he has been able to do since the second day
after he received the injury.
   9 A.  M.—Pain in the head no way troublesome ; skin moist and of
natural temperature ; tongue clean ; says his neck  feels stiff, but is not
painful; has  no difficulty  in swallowing.  His  cough has thus far been
much less frequent thau before the operation :  expectoration is also at-
tended with less  difficulty ;  pulse 75, full, but not  tense ; has taken a
dish of coffee, and  some  bread;  complains of some thirst; directed a
solution of supertartrate of potass to  be drank  occasionally.
   10 A. M.—Symptoms as before ; the veins of the fore-arm and hand
since the operation have been as much  distended as previous to it, and
■upon compressing them so as to stop the circulation, and allow the vein
to become empty for some distance above, the  column  of blood is seen
to distend the vein immediately upon the removal of the pressure, plainly
showing that the circulation  is going on with  considerable rapidity, al-
though  no pulsation has been felt in the brachial or radial arteries.  The
radial  artery can be easily distinguished by the fingers, and seems to be
filled with blood.  There  is  evidently a pulsation in the anterior branch
of the  temporal  artery, just as it is passing a little above the exterior
canthus of the orbit; the left external carotid  is beating with increased
action, and appears larger than natural.
   3 p. M.—Has taken a light dinner, and  complains  of a little  head-
ache ;  pulse has become tense, and is also increased in frequency ; skin
is considerably hotter than  natural;  tongue too indicates a febrile ac-
tion :  was bled to § viij.,  and directed to drink freely  of a  solution of
the supertartrate of potass.
   10 P. M.—Since the last report he has become more comfortable ; com-
plains  of no  pain, and says  he  lies perfectly  easy; pulse increased in
frequency to  78, but of the natural soft feel;  the  right side of the face
has been at times a little  cooler  than the left, and is so at the present
time : it is however, not so  much as to be perceptible to the patient;
temperature of the right  arm natural; that of the left, and the whole
body, is above the natural  standard, but it is moist; tongue is clean:
having had no evacuation from his bowels since the operation, is directed
to take a saline cathartic, in divided  doses.
   1 A. M.—Complains of nothing;  has  not  slept any ;  cathartic  has
operated twice. 
  920            NEW ELEMENTS  OF OPERATIVE SURGERY.

    Third day, 5 A. M.—Has had no sleep in consequence of the opera-
  tion of the medicine, it having  produced  free evacuation in the course
  of the night; skin not  so moist, but of natural  temperature ; the two
  arms have equal warmth;  pulse full, and rather more frequent  than last
'  evening : says his right elbow is a little painful, and the arm feels tired.
  The complete flexion of the arm at the elbow is prevented by a little
  rigidity of the extensor muscles.
    9 A. M.—He is now comfortable, has slept a little, and feels refreshed ;
  pulse is full, and rather more frequent than natural; skin natural and
  moist:  the size of the tumour is considerably diminished; has taken a
  dish of chocolate and some rusk.
    11 \  A. M.—Patient still free from pain, or any uneasiness ;  medicine
  has operated  seven times ; skin not  hotter than natural, and moist;
  tongue  clean ;  the right facial and anterior temporal arteries communi-
  cate a distinct pulsation  to the fingers :  having slept but little during the
  last night, directed him to take an anodyne of Tinct. Opii. gtt. xxx., and
  to have the  room made dark, and  kept quiet, in order to procure him
  some sleep ; let him have sago or panada as often as he inclines to take
  nourishment.
    4 P.  M.—Has slept the  last two hours, and is. s'till  sleeping;  respira-
  tion free and easy ;  nothing the least unnatural in his appearance.
    10 P. M.—He has slept four  hours,  and is much refreshed ; is free
  from pain, except a  little  in  the  elbow; pulse small and soft, beating
  105 strokes in a minute ;  tongue clean; feels a  little  soreness  in the
  wound when swallowing ; has taken a considerable quantity of sago and
  panada ; his appetite is good ; temperature natural and uniform in both
  arms.
    12 P. M.—Patient has slept the greater part of the time ; is free from
  pain, and  perfectly comfortable ; skin moist and natural; pulse soft,
  small, and frequent.
    Fourth day, 6 o'clock, A. M.—Patient has passed a good night; says
  his right elbow gives him some uneasiness, but complains of nothing else ;
  tongue is clean ;  skin moist and natural; can move the right  arm with
  considerable ease : says he takes as much light nourishment as he has
  been accustomed to for some time past: no unfavorable symptom has  as
  yet made its appearance.
    11 A. M.—Symptoms continue much the same ; tongue slightly furred ;
  pulse comparatively small  and soft, beats, 105, and  irregular ;  respira-
  tion has been uniformly natural  since  the operation ; suppuration has
  begun  to appear through  the dressings, and is  attended with a little
  foetor;  let them be covered with  a  yeast poultice: it is thought  that a
  faint pulsation or undulation is at intervals felt in the radial artery  of
  the right arm: the left external  carotid continues its increased  action.
*    6 P.  M.—No change  is observable in the patient's symptoms ; he still
  continues comfortable and  complains of nothing.
    Fifth day, 11| o'clock A. M.—The wound was dressed to-day: on re-
  moving the poultice  the dressings were soft and easily came away ; the
  suppuration  was considerable,  and of a  healthy appearance ; it was
  found that the extremities  of the two incisions were united as far as the
  sutures,  each about one  inch  in extent; one suture at the angle of the
  wound was  removed;  the wound was dressed  with dry  lint,  gently
N 
DR. MOTT ON  ANEURISMS.
921
  pressed into it; adhesive straps and a compress: his pulse beats 110, is
  fuller and stronger than yesterday.
     6 P. M.—Patient is very comfortable, subject to no pain or unnatural
  sensation ; pulse still 110,  but softer.
     Sixth day, 6 A.  M.—Patient sleeps ; respiration  not attended with
  the least difficulty ;  skin moist  and natural.
     9 A. M.—He rested well during the night, and is  perfectly free from
  pain; pulse  110, and  soft; skin moist; tongue  clean:  having* had  no
  alvine  evacuation  since  the 13th, directed to take of sulphate of soda
  §j, in divided doses.
     11 A. M.—The  dressings  were again  removed, and the discharge
  seemed more considerable than  at the former dressing;  the sides  of the
  wound are  granulating, and  appear perfectly healthy ; on the ends of
  the muscles  that were divided in the operation, there are  small sloughs
  which are beginning to separate, leaving a healthy surface underneath  :
  wound was dressed with lint spread with Ung.  Res.  Flav. and adhesive
  straps: pulsation is now perfectly distinct in the branches of the  right
  external carotid artery : complains a little*of the back part of his head,
  which he says is sore from lying  ; in other respects is comfortable.
     6 P. M.—Has no pain, and is in every respect much as usual; tongue
  clean ;  skin natural ;  says he  feels " no weaker than before  the op-
  eration."
     Seventh day, 6 A. M.—He has passed a comfortable night, and is free
  from pain or any uneasiness ; pulse regular and soft, and beats 105 in a
  minute ; skin moist, and of natural temperature.
    11 A. M.—The wound was again dressed : suppuration considerable
  and healthy; some of the small sloughs came  away, leaving a  healthy
  and florid surface beneath :  sprinkled the wound with powdered carbon,
  then filled it lightly  with lint, and over this applied the yeast poultice,
  which was secured  with adhesive straps : temperature of the two arms
  is the same,  cathartic having produced no effect; habeat enema purgans
  statim.
    9 P. M.—Symptoms have not varied  materially ; the enema has pro-
  duced a copious evacuation  : says he feels more comfortable, and desires
  to  set up in bed, which was  allowed, taking care to have him raised up
  very cautiously, in  order to prevent any exertion being made with the
  right arm and shoulder.
    Eighth day,  6 A. M.—Patient has rested well during the night; says
  he  feels some pain on swallowing,  and that when the  attempt is made, it
  gives rise to  a fit of coughing, which fatigues him ; it also occasions some
  soreness in the  wound : pulse  still soft  and less frequent than yester-
  day : he takes a reasonable quantity of light food every day:—Directed
  a cetaceous mixture for his  cough, and is permitted to set up for a short
  time if he feels disposed.
   11 A. M.~-Pulsation of the radial artery of the right arm to be felt
  occasionally pretty  distinct; cough has become more troublesome ;  pulse
,  100 ; skin natural and moist.  The dressings were again removed, and
  the suppuration is more profuse,  apparently healthy though attended with
  considerable  fcetor ;  appearance of  the wound  every way  favorable ;
  small portions of the sloughs are removed at each dressing, and the sides
  0f the wound look perfectly healthy ; the same dressings to be continued.
    Vol. I.                  116 
922
NEW ELEMENTS OF OPERATIVE SURGERY.
 p        r"    pIains only of llis cong°» which troubles him frequently,
 can move his arm with much more facility, and has no pain in it; circu-
 lation as before, and the temperature uniform and  natural.   The wound
 was dressed this evening in consequence of the foetor being unpleasant to
 the patient; continue the dressings.
   Ninth day, 7 A. M.—Patient was  found  sitting up  in bed, supported
 by a bed-chair, having passed a good night;  is in good spirits, and ex-
 presses his gratitude "for the relief afforded  by the operation ; says he
 can move the arm with greater ease, and it  gives him no pain ; pulse
 105, regular and  soft; skin  natural; every symptom as favourable as
 could be wished.
   10  A. M.—Pulse less frequent, regular  and soft;  temperature per-
 fectly  natural; wound has  a more  favourable  appearance, discharges
 less in quantity, and it possesses less foetor ; dressed the  wound as yes-
 terday ; tumour has diminished two thirds, is soft,  and less  florid.  The
 apex of the tumor is now below the clavicle.
   6-—P- M.—Patient still in every respect as comfortable as at the last
 report.
   9 P. M.—Pulse 110, reguftr and  soft; the dressings were  removed
 this evening; the wound is  much  contracted in size, and  is  perfectly
 healthy, except a small slough which still remains in the deepest part of
 the wound ; granulations are shooting up rapidly from the sides.  When
 preparing to remove the dressings, an  unexpected and unaccountable
 hemorrhage took place, which suddenly filled  the cavity of the wound.
 The rapidity with which the  blood  flowed, and the size of the stream,
 gave rise to fearful apprehensions  for the man's safety:  dry lint was im-
 mediately placed in the wound, and as much pressure made as the patient
 could  conveniently bear, which quickly  stopped  it.   After continuing
 the pressure for a short time, the lint was removed, when no hemorrhage
 recurring, the usual dressings were  repeated : the patient  experienced
 no ill effects from the bleeding, nor did he seem to be much agitated.  At
 10 o'clock, P.  M., has no pain, nor has he as yet had any sleep.
   Tenth day, 7 A. M.—Has passed a comfortable night, except that  he
 has been frequently disturbed by his cough : tongue clean ; skin moist;
 pulse  soft, and has much less strength than before.
  11 A. M.—The dressings were  again  removed, and the wound made
 ciean ; its appearance is in every respect favorable ; does not appear to
 have been the  least injured by the hemorrhage ;  the dressings  were re-
newed as before : he is directed to take half an ounce of the cold infusion
of cinchona every hour, and to  drink occasionally of ale when thirsty :
has had an evacuation from his bowels to-day.
  6 P. M.—Symptoms  much as before ; complains a little of his elbow,
and a numbness in his hand, to relieve which  he  is directed to  have the
arm and hand rubbed well, and wrapped in wadding.
  Eleventh day, 6 A. M.—Patient  has  rested well during the night;
 cough has  not been  so troublesome;  says he has no pain, and feels per-
 fectly comfortable ;  pulse better  than  yesterday ; other symptoms  as
 before.
  11 A. M.—The wound is dressed daily at this hour;  its appearance is
 still very favorable,  although there is still some fcetor in the suppuration :
 the wound has contracted perhaps one third :  the tumor is also consider- 
DR. MOTT ON  ANEURISMS.                   923
 ably diminished, and softer than before; pulsation in the right temporal
 and radial arteries as before :  the same dressings to be continued.
   6 P. M.—No change in the patient's general symptoms; pulse  soft,
 and rather more frequent;  appetite is as good as usual.
   9 P. M.—Appearances have not varied.
   Twelfth day, 6 A. M.—Our patient was visited as usual  this morning,
 but there is no evident change in any of his  symptoms ;  says he  now
 rests  well at night.
   11  A. M.—To-day, when the dressings were removed, that portion of
 the slough which occupied the bottom of the wound  (apparently a portion
 of the sheath of the vessels) came away : every part of the wound  now,
 where its surface can be seen,  has  a healthy look ; the most  depending
 part is obscured by a quantity  of pus,  which cannot be wholly removed
 by lint, and it  is not thought safe  to  permit the patient to lie in such  a
 position as will allow it to be  discharged:  with the  slough came  away
 the ligature which  had been applied to an artery under thelower portion
 of the sterno-thyroid muscle;  it was followed by no hemorrhage: the
 wound was now dressed with pledgets of lint,  spread with  Ung. Resinae
 Flavas and adhesive  straps.  He remains much as yesterday, has drank
 freely of ale ;  pulse rather stronger than yesterday.
   Thirteenth  day, 7 A. M.—No perceptible  change in  his  symptoms ;
 complains  of no pain, says he  feels very comfortable; cough has given
 him very little trouble for the last two days ; he is evidently considerably
 weaker than before the operation, but is not sensible of it  himself.
   11  A. M.—The wound was  again exposed ; it is not as  florid as yes-
 terday, and there  is a greater secretion of pus : the cavity of the wound
 was filled with dry lint only ;  the pus appears well formed, and has very
 little  foetor.
   The same dressings were repeated in the evening ; there  is still a
 quantity of pus at the bottom of the wound, which rises and falls at each
 inspiration and expiration: it continues to contract above, leaving us
 uncertain of its extent beneath : during the last three days, the patient
 has set up for  several hours each day.
   9 P. M.—Pulse and skin perfectly natural; has had a natural  evac-
 uation from his bowels to-day;  continues the  infusion of  bark as pre-
 scribed before.
  Wound was again dressed, and  is  as  healthy as usual; suppuration
just sufficient to moisten the lint: the same dressings to be continued.
   Fourteenth day, 7 A. M.—Patient has slept well during  the night, and
 is as well as usual; complains  of soreness of an ulcer which he has had
 for some time between his shoulders ; it is  improving in its appearance,
 and is directed to  be dressed as usual with Ung.  Resinae  Flavaa.  The
 erysipelatous blush which  surrounded it, is not as florid as heretofore ;
it is beginning to granulate, and assume a healthy  appearance : in other
respects  he is  perfectly comfortable :  he is now able to raise the  right
 arm to his lips,  which he has not  done since  the fourth  day  after
 the accident by which his shoulder was  injured ; says too that he is get-
 ting stronger, and that he walked  across the floor this morning without
 any assistance.
   11  A. M.—On removing the dressing, the  granulations appear per-
 fectly florid and healthy : the  bottom  of the wonnd is not  visible, owing 
924
NEW ELEMENTS OF OPERATIVE SURGERY.
to the small quantity of matter which collects there, and from its depth
cannot be easily removed, and perhaps not  altogether safely ; the posi-
tion of the patient in bed must necessarily make the bottom of the wound
the lowest:  when  he  coughs or swallows, a small  quantity of fluid pus
at the bottom of the wound is seen to rise and fall; from the general ap-
pearance, however, of the wound, the man's feelings, and  many  other
circumstances, it is not probable that there is any considerable quantity :
the large ligature  lying very  loose in the  wound, was taken hold of,
merely however to see if it was separated ; no force was used : pulsation
of the  right radial artery more  distinct than heretofore: countenance
of our patient is improving; says he feels more comfortable than before
the operation :  he can now straighten his arm, and  raise it to his mouth
with  facility : as yet he has not recovered his strength, but is improving
daily ;  has been setting up all day : directed  him when  lying down, to
assume a more recumbent  posture ;  continues the sulphuric acid and in-
fusion of cinchona,  as before;  complains of the ale being too strong;
let it be diluted and made pleasant with  sugar and nutmeg.
  9 P. M.—The large ligature since the operation, has been confined
upon the upper part of the  sternum by a piece  of adhesive plaster to
prevent any accident during  the  dressings.   Upon dressing the wound
this evening, the large ligature as it lay in the wound, appearing to be
loose, was again taken hold of with the forceps, and found floating upon
the pus, being completely  separated from the artery below.   The liga-
ture  was  drawn  so firmly upon  the artery  that the noose was  only
large  enough  to admit  the  rounded end of a  common probe.   The
wound looks healthy, and is contracting rapidly; it is now perhaps not
more than one third of its original size.   Suppuration is now only suffi-
cient to moisten the lint through.
  Fifteenth  day, 12 o'clock.—The  patient is comfortable in every res-
pect ; pulse  and skin perfectly  natural; is  sitting  up in bed, and occa-
sionally amusing himself with a book ; not the least symptom about him
indicating indisposition : wound is healthy, and continues to improve in
appearance.   The right arm at intervals gives him a sensation of numb-
ness,—not more, however, than can be  accounted  for from the  uniform
position in which the arm rests, and no doubt a more languid circulation,
as it is readily removed  by a little friction and motion of the arm.  His
appetite  improves, and  he expresses a desire to walk about the room.
The bark and sulphuric acid to be continued.
  9 P. M.—In the afternoon he was removed down stairs, from the  pri-
vate room in which he was placed  immediately  after the operation, to
the ward in  which he formerly lay,  and  appeared highly gratified with
the idea of again seeing his  friends, whom he had left with very little
hope of ever returning to.  The wound, upon being dressed,  did not ap-
pear to have undergone  any perceptible  change.
   Sixteenth day, 11 A. M.—Our patient's strength is improving.   To-
day he made an effort, and with success, to visit his friends in Ward No.
7, where he lay previous to his being transferred to the surgical depart-
ment, and returned without having any support; pulse as strong as be-
fore the operation; and in every  respect natural;  appetite  better than
before the operation, cough a little troublesome, but less so than for se-
veral days previous; wound dressed with dry lint. 
DR. MOTT ON ANEURISMS.
925
   9 P. M.—Dressing removed; patient as before ;  suppuration small in
 quantity, and appears to be well-formed  pus, and  is not attended with
 the least foetor.
   Seventeenth day, 11 o'clock.—The ends of the divided muscles  are
 nearly in contact, and the surfaces of the wound are rapidly granulat-
 ing, and in  every respect look well: patient's health continues to  im-
 prove ; he walks  about  the  room with  perfect ease, and into several
 wards in the same story; the  ability to move the arm increases;  pulse
 and skin natural.   The dressings were removed at 4 P. M., and also at
 10 P. M.
   Eighteenth day.—The patient's strength continues to improve ;  every
 symptom remains highly flattering ; cough less troublesome.   The dress-
 ings were again removed to-day three times.
   Nineteenth day.—Continues  the same as yesterday; wound  dressed
 three times.
   Twentieth day.—To-day he passed down two pair of stairs, and walked
 several times across the yard, and was highly delighted with his perform-
 ance, and felt  not the least  inconvenience  from it; sleeps  uniformly
 well during  the night, and takes more food during  the day than he  did
 previous to the operation ;  continues the infusion of cinchona and sulph.
 acid as before,  and directed to  use dry lint as the dressing.
   Twenty-first day.—Dressed  the wound three  times again to-day ; it
 is nearly closed at the bottom ; the  power of motion in the  right arm
 continues to increase: he can now move it with as much facility as  the
 left, though  not to the same extent: his strength is daily improving, and
 the operation is considered by all to have been completely successful;
 size of the tumor  continues the same, no diminution of it having been
 perceived for the last week ;  the most  prominent part of the tumor is
 yet below the clavicle, that above rises to about the height of the clavicle,
 which gives  a little convexity to the place between the clavicle and tra-
 pezius muscle.
   Twenty-second day.—Continues to improve in every respect; dressings
 renewed as often as yesterday; owing to the  weather he has not left  his
 ward to-day ; pulse full and strong ;  temperature of both arms the same.
   Twenty-third day.—A few minutes before the hour of visiting to-day,
 a message was brought that the  patient was bleeding from the wound.
 The dressings were immediately torn off, and dry lint crowded into  the
 wound,  and  slight pressure  applied  for a few  minutes, when  the  he-
 morrhage ceased.  The patient lost at this time, perhaps about  24 ounces
 of blood, and was very much prostrated.   Pulsation ceased in  the radial
 artery  of the left arm, and the  countenance, gasping, and  convlusive
throes of the patient, threatened  immediate dissolution ; all present  ap-
prehended the  instant death of the patient.   The first impression was
that the trunk of the arteria innominata had given way.  The conjecture
afterwards was, that the subclavian artery, from the diseased state of it,
had  not united by adhesion, and  the fluid blood  from the tumor had
 regurgitated through its  ulcerated coats.  This appeared to be the most
 probable, both from the suddenness with which the blood ceased flowing,
 and the  cause the patient assigned for the hemorrhage.  He says that he
 felt weary of lying on his left side and back ; that he had just turned
 on the right, which he had not done before since the operation,  agreeably 
926            NEW ELEMENTS  OF OPERATIVE SURGERY.

to my request.  At the instant of turning over, something  arrested his
attention, which caused him to turn his head to the opposite  side sudden-
ly, and he felt the gush of blood from the wound.
  He was directed some wine and water frequently, which  soon revived
the circulation.  The wound was dressed with dry lint and a compress.
Pulse as frequent as natural, but very small and soft;  he appears very
languid, and complains of a numbness and painful sensation in his hands;
says also that his back aches.  During the last twenty-four  hours he has
taken a  pint and a half of Madeira wine : he took also occasionally some
>ggand wine, which was immediately rejected from the  stomach.
  9 P. M.—Patient has lost his  appetite, and appears  considerably de-
pressed ; circulation very languid in the right arm ; its temperature is
a little less  than in the  left: directed  a hot brick to be wrapped in a
flannel,  and placed close  to the arm.  For a profuse perspiration  which
he has been in for the last three hours, he was ordered to be bathed with
cold rum.
   Twenty-fourth day, 6 A. M.—Slept the greater part of the night, and
feels comfortable ;  is still languid, and has no disposition to eat anything;
says he  feels  sick, and  once last evening  vomited after drinking some
wine and water.
  Wound looks exceedingly pale, and the discharge is thin and foetid,
for which the carbon and yeast dressings were applied.  He has vomited
several times to-day, and has some considerable difficulty in swallowing,
and complains of a soreness in the wound upon pressure.
  9 P. M.—Dressings removed ; wound very  pale ; right  arm of the
natural  temperature ; feels occasionally  a little numbness in the hand ;
has taken very little nourishment during the day, pulse natural as to fre-
quency, but small and feeble ;  a few minutes after dressing  the  wound,
information was brought  that hemorrhage had ensued, and before it could
be commanded, he probably lost four ounces of blood.'  For his restless-
ness and pain in the bones he was ordered two grains of opium.
   Twenty-fifth day.—Has rested well during the night, and is perhaps
a little  better this morning.   The repeated hemorrhages  have  debilitat-
ed him  exceedingly, and from the irritable state of  the stomach, he can
take only a very little nourishment.  In the morning he was  directed
the effervescing draught to be repeated  every two hours ;  this  allayed
the irritability of his stomach, and enabled him to take a  little break-
fast.
  His countenance  has altered since the first bleeding, surprisingly; his
eyes are now heavy, and for the most part fixed ; his cheeks are sunken,
and an universal pallor has spread itself over his countenance ;  and, from
every appearance, a short time will terminate  his existence.  He has
not vomited since early in the morning ; is advised to take a little sou^p
and to  drink freely of wine  and  water; dressings were renewed at 3
o'clock, P.  M., shortly after which the patient again bled, but  not to ex-
ceed, however, an  ounce.  He was  dressed with dry lint as usual.
  11 P. M.—Patient  has not as yet had  any sound sleep, is restless and
apparently distressed, although he says he feels no pain;  breathing is
attended with some  difficulty ; his hands  and  legs are continually  in
motion ; pulse small and feeble.
  Twenty-sixth day, 6 A. M.—Patient has not rested well; is occasionally 
DR. MOTT ON ANEURISMS.
927
falling into  little slumbers, but is awakened by the least motion :  pulse
small and feeble;  respiration somewhat laboured ;  appears to be sinking ;
seems disinclined to take any thing ;  legs and arms constantly in motion.
  11  A. M.—More feeble than before ;  has been forced to take a little
chocolate ; is evidently sinking ; wound was dressed, but there was no
secretion of pus in it;  countenance of the patient foretels his approach-
ing dissolution.
  6 P. M.—Is extremely low; respiration very much laboured ; is not
able to articulate; for the last three  hours there has not been such con
tinued throwing of the legs and arms  about the bed :  he lies in a state of
insensibility ; temperature of the two arms the same to the last.  My pupil,
Abraham I. Duryee, the House Surgeon, (to whom I am indebted for the
correct reports, and the most unwearied attention to this case, and whose
ingenious  application of means for the recovery of many of  my patients,
will long be held by them in grateful remembrance,) having  for a few
minutes left the patient, he was sent for immediately, as there was another
bleeding from the wound, by which he lost  probably eight ounces of
blood ;  during the whole time he did not manifest the  least apparance of
consciousness, nor was the least motion perceptible, except that necessa-
ry for respiration and circulation :  the hemorrhage was stopped  with
lint, after removing the former dressings;  respiration is now  performed
with the utmost difficulty, and the patient appears as if every respiration
would be the last-:  he expired at  half  past six  in the afternoon: the
temperature of the  right arm after death, appeared by the touch to be
the same as that of the left; it was  as natural and  uniform as  in other
parts of the body.

                     EXAMINATION OF  THE BODY.

  About eighteen hours after death, I opened his body; there was con-
siderable emaciation, and  the surface of a wound was of a dark-brown
color, and foetid ; the wound was perhaps about one-third of its original
size;  it had  been enlarged by the  pressure  of  lint  into it, and other
means  to arrest  from time to time the hemorrhage :  the ulcer between
his  shoulders was ill-conditioned.
  For  the purpose of examining the condition of  the aorta, where the
arteria  innominata is given off, as also the origin  of the latter vessel,
as well as the  state of the pleura at the part about which the ligature
had been applied around the artery,  the chest was opened in the follow-
ing manner:  after removing the integuments and muscles from the fore-
part of the  chest, the sternum was carefully  sawed through about an
inch from  its upper extremity, and  raised by sawing through the ribs
below the junction of the cartilages ; this removed  so much of the front
part of  the chest as to facilitate and  expose fully to view the subsequent
steps of the dissection ; by thus leaving  the clavicles attached, every
part connected  with the ulcer and great vessels could be seen and ex-
amined in situ.
  The arch  of the aorta and origin of the innominata being fairly ex
posed., not a. vestige of inflammation or its consequences could be dis-
covered, either  upon them, the lungs,  or the  pleura, at any part.   An
incision was next made longitudinally into the aorta opposite the origin 
928            NEW ELEMENTS  OF OPERATIVE SURGERY.
of the innominata, and upon introducing a probe cautiously up the lat-
ter vessel, it was seen to pass into the cavity of the ulcer ;  the  innomi-
nata was then laid open with a pair of scissors into the ulcer; the in-
ternal coat of this vessel was smooth and natural about its origin, but
for half an inch below where the ligature had  cut through  the  artery,
it showed appearances of inflammation, and there was a coagulum adher-
ing with considerable firmness to one of its sides ; showing that nature
had made an effect to plug up the extremity of so large a vessel, after
the adhesion, which no doubt had been effected by the ligature, was swept
away by the destructive process of ulceration.   The  upper extremity
of this vessel was considerably diminished in its diameter by the  thick-
ened state of its coats, occasioned by the surrounding inflammation.  The
innominata about half an inch from  the aorta, and a little to the left side,
gave off an anomalous artery large enough to admit a small sized crow-
quill.
  The ulcer at the bottom was more than twice the size  of the  wound
in the neck ;  it extended laterally towards the trachea, and under the
clavicle towards the tumor.   The tripod of great  vessels, consisting  of
the innominata, subclavian, and carotid arteries, to the extent of nearly
an inch, was  dissolved  and carried away by  the ulceration.   The ex-
tremities of the two latter vessels were found also to open into the cavi-
ty of  the ulcer. The upper surface of the  pleura was very much thick-
ened by the deposit of newly  organised  matter,  for the safety and pro-
tection of the cavity of the thorax.  Indeed, instead of having increased
the danger of  penetrating this membrane, the  adhesive inflammation
which preceded the ulcerative, seemed, by the consolidation of cellular
membrane, and the addition of new substance, to have more securely and
effectually shielded it from harm.
  The internal surface of the carotid artery was  lined with a coagulum
of blood, more than twice the  thickness of its  coats, and extending
above  the  division  into  the internal  and external, so as almost to give
them  a solid  appearance, insomuch that a probe  could barely be intro-
duced.   The  subclavian artery, internally and externally to the disease
was pervious.   The brachial  and other arteries  of the right arm were
of their common diameter, and in every respect natural.   The  external
thoracic or mammary arteries, as they  went  off from  the subclavian, were
larger than natural:  the  right  internal mammary was pervious, and of
the usual appearance.   Upon opening into the tumor, which now gave
(from its small size,) no deformity to  the shoulder, the clavicle was in-
volved in it, and found carious, and entirely disunited about the middle.
Several coagula of blood were also found in the sac.   A number of lym-
phatic glands under the clavicles, and particularly the left, were  con-
siderably enlarged, and, when  cut into, very soft,  and evidently in a
state of scrofulous suppuration.  No other morbid  appearances were
observed.

   Several very important facts are established by this operation—facts
which no surgical operation has ever before confirmed.  11 proves very
conclusively, that  the heart, the brain, and the right-arm, were not the
least injured  by it, in any of their functions.   To tie so large a vessel,
so  near  the heart, might very reasonably be expected to occasion some 
                        DR. MOTT ON  ANEURISMS.                    C)29

immediate derangement in the actions of that organ : out it was neither
increased  nor diminished in its  contractions, nor  did it give rise to the
least  visible  change  in the  respiration.  All this could not  have been
anticipated.   I apprehend there are  no ingenuous surgeons, who would
not have  expected quite a contrary  result.  For my own part, I must
confess, that  this  was to me an anxious moment, when I drew the liga
ture upon this artery.   Indeed, so apprehensive was I that some serious
if not almost  immediately  fatal consequences, would follow  from ar-
resting so large a proportion  of the whole mass of blood suddenly, that I
drew the ligature very little at first.  But when no change took place in
the action  of the heart, or  respiration, I felt a confidence in complete
ly intercepting the whole current of blood through this  great vessel.
   The brain in no  operation  has been deprived of so large a quantity  of
blood as in this, and yet it suffered  no inconvenience : from the effect  of
experiments however upon animals, I entertain no fear  as to the conse-
quences of my operation upon this organ.
   The right arm as the reports of  the  case from day to day will show,
was in no want of a  sufficient  supply of blood  for  the purposes of  its
economy.  That circulation went on  to a degree adequate to its  wants,
                                (Plate I.)
  Represents the tumor very correctly, with its elevation above and below the clavicle, and
the extent of it towards the acromion scapulae, and likewise as it encroached upon the trachea.
The form of the external incision with the subsequent steps of the operation, as far as  can be
given in a drawing, are also shown.
  a, a, a The angles of the integuments as turned over upon the tumor.
  b The sternal and a part of the clavicular portion of sterno-cleido mastoid muscle, raised,
and reflected over upon the integuments.
  c The sterno-hyoid muscle laid over upon the trachea.
   The sterno-thyroid muscle also raised and reflected inwards over the trachea.
   Vol. I.                    117 
930
NEW ELEMENTS  OF OPERATIVE SURGERY.
the natural warmth  and function of the skin fully prove; and although
at no time could all  be satisfied  that a  pulsation was perceptible in the
radial artery, yet many at times were of the opinion  that an occasional
undulatory motion was very  evident; every one was confident of the
distended  and  elastic  feel of this artery, and  could plainly see, from
pressing on the  distended veins upon the back of the  hand, that a free
circulation of blood was going on :  but  independent  of these evidences,
the natural warmth  and free perspiration would alone  be  sufficient to
establish the fact.
   The route of  circulation to the right  arm, was somewhat different at
first, from what took place after the ulceration had extended.   The in
osculation of the epigastric and  internal mammary must have thrown a
considerable retrograde current of  blood through the latter vessel into
the subclavian  directly, and which in all probability passed on into the
arm ;  after the  ulceration had extended, this communication was cut off
by the destruction of the subclavian to some distance.   It was now that
the principal supply of blood to  the arm must  have been derived from
the free communication  of the  intercostals with the  thoracic arteries.
From the large size of these, as found in the dissection, I apprehend they
must have afforded the  principal channels  through which the blood was
conveyed to the arm  after the operation :  the anastomoses of the infra-
scapular and  other  arteries of the axilla, more or less with  small
branches of the intercostals, as  also the occipital, with small ascending
branches from the subclavian, may have given some trifling assistance.
   The ulceration which went on so insidiously at the bottom of the
wound, was the sole cause of the death of my patient.   While the upper
part of the wound put on  a  favorable  appearance, and seemed healing,
mischief was extending below.   The  separation of the ligature on the
fourteenth  day, spontaneously, without being  followed by any henior-

                                 (Plate II.)
                                     Exhibits the morbid appearances which were
                                    found upon dissection.
                                     a, a, a View of the ulcer as it extended under
                                    the clavicle, and toward the trachea.
                                     b The  upper part of the arteria innominata,
                                    about which the ligature had been applied, ap-
                                    pearing rough and irregular from the erosion of
                                    the ulcer.       •
                                     c A coagulum of blood adhering pretty firmly
                                .   to one side of the innominata.
                                     d Contracted and puckered appearance of the
                                 *  upper part of the innominata, and particularly
                                p  of its internal coat.
                                     e Arteria innominata cut open from the aorta.
                                     / Anomalous branch of the innominata.
                                     g g The aorta.           h Left Carotid.
                                     i Left subclavian.   k The  heart collapsed.
                                      I Sternum and clavicle turned up.
                                      m, m Pleura much thickened.
                                      n  Probe  introduced into the axillary artery,
                                    passed through  the subclavian,  and appearing
                                    in the cavity of the ulcer.
                                      o A small bougie passed along the common
                                v&  carotid,  and its extremity also seen in the  ul-
                                    cer.
 
DR. MOTT ON ANEURISMS.
931
 rhage for a number of days, and not until ulceration had extended, con-
 clusively proves  to my mind, that all the purposes  of the ligature were
 completely  answered—that adhesion was fully affected.  Had  it not
 been for the ulcerative inflammation, no doubt will be entertained I think
 by surgeons, but  that my patient would have recovered.  From occupa-
 tion his  constitution was indeed  very old,  and with an ill-conditioned
 habit, every thing favored  the  process  of ulceration.   The'position of
 the wound may be said by some  to favor this  process, but in a sound
 healthy habit it would  only retard the wound in its recovery, but would
 never promote ulceration.
   The  practicability  and  propriety of  the  operation  appear  to me
 to be satisfactorily established by this case :  and although I feel a regret,
 that none can realize who have not performed surgical operations, in the
 fatal termination  of it,  and especially after the high and just expectations
 of recovery which it exhibited ; yet I am happy in the reflection, as it is
 the only time it has ever been performed,  that it is the bearer of a mes-
 sage to Surgery,  containing new and important results.

 No. II.—Nov. 14,1818.  The Right Carotid  tied for the Safe Re-
   moval, of a Fungous Tumor  in the  Neck, by Valentine  Mott,
   M. D., &c.  (See the Medical and Surgical Register, consisting chiefly
   of Cases in the New York Hospital, New  York, 1820, part II., vol.
   I., p. 381—400, with three plates and Explanations at p. 405-6 of the
   same work.  The same is published also in  Tie American Journal of
   the Medical  Sciences, with the same plates, Philadelphia,  1831, vol.
   VIIL, p. 45, &c.)

   John McGarrigle, born in Ireland,  aged forty-nine years, a mason by
 occupation, was admitted into the  New  York hospital on  the 10th of
 November, 1818, for a carcinomatous fungus.
   The fungus was situated  upon the right  side of the face and neck, and
 occupied a considerable portion of each.  It extended from the inferior
 lobe of the ear nearly to the chin, and downward  to a  horizontal line,
 passing through the inferior edge of the thyroid cartilage.
  It  projected  downward  and forward,  to the extent of about four
 inches.
  At its  most  prominent part, there was an opening, nearly circular in
 its  form, and about one and a half inches in diameter ; gradually dimin-
 ishing as it extended through the fungus, and terminating just within the
 margin of the inferior maxillary bone.
  The edges were everted, and studded round with clusters of fungous
 excrescences, varying in size from that of  a pea to a marble; of a pale
red colour, and of a granulated appearance;  extremely flabby in their
structure, and bleeding upon the slightest  touch.
  From its cavity there was a constant discharge of a thin acrid fluid,
amounting to about a pint in twenty-four hours; extremely offensive, and
 excoriating the surface with which it happened to come in contact.
  He seems to  have been originally a man of  strong and vigorous con-
 stitution, but at the time of his admission, he had suffered much from the
 disease.  His countenance  was  pale ; pulse feeble ;  he had no appetite,
 and his whole appearance evinced the utmost langour and depression. 
932
NEW ELEMENTS OF OPERATIVE SURGERY.
  About eight months  previous to the appearance of this tumor, he had
been cured of an ulcer situated on his lower lip, that-had troubled him
more than two years.   He says it resembled a wart, that at times it gave
him severe pain, and that he had tried various applications without de-
riving any benefit, until a cancer doctor gave him a " burning plaster,"
which brought out the core, and then it soon got well.
  The patient ascribes the origin of his disease to a severe  tooth-ache,
which  was attended with a swelling  of that side of his face, in April
last.  When  the  swelling subsided, he discovered a small moveable tu-
mor, very little larger than a pea, immediately under the margin of the
lower jaw.   It remained nearly stationary  for two months, giving him
but little pain and no inconvenience.  It then began to swell, and be-
came troublesome ; the pain  was severe, and of that peculiar kind which
characterizes carcinoma.  He  was advised by his  physician  to apply
poultices, which were  continued for five or six weeks.   The tumor was
then punctured with a  lancet.  A little bloody serum alone flowed from
the puncture.
  Shortly after this, the tumor began to increase with  more  rapidity;
two other openings formed spontaneously, which soon communicated with
the first, making the large circular opening before described.
  In  consultation it was  agreed, that an operation  which would lessen
the flow of blood to the fungus, and permit  as much of  the tumor to be
removed as possible, afforded the only possible means of prolonging the
existence of  the  patient, or  of mitigating his  sufferings.  With these
views, I accordingly performed the following operation, on the 14th day
of November, at 12 o'clock.
  The right carotid was taken up about an inch below the cricoid carti-
lage, and secured by two ligatures, but not divided in the interspace, in
consequence of the depth of the artery, from the swelling of all the parts
around the disease.   Such was the enlarged size of the vessels, that it
became necessary to take up  several arteries and veins before the carotid
could be exposed.
  The tumor was removed by an incision commencing at the ear, oppo-
site the meatus auditorius, and carried  obliquely downward and forward,
so that it passed  over the base  of the lower jaw near the chin, passed
under the chin, and  terminated upon the outer edge of the anterior belly
of the left digastric muscle.   From thence downward to the thyroid car-
tilage, along  the lower  edge  of this, across the  sterno-mastoid muscle,
and terminating about an inch behind the mastoid process of the tempo-
ral bone, upon the os occipitis.   Another  incision from the termination
of this, passed along under the ear to meet the  commencement of the
first.   (See dotted line in plate I.)
  The tumor was now dissected from the parts beneath, beginning op-
posite the thyroid cartilage, so as to detach the lower part first, in order
not to have the dissection obscured by the flow of blood.  In  this way,
the operation was carefully continued until the base of the jaw was ex-
posed, then separating  the cheek  from above  downwards, the morbid
mass was removed.  The  jaw-bone was denuded to the extent of about
an inch, near the posterior angle, but only slightly carious.   In this
operation, almost the whole of the digastric muscle, anteriorly and poste-
riorly, all the sub-maxillary gland, part of the mylo-hyoideus, and stylo- 
DR. MOTT ON  ANEURISMS.
933
 hyoideus muscles, were removed.   The venous hemorrhage was very
 great from the large size of the veins, which returned the blood from the
 tumor ;  they were visible upon  the  surface of the tumor.  Only three
 arteries were divided ;  the  labial, and  two smaller branches; one ap-
 peared  to be a branch  of the superior thyroidal, and the other of the
 occipital.  They bled very little.
   The operations occupied about one hour and fifteen  minutes, and the
 patient lost perhaps nearly thirty ounces of blood, mostly venous.
   6 P.  M.—The patient is somewhat exhausted by the loss of blood and
 the exertion he has been obliged to use during the day:  complains of a
 good deal of pain in the wound, and  has some difficulty in swallowing;
 he is also subject to a cough, which now becomes  exceedingly  trouble-
 some ; pulse feeble, small, and frequent; skin hot and dry.  Is  directed
 to take of Tinct. Opii. gtt. lx.
   Nov. 15, 9 A.  M.—Has rested well during the night, and is comfort-
 able when not disturbed by the cough ; has taken very little nourishment,
 in consequence  of the  difficulty  of  swallowing ;  skin is natural; pulse
 less frequent, and fuller ;  tongue does not manifest  any febrile  disposi-
 tion.
   12£ P. M.—The difficulty of swallowing food and the  cough  are the
 only unpleasant symptoms under which the patient labors.  Directed an
 anodyne draught  in the evening.  Contrary  to direct injunction, the
 patient left his bed and walked across the floor.
   Nov. 16, 12 o'clock.—Patient passed a comfortable night, and is con-
 siderably better this morning.  State of pulse and skin  favorable ; tho
 former rather feeble ; has had an evacuation from his bowels  spontane-
 ously ; is directed to take  as much nourishment as the state of his throat
 will permit;  is allowed a bottle of ale.
   Nov. 17, 12 o'clock.—The inflammation  which rendered  deglutition
 so difficult, has in  a great measure  abated ; he is now able to take a
 sufficient quantity of nourishment, in consequence of which his  pulse is
 better, and his whole  appearance has improved;  he is now  allowed, in
 addition  to the ale, a little wine.  Suppuration had softened  the dress-
 ings, and they appeared loose, in consequence of which  they were re
 moved and the wound dressed.   Its appearance is rather more favorable
 than was anticipated ; but the whole of the  disease is by no means re-
 moved.
   The extent of the wound in length  is six inches, and  three in width.
 There is a small black slough just where the tumor was first discovered;
 below that and the chin, there is a cluster of exuberant granulations,
 somewhat resembling those situated on the  edges of the opening of the
 tumor.
   The wound made for taking up the carotid artery is very florid; there
is  a slough at the bottom, which is becoming loose ;  its  edges are highly
inflamed  by the acrimony of the discharge from the wound above, which
is  constantly running into it.
   Nov.  18, 12  o'clock.—The patient is improved, he takes solid food
with more facility, and is in every respect more comfortable.  The wound
was again dressed ; its general appearance is somewhat more favorable;
 the discharge is very acrid, and excoriates  the parts about the lower
 wound.   He is directed to take freely of ale and wine. 
934
NEW ELEMENTS OF OPERATIVE SURGERY.
   Nov. 19, 12  o'clock.—Patient is still improving ; the  wound was
again dressed;  directed a lotion  of 5 ij« of Fowler's solution of arse-
nic, in § viij. of water, to be applied to the exuberant and spongy gran-
ulations.
   Nov. 20.—The wound is improved ; patient is also comfortable ;  ap-
petite is good ;  bowels costive ;  is directed to take, immediately, Rhei.
palmat  9j. and Sup. tart, potass. 9ij.,  and to continue the  other pre-
scriptions as before.
   Nov. 21, 12 o'clock.—Discharge  is more abundant, and  has  inflamed
the lower wound considerably, and  excoriated  the  parts  about it;  his
general appearance is better ;  cough still troublesome, more particularly
at night; bowels free ; no febrile symptoms.
   Nov.  22, 12 o'clock.—The upper wound  is much contracted,  the
posterior part  of it  is granulating  and  cicatrizing rapidly; the lower
is still very much inflamed, and rendered extremely sensitive by the dis-
charge of the other ;  directed to cover the upper wound with flour and
lint, and to take the  Spermaceti mixture whenever the cough is urgent.
   Patient is improving, and would be very comfortable if not disturbed
by the cough which prevents him from resting  well.

                               (Plate 1.)
  This plate will convey a very good idea of the tumor.  The shaded part is intended to rep-
resent the disease far beyond the ulcerated, or fungous projections.  It was wished to avoid
all the morbid hardness  in the incision, and as the  dottel lines will  show, th'n was very
nearly accomplished. The cutaneous veins anterior to the ear, are seen much enlarged, and
the arteries and veins on other parts of the tumor, and around it were in a  very distend-jd
state. 
DR. MOTT ON ANEURISMS.
935
  Nov. 23, 9 A. M.—Patient has not rested well, cough exceedingly
troublesome; pulse still feeble ; dressings were again removed; the wound
above looks well ;  the lower is very much irritated by the discharge, its
edges are highly inflamed, aud bleed upon  a slight touch ; his  appetite is
good, and he takes sufficient quantity of nourishment, with wine and por-
ter ; is directed to take in addition to the other remedies, Tinct. Cinch.
§ ss. every two hours ; the upper wound is granulating rapidly; all the
old sloughs are removed;  the  ligatures have  all come away ; the sup-
puration  has the appearance of healthy pus, but is extremely acrid ;  has
no foetor.
  Nov. 24.—Patient is in a fair  way to do well.   The cough remains by
far the most  troublesome  symptom he has; it frequently prevents  him
from sleeping, and irritates the  wounds by the motion it occasions; his
general appearance is however improving, his appetite is  good, and he is
subject to no pain.   The wound is dressed daily ;  its appearance is highly
flattering ;  the whole surface now is florid, since the sloughs are removed  ;
the granulations, are, however,  spongy on the anterior part,  but  at the
other parts they  are  perfectly  healthy ; the lower wound is less highly
inflamed, and the discharge is  considerable, but less acrid.
  Nov. 27.—The patient is perhaps a little better than at the last report;
cough is still frequent, and renders him restless at night; it is now attend-
ed  with  a copious expectoration ; deglutition is less difficult, and his
appetite is  reasonably good ;  he has  been constantly free from  fever,
though his pulse still frequent.
  The  wounds are dressed daily;  the lower edge of the upper wound is
contracting rapidly ;  along the upper  edge there is a range  of exuberant
and morbid  granulations, projecting a quarter of an inch  above the skin,
partaking somewhat  of the character  of the original fungus.
  The  ligatures on the carotid came away to-day, adhering to the portion
of artery included between them, and separating nearly  half  an inch of
artery  from the points at which they were applied.
  jVby. 30.—Patient continues to do well; his health generally is much
better  than before  the operation ; he is  not  as strong,  but is  in every
respect more comfortab]^; the cough is an  accidental  thing, and in no
way necessarily  connected with  the  consequences of the operation ; it
gives him more uneasiness at present, than the wounds themselves.
  He prefers a sitting posture in bed and is supported in that posture by
a bed-chair.  All his symptoms continue favourable, but his  improvement
is very gradual.
  The  wounds have  not altered much in their appearance ; the acrid
discharge from  the  upper, operates very  much against  the amendment
of the  lower, and the granulations have somewhat the character of the
original  tumor, bleediug upon the slightest  touch, and  are exquisitely
sensitive.
  Dec. 7.—Patient has not been as well as usual; cough prevents him trom
sleeping, and the motion produced by it irritates the wounds ; expector-
ation is"very considerable ; he seems to be depressed and anxious.  The
discharge from the wound is less acrid, and has allowed the lower wound
to get into a much better state ;  it is now completely filled up ; the gran-
ulations  are, however, flabby, and do not appear  inclined to cicatrize.
The surrounding parts are not so florid and sensitive as they have been. 
936
NEW ELEMENTS  OF OPERATIVE SURGERY.
    His neck is drawn considerably to one side, and he is unable to move
  it;  he thinks it partly owing to its resting constantly in one position on
  the bed-chair.   Is directed to lay in a recumbent posture, and occasional
  ly to leave his bed and  sit  in an easy  chair; appetite not so good as
>  usual.
    Dec. 15.—The patient has recovered a little from his late indisposition ;
  the  stiffness of the neck still remains ; appetite good ; an  anodyne pro-
  cures him rest at night; the upper wound not improved much ; the mor-
  bid granulations  are at least half  an inch above the skin, and in some
  places a little higher;  he leaves his bed daily and passes several  hours
  in an easy chair.
    From this time, his health appeared to bo  gradually on the decline.
  The lower wound in a little while healed up ;  the upper underwent but
  little alteration from this time forward.   The cough continued to be very
  troublesome, the expectoration very copious, and  evidently purulent.
  He  became  regularly hectic, accompanied  with great emaciation, and
  died on the 3d of March,  1819, having  lived three months and nineteen
  days after the  operation.

    It will be  perceived, from the account of this case, that the cough
  was aggravated by the operation, but not  produced  by it.   In three in-
  stances  in  which  we have seen the carotid  tied, a very considerable
  cough has attended, until suppuration was fully established in the wound,
  when it has subsided.  My  patient laboured  under a cough before  tho
  operation, and there was a  manifest  increase of it for a week or more
  after its  performance, but  it by no means was the  cause of its contin-
  uance, as the dissection after death will evince.  The hectic  symptoms
  arose from the diseased condition of the  mucous membrane of the trachea
  and its  bronchial ramifications, rather  than  the  irritation  of the ulcer
  left from the operation.   His death may therefore, with more propriety,
  be attributed to the pulmonary, than the fungous disease.

                             Dissection.

    The carcinomatous granulations had risen a nttle above the surround-
  ing surface ;  the size of the ulcer had considerably contracted since the
  operation ; the lower jaw  was exposed to  some extent about the posteri-
'  or angle, but very little carious.
    On opening the thorax,  the lungs appeared  externally to  be in a
  healthy state, with  the exception of several adhesions of one lung to the
  pleura costalis.  Upon dividing  the trachea a little above the bronchia?,
  it was found nearly filled with pus ;  the lungs, when cut into, exhibited
  the same appearance at innumerable points,  without  the least vestige of
  ulceration at any part.  The  mucous membrane was rough, and thick-
  ened in  the trachea, and also in the bronchial ramifications.
    The abdominal viscera were sound, except the kidneys.  In the tu-
  bular part of each was found a small abscess about the size of a nutmeg,
  apparently containing a healthy looking pus.
    As this afforded me an excellent opportunity of examining the arteries
  on the right side of the head and neck, after the carotid had been tied;
  and  not knowing that any such case had been recorded, I gladly availed 
DR. MOTT ON ANEURrSMS.
937
I availed myself* of it, and separated the head, neck, and shoulders, in
the following manner :
  Having sawed through the sternum at the upper part, so  as to leave
the clavicles attached, the  superior extremities were  removed from the
trunk, and the dorsal vertebras and ribs divided between the second and
third, so as to leave it of a bust-like shape.  This preserved the shoulders
in such a way that the subclavians and their branches might be injected.
The ascending arch and a portion of the descending aorta were also in-
cluded in the preparation.
  To  secure the filling of the arteries of the head and neck, a long pipe
was passed up the aorta into the left carotid, and a fine wax injection was
thrown in with  great care, and, as the  subsequent  account will show,
with great success.   The aorta was next injected to fill the subclavians
and their  branches.   In the  dissection, which was conducted with  the
greatest care  and attention, I was assisted  by David  L. Rodgers and
Alexander F. Vache, two of my pupils, ardent  in the  pursuit of anatom-
ical and surgical knowledge.
  The following description  of arteries of the head  and neck is taken
from  the preparation, and they are delineated  as far as possible in the
annexed engravings.
1st.  The arteries that supplied the right side of the head and neck after
                the carotid had been tied.   See plate II.

  To give a regular description of these arteries, would be incompatible
with the principle of collateral circulation—inasmuch as they are found
to vary in different subjects, for " the inosculation is never carried on by
any  particular set of vessels, but by all the arteries of the neighboring
parts."
  Upon removing the integuments on the fore-part of the neck, and lay-
ing bare the carotid artery from the innominata to the angle of the jaw,
its calibre was found completely obliterated from its origin to its bifur-
cation ; leaving a  firm, ligamentous  cord,  which was divided into two
parts,  showing the place where the ligatures had been applied.
  The vein and nerve  were perfectly natural.   The right subclavian was
much enlarged, being equal in size to  the innominata, from its origin to
the scaleni muscles.
  The  left carotid  was enlarged to  twice its  natural diameter ; its
branches increased in the same ratio, and assumed a tortuous and irregu-
lar course.
  When we take into consideration the connection which the arteries of
the left have with those of the right side of the head, and their free inos-
culation with the subclavian, we can have in our imagination the branches
that must necessarily supply  the  place  of the  right carotid.  First, we
have the branches  arising from the subclavian, which are very numerous ;
secondly, those  arising from  the left  carotid, which are still more nu-
merous.
  A minute detail of the numerous vessels which communicate with the
carotid, would be tedious and uninteresting, and would perhaps tie im-
practicable, were it deemed expedient.   Suffice it to notice the principal
  Vol. I.                   118 
938
NEW ELEMENTS  OF  OPERATIVE SURGERY.
branches, and to give a  general description of the  smaller, but not less
beautiful inosculations.   We find, then, arising from the right subclavian,
first, the arteria thyroidea  inferior ;  secondly, the  cervicalis  profunda  ;
thirdly,  the  cervicalis superficialis ;  and  fourthly, the vertebral arteries.
   The inferior  thyroid, as  it arises  from  the  subclavian, divides  into
four branches—two passing downwards and outwards, and the other two

                                     (Plate 2.)
  In this plate  is represented the right carotid artery, obliterated from the innomihata to the
bifurcation.  The success with  which the circulation was carried on to the head through the
inosculating channels, may also be seen in the enlarged anastomosing branches.
  Fig 1. Right bronchial tube.              Fig. 6. Thyroidea ascendens.
   2. Aorta.
   3. Arteria Innominata.
   4. Ramus thyroideus arterisB thyroidese.
   5. Sterno-cleido mastoideus.
a Transversalis colli.
7. Scalenus anticus mus cle.
"8. Subclavian artery, after it  has  passed
      the scaleni muscles.
9. Transversalis humeri of its natural size.
b Cervicalis superficialis et profunda.
c Portion of the carotid separated by the ligatures.         d Obliterated carotid.
e Superior thyroidal artery. /Inferior portion of the labial as divided in the operation.
g Mental artery.       h Superior portion of the labial, where tied in the operation.
i Plexus of arteries formed by inosculations of  the ascending thyroid, and a  descending
      branch of the occipital.              k Descending branch of the occipital.
I External carotid filled with injection. 
DR.  MOTT ON ANEURISMS.
939
passing upwards ; the latter  are  called  the ramus  thyroideus, and the
thyroidea  ascendens.   These require particular attention from their large
size, and the important supply of blood which they furnish for the support
of  the arteries of the neck.   While the superior arteries were enlarged
to twice their natural diameter, the two inferior ones, viz., the transver-

                                    (plate 3.)
  This plate will give some idea of the success which attended the injection of the left  side of
the head and neck  Most of the more considerable vessels are here delineated, but i he beauty
of the preparation far surpasses the plate, in the minuteness with which the vessels are filled.
All of these are preternaturally enlarged.  Only a few of the arter.es which are mo,te.jlarged,
will be referred to in the explanation of this plate.   There is no variety m the course or dis-
tribution of the arteries.                         .         .
  Fig. 1. The two portions of the sterno-cleido mastoideus muscle.
      2. Left carotid artery, as large as the innominata.
      3. Left subclavian artery, external to the scaleni muscles.
      4. Superior thyroid artery.
      5. Labial artery much enlarged.
      6. Mental artery twice its common size.
      7. Par vagum raised up, and seen crossing the carotid artery.

   This tautit^pre^arSn is still in fine preservation in my museum at the Medical College
of the University. 
940
NEW ELEMENTS  OF OPERATIVE SURGERY.
salis colli, and the transversalis humeri, although arising from the same
trunk, and receiving their currents of blood in the  most favorable direc-
tion, still retain their natural dimensions.  But this phenomenon usually
occurs in the  circulating system.  John Bell  observes, " that  in what-
ever way the demand of blood  upon  an artery  or set of arteries is in-
creased, the effect  is an  accelerated motion of blood towards that ar-
tery."  And again, " any demand of blood causes an enlargement of the
arteries leading to the part which demands the blood."
   Guided then by this principle, we need not be surprised that the sub-
clavian is so much enlarged from its  origin  to the scaleni muscles; for
here it affords a supply of blood to new and important parts.  The ra-
mus thyroideus passing upwards to  the thyroid gland, and anastomosing
with the superior thyroidal artery, was one great source of blood ; its
branches mere large and tortuous, forming communications in every
direction, with those from above.
   The thyroidea ascendens is naturally a small and unimportant branch ;
it  was here three times  its usual size,  mounting up  the neck in a zig-zag
direction, lying close to the vertebrae, forming frequent communications
with the vertebral  artery, dividing into many  small branches  at  the
upper part of the mastoid muscles, forming a beautiful plexus of vessels,
with the mastoid branch of the occipital artery, and sending branches to
all the muscles on the upper part of the neck.
   The cervicalis profunda and superficialis were  much enlarged, sending
frequent branches upwards to anastomose with the descending branches
of the occipital artery.   By far  the most important and interesting part
of the circulation yet remains to be described.


     2dly.   The arteries of the left side of the  head and neck.
                           See plate III.

   The left carotid  passing up the neck equal in size to the innominata,
furnished the greatest part of the blood for the right side.
   In order to determine what particular arteries  were enlarged, it is
necessary only to enumerate the  branches given off  from  the carotid, and
more particularly those which  arise from its forepart.  Below the jaw
there  are four: to wit,  the superior  thyroid, the  lingual,  pharyngeal,
and the maxillaris  interna, which inosculate with  open mouths, having
the appearance of continuous  trunks,  and sending a plentiful supply of
blood to the neck and internal parts of the face.
   The labial and temporal arteries leaving the axilla under the angle
of the jaw, and passing upwards upon the face, send off small branches
in  a beautiful  and fantastic manner.  Branches  which before were con-
sidered unworthy the attention  of the anatomist, now rise into impor-
tance.   The plexuses and inosculations formed by these branches, excite
alike our surprise and admiration,  and elucidate, in the most beautiful
manner, the principles of collateral  circulation.  These  arteries, in gen-
eral, are large and tortuous, and have frequent  communications among
themselves.   The arteries  most enlarged were  the mental, the inferior
labial, the coronary, and the angularis.  The optic artery was likewise
much enlarged, beautifully anastomosing with the angularis. 
DR. MOTT ON ANEURISMS.
941
  So freely did these arteries  inosculate with  those of the right side,
that before the operation was finished  it was found necessary to secure
the labial artery in a ligature.  This was clearly illustrated by the retro-
grade course of the injection, after  death, which passed  freely from thg
arteries of the opposite side, filling the superior  portion of  the labial, to
the point at which the ligature  had been applied.  The temporal artery
was of its natural size, receiving its blood from  " all the arteries of the
neighboring parts," from the ascending branches of the  occipital, the
left temporal, the ophthalmic, and the transverse facial.  This free com-
munication was distinctly shown by the  injection, which, passing down
the temporal, completely filled  the external and internal  carotids, and
several of their branches ; particularly the inferior portion  of the labial,
which is seen emerging from under the jaw, to pass upon the  face.   The
labial terminated at that point where the mental is given  off.   The men-
tal  itself passed on to  its usual destination,  and received blood from its
fellow of the opposite side.
  All of these  arteries will be easily  seen, and readily recognized, by
referring to the plates.
No.  III.—March 15,1827.—First Successful Case of Ligature upon
  the Primitive Illiac Artery,  for aneurism.   By Valentine Mott,
  M. D., Professor of  Surgery, N. Y.  (See  the American Journal of
  the Medical Sciences, Philadelphia, 1827, vol. I., p. 156-161.)

  A detailed account  of the  first operation ever performed  upon the
arteria iliaca communis, for the cure of aneurism, and especially of the
first attempt*to apply the ligature to so great a vessel, without dividing
the peritoneum, may prove interesting to the profession generally, and
must be immediately serviceable to practitioners of surgery.  It is there-
fore as an act of duty, rather  than of choice, that the following state-
ment has been prepared, during such a few  and brief intervals of leisure
as could be  obtained amid the daily engagements and solicitudes of busi-
ness.
  On the 15th of  March, 1827, I was requested to visit a patient with
Dr. Osborn, (of Westfield, New Jersey, about twenty-five miles distant
from New York,)  whom we found laboring under  a large aneurism of
the right external iliac  artery.
  Israel Crane,  aged thirty-three years, by occupation a farmer, of tem-
perate and  regular habits,  having generally enjoyed  excellent health,
says about the middle of January he felt some pain about the lower part
of the belly, which he  attributed  to a fall received during the winter.
He is in the habit of using great efforts in lifting heavy logs of wood, as
his employment  at this season consists in carrying wood to market.  It,
however,  was not until a fortnight since, that he perceived any tumor
about the lower part of the abdomen.  Upon examination, the  abdomen
on the right side was considerably enlarged from about the  crural arch,
as high  as the umbilicus.  When  the hand  was applied  to  the parietes
of the abdomen, a pulsation was felt and rendered visible to  some dis-
tance.  To  the touch the tumor beat violently, and  appeared to contain
only fluid blood.  It commenced a little above Poupart's ligament, and 
942
NEW ELEMENTS  OF OPERATIVE SURGERY.
reached, judging by the touch, from without, near  the  navel—inwards,
almost to the linea alba— outwards and backwards filling up all the con-
cavity of the ilium, and reaching  beyond the posterior spinous process
of that bone.
   The rapid increase of this aneurismal tumor occasioned, as the coun-
tenance of our patient indicated, the most extreme agony.   His suffer-
ings at  times were  so  great that  his screams could be  heard at  a dis-
tance from  the  house.   He  had been  bled  several times, taken  light
food, and was kept constantly under the effect of opium.  He was now in-
formed of the serious nature of his  case, and  that without  an operation
very little chance of his life remained ;  with  great composure he imme-
diately  consented  to whatever  would  give him the best prospect of
saving his life.
   From the extent and  situation of the tumor, he was apprised of the
uncertain nature of the operation, as well as the difficulty of performing
it, and indeed that it would require an artery  to  be  tied,  which  never
had before been operated upon for  aneurism.   With these views of his
situation, he cheerfully submitted  to be placed  upon a table of suitable
height, in a room which was well lighted.
   Then, in  the  presence of Dr.  Osborn, Dr. Liddle, and Dr. Cross, the
following operation was performed:—
   The pubes and groin of the right side being  shaved, an  incision was
commenced just above the external abdominal ring, and carried in a semi-
circular direction  half  an inch above Poupart's ligament, until  it ter-
minated a little beyond the anterior spinous process of the ilium, making
it  in extent about five inches.   The integuments  and superficial  fascia
were now divided, which exposed the tendinous part of  the external
oblique  muscle, upon cutting which, in  the whole course of the incision,
the muscular fibres of the internal oblique were exposed ; the fibres of which
were coutiously raised with the forceps, and cut from the upper edge of
Poupart's ligament. This exposed the spermatic cord, the cellular covering
of which was  now raised with the forceps, and divided to an extent suffi-
cient to admit the fore-finger of the left hand to pass upon the cord into the
internal abdominal ring. The finger serving now as a director, enabled me
to divide the  internal oblique and transversalis muscles  to the extent of
the external incision, while it protected the peritoneum.  In the division
of the last mentioned muscles outwardly, the circumflexa ilii  artery was
cut through, and it yielded for a few minutes a smart bleeding.   This,
with a smaller  artery upon the  surface of the  internal oblique muscle,
between the rings, and one  in  the integuments were  all  that required
ligatures.
   With the tumor beating furiously underneath, I now attempted to raise
the peritoneum from it, which we found difficult and dangerous, as it was
adherent to it in every direction.  By degrees we separated it with great
caution  from  the aneurismal tumor, which had  now bulged  up very much
into the incision.   But we soon found that the external incision did not
enable us to arrive to more than half the extent of the tumor upwards.
It was therefore extended upwards and backwards about half an inch
within the ilium, to the distance of three inches, making a wound in all
about eight inches in length.
   The  separation of  the peritoneum was now continued, unti^ the fin- 
DR. MOTT OX ANEURISMS.
943
 gers  arrived  at the upper part of the tumor, which was found to termi-
 nate at the going off of the internal iliac artery.   The common iliac was
 next examined, by passing the fingers upon the promontory of the sacrum ;
 and to the touch appearing to be sound, we determined to place our liga-
 ture upon it about half way  between the aneurism and the aorta, with a
 view to allow length of vessel enough on each side of it to be united by
 the adhesive process.
    The  great  current  of blood through the aorta madeit necessary to
 allow as much of the primitive iliac to remain between it and the  liga-
 ture as possible, and the  probable disease of the artery higher than the
 aneurism, required that it should not be too  low down.  The depth of
 this wound, the  size of the aneurism, and the pressure of the intestines
 downwards by the efforts to bear pain, made it almost impossible to see
 the vessel we  wished to tie.   By the aid of curved  spatulas^ such as I
 used in my operation upon the innnominata, together with a thin, smooth
 piece of board, about  three inches wide, prepared at the time, we suc-
 ceeded in  keeping up  the  peritoneal mass,  and getting a distinct view
 of the arteria iliaca  communis, on the side of  the sacro-vertebral  pro-
 montory.   This  required  great effort  on our part, and could only be con-
 tinued for a few seconds.  The difficulty was greatly augmented by the
 elevation  of the aneurismal  tumor, and the interception it gave to the
 admission of light.
    When we elevated the pelvis, the tumor obstructed our sight; when
 we depressed  it, the crowding down of the intestines presented another
 difficulty.   In this  part of the operation I was  greatly assisted by Dr.
 Osborn and my enterprising pupil, Adrian A. Kissam.
   Introducing my right hand now behind the peritoneum, the artery was
 denuded with  the nail  of the  fore-finger, and the needle conveying the
 ligature was introduced from within outwards, guided by the fore-finger
 of the left hand  in order to avoid  injuring the vein.   The ligature was
 very readily  passed  underneath the  artery,  but considerable  difficulty
 was experienced in  hooking the eye of the needle, from the great depth
 of the  wound and  the impossibility  of seeing it.  The distance of the
 artery from the wound was the whole length  of my aneurismal needle.
   After drawing the ligature under the artery,  we succeeded, by the aid
 of our spatulas and  board, in getting a fair vew of it, and were satisfied
 that it was  fairly under the primitive iliac, a  little below the bifurcation
 of the aorta.   It was now tied—the knots were  readily conveyed up to
 the artery by the fore-fingers—all pulsation in the tumor instantly ceased.
 The ligature upon the artery was very little  below a point opposite the
umbilicus.
   The wound was now dressed with five interrupted sutures, passing them
not only through  the integuments, but  the fibres of the cut muscles, so as
to  bring their divided edges together  at all parts of the incision, which
was muscular.  Adhesive plaster to  assist  the  stitches, and lint  and
straps to retain it, completed the dressing.  The operation lasted rather
less than one hour. *

 * Dr. Gibson, then professor of surgery in Baltimore, was near the spot during the riots in
that city, when a man was wounded by a musket ball, " which entered the left sfde of the ab-
domen, passed through the intestines  opened the iliaca communis artery, and lodged in n»>
sacrum."  The doctor states, ««thrusting into it (the wound) the fore-finger of  my left hand 
944
NEW ELEMENTS OF OPERATIVE SURGERY.
   He was removed from the table and  put into bed upon his back, with
 the knee a little elevated upon pillows, to relax the limb as much as pos-
 sible, and to avoid  pressure  upon it.   It was considerably  cooler than
 the opposite leg, and  flannels were  applied all over it, and a bottle of
 warm water to the foot.  From the habit he had been in of taking largely
 of anodynes, a  tea-spoonful of the tinct. opii: was administered, with
 directions to repeat it in an hour if the pain should be severe.
   In less than one hour from the operation, considerable reaction of the
 heart and arteries took place; he felt,  as he stated, altogether relieved
 from the excruciating agony he  had suffered  since the aneurism com-
 menced.   The whole  limb had now recovered its natural temperature.
   March 16th.—The  day after the operation, pulse eighty—skin moist—
 limb warm as the other—complains of some pain at the ligature—ordered
 a purgative of neutral salts.
   11th.—Pulse eighty, and  fuller  than  yesterday—trok  5 x of blood
 from  his arm—skin moist—tongue  brown—considerable uneasiness in
 the limb—no pain at  the ligature—leg of natural heat—salts had a
 good effect.
   18//i.—Pulse  seventy-five—skin  moist—tongue  white—pain in  the
 limb considerable—no pain at the ligature or in the wound—limb warm.
   l§th.—Bled him to-day to  ten ounces, the pulse being tense and beat-
 ing  eighty strokes  in a minute—repeated the cathartic—suppuration
 appearing to have taken place, the dressings were removed.
   20th.—Pulse seventy and soft—skin  mist—wound  looks  well—pain
 in the limb continues—leg warm as the other—cathartic operated well.
   21st.—Pulse seventy and soft—wound looks  well—repeated the lax-
 ative—pain in the leg  rather less—continues  warm.  There has been at
 no time  tension  of  the abdomen, or any particular uneasiness in that
 part.  The patient thus far has been  altogether more  comfortable  than
 could have been imagined.  He takes more or less opium daily, from the
 long habit he has been in of taking anodynes .
   26th.—No unpleasant symptoms—wound looks well—bled again to §
 xij,  as there was a little tumefaction and inflammation about the wound.
   30th.—Our patient continues to do well—wound dressed daily.
   April 3d.—Not being able to leave the city, I requested Dr. Proudfoot,
 my late pupil, and a most promising young surgeon, to visit the  patient.
 He  reports that he was free  of fever—wound all healed but where the
 large  ligature  was  passing.   The ligature appearing  to be detached,
 the  Dr. took hold of it and removed it:  this was on the eighteenth day
 from the time of its  application.  Limb of the natural temperature—
 enjoined  upon him to keep very quiet and in bed.
   Sth.—There  are no disagreeable appearances whatever—he  appears
 to be doing remarkably well—has been bled once since the last report—
 takes a purgative  every other day, and  an opiate every night—pulse as
 in health—no pain—says he is entirely comfortable—wound is  dressed
 withdry lint.

 I discovered that a very large artery had been torn across, and was pouring out blood in con-
 siderable quantity."  The man died in a few daj*s.  " Upon inspecting the vessels  of the ab-
domen," says the doctor, " I found that I had placed two ligatures  upon the common iliac ar-
 tery of the left side, one about half an inch below the bifurcation of the aorta, and the other
immediately above the division of the artery, into the external and internal iliacs."  S*^
Medical Recorder, Vol. III., p. 185. 
DR. MOTT ON ANEURISMS.
945
  16^.—Has  improved rapidly since the last report.  Two days after
the ligature came away, he very imprudently got out of bed, without
experiencing any difficulty except weakness.  Rode out to-day—wound
perfectly healed.
  April 26th.—He has been using crutches for a few days to favor the
lame  leg, which, as yet, feels rather weak.   General health greatly im-
proved.
  30th.—Is  perfectly restored in health—has a little stoop in his walk,
which he  says  is occasioned by the  external cicatrix.  Leg is not yet
of its full size, nor quite so strong as the other.   From the period of the
operation to the recovery of our patient, he did not appear to suffer more
pain,  or have more unpleasant symptoms, than would ordinarily take place
in a flesh wound of equal extent.  Much of this, in my opinion, is to be
attributed to the prompt and judicious antiphlogistic treatment pursued
by  Dr. Osborn, to whom I  am indebted for the daily  reports of the
case.
  May 29lh.—My patient visited me to-day, having come twenty-five
miles ;  he was so much improved in health that I did not recognize him.
Examined the cicatrix, and found it perfectly sound—could not discover
any remains of aneurismal  tumor—felt the epigastric artery much en-
larged and beating strongly,  and feeble, though distinct pulsation in the
femoral artery immediately below the  crural arch.   The leg has its natu-
ral temperature and feeling, and he says it is  as strong as the other.
  Much credit is due the patient for his firmness on the occasion; although
apprised of the great danger attending so formidable an experiment, and
the uncertainty of its results, yet, with a fortitude unshaken, and a full
conviction that it was  the only chance of prolonging his life, he cheerfully
and resolutely submitted to the operation.
  The  gratification his visit afforded me is not to be imagined, save by
those  who have been placed under similar circumstances.  The perfect
success of so important and novel an operation, with the entire  restora-
tion of the patient's  health, was a rich reward for the anxiety I expe-
rienced in the case, and in a measure compensated for the unexpected fail-
ure of my operation on the arteria innominata.
  This  patient very  recently paid me a visit, and  is up to the present
moment, (December, 1845,) in the enjoyment  of excellent health, and
pursuing his occupation of carpenter.
No. IV.—Septemrer 26th, 1829.   The Brasdoreal, Distal, or Anti-
  Cardial operation  for Aneurism  of  the Arteria  Innominata
  involving the Subclavian and the root of the Carotid, success-
  fully   performed by  tying the Carotid Artery.   Bv Valentine
  Mott, M. D., &c.   (See the American Journal of the Medical Sciences
  Philadelphia, 1829, Vol. V., p. 297-300.)                        '

  Notwithstanding the tone of decided reprobation and ridicule with
which  Allan Burns*  expresses himself concerning Brasdor's proposi-
tion to apply the ligature upon the anticardial side of certain aneurismal

                  * Surgical Anatomy of the Head and Neck
  Vol. I.                  119 
946
NEW ELEMENTS OF OPERATIVE SURGERY.
tumors, and the numerous arguments urged  against the revival of his
operation by  some professional critics of considerable authority, expe-
rience seems  to  have shown that it is not only safe, but in some cases
superior to the Hunterian mode of treatment.   Some of the cases in which
the operation on the anticardial side of the tumor has been lately perform-
ed in Europe, are said to have proved successful ;* and I am gratified to
have  it in my power to add another instance of its success in perhaps
the first case, in which this operation has been performed in America.
  Moses R. Gardner, aetat.  51, by profession a farmer, of sound consti-
tution and good habits of life, applied to me some time in March for ad-
vice.
  He gave the following relation of his case :—About three years ago,
while occupied in removing a building, and compelled to lift heavy weights
he  was attacked with pain  in the  upper and back  part of the  neck.
This lasted  until the  month of January, when it extended to the right
shoulder and arm, and continued until the following May;  it then par-
tially subsided, and he observed his voice was becoming hoarse, which
he attributed to exposure and consequent cold.   About eighteen months
since, while shaving, he discovered a small swelling at the upper part of
the breast bone, but did not remark any throbbing in it until some time
afterwards.   He  had consulted a physcian, but received  no positive
opinion on the case.
   Upon examination, I found above the sternum a pulsating  tumor,
about the size of a pigeon's egg, spreading some  distance under the cla-
vicular and sterna' portions of the right sterno-mastoideus muscle, in the
course of the  subclavian artery, and extending as low down upon the
pleura as the second rib, compressing more or less the bronchial  tubes,
and producing on the least  coughing or exercise a wheezing, not  unlike
that of asthma.   He shrunk from the least pressure upon it; complain-
ing of impeded respiration, followed by pain.  Its pulsations were syn-
chronous with those of the heart, and decidedly aneurismal.
  After fully explaining to him the nature of his disease, and its prob-
able fatal termination, should it increase and be  left to itself,  I advised
him to return home ; to avoid all exertion; to be occasionally bled, and
to confine himself principally to a vegetable diet; but should he observe
the least increase, either of the tumor or any of his symptoms, to come
again to me, and I would decide on the propriety of an operation.
   After that time, I occasionally saw him ; he seemed to understand his
case fully, and was  very desirous  to take the chance of the operation ;
but as I could not observe any material change in the disease, I recommen-
ded him to pursue the same  directions, and wait patiently until it should
occur.
   On the 12th of September he again came to the city.   I  found the tu-
mor  above  the  sternum had increased to  the  size  of a large  walnut,
and upon a careful application of the  stethoscope, it was  evidently en-
croaching more upon the chest.  The whizzing sound, (bruit de soufflet)
could be heard ;  the thoracic viscera were sound, the respiratory murmur
being distinct throughout.   His respiration was very much impeded by
 speaking, walking, or coughing, and almost entirely suspended  by the
* See Wardrop on Aneurism.  London, 8vo. 1828. 
DR. MOTT ON ANEURISMS.
947
 least pressure upon the tumor; the action of the right carotid was much
 more feeble than that of the left; no pulsation could be  discovered in
 its branches ;  the right subclavian external to  the scaleni muscles was
 natural, while the axillary and brachial arteries could hardly be felt;
 at the wrist no  pulse  could be found ; the  pulsations of the arteries of
 the left side were natural.   His general  health was good.
   In reflecting upon this case, and comparing the relative situation of the
 parts, I was  persuaded the aneurism was of the arteria innominata, in-
 volving the subclavian and the root of the carotid ; having formed this
 conclusion, I considered it a proper case for the operation proposed by
 Brasdor, and  recently so  ably revived, and first successfully performed
 by the distinguished' Wardrop, whose scientific researches and master-
 ly views  of this subject, have since been so fully confirmed by himself
 and  others.
   I thought further delay unnecessary,  and the patient being willing to
 abide  by my  judgment, after having stated to him the chances of the
 operation,  I resolved on its performance.  From the evident interruption
 in the circulation of the right arm, and  the  apparent effort of nature to
 effect a spontaneous  cure,  I determined  upon tying  the carotid first, to
 observe the result, and afterwards to secure the subclavian, should it be
 required.
   On the 26th of September I operated.  The arterywas taken up in the
 usual manner ; no material change was observed.
   21th.—9 A. M.  Slept well, and feels refreshed ; thinks  there is more
 room, as  he expresses  it,in  breathing;  complains of a little soreness
 of the tonsils in swallowing; pulse 58, regular and tranquil;  skin natu-
 ral, pulsation and size of the tumor evidently diminished.  9 P. M.  Much
 more restless  from mental alarm ; pulse 68, tense.  In other respects,
 the same  as in the morning ;  being habituated to laudanum, was permit-
 ed to take  a tea-spoonful.
   28th.—9 A. M. Slept well after  the opiate ; breathes  easily, and says
 he takes " a more satisfactory breath," than he did before the operation;
 feels  much  less of the  pulsation  in the  tumor ; pulse 63, not so tense ;
 skin natural;  cough much  less.   Ordered a dose of calcined  magnesia
 and  Epsom salts.  9. P. M.  Has passed a comfortable day ; his wife,
 who arrived from the country since the morning, expressed her surprise
 at the improvement of  his  voice and  breathing ; and  the  difference in
 the beating  of the tumor.  Pulse of the right radial artery very distinct,
 but intermitting once in every ten to fifteen beats; in the  left arm 80 ;
 cough frequently, and expectorates freely ;  skin natural; tongue a little
 white ; salts have not  operated.   Ordered  the dose to be repeated and
 if restless, after its operation, to take his usual anodyne.
   29//i.—Saluted me this  morning upon entering  his room, with a full
 and fine voice,  and said he was well enough to call  on me ;  salts  opera-
 ted freely ;  thinks his cough and expectoration much less.   I found him
 lying down, and  breathing  quietly ; pulse 71, and regular.  The radial
artery of the right arm  beating as last evening, with fewer intermissions
but of longer continuance;  skin over the tumor more wrinkled; pulsation
appears less, and feels weaker.  Directed to continue his tea,'toast and
gruel.  8  o'cloqjc.  As  well as in the morning ;  takes a full breath with-
out the least wheezing; pulsation in the  right wrist very distinct and
regular ; in  the left 62  to the  minute.   Continues the opiate. 
948
NEW ELEMENTS OF OPERATIVE SURGERY.
   30th.—Found  him lying  more recumbent than at any former period ;
 pulse 70, and regular ;  right radial artery does not beat quite so firm as
 yesterday ;  the wound discharging a little, was dressed.
   October 2d.—Says he now feels as if he would get well;  cough rather
 more troublesome; pulse 57; pulsation of the  right radial the same;
 his bowels not being free, directed  sub. mur. hydr. grs. viij.—sup. tart.
 potassse, pulv. jalapae, aaBj. Mix. Evening.  Medicine has not  operat-
 ed ; directed a dose of  sulphate of magnesia.
  3d.—Cough and bronchial effusion very much diminished by the ope-
 ration of the cathartic; pulse 68.
  4:th—Feels very well; passed a good night; all liis symptoms improv-
 ed ; pulse 74; can bear any  degree of pressure upon the tumor without
 the least pain or difficulty of breathing.
  10^/i.—Continues to mend, and is sanguine as to his recovery; pul-
 sation of the tumor hardly perceptible, and to the touch very much di-
 minished ; cough less troublesome ;  left pulse 66 ; right, very feeble.
  16^.—Ligature separated and came away last night;  the tumor above
 the sternum, and  pulsation  entirely disappeared ; cough and breathing
 better; voice  nearly natural; pulse 66 ; now and then a very faint pul-
 sation of the right radial artery ; right hand a little swelled, and feels
 numb, and the patient complains of  the want of power to close it.
  22d.—Wound just  healed; weakness of the arm very considerable ;
 fingers very thick and clumsy; arm swelled and  pits  upon pressure ;
 no  pulse  in the right radial artery ; breathing  very easy ; cough and
 expectoration  much less; can sleep easy in any position, which  he has
 not been  able to do for many months.
  26th.—Left town this morning for his residence in New Jersey.

  Second Report of Professor Mott's Case of  Aneurism, treated
  by tying the Artery ultra Tumorem.  (lb., Amer. Jour, of the Med.
  Sciences, Phil., 1830, Vol. VI., p. 532.)

  After  the return of Moses Gardner to the  country, he occasionally
 wrote to  me:  one of his letters stated, " his breathing was much  better,
 and his friends on calling to  see him, were suprised at the improvement,
particularly at the disappearance of the tumor."  On the 22d of April,
however, I received information of his  death, with  an invitation to ex-
amine the body : all that could be ascertained relating to the case, was,
that the  difficulty  of breathing had returned and at times  threatened
immediate suffocation ;  he had  confined  himself to the most abstemious
living, and gradually  declined  in general health.   The  dissection was
conducted by  my demonstrator, Dr. Vache, to whom I am indebted for
the  following particulars:—
  " Dissection.—On viewing the body, no tumor appeared externally:
the  right clavicle  was rather more  elevated  than that of the opposite
side, and on removing the integuments, it was found partially dislocated
from its sternal articulation, the under surface of which has undergone
considerable absorption from the pressure of the aneurism.  Immediate-
ly beneath, and imbedded in the surrounding  parts, was the tumor ; it
extended from the sternal extremity of the left clavicle„along the inner
 and upper surface of the sternum, to which it closely adhered, to about 
DR. MOTT ON ANEURISMS.
949
midway  of  the right clavicle, and passed as low down upon the pleura
as the third rib.  Laterally it was adherent  to the right lung, and pos-
teriorly rested upon the lower cervical and upper dorsal vertebra?.
  The trachea was greatly displaced;  it was closely attached to the left
side of the tumor, passing obliquely downward and backward, and very
much flattened by pressure.
  On removing  the tumor from  the body with  its connexions, it was
about the size of the two fists, and its parietes were found to be firmly
consolidated.   It emanated from  the arteria innominata, involving the
subclavian and the root of the carotid.   Superiorly it was of a globular
form, and inferiorly terminated  in an apex, which passed down below
the division of the trachea, and behind the  aorta.  The right  carotid
was obliterated, the right subclavian, beyond the tumor, was pervious
and natural in its structure.   The heart aud lungs were sound."
  On reviewing  briefly  the  circumstances of this  case, no one, I may
venture  to  observe, will attribute its fatal  termination to a  failure of
this form of operation,  or of the principles upon which it is founded.
The attending symptoms, as well as the dissection, fully prove the cause
of death to have been  the displacement of  the trachea, and the conse-
quent  pressure of the consolidating tumor  upon it and the bronchial
tubes.  The absence of pulse in the right arm, the oedema and the numb-
ness must also be attributed to  the pressure  of the  tumor.  Had the
operation been  performed at an  earlier stage of the disease, there is
every  reason to expect  it would have terminated successfully.  Should
I have another  opportunity, I will operate  without any delay, and tie
both vessels at the same time, and not leave one for a future performance,
to be decided upon by the effect of the first.
  It is perhaps  a little singular,  that a tumor of this magnitude, should
not have appeared much larger externally, for it  will be  recollected that
it never  exceeded  the  size of a walnut.  I am  happy to add,  that the
diagnosis for aneurisms of the vessels  of the neck and shoulder as given
by Mr. Wardrop, in his very able work  on this subject, has  been fully
confirmed in regard to this case.
  Dr. Vache, in  a recent note to Dr. Mott, (dated New  York, Nov. 27,
1845,) says in relation to this case:—" To reply to your note of yester-
day, I found it necessary  to refer to the  case of Moses R.  Gardner,  as
published in the American Journal of Medical Sciences, Nos. 10 and
12, Vols. V. and VI., where it is so truly described as to leave nothing
to add, from subsequent reflection, to  its history.  No person  familiar
with  the surgical anatomy of the neck and shoulder, can  read the de-
tails of the case, and doubt that he died from impeded respiration, con-
sequent on pressure and displacement of the  trachea, as well as the lung
and contiguous nerves and blood vessels.  From the dissection I made
at the time, I was fully  convinced  that the operation was perfectly suc-
cessful ;  and that he did not die directly of aneurism, the large  consoli-
dated tumor, I suppose  still  in your  museum, will fully  establish at the
present day." 
950           NEW ELEMENTS OF OPERATIVE SURGERY.
No. V.—New-York, 1830.   Ligatures of the Carotid for anatonos-
  ing Aneurism in a Child three months old.  The American Journal
  of the  Bledical  Sciences, Philadelphia, 1830,  Vol.  VII.,  p.  271,
  says :—

  In our fifth volume, pa2,e 255, we  announced Dr. Mott's  having per-
formed this operation.  The  following  extract from a letter  recently
received  from our friend, Dr. A. F. Vache of New York, gives further
particulars of this interesting case :—" You wish to be informed of the
termination of the case of the infant whose carotid artery was tied for
an aneurism by anastomosis, involving  both orbits, the nose, and part
of the forehead, and in whom it was intended to tie the other  should the
first  not prove curative.  After the operation the tumor evidently di-
minished, and induced the belief that in time it would be removed alto-
gether without taking off the circulation from the opposite side.  Since
then the little patient was lost sight of until 3resterday, (September 10th,)
when Dr. Mott heard of the residence of the parents and visited it.  He
informs me  that he found the tumor diminished about one-third, and so
much consolidated as to lead to the opinion of the  possibility of extir-
pating it, should it hereafter be thought necessary.  In every other re-
spect the child was in perfect health.*

No. VI.—Sept. 1830.  Amputation  of the thigh, followed by Se-
  condary  Hemorrhage.    The  Femoral Artery tied in  several
  places.  By Valentine  Mott, M.  D., &c.   (See  this case in an ac-
  count of the surgical cases of the New York Hospital for July, August,
  September and October,  1830, drawn up by Alfred C.  Post, M. D.,
  in the  New  York Bledical Journal, New York, 1830.  No. 2, Vol. I.,
  p.  271—273.)

  John Shannon,  aged about thirty years, came into the hospital on ac-
count of a disease of the knee joint, of several years standing.   He had
been addicted to intemperate habits.  On the 25th of September, Dr.
Mott amputated the  thigh a short distance above the knee, by the double
flap operation.  Every thing went on favorably after the operation.  The
patient, however,  complained of severe pain in the stump recurring every
afternoon, for which he took anodynes.  The stump was  dressed on the
seventh day, and was found to be nearly healed.   No untoward circum-
stance  occurred until  the morning of the 6th of October, (the 12th day
from the operation,) when the patient suddenly coughed, and sneezed
violently at the same  time, and a gush of arterial blood, to the amount
of three or four ounces, took place from the stump.   The tourniquet was
applied, so as to compress  the  femoral  artery, and  the hemorrhage was
thus  arrested for the time.   After an hour or two the tourniquet was re-
moved, and the hemorrhage did not  recur till the night of the 7th, when
about the same quantity of blood was lost as before, and the hemorrhage
was temporarily arrested ;n the same way.  At midnight, Dr. Mott tied
the femoral artery three or four inches below Poupart's  ligament.  He
*This tumor eventually disappeared entirely, December 1815.  V. M. 
DR. MOTT ON  ANEURISMS.
951
the artery in two  places, and divided it  in  the  intervening space.
On the morning  of the  eighth, a new hemorrhage took place to  the
amount of about eight ounces.  It  was arrested  by pressure in the groin.
At 11 A. M., a consultation of surgeons was held, when it was determined
to tie the femoral artery above the profunda, which Dr. Mott accordingly
did.  On the morning of the ninth, a hemorrhage again took place from
the stump to the amount of about  five  or six ounces.  Pressure on the
artery, as high in the groin as it could  be felt, appeared to  exert no
control over the hemorrhage, but it soon ceased spontaneously. ^ Dr.
Mott directed, if  the hemorrhage should be renewed,  that a tourniquet
should be applied around the middle of the thigh, with the view of com-
pressing the arterial branches  in the posterior  part of the limb. ^ Early
on the morning of the tenth, a slight hemorrhage  occurred, which was
not arrested by the tourniquet.  Spasms came  on in the stump, and the
hemorrhage became more profuse,  amounting to about eight ounces.
The spasms were frequently  repeated.   The  pulse became small  and
feeble, the skin cold and moist, the countenance had a haggard expres-
sion,  and there was occasional hiccup.  On dressing the stump the an-
gles of the wound, which had been united,  were found to  have been
pressed asunder by coagula of blood, and had a ragged spongy appear-
ance.  The wound was dressed with Peruvian  ointment.  Brandy toddy
was given to the patient in the morning, but his stomach soon revolted
against it.   A sinapism was applied over the  epigastrium, but he could
not long bear it.   Porter and lime water were  given in the evening, and
a blister applied over the epigastrium.   The pulse  gradually became
fuller  and stronger, the irritability of the stomach  ceased, and the cold-
ness of the skin diminished.   11th Noon.  There has been a very slight
oozing of blood, but no considerable hemorrhage.  The symptoms  have
all become more favorable.   The wound has been dressed this morning
with  pure balsam of Peru.  22d. No hemorrhage has  since occurred.
The ligatures, which were passed around the femoral artery on the night
'of the 7th, both came away this morning with  the dressings.  25th. The
ligaturo which was applied around  the artery, in the groin, came away
this morning.  In the early part  of November the patient left the hospi-
tal, the wound being nearly healed.
   The hemorrhagic disposition,  in this case was very remarkable, and
appears to have affected all the arteries of the stump.  The hemorrhage
which occurred after  the inguinal artery was tied, probably proceeded
from the branches of the gluteal and ischiatic arteries ; and, on this sup-
position, it was Dr. Mott's intention to have secured the primitive iliac
ortcry, if the patient had not been so much prostrated by the last hemor-
 rhage as to have rendered any operation unjustifiable at that time.  The
 recovery of the patient was contrary to the prognosis of all the attending
 surgeons.

 No. VII.—August 30, 1830.  Case of Axillary Aneurism in which
   the Subclavian Artery was successfully secured in a Ligature.
   By Valentine Mott, BI. D.,  See  (See the American Journal of
   the Bledical Sciences, Philadelphia, 1830,  Vol.  VII., p. 309-311.)

   William Hines, aged twenty-eight, of Smithville, Virginia, came to
 New-York August 24th, 1830, and became my patient. 
  952            NEW elements of operative  surgery.

    The account he gave of his case, was " that about seven weeks ago he
  received a violent strain while carrying a canoe on hand-bars across  the
  arms, which was followed by an extensive discoloration of the skin of the
  right arm, extending to the chest, and attended with considerable pain.
\ It  however yielded to the usual remedies in such cases.   Three weeks
.' subsequent to the accident he  observed a swelling about the size  of  a
 j pigeon's egg under the right arm, which had rapidly increased."
    On  examination I found a tumor about the size of a  goose egg, and
  decidedly an aneurism of the axillary artery.  His general health being
  good,  I directed him to keep quiet, to be bled,  and to take some  purga-
  tive medicines ; and fixed on Monday, the 30th, for tying the subclavian
  artery.
    At 11 o'clock, A. M.,he was placed upon the table, with the shoulders
  elevated and inclined to the right side.   An oblique incision was made,
  two inches in length, through the integuments and platisma myoides mus-
  cle, and corresponding to a middle line of the triangular interval formed
  on  the inner side by the  scalenus muscle, on the outer by the omo-hyoi-
  deus, and below  by the clavicle.  The cervical fascia was next divided
  to the extent  of an inch, and with the fore-finger and the handle of a
  knife, the adipose and cellular tissues were put aside,  and the artery
  readily exposed as it  passes  from between the scaleni muscles.  After
  denuding the artery a little of the filamentous tissue with a knife round-
  ed at the  point  and  cutting only at the extremity, a ligature was con-
  veyed around  it, from  below upward, by the American needle, and the
  artery tied a little without the scaleni muscles.
   No other ligature was required.   The patient lost less than  two  tea-
 spoonfuls  of blood.  The operation lasted  about fifteen  minutes, and
 was performed, with the  assistance of Drs.  Vache  and Hosack, in the
 presence of Drs. Barrow, Kissam, Rogers and Wilkes.   The wound was
 closed by two  stitches and adhesive straps ; the arm was immediately
 wrapped in  cotton wadding ; no diminution of temperature took place.
   8 P. M.  Found the patient comfortable ; says he has less pain in the arm
 than before the operation ; heat rather more than natural; a faint pulsa-
 tion in the  right radial artery ; pulse  88.
   31st, Morning.  Passed a comfortable  night after taking fifteen drops
 of the sol.  sulph. morphine, which was given to allay the pain about the
 elbow, and which he considered rheumatic, having had  more or less of
 it for some time  previous to  the operation.   This pain was no doubt
 caused by the pressure of the tumor upon the  brachial  plexus.  Pulse
 70 ; skin natural;  says that he feels very comfortable.
   Evening.  Complains of headache ; directed a saline cathartic ; pulse
  90 ; skin pleasantly moist; pulsation  in the right radial artery occasion-
 ally very distinct and regular;  temperature  of the right arm a little
 higher than that of the left.
    September 1st.   Pain of the arm  obliged  him to set up most of the
  night in an  easy chair—after the operation of the salts, took again fifteen
  drops  of the  morphine, and slept quietly about  five hours.  Feels at
  present very comfortable ; pulse 75 ;  not the  least  evidence  of febrile
  disturbance in any of his symptoms.
    2d.   Feels  much more comfortable than yesterday; slept composedly
  all night;  little or  no pain in the arm ;  pulse 80;  removed the wadding 
DR. MOTT ON ANEURISMS.
953
from the arm, and enveloped it in flannel, which keeps it very comfort-
able.
  3d. Slept well all night after taking his dose of morphine, and feels
very well to-day ; pulse 74; pulsation of the right radial more regular
and distinct.
  4th and 5th. Continues to improve.
  6th and 7th. Every way comfortable; right radial pulsates regularly,
though more feeble than the left.
  9th. Dr*essed the wound and removed  the stitches ; mostly healed,
except where the ligature from  the artery passes out.  Pain in the arm
for some days past has not been felt; makes no complaint;  pulse in the
radial artery very distinct and  regular with the actions of the heart. _
  11th.  Dressed the wound, which looks  remarkably well; everything
appears very favorable.
  14th.  On removing the dressings to-day,  the ligature came away; all
promises well.
  20th.  Wound being just closed, permitted him to walk about the room,
and to take  his usual allowance of food ; aneurismal tumor much dimin-
ished in  size, and very hard.
  27th.  Left the city to day on his return by water to Virginia.
  When I reflect on the disease for which this operation was performed,
and upon the situation, importance  and size  of  the  vessel which was
tied for its removal, it appears  to me almost incredible that but twenty-
seven days should have been required for its cure.  That it should have
succeeded is particularly grateful to my feelings, inasmuch  as it was first
successfully performed  by  an  American  surgeon,* and is an additional
proof of the triumph of surgery over disease and death.

No. VIII.—April  25th, 1831.  Case of  Diffused Femoral Aneu-
  rism, for which the External Iliac Artery was tied.   By Val-
  entine Mott, M. D., Professor of Surgery in the College of Physicians
  and Surgeons.  (See the American Journal of the Bledical Sciences,
  Philadelphia, 1831, Vol.  VIIL, p. 393-397.)

  The external iliac artery has been so repeatedly tied with success, that
perhaps, the only interest attached to this  case is the obscurity which at-
tended its diagnosis.   Whilst the leading features of its history, as well
as the  condition of the tumor, and the absence  of some  of the most
prominent symptoms of aneurism were strongly indicative of the pres-
ence of matter, the situation of the wound and the location of the swell-
ing, induced me to suspect the  existence of the last mentioned disease.
  Not the least pulsation could be felt, and it was not until visible mo-
tion, communicated  to the hand by the tumor, and the cessation of it on
compressing the artery above, were observed whilst viewing it obliquely
that I could form any opinion upon the nature of the disease.  This, to-
gether with the situation of the cicatrix and  pulsatory thrill communi-
cated through the stethoscope,  decided, in my estimation, its aneurismal
character, and determined me  on tying the vessel.  The  result of the
case will show that opinion  to have been correctly founded.

                      *Dr. Wright Post, of New York.
  Vol.  I.                 120 
954            NEW ELEMENTS OF OPERATIVE SURGERY.
  Charles Fordham, aged 13, came under my care April 23d, on account
of a tumor of his right thigh.   The history given of it by the parents
of the lad is as follows.  On the morning of March 18th, while he was
at school, a pen knife slid  off the desk at which he was sitting; when
clapping his  knees suddenly together, to save it from falling, the blade
pierced  his right thigh, a short distance above the knee.  On withdraw-
ing the  knife, it was found to have penetrated to the depth of an inch.
Little or no blood  escaped from the wound.   Soon after the occurrence
of the accident, he walked home, a distance of about  twenty rods, but
was so faint as to be obliged  to stop twice on the way.  In the afternoon
the thigh became painful, and  was uniformly swelled.  It continued
gradually to enlarge for about a week, at the end of which time a throb-
bing sensation was felt throughout the thigh, and an obscure  pulsation
was thought to be occasionally perceived near the wound by one of the
attending physicians,  who expressed his belief that  the femoral artery
had been opened.   Both the  throbbing sensation and the supposed pulsa-
tion, however subsided in an hour or two, and chilliness, followed by fe-
ver, supervened.  The pain  in  the thigh was  aggravated, and the boy
complained also of severe pain in his back.
  An abscess  was now  supposed to be forming ; accordingly  poultices
were  kept  constantly  applied to the thigh and purgatives occasionally
administered.
  Under this  treatment the  swelling  progressively  increased until the
end of the  third week after the accident, when it became softer and ap-
peared to be subsiding.  In the mean time, chilliness and fever at inter-
vals returned, and the pain in his thigh and back continued, to relieve
which anodynes were freely given.  The tumor again increasing, the lad
was brought to this city, and placed under my care.
  At  my first visit, April 23d, I found the patient much emaciated, and
complaining chiefly of numbness, alternating with a burning sensation in
his foot.
  The thigh was enlarged to  nearly twice its natural size, being occupied
by a tumor which  extended from the inside of the knee to the groin.   It
was most prominent in the middle of  the thigh, where it was also softer
than at the circumference.  The integuments  covering the tumor were
nearly of their natural colour, but oedematous.
  The leg and foot were in the same  condition.  The cicatrix  showing
where the  knife  had  entered, was situated  directly over  the  point at
which the femoral artery perforates the triceps adductor muscles.
  Fluctuation could be distinctly felt in almost every part of the tumor,
but after the most careful examination, not the slightest pulsation could
be detected either in the tumor or in the arteries of the leg.   Pressure
made upon the artery at the  groin had no apparent effect upon the size
of the swelling.
  Under these circumstances I had determined to  puncture the tumor,
and in the event of its being aneurismal, to tie the external iliac artery,
as the extent of the tumor precluded an operation below Poupart's liga-
ment.
  But on the following day,  a very feeble motion was perceptible in the
hand, when firmly placed upon the tumor and viewed  obliquely, which
Ceased upon compressing the inguinal artery. 
DR. MOTT ON ANEURISMS.
955
  On visiting the patient the next day, the very visible motion communi-
cated to the hand, especially when placed over the cicatrix, and the evi-
dent pulsation in the tumor, conveyed through the stethoscope, decided
me  in the opinion of its being an aueurism and upon tying the artery.
  The operation was performed at 5  o'clock, P. M., 25th April, with the
assistance of Dr. Vache, and  in the presence of several of my medical
friends, according to the method recommended by Sir Astley Cooper,
which has  been so frequently  executed  by myself and  others, and  the
manner of doing it so well known, that to specify the steps of it is unne-
cessary.
  The limb was enveloped in cotton wadding as is usual, and the patient
put to bed.   R. Sol. sulp. morph. gtt. xvi.
  26th. Passed a better night, his mother thinks, than before the opera-
tion.  Pulse 128.   Says he has less pain.  Foot and  leg of a natural
temperature.  For some  time before the operation he  suffered  from a
burning sensation in the bottom of the foot, which was relieved by wet-
ting it frequently with cold vinegar or applying to it a bottle of cold water.
  This  sensation left him soon after the operation, and at present he says
there is only a sensation of numbness, or as though the foot was asleep.
  In the evening, being restless and uneasy, took his usual dose of forty
drops of laudanum.
  27//j. Says that he feels better  than before the operation—had a com-
fortable night.  Bowels being confined, took a dose of ol. ricini.  which
operated three times—pulse 108—skin natural—foot of natural tempera-
ture—tumor of the thigh visibly  diminished—upon the more prominent
part of it the skin appears wrinkled.
  28^/*. Diminished the quantity of anodyne a little—passed a good night
—feels  no pain—pulse 118—limb naturally warm.
  29th. Is very comfortable—took less of the anodyne last night—bowels
open—pulse  112—tumor  evidently diminished—limb naturally warm—
upon  looking at the foot, discovered a blister on the under part of the
ball of the great toe, about the size of a dollar, with a little redness around
the margin.  Passed a lancet into it and evacuated the water.
  30th. No more  vesications and no spreading of the first.   Removed
the cuticle to the full  extent of its detachment, and to my  great grief,
found it below  livid and cold.   The foot and toes naturally warm—slept
well and feel better than yesterday—pulse 120—bowels open—directed
him some  Madeira  wine in his food  and drink, and to apply over the
livid part frequently in  the course of the day, some warm bals. Peru.
  Eight P. M.   Has taken more food and with an appetite—livid spot
less in  size than in the  morning, and evidently  has resumed a natural
warmth.  Directed to continue the same means as in the morning, with
the anodyne  at bed-time if necessary.
  May 1st.  Passed a good night and feels better than yesterday—pulse
128.  The bottom  of the foot appears the same as  last evening.   At a
small point near the extremity of the great toe, and at the under part
the cuticle is detached about the size of" a shilling, but the subjacent in-
tegument is  of a healthy red colour—foot  and leg of a proper decree
of warmth.  To continue the same treatment*

  * The mother now informed me, that a bottle of very hot water had been applied to the font
by the attendants, during the night preceding the day on which the first blister had appeared
which greatly diminished my apprehensions of the result.                   i>iKM™, 
956            NEW ELEMENTS  OF OPERATIVE SURGERY.

   2d. Was somewhat disturbed in the night by a noise in the house which
prevented sleep—complains of no pain—pulse  120—bowels  open—no
change in the foot—same application to be repeated.
   3d. Says he has a more natural feeling in the foot and leg than before
the operation—he can now feel when the sound foot touches the diseased
one,  which he could not for some time previous to the operation.  His
symptoms and pulse the same as yesterday.
   4th. Slept very well—appetite  good—feels and looks better—pulse
110.  Bowels regular—temperature of the foot  natural—bottom of the
foot  better—swelling of the thigh less.
   5th. Line of  separation of the slough at the bottom of the  foot  very
evident—feels well in every respect—pulse 112—bowels open—urged to
take a nourishing diet and to use porter and wine in moderate quantities.
   1th. Very comfortable—separation of the slough in the bottom of the
foot  progressing, pulse 116 ; oedema of the foot and leg much diminish-
ed.
   lOt/i. Fourteenth day from the operation, dressed the wound—all heal-
ed by the first  intention, except  the  openings  made by the  ligatures.
Removed the three sutures and two of the ligatures ; pulse more frequent
than usual, in consequence  of his feelings  being much excited  by his
father leaving town.  In all other respects he is as well as before.   Slough
at the bottom of his foot rapidly  separating, it appears to be  no deeper
than the corium—directed to continue the balsam to the foot, and  take
nourishing diet with  porter and wine.
   15th. Improving very much in general health—slough from the bottom
of the foot came  away to-day—the granulations look  very  healthy—
wound entirely healed at every part except where the ligature  passes—
ligature does not yet appear to  be detached  from the  external  iliac—
oedema of the foot and leg mostly disappeared.
   29th. Ligature from the external iliac came away  to day—aneurismal
tumor about half removed—ulcer on the great toe healed—that on the
bottom of the foot nearly closed—general health much  improved.   Left
the city to-day for his residence in the country.

The  American Journal of the  Medical  Sciences, Philadelphia, 1833 ;
   vol. XII., p. 274, speaking of this case, says :—

   Dr. Vache, in a letter we have recently received from him, informs
us that the patient in whom Dr. Mott tied the external iliac for the cure
of diffused femoral  aneurism, and an account of which was  published
in our 8th volume, has done well and enjoys perfect health.

No.  IX.—September  22d,  1831.  Case of Aneurism of the  Right
   Subclavian  Artery, in  which  that vessel was  tied within the
   Scaleni Muscles.  By Valentine Mott, M. D., &c.   (See the Ameri-
   can Journal of the Medical  Sciences,  Philadelphia,  1833, Vol.  XII.
   p.  354-359.)

   In the early part  of September, 1831,1 was  requested to visit  Mrs.
B ■---, a lady, twenty-one years of age, in reference to a tumor situated 
DR. MOTT ON ANEURISMS.
957
in the lower part of the neck.  The history of the case was  br efly as
follows-.-A year or two before,  she  had been  thrown tomagig, ana
received a violent contusion of the right shoulder  and left  side, ot tne
body, from which she had gradually recovered with the exception 01 a
fixed pain in the injured shoulder, and  the  subsequent  appearance: 01:*
small throbbing tumor above the collar-bone.  Her physicians had inform-
ed her of its  character, and the  object of her visit to New-York was to
place herself  under my care and abide by my judgment.   On examina-
tion, I found a tumour as large as a hen's egg on the outer edge ot tne
scaleni muscles, and immediately over the subclavian artery.   Its pulsa-
tions were unequivocally aneurismal, and left no hesitation as  to the cor-
rectness of the opinion already given on the nature of the disease.   Her
general health was considerably impaired, and the tumor was rapidly in-
creasing in size.                                                 ,
   With no other  precedent  than Dr.  Colles' case,* and aware ot the
uncertainty that must ever attend the result, of putting a ligature amidst
large collateral branches upon a  great vessel so near the heart, I deemed
it a duty to explain to my patient, her husband, and  her  friends, the
critical situation in which she was placed, and leave it for them to decide
on the course to be pursued.   In a few days I was informed of her reso-
lution to take the chances of the  operation, and fixed on the 22d of Sep-
tember for its performance.                                  .
   At 12 o'clock on that day, she was placed upon a table, having  taken
an hour previously sol. sulph. morph. gtt. xx.  The shoulders were ele-
vated on pillows, with the head thrown backward, and the face and body
inclined to the left side.  An incision was begun at the lower part of the
outer edge of the sternal  portion of the  mastoid muscle, apd carried
upwards about two inches, and another from the commencement of the
first along the upper surface of the clavicle of the same extent.  The
triangular flap, and a corresponding portion of the platisma  myoides
with its  investments, were  separately dissected from their  connexions
and  turned aside.  The clavicular portion of the  mastoid  muscle was
next severed  immediately above  its  insertion, and reflected upon the
neck.  This laid bare the deep-seated fascia, which was raised with the
forceps and divided  a  little below the course of the omo-hyoid muscle
and  outside of the deep jugular vein.   Upon  enlarging this opening an
inch downward, the adipose and cellular  tissues  were readily pushed
aside, and the scalenus anticus exposed to view.  ^ Desirous of tying the
artery, if admissible, on the acromial  side of this  muscle,  I passed a
finger carefully down upon its outer edge, but found from the vicinity of
the tumor, that it would be best  to secure  it on the tracheal side, and
avoid all  disturbance of the parts in that situation.  Accordingly, the
cellular substance was separated  with the fingers and handle of the knife,
and  the subclavian exposed  just within the thyroid axis, the branches
of which could be plainly seen.   The filamentous tissue was  raised from
the artery with the forceps, and cautiously divided with a small scalpel,
and  the ligature  conveyed under the vessel from  below upward by the
American needle.  In accomplishing this part of the operation, curved
spatulas were used to separate the wound, and a blunt hook to draw tho

  *The patient died on the eighth day after the operation.  See the particulars, in the Edinb
Med.  and Surg. Journ. for January, 1815. 
958
NEW ELEMENTS  OF OPERATIVE SURGERY.
 deep  jugular towards the trachea.  The knots were readily made with
 the fore-fingers.  Pulsation  in the aneurism and vessels of the arm im-
 mediately ceased.
   The detached parts were  restored,  aud the integuments  retained by
 the interrupted suture and adhesive straps.  Three small arteries were
 tied—no vein was cut that required a ligature—about four table-spoon-
 fuls of blood were lost.
   Dr. Vache  assisted me in  the operation, and it was performed in the
 presence of Drs. Parkin and Howard, and a number of my pupils.  The
 patient sustained  it remarkably well, and did not evince any particular
 sensation, or effect when the artery was tied.
   Evening.  Has vomited several times, which she attributes to the mor-
 phine taken in the morning; right hand and arm warmer than natural; has
 a little reaction of heart and arteries ;  complains  of pain in tho right
 arm and side of the neck; radial artery feels full, but has not any pul-
 sation in it.
   23rd, morning. Passed a comfortable night; the vomiting was allayed
 by mint tea  ; arm warmer than natural, and  feeble pulsation in the ra-
 dial artery ;  pulse 88, soft; still feel pain in the arm and neck.
   Evening.  Complains of head-ache ; pulse  the same ;  skin moist and
 not heated ;  temperature of  both arms  alike, counted  eighteen feeble
 pulsations in the right radial artery.   The pulsation of the carotids be-
 ing unpleasant, recommended  the head and shoulders to be elevated on
 pillows.
   24^. Pain in the neck and arm less than yesterday ;  head-ache con-
 tinues  ; skin natural;  tongue  a little  furred ;  temperature  of the limb
 uatural; pulse  the same ; counted  nine or ten pulsations in the radial
 artery in a minute, but more feeble than yesterday.   Directed a Seidlitz
 powder to be taken at intervals until the bowels are moved.
   Evening.  The aperient has operated but once ; pulse 70; only a
 slight tremulous motion  to be felt in the radial artery ; has had several
 turns during  the day of cool hands  and feet, followed by flushes of beat,
 and attended with some feeling of weight about the chest; violent pain in
 the head, with a flushed  countenance ;  pain in the arm less, and in both
 arms alike.. Took eight ounces of blood  from the left arm, which re-
 lieved  her unpleasant feelings immediately.
   25th. morning. Has slept but little during the night, notwithstanding
 the relief  afforded  by the bleeding.   Complains of pain  through the
 upper part of the right shoulder and base of the scapula, and occasional
 sensation of a tingling or  creeping motion in the arm to a painful degree;
 pulse 80 ;  skin  natural;  no distinct pulsation in the  right radial artery,
 but tremulous as yesterday.  Seidlitz powders to be repeated.
   Evening. The medicine has operated freely; has had some sleep ;
 head-ache  much less  ; pulse 80 ; skin moist and natural.  Complains of
 great pain  in  the upper part of the right  arm, also deep in the neck and
extending to the spine, between the  scapulae ; says she has pain in swal-
lowing and in taking a full inspiration.   Advised her to take seven drops
 Sol. acet.  morph.
   26th, morning. Has slept well, and feels much better ; breathing good ;
head, back, shoulders, and arm free from pain; pulse 80 ; skin natural
 and moist; tongue white.  Pulsation in the radial artery  more distinct;
 counted forty-one beats in a minute. 
DR. MOTT ON ANEURISMS.
959
  Evening. Says she has passed a very comfortable day.  No alteration
since the morning.   Directed ten drops of the Sol. acet. morph. at bed-
time.
  21th, morning. Did not pass as good a night as the preceding; pulse
74 ;  arm  and body of natural  temperature; pulsations of the radial
artery  fifty in a minute.
  Evening. About the same as in the morning; bowels have been moved
by some ripe fruit eaten during the day.  Ordered thirteen drops of the
morphine  at bed-time.
  28th, morning. Feels much better; very little  pain in the shoulder,
and none  in the arm ; pulse 79;  pulsation in the radial artery more dis-
tinct, and beats sixty-one in a minute.
  Evening. Only complains of a trifling pain in the shoulder, such as
lying in one  position occasions ;  pulse 75 ;  in the right arm 71 distinct
beats in a minute.   The wound  discharging a little sanious  fluid  un-
pleasant to the patient, removed the  bloody lint and part of the plasters,
and re-dressed the wound ; it looks very well.
  29th, morning.  Omitted the morphine last night and slept well;  in all
respects better ; pulse 72 ; in the right arm 69.
  Evening. The same as in the morning ; number of pulsations in both
arms alike, and much more feeble in the right.
  30^, morning.  On being  carefully raised up in the bed  in order to
take nourishment, after a little irritation from the absence of  the nurse
at the  moment when wanted, she suddenly  called out to a relation in
the room  and said that she  was bleeding.  About two table-spoonfuls
of dark-colored  blood were slowly discharged.  It ceased on a little
pressure; pulse  76 in both arms ;  removed the lint, and dressed the
lower part of the wound, which looks well;  gave eight drops of Sol. acet.
morph.
  Evening. At  eight o'clock, four  table-spoonfuls,  as near  as  could
be judged, were  again discharged from the wound, and at  12 perhaps
a tea-spoonful more.  It was of a dark color, and was readily checked
by pressure.
  October 1st.—Feeling sick at the  stomach this morning, some Colonge
was poured over the  epigastric region, which immediately occasioned a
chill that  lasted  half an  hour.   During it she  vomited several times.
Considerable increase of heat and  other  attendants of  the  hot stage
continued during the day.   Pulse 100 in both arms.
  Evening. Febrile  disturbance  still continues; pulse the same; no
further discharge of blocd from the wound.
  2d,  morning.   Complains of soreness  of the throat; febrile excite-
ment still continues ; pulse  110, rather tense ; directed  Epsom salt in
Seidlitz powders.
  Evening. Salts have operated  twice, and  she feels better; has had
several rigors during the  day, and  vomited several times; pulse 104
somewhat  tense ;  took § xviii.  blood from  the deft arm with manifest
abatement of the symptoms ;  the  blood upon standing exhibited strong
evidences of inflammatory action ; it was very buffy and much cupped
  3d, morning.  About 10 o'clock last night, had a trifling oozino- of
blood from  the wound, after a hard  turn of hawking; was comfortable
afterwards, but  did not sleep much;  complains of  headache • for two 
960
NEW ELEMENTS OF OPERATIVE SURGERY.
hours past, has been  in a free  and easy perspiration ;  pulse 109, soft;
says her throat is very painful in deglutition ; the left tonsil is swelled ;
directed a dose sulph. magnesia.
  Evening. Has had a severe  ague which  lasted about fifteen minutes,
during which she vomited; heat that followed very considerable ;  per-
spiration very copious for several hours; wound has discharged a  small
quantity of blood twice since  morning;  medicine has operated on the
bowels ; pulse 108 ; febrile heat much less.  Whilst sitting by the bed-
side and preparing to dress  the wound, four table-spoonfuls at least of
florid arterial blood  were suddenly discharged; on removing the plas-
ters and lint it as suddenly ceased.
  4th. Between  the hours  of four and five A. M., had an ague, which
continued half an hour,  accompanied  with  vomiting, heated skin, and
profuse perspiration.  Delirium commenced  with the chill, and continued
more or less until ten o'clock.  Directed to take on the subsidence of
these symptoms, one  tea-spoonful of the following medicine every hour
until another chill supervened :—
       R.   Sulph. quiniae,     .     .     .     grs. xxiv.
            Acid, sulph. arom..     .     .     5 ij-
            Sirup, simplicis,   .     .     .     giij.  M.
  In the afternoon between four and five o'clock, a slight chill came on,
attended with vomiting ; the fever which supervened was mild, and ear-
ly in the evening the quinine was  resumed.  At 10 P. M., the wound
was dressed ;  looks very well;  no bleeding since last night; pulse 100.
  5th. had a slight chill about midnight, and is now, 10 A. M., laboring
under  a similar  one;  pulse  110.  The bitterness of the preparation of
quinine being very offensive to her, ordered instead of it one grain of
the sulphate in pill every hour ; as soon as perspiration came on.  Dressed
the wound ;  two tea-spoonfuls of blood appeared to have been discharged;
says her throat is much better, and a cough which was quite harrassing
yesterday has left her.
  Evening.  Has had her  clothes changed, and  been removed into a
clean bed;  perspiration left her in a great measure about noon, and she
has had a refreshing sleep.
  6th, morning. Passed an excellent night; towards morning had slight
sensation  of the chill and  much less fever ; pulse 108 ; directed more
nourishment to be given and  the quinine continued.
  Evening. Has had a still less chill and fever in the early part of the
afternoon ; dressed the wound ; compress stained with perhaps a tablc-
spoonful of  blood.
  1th. Had  a verji comfortable night; feels but little pain in the shoulder
this morning; tongue beginning to clean  off; has  not had any ague
since yesterday;  feels some appetite ; pulse 100.  Quinine continued.
  8th.  In all respects better ; had a slight sensation of coldness this
morning; fur  upon the  tongue much  cleaned off; appetite greatly im-
proved ; no bleeding  since the evening of  the sixth; wound looks well;
all  of it healed except a small part above  the clavicle through  which
the ligature passes ; pulse 104 ; continues the quinine.
  9th. In the  early part of last evening, after a quiet day, she was at-
tacked with hemorrhage.  The discharge was sudden and  to the amount
of a pint; it stopped spontaneously.  The effect was great and alarming; 
DR. MOTT OM ANEURISMS.
961
She was pale, cold, and almost pulseless, when I reached her.  In about
an hour she rallied, but was restless and disturbed; any form of anodyne
was declined.  About midnight, three or four table-spoonfuls more ot
blood were lost.
  At six o'clock this  morning, a profuse gush took place, accompanied
with a jet and whizzing noise ; I thought it the moment of dissolution ;
she again revived.  Her mind is calm, and she is resigned to the event;
no  more hemorrhage  occurred.  She lived until  the afternoon of the
tenth, and died without a struggle.

No.  X.—December 29th, 1834. Aneurism of either the Ischiatic or Glu-
  teal Artery, in which the Right Internal Iliac Artery was success-
  fully tied.  By Valentine Mott, M. D.   (See the American Jour-
  nal of the Medical Sciences, Philadelphia, 1837, vol. XX., p. 14—15,
  reported by Dr.  W. C. Roberts, of N. Y.)

  Richard Charlton, the patient, is a colored man, born in this city, and
about  38 years of age.  He has worked in a grocery store.  He first
felt the symptoms of his disease in the summer season of 1832 ;—during
the cholera then prevalent he had a diarrhoea, and while making frequent
straining at stool, perceived a swelling and pulsation in the right buttock,
which has gradually increasdd until this time.   It is now about the  size
of a goose  egg, and contains  only fluid blood.
  On the 29th of December, 1834, at noon, I proceeded to tie the right in-
ternal iliac artery,  in the presence of Drs. J.  Kearney Rodgers and A.
E. Hosack, and assisted by Drs. Vache and Wilkes.  The incision which
was  fully five inches long, extended from a spot on a line with the um-
bilicus, about  midway between the linea alba  and the anterior superior
spinous process of  the ilium, to within half an inch   of Poupart's liga-
ment, and then curved forward an inch over the course of the spermatic
cnord.  The operation lasted about forty-five  minutes, owing to the al-
most unrestrainable intractability and frantic restleness of the patient.
His  great  straining and jactitation caused me to make a small opening
in the peritoneum, whilst separating it from the iliacus internus muscle.
The peritoneum and intestines being drawn up  and supported  by a large
curved spatula,  the internal iliac artery was readily seen, crossed  by
the ureter, which was easily pushed aside.
  The filamentous tissue was  quickly separated by the  fingers from about
the vessel, and the  ligature  conveyed under it by the American needle.
At  the moment of tightening the knot the hand was applied to the tumor,
in which all pulsation immediately ceased, and which itself almost entire-
ly disappeared directly after.  *The patient, being put to bed, took twenty
drops of a solution  of morphine, and in the evening was easy.
   December  30. Had a good night's rest, and was comfortable  in the
morning.  Some excitement coming on early in the  afternoon, he  was
bled from the arm to about 5, xviij., and took a solution  of sulph. magnes.
in  divided doses.   Evening—Much  easier;  salts had  not operated.
Directed an enema, and applied a  strip of blister plaster around the
wound.
    31st.  Has had a  good  night; is doing   well;  is free from pain,
   Vol.  I.                      121 
962
NEW ELEMENTS  OF OPERATIVE SURGERY.
 and the pulse is tranquil;  enema operated several times, and the plaster
 drew well.  In the evening he was still better than in the morning.
   January 1st, 1835.   Feels much more easy than he did yesterday, and
 can  move better—the abdomen is less tumid.   Pulse not more frequent,
 but rather quicker than it was yesterday.  Since the enema was admin-
 istered  has  had frequent teazing stools.  Ordered enema opii e amylo.
 Cold water and barley tea for drink.
   2nd.  Anodyne enema quieted the bowels.  Pulse, though still frequent,
 soft and compressible ; tension and tenderness of abdomen gone.
   3rd. Freedom from  tenderness  continues ;  pulse nearly natural.   Re-
 applied the blister and allowed panada and arrow-root.
   4th.  Much depressed by the intense cold of to-day, (10° below zero of
 Fahr.)
   6th.  Pulse natural; tongue nearly clean ; is cheerful and hungry.
   1th.  No unpleasant  symptom whatever.
   9th.  Removed the sutures from the wound, which is very much closed.
 Is free from  pain ; pulse natural and bowels regular.
   The report of the case terminates here ; and owing to  the absence of
 Dr. A. E.  Hosack, upon whom  the case of the patient devolved, we are
 only enabled further  to  state that the ligature came away on the 42d
 day.*

 NO. XI.—April 11,1844. Case of Ligature of the Subclavian Artery
   ABOVE THE CLAVICLE, FOR ENORMOUS DIFFUSED FALSE ANEURISM OF THE
   WHOLE UPPER EXTREMITY FROM THE ACROMION TO THE FlNGERS, FROM A
   gun-shot  Wound, followed by a complete cure.   By Valentine Mott,
   M. D., Professor of  Surgery  in  the  University of New-York.   (See
   New-York Journal of Medicine, Langleys, Publishers, Vol. IV., No.
   10, p. 16—19, Jan. 1845.

   C. R.  M., aged  thirty-five  years, by trade a  machinist, of Kingston,
 Ulster county,  New York, of a bilious temperament and sober habits,
 whilst on a hunting excursion with a friend, had occasion to pass through
 a thicket, and, in the act of stooping to clear away  some bushes which
 impeded his progress, the gun of his friend accidentally went off, lodging
 its contents  (buck-shot)  about the inferior angle of his scapula.   Two
 of the balls  passing obliquely  through the axilla, were extracted  from
 the anterior portion of the arm; twelve had been previously removed by
 means of poultices, from about the place of entrance ; two were still to
 be felt under the integuments, below and about the middle of the clavicle.
   At the time of the accident the patient was not stunned, nor did he
 experience a sensation of numbness  in  any part of the arm.   In the
 course of a  few hours, however, a tumor began to appear in the axilla,
 and  continued  to  increase until the third day,  when, for the first time,
 pulsation was detected.  It  was  not until the sixth day, when, after a
 paroxysm of  pain, extending through the whole arm, and so excruciating
 as almost to render him frantic, that he experienced a sensation of numb-
 ness through the  entire limb.   The  paroxysm  lasted about one hour,
 during which time he was obliged to take over one hundred drops of
laudanum.

   * I have seen this patient within the past year in excellent health.  Dec. 1845.—V, M. 
DR. MOTT ON ANEURISMS.
963
   t This was  followed by  an oedematous swelling of the arm, obliging
 him to sleep seated in a chair, with his arm placed on a pillow before
 him.   The paroxysms of pain returned  for two successive days at about
 the same hour, with the same violence, and lasting about the same length
 of time.   This was followed  by a violent burning sensation in the palm
 of his  hand,  which continued until  some time  after the  operation was
 performed.   This  was  the only sensation  that remained in the whole
 limb.
   He was now brought  to the city and placed under my care, being  the
 twenty-second day from the time of his receiving the injury.
   On my first visit, I found  the oedema to extend from the shoulder to
 the extremities of the finger.  So great was the extravasation in  the
 axilla, that the circumference of the upper part  of the arm was found to
 be about twenty-eight inches.
   On the day of the operation (11th of April, 1844,) the condition of
 the arm was such as clearly  showed that no time was to  be  lost.  The
 cuticle was detached to a considerable extent on  the most prominent part
 of the tumor in the axilla; the skin was cracked, and from it there oozed
 a thin sanious fluid.  In short, it presented the  appearance of a  slough,
 produced by  the application  of caustic.
   Operation.—The patient being seated in  a chair, with his arm and
 shoulder depressed as much as the  condition of the parts would admit
 of, an incision of about  three inches in length was made through the
 skin, extending  from  th« anterior border of the sterno-cleido-mastoid
 muscle one inch and a half above the clavicle, in a direction downwards
 and outwards  towards the acromion process  of the scapula.  The super-
 ficial fascia and platisma myoides being successively exposed and divided,
 a mass  of extravasated blood was brought into view, which entirely ob-
 scured the subjacent parts.   On the patient making attempts to swallow,
 a prominent line, extending in a direction  upwards and  inwards, was
 observed in this confused mass, which, after  a  little dissection,  proved
to be the omo-hyoid muscle, but  of  a much  darker color  than natural.
The deep cervical fascia being now  cut through, the subclavian  artery,
accompanied on its  external and superior side by one of the cords of the
axillary plexus, appeared just where it emerges from  behind the scalenus
anticus  muscle.  An aneurismal  needle,  armed with a strong  silk liga-
ture, was now passed round the vessel, the point  of the instrument being
directed outwards and backwards, so as to avoid the subclavian vein.
The artery being then tied, the edges  of the wound were brought together
by two  uninterrupted sutures and adhesive plasters.
  In the course of  this operation, two  or three  small vessels, branches
of the transversalis humeri and tranversalis colli  arteries, had to  be
taken  up.   The external jugular vein  was divided, and tied on each
side of the wound.
  Progress of the  Case.  April 12.—Patient says he has  felt much
more comfortable since  the artery was tied ; the tension and weight of
the arm having greatly diminished.   On taking a view of the upper part
of the arm and shoulder, the attention was at once  arrested by  the gen-
eral reduction  in its size; the skin was softer and more natural.  About
the elbow it has also subsided, but the oedema of the fore-arm and hand
are about the same.  Temperature of the arm has remained about nat- 
964
NEW ELEMENTS  OF OPERATIVE SURGERY.
 ural since the operation, but  at  present the heat is a little augmented.
 By  accurate measurement, taken before the artery was tied, and ao-ain
 to-day, there is  about three-quarters of an inch abatement in the size of
 the  aneurismal tumor in the axilla and under the pectoralis major muscle ;
 lividness of the axillary part of  the tumor  much  less  than yesterday.
 Pulse 117 ; tongue and skin natural.
  ^ Owing to the frequency and irritability of his pulse, I directed him,
 since he came  to the city, to  take a good nourishing diet.  This he is
 requested to continue.   Also, to keep the arm wrapped up in  cotton
 wadding.
   April 13.—General expression of his countenance much improved—
 says he feels much better; temperature of the arm  and  hand about nat-
 ural ;  more oedema of the hand ;  diminution of the tumor a quarter of an
 inch, by actual measurement, since yesterday.   Pulse 101.   General
 irritability of the system lessened.  Directed him  to continue the same
 diet.
   April 14.—Pulse 100.  GCdema of arm gradually  subsiding, that of the
 hand remaining nearly the same ;  temperature of the limb nearly natural:
 the size of the tumor has diminished half an inch since yesterday: feet being
 oedematous, I put on a bandage, and directed him to keep his legs in a
 horizontal position.
   April 15.—Patient expresses  himself, this morning,  as being  more
 comfortable, and says that he has passed the  best night  since the opera-
 tion, having remained in his  easy chair in a reclining position. Tempera-
 ture of the arm  natural; dimensions of the tumor  and shoulder the same
 as yesterday.  Pulse 94; appetite good.
   On the under part of the fore-arm, near the elbow, some  threatening
 of ulceration was visible before the operation.  This arose from the pres-
 sure and weight of the limb.  As some redness  extended from it over
 and  about the olecranon, he was  directed to  cover  over the whole with
 an emollient poultice.
  The most projecting part of the tumor is at the axilla, which was quite
livid before the  operation, continues now to  have the  cuticle cracked,
 and is oozing a watery, and somewhat purulent fluid ; it is quite soft and
fluctuating to the touch.
  The lint over  the strips of plaster  covering the  wound, being some-
what saturated  with matter, was removed, together with  the adhesive
straps which retained  the edges in contact.  Most of the wound, except
at the outer extremity, is united by  the adhesive process.
  April 16.—Better than since he received the injury; is a little excited
by a  visit from several of his friends from the country.  Pulse 100; ap-
petite good ; slept very well during the night; tumor in the axilla dis-
charges from the cracks a sanious fluid.
  April 17.—In all respects  as  comfortable  as yesterday; more of his
friends visited him to-day ; pulse eight or ten beats more frequent than
yesterday; directed him  to be kept more quiet;  dressed the wound ; it
looks well.
  April 18.—Does not look so well; says he  did not have a good night's
 rest; was not in any pain, but could not get into  the right position ; is
 sleeping from time to time during the day ; pulse  120: arm of the natu-
 ral temperature; circumference of the  tumor the same as  yesterday; a 
DR. MOTT ON ANEURISMS.
965
 small quantity of dark grumous blood is being discharged from the most
 prominent point of the aneurismal swelling in the axilla.
   Sense  of feeling begins to return in the arm from the -shoulder to the
 elbow ; it is accompanied with  a painful sensation when the finger is
 passed over it.  Directed him to continue his nourishing  diet, take por-
 ter, and if his restlessness requires, to take his tea-spoonful of laudanum.
   April 19.—Found  him  this morning in  a recumbent  position on his
 couch.  At  my  urgent request, he, yesterday  afternoon, went  to  bed,
 previous  to which he was  somewhat incoherent, and now says that he
 hardly knew what occurred yesterday.
   Passed a much better night, looks and expresses himself as much bet-
 ter than yesterday ; oedema of the fore-arm, hand and feet, much dimin-
 ished.  Aneurismal tumor discharged dark-colored blood  in small  quan-
 tities ; size, the  same as yesterday ; pulse, 103,  soft, and  free from the
 irritability  it had  yesterday, and for  sometime  before  the operation.
 This more  tranquil condition of his vascular system is to  be ascribed to
 the exclusion of  his friends since yesterday.
   April 20.—Passed  but  an indifferent night, not being  able to relieve
 himself by  any  change of position; feels better, however, to-day than
 for several days past.  Dressed  the wound, which is granulating very
 well;  removed the second suture and two of the ligatures ;  circumference
 of the aneurism diminished one quarter of  an inch since  yesterday: it
 continues to discharge from the most prominent part of the tumor;  oede-
 ma of the  hand and fore-arm much diminished.   Indeed,  the whole ex-
 tremity begins to assume a much more natural appearance ; tongue clean;
 appetite better than for two days ;  pulse 94.
   April 21.—Passed a better night; the  tumor  has not undergone any
 perceptible  change since yesterday ; oedema of fore-arm and hand is gra-
 dually diminishing ; pulse, 84 ; temperature of hand nearly natural.
   April 22.—Tumor in the axilla has discharged more freely since yes-
 terday : all his  symptoms are ameliorated; dressed the wound; looks
 well ;  another ligature came away; pulse 86.
   Sense of feeling in the arm increases gradually ; it has  now extended
 to the elbow.   In the  fore-arm and hand sensation and motion are en-
 tirely abolished.
   April 24.—Is sitting up, and says he is in all respects  much better ;
 dressed the wound ; it is granulating beautifully ; removed the other liga-
 ture from the external  jugular vein ;  pulse  ninety-six;  appetite good;
 sleeps  well, without his accustomed tea-spoonful of laudanum.
   April 26.—Says he feels constantly  improving ; dressed the wound;
 much filled up since the last dressing ; ligature from the subclavian came
 away, having separated spontaneously ; pulse ninety-four; more grumous
 blood  discharged from the tumor ;  scab upon the apex of  the aneurism
 about the size of  a dollar.                                           '
   April 28.—In all respects improving; wound  looks very well; but for
 the weight of his arm,  he would feel perfectly well.
   Blay 2.—Wound  nearly healed;  walks  about the room;  in all
 respects improved.
   Blay 16.—Greatly improved in appearance ; feels in all respects very
well; eschar from the tumor in the axilla came away spontaneously yes-
terday, leaving a fresh  surface of coagulated blood.  There was an in- 
966            NEW ELEMENTS OF  OPERATIVE SURGERY.
 creased flow of grumous blood when it  came off; it was about the cir-
 cumference of a dollar, and nearly half  an inch thick ; it had remained
 on about twenty-eight days ;  it was composed of black grumous  blood,
 very hard,  dry externally, and cracked.
   June.—Has continued to  improve  regularly;  is  permitted to return
 home.
   After  the first  slough  of  integuments  took  place, it was  curious to
 watch the steps of nature to prevent hemorrhage.   As one eschar would
 come away, another would very quickly  form, to plug up the  opening ;
 it would be many  days in separating, and had the  appearance of a regu-
 lar slough from the application of caustic ;  it was, however, a thick layer
 of the grumous and lamellated blood of  the sac.
   In this way, plug after plug of hard coagulated blood would form and
 be cast off,  and then there would be a pretty free  discharge of this gru-
 mous blood, with some coagulated portions.  The sac was gradually evac-
 uated in this way  until all its contents were removed, and a fresh granu-
 lating surface was left, which readily healed up.
   November.—Came to the city to see me ; appearance of the whole arm
 very natural;  sensation  and motion  considerably restored in the fore-
 arm and fingers.
   Those interested in the advancement of  surgery in our  country, may,
 perhaps, be  gratified to learn that this is  the fourth time that I have put
 a ligature around the subclavian artery above the  clavicle, on the acro-
 mial side of the scaleni muscles.   All the operations have been attended
 with success.

 Case of Aneurism, and  Ligature of the Left  Subclavian Artery,
   Attended with  peculiar circumstances.  By Valentine  Mott,  M.D.
   Read May 7, 1851.   (From the  Transaction of the New  York  Acad-
   emy of Medicine, Vol. I., Part 1.)

   The course of the subclavian arteries after they leave the outer  edges
 of the scaleni muscles, is the same on both sides.  The artery can there-
 fore be tied  with equal facility, ceteris paribus, on both shoulders.   The
 instances are now numerous in which ligatures have been applied to these
 vessels, but  as there are some points about the following case which are
novel and interesting, it is deemed worthy of record.   In the seven* cases
which have  come under my notice, in which I have tied this vessel, this
presents two points of great interest.  It will show  what may be d<3ne
by patience and perseverance under distressing and almost desperate cir-
 cumstances.
   In the  early  part of November  last, Dr. O'Reily, an intelligent and
well educated  surgeon, sent a man to me  with a  tumor which  he had
very  correctly diagnosed as an aneurism.  It was situated below and
behind the clavicle, occupying nearly the whole extent of  the bone, and
reaching  into the axilla.   It had  the  full  character  of an aneurism in
 the first stage, all  the blood being fluid.
   The history  as given by the patient is the following:

  * I am happy to say that six of the cases have been successful.  They have been on the right
   left shoulder, without the scaleni muscles. The present case was under the anterior scale-
nu9.  ike fatal one was when the ligature wag placed Within the thyroid axis of the right sub- 
DR. MOTT ON ANEURISMS.
967
   James Smith, aged thirty-five years, a laborer, about five weeks since
 received a violent blow from a cask of lime, the edge  of which struck
 him just below the left clavicle.  It stunned him for a few minutes.  For
 some days afterwards he suffered pain in using the arm, which extended
 in a short time to the scapula of that  side.  Several applications were
 made to the pained parts, treating it as a contusion only, for as yet there
 was nothing else manifested.  About a month after the accident, a swell-
 ing was perceived under the collar bone, which gradually increased in
 size, attended with severe pain.  As the tumor enlarged, the whole arm
 became tumefied and exceedingly painful.  He passed sleepless nights,
 and his countenance bore marks of great distress.
   About two weeks from the discovery of the  tumor he was sent to me
 to be examined.   The nature and character of  the case being very evi-
 dent, I requested by a note  an interview with Dr. O'Reilly.   As the ar-
 tery  could  now be compressed by the fingers at the outer edge  of the
 scalenus anticus muscle, and the pulsation of the aneurism entirely sus-
 pended, I proposed to the  Dr. that a ligature  should be applied at that
 point, as a probable means  of cure.   This was  communicated to the
 patient, who immediately consented to anything that would even give him
 a temporary respite from the intense suffering under which he labored.
   The reduced state of the  patient's health from constant suffering, and
 the immense size of the whole arm  from oedematous  tumefaction, accom-
 panied  with an erythematic redness throughout its  whole extent with
 great tenderness to the touch, and an almost useless  state of it, present-
 ed by no means a favorable  prospect for the result of the operation.   I,
 however, stated to the doctor that if he preferred it, I would perform the
 operation.
  The tumor externally was mostly  below the clavicle in its entire length,
 reaching also considerably into the  axilla.  It extended behind the clav-
icle, and penetrated below this bone to near the outer edge of the sca-
leni muscles.  The clavicle  and shoulder were raised by it.
  The intense suffering of the patient from pain in the tumor and arm,
together with the enormous  oedema of it, and  inflammation throughout
its entire extent, seemed to  admit of no delay of the operation.  From
the aspect of the whole case, I confess I felt  many  misgivings as to  the
result of an operation, but it was  every way justifiable and  proper to
 give him the chance, though ever so doubtful  and  uncertain.  This he
fully understood, and  was very urgent in his entreaties for its perform-
ance.
  On the 15th of November, he was seated in a chair, with the left side
to the light, his  head reclining a little, and supported by an assistant.
The external jugular being made manifest by pressure, an incision was
made along its  external margin, close to the outer  edge of the sterno-
cleido  mastoid muscle, and carried down to the  clavicle, about three
inches in  length.  From the inner  point  of this another  was carried
along the upper edge of this bone, outward to the  same extent.  The
integuments, including the platisma myoides, were dissected up, and the
flap turned toward the shoulder,  On  cutting through the deep cervical
fascia, the omo-hyoid muscle was  exposed.  With  my fingers and the
handle of the.  scalpel, the loose cellular and fatty tissues were pressed
aside, and the subclavian artery readily  felt and exposed  just  at the 
968            NEW ELEMENTS  OF OPERATIVE SURGERY.
 point  where it passes from under the anterior scalenus muscle.  With
 the aneurismal needle properly armed with a ligature, I now passed it
 from below upward, the artery being distinctly felt and even exposed to
 view.
   Feeling for the artery a second time, I tried carefully to pass the hook
 under  the  vessel, but could not;  but why, I could not understand, nor
 can I now comprehend.  It appeared as if the artery was so firmly bound
 down, as to be apparently  incorporated with the parts beneath.  Per-
 haps  the proximity  of the aneurismal sac, and elevation of the clavicle
 may have had  some agency in fixing the artery in this manner.   I now
 turned the instrument, and  with the hook  from above downward, with
 great  difficulty, patience, and perseverance, was enabled to pass  the
 hook under the vessel.   In turning  the point upward, to enable  me to
 get at the  eye, an instantaneous  gush of arterial blood flowed, which
 obscured all the parts.  It was a torrent indeed,  and filled with  dismay
 several professional men present,  who instantly left the room.   At the
 moment of the  gush, I passed  the two forefingers of the left hand into
 the wound, and applied the points  of them over the wound of the aneu-
 rismal sac, which completely commanded the haemorrhage.   In the midst
 of the blood I now passed the needle, and brought out the hook and liga-
 ture from below upward.
   After the hook  was passed, all  present  felt the artery, and said they
 were perfectly satisfied that  the ligature was under the vessel.   I frank-
 ly owned it was not entirely satisfactory  to myself.   I, however, with
 their full concurrence tied the  ligature.  The pulsation of the aneurism
 instantly ceased.  I then took  my seat in another  part of  the room, and
 requested my assistants to dress  the wound.   The parts  around were
 cleansed, and the wound about to be dressed, when Dr. Proudfoot said,
 " there is some pulsation returned in the  tumor."  At which remark I
 went to the patient, and to my great suprise it again pulsated.
  My first remark was, can there be two subclavian arteries in this case,
 or have we  all been mistaken, and tied  something else.  The  latter
 seemed the most probable.   But what was  it—not a nerve, for the tying
 it gave him no pain.  The  relative position of the parts was distinctly
 made out, and  seen during the  operation.   The  ligature was therefore
 as it appeared on a review of the parts, to be upon  the subclavian artery.
 But in the normal  state of  things it could not be, as the aneurism had
 again pulsated.  What was it that this ligature was around ?  I frankly
 own that I do not know.
  The wound being now well sponged, I divided a portion of the clav-
icular  part of the sterno-mastoid  muscle, also laid bare the subclavian
artery  a little under the outer edge of the scalenus anticus muscle.  When
the wound was  freed of blood, I made another attempt to pass the hook,
but could not get it under the artery.
  I now  requested  Dr. Proudfoot  to pass the ligature under the artery.
He made several  attempts  from below upward, then from above down-
ward, but could not succeed.  My  son, Dr.  V. Mott, Jun., then took  the
hook, and passing it from under the edge of the scalenus, more obliquely
in the course of the artery  from below, was fortunate enough in getting
it under the vessel, after using very considerable force, and the ligature
was thereby conveyed around the artery.   I then tied it. 
                      DR.  MOTT ON  ANEURISMS.                   969

  The pulsation again ceased in the tumor, and it fell to the level of the
clavicle, and was diminished to about half its original size.   He remained
in the sitting posture in the chair during the operation.  On being asked
how he now felt, he replied, " first rate"—that his sufferings were now
greatly diminished in the arm.  The wound was now dressed  with three
interrupted stitches, strips  of adhesive plaster, lint, and a roller bandage
moderately tight over the  neck and shoulders.  After getting into bed,
his arm was loosely enveloped in cotton wadding, and he did not expe-
rience pain enough to require an anodyne.  To procure rest at night he
was however, ordered to take fifteen drops of Majendie's solution of the
sulphate of morphine.
  In a few  days after the operation the aneurismal tumor had almost
entirely disappeared, and  the clavicle had returned to its natural posi-
tion.   Very little constitutional disturbance or local suffering followed.
Every day he  was  cheerful and  happy,  and when asked how he was,
replied with a  smile  that he was well, and felt only the  inconvenience
of his restraint as to position and confinement in bed.  The erythematic
redness which  pervaded the entire arm from the fingers to the shoulder
gradually subsided, together with the enormous cedematous tumefaction
of the whole extremity.   The arm I should think was nearly three times
larger than the second one, and so heavy that he had been  obliged for
some time to move it about with the other hand.
  He was requested to  take light and unstimulating diet, and his treat-
ment was moderately  antiphlogistic.  On the fifth day the wound was
dressed, a little discharge having appeared at the  lower part of it.  On
removing  the dressings, the  wound had mostly united by the adhesive
process.   The  cedematous  tumefaction had considerably abated, and the
erythematic inflammation had also  greatly subsided.   His sufferings had
in a great measure passed away from the first hour of the operation, and
he  is  cheerful  and  happy from  the relief the tying of the artery has
given him, and the hope and full confidence he indulges that he will re-
cover.
  He  was directed  to  remain in bed in a recumbent posture, mostly on
his back,  which he strictly  and rigidly carried out.   The strict regimen
which he  practised, dispensed with almost all medication, except a small
quantity  of laxatives from time  to  time, and  occasionally anodyne at
night.  In a short  time all parts of the wound were healed, except at
the exit of the  ligatures.
   The second  ligature (perhaps the veritable artery ligature) was re-
moved with  slight  traction on the seventeenth day.  On observing the
noose, it is larger than from any other artery I have seen tied, although
the  knot  was  made very  tight at the time of the operation ; showing,
conclusively, that the  artery was unusually large, as it appeared to the
feel, yet it must have been  healthy to have healed so kindly.   The arm
was reduced to  its natural size,  and  all  the  oedema and redness had
disappeared.   He was now  permitted to be raised up in bed, and in a
day or two  after, to be got into a chair for a few hours a day.   From
the  first  week after the operation  the suppurative process  being well
established, he was allowed a nourishing diet, and after the discharge
of  this ligature he was  directed to take malt liquor, as the perspirations
   Vol. I.                      122 
970            NEW ELEMENTS OF OPERATIVE SURGERY.
at night denoted considerable debility.   The aneurismal tumor has now
entirely disappeared.
  His general health soon improved under this treatment.   And now we
give attention to the other ligature.   Slight traction of it gave him pain,
which  extended down the whole arm, following, however, the course of
no particular nerve.  No pain was felt except  when the ligature was
pulled  upon, and it did not continue any length of time  after.   When
the artery ligature was slightly drawn upon, he complained of the same
kind of pain, but to a  trifling degree.
  This  first  ligature  (or the  other  ligature) did not separate until the
thirtieth day.  To hasten its  coming away almost daily traction was
practised, and  for  ten days  it was twisted firmly by a fold of linen.
The noose of this  almost equals in size  that of the other ligature.
During the  time  this was being removed he was walking  about his
rooms, in greatly improved health, and impatient of  the confinement.
In a few days after it came away, he went  home, the wound healed di-
rectly, and he resumed his former occupation, that of a laborer.
  I am sure that the first  ligature was not around a nerve, as the pain
at the instant of its  application  would have  been insupportable, and
numbness of some part of the arm and forearm and fingers would have
been an  inseparable accompaniment.  But  neither  of these effects was
produced.   While the ligature was beneath it, as is my custom, I press-
ed  opposite  it  with  the forefinger, and so did my assistants, and the
pulsation of the aneurism ceased.  And on tying  it, the tumor ceased
to beat, and as before stated I had taken my seat and requested the wound
to be dressed.
  Now what did I tie in this ligature ?  I frankly  own I do not know.
I cannot feel willing to admit that I was mistaken in the artery, when
it was  plainly felt and even seen, and when  too the relative anatomy was
all exposed before me, and which  I feel that I ought to be familiar with.
But so it  is—the facts I have stated—others may  judge.  If two sub-
clavian arteries had  ever  been seen on one  side, that would be  my
refuge.
   To  me  this  case is peculiarly  interesting and instructive.  First, on
account  of the possibility of two subclavian arteries on the same side.
Secondly, the laceration  of the aneurismal sac by the  hook.   Thirdly,
my being  able to command the frightful torrent of arterial blood from
the  opening in  the sac by two fingers of my left hand.  Then making
a further dissection as before described, and tying  the artery under the
edge of the scalenus anticus.   And  lastly, and best, and most certain of
all, for the patient to  recover.
END OF VOL. I.
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