NEW  ELEMENTS
OP
OPERATIVE    SURGERY:
                        BY

           ALF. A. L. M, VELPEAU,

Professor of Surgical Clinique of the Faculty of Medicine of Paris, Surgeon of the Hospital of La
      Charity, 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,

     REPBESENTINQ 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 OP, 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 Academie Royale de Medecine of Pans,
               of that of Berlin, Brussels, Athens, etc.
                                y
                FOURTH EDITION, WITH ADDJTICpW BY
        GEORGE  C. BLACKMAN,  M.D.,
  Professor of Surgery in the Medical College of Ohio, Surgeon io the Commercial Hospital, etc.

               IN THREE VQliUMES.
                    VOL,' II.
                       CO
: wrri
         NEW  YORK:
SAMUEL S. &  W.  WOOD,
       No. 389 BROADWAY.
              1856. 
^•A,
wo
It ft
~>?-£-V    2-k/<
       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 Tork.
STEREOTYPED BY
                                   PRINTED BY
 THOMAS B SMITH,                E< N. GROSSMAN
82 & 84 Beekman Street, N. T.                  84 Beekmall st 
;
NEW  ELEMENTS
OP
OPERATIVE   SURGERY.
                  SECTION  SIXTH.

                       VENOUS SYSTEM.

   The  same operations are practised upon the veins as upon the
 arteries ; this  class of vessels in  fact, like the  arterial  system, is
 liable to wounds, fungous degenerations, and hypertrophy.
   Wounds.—The wounds  of the venous system, however, unless
 they should be situated upon trunks of the first order, the vena
 cava, internal jugular veins, subclavians, axillaries, iliacs, femorals,
 or popliteals, rarely give  rise to dangerous hemorrhages, and if
 they are formidable they are rendered much more so by the inflam-
 mation  they  cause, than by the loss of blood that proceeds from
 them.
   [A blow on the jugular vein has in several instances been the
 cause of almost immediate death.   Two instances of the  kind have
 lately come to our knowledge, and in the Lond. Lancet, Jan. 1845,
 two other cases are reported, in one of which, a blow on the  side
 of the  neck caused death  in 24  hours;  in  the other, the person
 struck fell dead instantly.   In the last case, a large quantity of
 effused blood was  found in the lateral ventricles, and in  the fourth
 ventricle.  Effusion was likewise found on the surface of the brain,
 in the instance where  the patient survived for a day.  Vid. Amer.
 Journ. Med. Sciences,  Oct.  1845.   G. C.  B.]
   Wounds of veins differ also 'essentially  from wounds of arteries
 in cicatrizing with facility, without necessarily involving the ob-
 literation of the wounded  vessel.  It results from this, that if a
 large  vein is divided upon  its side, and  that compression is not
 sufficient to  put an end to  the hemorrhage,  the ligature will not
 have to embrace  its  entire calibre.   The most  convenient  and
 secure process in such  cases, consists in seizing the two lips of the
opening  with the tenaculum, and in then  passing a thread  around
the wound on the  side of the vein, which  thus cicatrizes without
difficulty and without interposing any obstacle to the circulation.
  Vol. II.                 1 
2            NEW  ELEMENTS OF  OPERATIVE SURGERY.
   [Mr. Guthrie  treated a case of wound of the internal jugular
 vein in this manner.  The thread was passed around the opening
 so as not to obliterate the trunk of the vessel.  G. C. B.]
   When a vein is divided transversely, whether we compress it or
 apply a ligature to it, it rarely happens that it becomes necessary
 to act upon  any other  portion of it than the inferior extremity.
 However, it might be necessary to obliterate the  other end also, if
 the  wound was situated in the neck, in the upper  part of the arm,
 or even in the  fold of the  groin.   I have often  seen the popliteal
 vein pour out blood copiously by an actual reflux  movement.
   When veins are found in the wounds of an amputation, it is gene-
 rally useless to  apply a ligature  to  them.   Nevertheless, if they
 keep up a hemorrhage, I think we should do wrong  not to tie
 them.  The dangers of  this ligature, upon which so many surgeons
 have insisted for  half a  century, are shown to  be farthest from the
 truth, (vid. Process  for tying  the  Carotid,) and I should not be
 surprised  to  find that it would prove more  advantageous to sur-
 round them immediately with a ligature,  than to  leave  them free
at the bottom of the  wound.
   As for the  rest, almost all the operations that  have been  prac-
tised on  veins, seem  to have  been devised for cases of varices.
This article, therefore, will be devoted to the treatment of these
affections.
                      CHAPTER  I.

               OPERATIONS REQUIRED FOR VARICES.

  Though varices do not constitute a disease essentially dangerous,
they may  often so far incommode  those who are affected by them,
as to make it proper that surgical aid should be had' recourse to
for their treatment.  The trouble, deformity, and  ulcers that they
cause or keep up, and the hemorrhages which sometimes take place
from them, sufficiently explain the solicitude which they have occa-
sioned at every epoch of the science.

               Article I.—Varices in  General.

 ^ The ancients, who employed topical applications, astringents de-
siccatives, and  resolvents  for varices, used, also the  compressing
bandage, applied to the whole extent of the limb, and  professed to
aid their  action  by means of internal  remedies.  Then, as at the
present  day, those different modes of treatment were nothing more
than simple palliatives.  To obtain a radical cure, they had re-
course to operations properly so called. 
operations required for varices.
3
                    § I.—Ancient Methods.

  A.  Acupuncture.—Sometimes it was  thought  sufficient  in  con-
formity with the recommendations of Hippocrates, and as was also
advised by Pare and Dionis, to puncture the varices, (Hipp. Traite
des Ulceres, a la fin,) and incise them lengthwise, but more freely
than in phlebotomy, in order to empty them of their blood and clots.
" Practitioners of the present day," says De Gouey, {La Veritable
Chirurgie, p. 236,) make use of  a  needle of gold or silver, with
which they puncture these tumors to empty them of their blood ;
but this operation is but a feeble resource."
   [In Ranking''s Abstract &c. p. 110. Nov. 1847. is the report of
a very remarkable case of varices in the lower extremity cured by
means of the Electro-Puncture.   G. C.  B.]
  B.  Cauterization.—According to Avicenna, the vein  should  be
seized with hooks at two points, distant three fingers' width apart,
then tied with a good silk  thread, and  divided  transversely upon
the space  between  the ligatures  ; after which, the ligature upon
the lower  end is to be removed,  in order to bring the blood  from
below upwards, and to force out as much  of it as is possible with
the hand;  then to cauterize the upper end of the vessel, and even
the whole  extent of the  wound, with a  hot iron or arsenic.   Avi-
cenna appears  to have been the  first, in the  treatment of varices,
who actually applied methodical compression from the foot to the
knee.
  Others tore out the varices, after having cut into them ; this, at
least, is what  Ali-Abbas appears to recommend.   Celsus  {De Re
Med., lib.  7, cap. 31, OuNinnin, t. II.,  p. 371) speaks of cauteri-
zation and extirpation,  and all  the world know from Plutarch,
{Hommes  lllust., t. IV., p. 380,  Trad,  de Dacier,) that the  stoic
Marius—who, remarking  that the remedy was worse than the dis-
ease, declined presenting his other leg covered with varices^to the
surgeon, who  had removed them from the first—had  undergone
this last named operation.   Dionis {Operat.,ip. 766, 9e Demonstr.)
is astonished that the ancients did not advise the hot iron to tra-
verse {barrer) the varicose veins, as is  done with horses, and that
they  should have been  satisfied with the potential  cautery.  An
enormous  varix was cauterized  and cured by  Bidloo,) Coll. de.
Villars, Cours de Chirurgie, t.  I., p. 434—439.)  Bayrns (Louis,
Diet, de Chirur., t. I., p. 561) speaks  of a varix that resembled
gutta rosa, and which he cured by cauterization of the frontal vein.
We are not surprised to see M. A. Severin  {Med eff., p.  368, ch.
98, Exopirie) cauterize with the red-hot  iron.   Dionis admitted,
however, that the roller  bandage, in form of a buskin, (bottine,)
was preferable  to all other means.  This was also the recommenda-
tion of the greater number of the surgeons of our epoch, when an
attempt was made, some  years since, to simplify the  operations of
the Greeks and Arabs.
  [The application of caustics has  been highly lauded by M. Bon-
net of Lyons.  Mr. Skey? of St. Bartholomew's Hospital, London, 
4.            new  elements of operative surgery.
has employed this method of treatment in  an immense number of
cases, and he claims for it, that it is effectual and unattended with
danger.  He employs a paste, composed of  three  parts of lime
and two of potass, and prepared with spirits  of wine, at the time
of its application.   The eschars must not be larger than a pea, and
their number should be in proportion to the extent of the disease.
A paste of the chloride of zinc is used by others for the  same pur-
pose.   G. C. B.]
  C.  Excision,  either simple, or  as  Celcus describes it, or as  it
must have been performed upon  the  leg of Marius, or  combined
with the ligature as in the process of Galen, or that preferred by
Paul of Egina, (Vid. Vidius, Comment sur Gal., lib. 6, cap. 83,)  is
but rarely necessary, and cannot  be required, as Boyer remarks,
but for those large tumors or varicose bunches which are  some-
times met with in the legs ; it is also uncertain if it might not even
then be superseded with advantage by processes more simple.  We
may learn," from  J. L. Petit, (CEuvr.  Chir., p. 266, 267,  279, 280,)
the kind of hemorrhage to which patients may be exposed from
the incomplete extirpation of varicose veins.
  D.  The Ligature, which was distinctly recommonded  by the an-
cients after excision, and which Dionis describes with  much mi-
nuteness, {Oper. Cit.,-p. 765,) was frequently  employed by  Ev.
Home, in England, and by Beclard in  France. ■ We take up, says
M. Briquet,  (These No. 193, Paris,  1824,) who relates the  results
obtained by  Beclard, a longitudinal fold of the  skin  on  the point
where the vein is alone and most  superficial, and divide the  fold
down to its base;  we then  pass under the vein an eyed  probe
furnished with a ligature, and after  having tied  the  same,  divide
the vessel immediately above it.   We may also  cut  the skin  and
the vein at a single stroke, and then tie the lower end  of the venous
canal by seizing  it  with  the  forceps.  Strips  of adhesive plaster
serve to hold together the lips of this little wound, and the patient
is to be kept at rest.
  MM.  Smith, Travers, and  Oulknow, have  followed the method
of Home; but not  with  as constant  success.  Physic,  however,
says, he has great reason to be satisfied with it, and M. Dorsey,
(Elements of Surgery, Vol. II., p. 404,) who frequently made trial
of it, affirms it, that it was  never, in his practice, attended with any
serious accidents.  According to  Briquet, at no  time during the
service of Beclard at La Pitie,  did this method ever produce an
unpleasant symptom, except  in two cases,  out of an aggregate of
sixty persons operated upon.  It is difficult, in fact, to understand
bow this ligature, if properly applied, could be attended  with much
pain, or be  followed by  tetanus, as has  been pretended, or why
inflammation of the vein, on the cardial side of the disease, should
be more frequently caused by this than by any operative process,
which causes the obliteration  of the vessel.
  The process of M. Gagneles, referred toby Marechal,  (Thhse de
Concours,) and which consists in passing a  ligature around  the
vein through a simple puncture in the skin, would have  no other
effect than to render the operation more difficult without diminish- 
operations required for varices.             5
ing its inconveniences.   " Nevertheless," says Chumette, (Enchi-
ridion de  Chirurg.,\\y.  1, cap. 58, p. 278,) " I am in the habit of
introducing with less trouble and pain, and by  means of a  sharp,
curved needle, a ligature under the vein, then tying it and leaving
the thread there until  it comes away of itself."   Does Lombard,
(Clinique des Plaies Recentes, an VIII., p. 248,) where he relates
that some recommended incising, to the right and  the left upon the
side of the vein to avoid the inflammation which  must ensue from
puncture with the needle and insertion of the ligature ; and that
others call this inflammation in question, wish us to infer that they
knotted the ligature upon the skin ?   De Gouey, ( Op.  Cit., p. 237,)
who tied the vein below  the varix,  and then divided it  above,
followed this practice with much success.   Lombard, (Op. Cit., p.
248,) who had recourse but once to the ligature, applied it at 6 or
7 millimeters below the tumor, inserting under the vein a needle of
the shortest possible curvature, and laying a small compress of four
double along the course of the vessel, in order to support the knot
of the ligature, and render the whole secure.   Afterwards opening
the tumor, he dressed with a pledget of lint dipped in alcohol.   M.
Cantoni, (Observature des Sc. Mid. de Marseille, Juillet, 1825,
trad, par Gerard.) who relates twenty cases, four of  which are taken
from his own practice, and  others from  that of Vacca, Mori, and
Orlandi, says, that after having made trial of the ligature, recision
and excision, this last offers the most favorable prospect of success:
but Vaca Berlinghieri,  (Valentin, Voyage en Italie, Ire edit., 1825,
p. 94, et trad, par Gerard, 2e edit., 1826,) who, in 1820, had already
in six cases effected the cure of varices by the ligature according to
the method  of Home,  has seen  the  disease reproduced, and some  '
time after, having seen a man upon whom  a surgeon had  per-
formed incision of the vein above the knee with  success, he wrote
to Valentin, that seeing that the  dangers surpassed the advantages
that had been hoped for by different processes, he had abandoned all
of them, and no longer practised the operation for varices.
   E. Incision.   Not wishing to confine himself to the simple liga-
ture^. Kicherand supposed that by incising in a direction paralled
to the limb, and  to a great extent the tortuous bunches or varicose
pelotons, he would be  more sure to succeed.   I  have many times
 seen him at the hospital of San Louis employ this practice with en-
 tire succees, and I have myself used it with advantage upon a num-
 ber of patients ; but the only  one upon whom I performed it at the
 hospital of La Pitie died on the ninth day.  We select the  part on
 the limb where there are the  greatest number of varices collected
 together, then with a convex and very sharp bistoury, we cut deeply
 and to the extent of four, five, six,  and even eight inches.   After
 having emptied the veins  of the clots by pressure, the  wound is
 filled with lint covered with cerate, and applied  either directly or
 upon a piece of fine perforated linen; the first dressing after this :3
 not made until at the end of three or four days.  Then the venous
 orifices are found closed, and the wound may be dressed flat like any
 other simple solution  of continuity.  Beclard  proceeded   m  the
 same manner in  several cases, and was not less fortunate than M. 
6
NEW ELEMENTS OF OPERATIVE SURGERY.
Richerand.  Those long gashes, however, have something  frightful
in them  to  the patient,  and reflecting seriously upon them,  we
cannot see what great utility they can have.   In conclusion, we
must not confound this method with the simple long incision recom-
mended by Avicenna,  (Huguier, These de  Concours, 1825, p. 12.)
  P. The section, upon  a single  point  selected, or  on  different
branches  when we do not wish to act upon the principal trunk of
the vein, would be evidently preferable to  the preceding operation.
I have performed it fifty-two times at the Hospital of San Antoine
and at La Pitie, in the space of six years.   One of the patients, it
is true, died on the  twelfth day, but with ataxic symptoms of a
very unusual character, which could only be accounted for from the
state  of fear or  unaccountable morbid apprehension under which
he  labored  before the  operation.  We  met with  no traces  of
phlebitis  above the  wound, and  that which existed below it wa-
found to be wholly disproportionate  to the severity  of the symp-
toms.  Another died from the effects of a  true phlebitis.   In three
other cases,  the phlebitis, after having given occasion to unpleasant
symptoms, terminated in abscesses about the wounded vein.  The
cure was afterwards accomplished without  difficulty.  M.  Warren,
who has  frequently practised this method, told me that he had al-
ways  found it  to  answer well.  Nothing is more simple than an
operation of this  kind;  the  vein is first raised up in a fold of the
skin ; a narrow and  keen-edged bistoury then passed through the
base of this fold, effects the division of it  with a single stroke; we
thus successively  practise the incision upon all the veins that are
somewhat considerable in size, and  that appear to come from the
varicose bunches.  The blood immediately escapes in large quanti-
ty ; and we allow it to flow for a greater or less length of time ac-
cording  to  the  strength  of the  patient, after which the  wound is
filled with  small  balls  of lint, before covering  it with a plumas-
seau  of  the same material spread with cerate, and then  with soft
compresses ; the  whole should afterwards be supported with a rol-
ler bandage moderately tightened ; if we attempted primitive coap-
tatation, the continuity of the vein might be re-established, and thus
defeat the object of the operation.
   G.  M. Brodie, with the view more effectually to guard against
phlebitis, (S. Cooper, Surgical Dictionary, t. II, p. 594,) confines
himself to dividing the veins transversely  by making only a simple
puncture in  the skin.  For that purpose he makes use of a bistoury
with  a narrow blade and  a little concave upon its cutting edge.
The point of the instrument is first passed through the integuments
upon one of the sides of the vessel; it is then made to glide flat-
wise between the vein and the dermis; when it has reached the op-
posite side, its cutting edge is turned backwards, and the wrist at
the same time  raised in such manner as to divide the venous cord
 perfectly while withdrawing the bistoury.   M. Carmichael and other
 practitioners have greatly  extolled this  process; a  patient  upon
 whom M. Bougon performed it in my presence, also did remarkably
 well under  it; but Beclard, who make trial of it at La Pitie, affirms
 that  it  gives us no better security against phlebitis and  phlegmo- 
OPERATIONS REQUIRED FOR VARICES.
7
nous  erysipelas than the  ordinary incision, and moreover, that it
sometimes  fails in producing the obliteration of the vein.   I ao-ree
entirely  in  opinion with Beclard,  and can add, that without secur-
ing us against any danger, this process is the most difficult and the
least certain of all.
  H.  Exsection  which had already been practised from the time
of Celus, Paul of Egina, Avicenna and Albucasis, has found some
partisans among surgeons  of the present day.  The  two ends of
the vein, by retracting under  the lips  of the  wound, cease to be
exposed to the  influence  of the external air, an action which, ac-
cording  to  M. Brodie, is a powerful cause of phlebitis.   This last
argument is entirely hypothetical, and not deserving of the impor-
tance  that a surgeon of Paris (Rev.  Mid., 1836, t. I., p. 29,) has
given  to it while claiming it as his own property.  To say that if
an inch of each end of the vein under the skin is not removed, the
air may bring on a phlebitis capable of causing death in twenty-
four hours, is  an absurdity which I have no need of making any
remark upon.
   [About twelve years since, a number of cases of varicose veins
in the lower extremity, were treated in this city by exsection, and
the application of tbe starched bandage.  At length fatal cases oc-
cured, and this method was abandoned. . G. C. B.]
   1.  Appreciation.—In conclusion, the avowed and unquestionable
purpose of the operator  is to obliterate the veins that  have become
varicose ;  but it cannot be denied that the ligature, without or with
the section, or whether  that section be transverse or  longitudinal,
open  or under the skin, and that extirpation itself as well as cau-
terization with potash or the red-hot iron, may all bring about this
result,  and that this constitutes the whole amount of relief they are
capable  of affording to  the patient.  It is desirable, therefore, to
know  which of  all  these  means  is that which produces the least
pain, may  be  performed with  the most ease, and exposes to the
least  danger.  The transverse section  of the vein, including the
skin  with it, possesses  the different advantages of the other me-
thods, combined with all the simplicity that could be desired.
   [Whoever may be the author of the germ of the idea, it is one that
undoubtedly belongs to sub-cutaneous surgery, though tUps is obvi-
ously one of those cases where the principle or leading feature of
this method seems not only not  applicable, but injurious, by confin-
ing the immense sub-cutaneous extravasation and dangerous infiltra-
tion of venous blood that must ensue.  T.]
   It is finished in an instant;  and the youngest pupil can perform
it with ease; the pain is  almost nothing, and the whole  operation
differs but little from an ordinary bleeding.  What is  to be obtain-
ed by the ligature so much extolled by Home  and Beclard, except
to make the operation considerably  longer and more dangerous?
Why  run the risk, in imitating M. Brodie, of an incomplete divi-
sion of the vein, and of seeing the blood effused into  the sub-cuta-
neous tissue, and forming there a nucleus and centre for phlegmon
or abscess ?   Is it the division of  the skin that should ever disturb
us after such an operation?  And who does not now  know that the
action of the air upon the veins is incapable of producing any of 
8
NEW ELEMENTS OF  OPERATIVE SURGERY.
 those formidable accidents which have been so gratuitously imputed
 to it ?  As to the longand deep incisions recommonded by M. Riche-
 rand, and formerly by J. L. Petit;  and to excision according to the
 method  of Celsus,  and  as Boyer  has  practised  it,  they never
^ should be countenanced except for  those cases  where the varices
: form painful masses, or have given place, by their degeneration, to
. tumors that can only be removed by extirpation.
   J.  But above all  other considerations, is it not allowable to have
 recourse to the mildest of these operations ?  For has not humanity
 a right to recoil from the danger of  phlegmons, erysipelas, purulent
 abscesses, phlebitis, and all other accidents which have more than
 once  followed in the train of the operation ?   Why should we not
 confine  ourselves to a laced stocking or to a roller bandage, which
 securely supports the  parts without making the  patient incur any
 risk ?  These objections are more specious than solid.  It is incor-
 rect to say that varices left  to themselves involve  no danger-
 M. Girod, (Journ. Gin.de Med., t. XIX., p. 65,) in 1824, satisfac-
 torily established this, and  Petit (Mercure de France,  Nov., 1743,
 p. 2418,) had already shown  the  danger of rupture of varices.
 Two patients of whom Lombard (Plaies Ricentes, &c, 229) speaks,
 died  from the effects of it.  Chaussier has related an instance of
 the rupture of a varicose vein in a pregnant woman, which speedily
 caused  death.  Murat has  given the  case of a washerwoman, in
 whom death took place from the same accident.   In 1827, a state-
 ment was made at the  Academy of  Medicine, of a man in whom it
 had a similar fatal termination.  In 1819,1 saw a countryman per-
 ish from the loss of blood twenty-four hours after rupturing a varix.
 The death of Copernicus is attributed  to this  cause.   MM. Reis,
 Lacroix and Lebrun,  (Nouv. Bibliot.  Med., t.  II., p. 275,) have
 each  made known a similar fact.  A pregnant woman  to whom M.
 Forestier was called,  also ran the greatest degree of danger.
   Those bandages or gaiters  that are recommended to every one,
 require care and precaution ;  they incommode more than is  gener-
 ally thought, give rise to excoriations and  exudations, on different
 parts of the  limb  and are not, therefore, so perfectly free  of in-
 convenience.  Madame Boivin cites a case of a young  woman who
 could produce a miscarriage at pleasure, by applying a bandage
 to her varicose legs.  Those eczemas too in fine, and eruptions and
 ulcerations so difficult of cure, which are almost always produced
 as soon as the patient takes any exercise, and which inspire terror
 to  the surgeon  as  well as to the  persons who are afflicted with
 them can it be said they have never caused death in a single instance
 nor never given origin to any dangerous disease, nor made  it nec-
 essary to amputate the limb ?
    On the other  hand, if it be admitted  that after  incision of the
 veins, there sometimes supervene phlegmonous  inflammations, and
 engorgements of various kinds, and that phlebitis also  may be pro-
 duced, it is not the  less true that all those  accidents are rare, that
 for the most part they are easily subdued, and that moreover, we
 may  almost always prevent them, if after the simple  incision such
 as I have  described it, we  take the precaution while  inflammation 
OPERATIONS REQUIRED FOR VARICES.
9
is to be apprehended, to keep the limb enveloped in a compressing
bandage from its extremity to its root;  the presence in fact, of the
varices themselves,  endangers  the liability to  such  accidents as
much perhaps as the operation does.

                      § II.—New Methods.

  We possess, after all, at the present time, processes more simple
than  the  preceding, to effect the  obliteration of superficial veins.
The experiments  upon the  acupuncture  and ligature  of vessels,
which I described in this work in 1830 and  1832, brought about
results which have since been adopted in practice.   M. Davat and
M.  Fricke have proved, as I also have  done, that a needle  or a
thread passing  through each varix, and left for  some days, is  suffi-
cient to effect its occlusion.  I have  myself  devised a plan which
is yet more  simple.  In place of perforating  the vessel  with the
needle, I seize it, and  raise it up in a fold of the integuments,  with
two fingers, in  order to pass a pin  below it, and form a kind of
twisted suture,  or one of circular construction.   The vein is thus
strangulated between the body of the pin, which should be strong,
and the skin which the thread  tends to divide backwards.  We
may  thus  place from ten to twenty pins in the same sitting,  or at
intervals  of a few  days,  upon  the  principal  varicose branches.
No dressing is afterwards necessary.   If we cut off  the points of
the pins, or apply a piece of linen or a containing bandage,  it  is
only  to prevent the possibility of the patient  wounding himself
while  turning in bed.   I remove the pins on the sixth, eighth, or
even twelfth day, according  as the vein appears more or lesf  com-
pletely obliterated.   The puncture closes soon, and in a few  days
after, the patient may recommence walking.   When the portion of
the skin included between the pin and the thread forms an eschar,
we  must wait for its separation, and treat the wound afterwards as
for a burn of the fourth degree.
  Nevertheless, we must not count on the efficacy of these opera-
tions,  which can  be performed  only upon  patients whose deep-
seated veins have preserved  their natural condition, and where the
patients themselves desire the operation, and that the varices  have
produced  effects that are calculated to interfere  with the  functions
of the diseased part, or to compromise the  general  health.  The
cure at best, is rarely  complete.   The anastomoses soon reproduce
the varices, and at most, prudence suggests that we should confine
ourselves  to the obliteration of  the  branches  which  are in the
neighborhood of the ulcer or the eruption which alone have caused
the patient to  ask  for relief.   I have already performed on one
hundred and fifty  persons the operation  which I have  described;
and up to  the  present time, no accident of a  grave nature has
occurred.  A very small  circumscribed phlegmon is the  most se-
rious one I have noticed.   More  circumstantial details,  however,
will be given upon this subject in the following article.
  [The question of operative interference in the treatment ot vari-
cose veins, has been most ably considered by Dr. John Watson, ot
  Vol. II.                    2 
10
NEW ELEMENTS OF OPERATIVE SURGERY.
 this  city, in his critical  notice of Chelius' Surgery, published in
 the American Journal of Medical  Sciences, Jan.  1848, p.  175.
 Dr. W. remarks :
   " We hold that the danger incidental to operations on varicose
 veins, has less to do with the special mode of attacking them, than
 with the condition of these vessels at the  time of operation ;  and
 that they should never be interfered with by any sort of operative
 procedure,  whether that be the knife, the ligature, the pin, or the
 potential cautery, when in a state of inflammation."
   Through the journal above mentioned, Dr. Watson's^ontributions
 on the subject of varicose veins, varicocele &c, have become widely
 and most favorably known to the profession.  Their truly practical
 character entitles them to a conspicuous place in the surgical litera-
 ture of these important affections.   G. C. B.]

             Article II.—Varices in particular.

   Although varices of the  lower limbs  have almost exclusively
 attracted attention, all the other regions of the body  are not less
 liable to be  affected with this kind of disease. Wedel, ( Collection
 Academique ; partie entrangere, t. VII., p. 450,) speaks of varices
 of the upper extremities which gave place to dangerous hemorrhages
 by their  spontaneous rupture.   I have twice seen the arms, fore-
 arms and hands covered with varicose  enlargements.   A young
 man admitted into the hospital of La Charite  in 1838, had from
 his infancy  a varicose tumor (un  peloton de varices) as large as
 the fist, between the angle of the  jaw and clavicle on the  right
 side <n the  neck.  M.  Champion  informs me that  he has  seen a
 young lady  who had a varix of the size  of a small egg, under the
 tongue.  I have met with a young  person who had one of the size
 of the thumb under the superciliary ridge.  I  have in fact seen
 one  in a man of about  thirty years of  age, situated  upon  the
 course of the sagittal suture,  and  which appeared to be connect-
 ed with the  longitudinal  sinus in the  falx of the brain.   Baillie,
 Aliburt and M. Huguier (These  de Concours, p. 19)  have given
 instances  of them upon the  cranium or jugular vein.   Varicosities
upon the nose, eyelids, and the entire  face are far from, being unu-
 sual.   The chest also is frequently the seat of them.  But the. hy-
pogastrium,  the external genital organs, and the lower extremities
 are nevertheless  their favorite localities.
  If it is  true that  in the hypogastric region the sub-cutaneous or
 deep-seated  veins may acquire a volume so considerable, and inter-
twine and fold themselves in such manner as to resemble numerous
leeches gorged with blood, as I have seen in three instances, it is
 also true that such varices scarcely ever create any solicitude either
 in the patient or the surgeon.   In treating of hernia I shall speak
 of the danger which results from such varices when they spread in
 the neighborhood  of the  groin, or are prolonged in the form of
 cylinders or tumors as highup as the umbilicus.
  We find in Theden (Neue Bemerkungen, etc., t. II., chap. 5, p.
 75) an instance of aneurismal dilatation of the veins of the belly, 
OPERATIONS REQUIRED FOR VARICES.
11
which appeared to have no influence upon the health of the patient.
Theden also  speaks of a vena  cava  whose  dilatation might  have
given rise to  the belief of a hernia of the heart.   If operations are
not practised upon the veins of which I have been speaking, it is
not because the obliteration of these vessels, however enlarged they
may be, are in reality dangerous. I have elsewhere given an instance
of a vena cava descendens obliterated by a tumor at the apex of
the chest.  Dance (Nouv. Bibliot. Med., 1828,1.1., p. 451) speaks
of a similar  obliteration, which was  accompanied by that of the
subclavian veins  and the  azygos, without there having  been any
cedema or infiltration above.  In the patient mentioned by Wilson,
(Exper.,  t. II., p. 336,) this obliteration had caused only a  slight
cedema in the face.
   [Complete obliteration of the vena cava ascendens, has also been
observed  by  Dr. Peacock,  of Edinburgh ( Cormack's Journal. Feb.
1843.)   M.  Gintrac  has reported another in the Gaz.  Mid, de
Paris, March, 1844.)   All the veins of the abdomen communicating
with this vessel, were in a varicose  condition.  Both of those  pa-
rents died of ascites.  T.]
   The  external  iliac veins were  obliterated in a patient who had
never  been attacked  with  dropsy, which case has  been published
by M.  Manec  (Nouv.  Bibliot. Med., 1827—28, t. I., p.  451.)
Descot (Affect. Loc. des  Nerfs, p.  124) mentions  a case  of the
same kind from  Beclard.   We are indebted for another to Baillie
(Anat. Pathol, p.  20—22).  In the case of M. H. Berard (These
No. 23, Paris, 1826)  it was the vena  cava ascendens  which was
closed ; so that  there  is  scarcely  perhaps  a vein  in the animal
economy whose obliteration, and that without endangering life, has
not been noticed.   In some regions, where they are found externally,
the varices might in truth be reached by the operations which have
been described above; but in reality we occupy ourselves only with
those  of  the legs  and the external  genital organs.   It follows,
therefore, that in  treating of particular  kinds of varices I shall
confine myself to those of the abdominal extremities and the scro-
tum.
               § I.— Varices of the  Lower Limbs.

   All that I have  said of varices in general, applies particularly
to those of the  pelvic extremities;  I have only now therefore  to
point out what there may be  of a special nature in the manipula-
tion of the operation on these organs.
   [Before which we take occasion to speak in this place of two
extraordinary  cases  of varicose enlargement, or hypertrophy of
the veins of the lower extremities, which  have been observed in
this country, and which are both now  living, one an adult of  about
60 as observed by Dr.  Mott, the other a young  man of about 21
which  recently occurred in my own  practice.  There are perhaps
not on  record two more remarkable  cases.  Dr. Mott  states that
in his patient, who is a person of unusually tall and erect stature,
and of stout frame and otherwise perfect  health, but  from  habit
and his profession much accustomed to walk or to be in the  erect 
12
VEW ELEMENTS OF OPERATIVE  SURGERY.
position, the entire mass of venous trunks  and anastomoses in#the
sub-cutaneous  tissues are so enormously  distended, that they seem
to constitute in each leg from the toes to the hips one  general
diffused encasement of venous  blood and aneurismal  dilatation.
Were it not for firm containing  bandages in which both limbs are
kept constantly  enveloped  throughout their whole extent, death
would  inevitably ensue  from the continual danger of exhausting
hemorrhage by the  spontaneous  rupture which the gravitation of
the blood above would doubtless  cause.   When the bandages are
momentarily removed, the veins fill up to such degree as to enlarge
each leg and  thigh almost to the dimensions  of  the body of an
ordinary sized  man.  When  the bandages are on, the  power of
walking slowly, though even that is much impeded,  is not destroyed.
This patient is of a highly  sanguineous  temperament and of  very
florid fair skin, though very temperate and regular in his habits,
and  tall, robust, remarkably straight and  well  made in his frame,
and  of unusually symmetrical proportions, though  near  6 feet 6
inches  high.
  In the case of the  youth, in my own practice, and who on the
other hand is of unusually  pale  complexion and of delicate make
and  dark hair and eyes,  indicative of that  order of scrofulous tem-
peraments, the disease is congenital, similar in some respects to the
remarkable case only described by Breschet, but infinitely more
extraordinary.   The superficial veins of one leg only appear to be
affected.  The  dorsum of the foot and the entire outer  part of the
lower  leg  are covered  with  their convolutions so thickly  and to
such extent as to resemble  large worms intertwined in every possi-
ble tortuous  and serpentine  shape—making a perfect  net-work.
But about the ankles  they form large reservoirs of several inches
in length  and near three-quarters of an  inch in calibre.  One ol
these also  crosses the patella obliquely, where it  may be seen and
felt through woollen pantaloons, as large as the thumb and slightly
pulsatory.  It  then proceeds obliquely upwards  and  backwards
upon the  outer  part of  the thigh. Here on the outer part of the
thigh  it forms a tortuous reservoir of near an inch in  diameter.
When lying down they all  nearly disappear for the moment.  The
disease seems hereditary.   The general health is unaffected.  T-]
   A. Ancient processes.—I.  Compression.—When varices of the
legs are treated by compression we generally envelop the whole of
the limb in a roller bandage or a laced  stocking,  in order that the
entire mass of  veins may be supported  in a uniform manner.   M.
Colles, however, a distinguished surgeon of  Dublin, informs  me
that he has limited  himself to making strong compression upon the
internal saphena vein in the fold of the groin by a kind of circular
pelote, and that he has by this means effected cures.  This method
appears to me so contrary to what we know of  the progress of va-
rices,  that up to the present time I have not ventured to make trial
of it.   As however I have  particularly  remarked, that the garters
though tied somewhat tight, did not always increase the size of the
varices, and  that compression  made at the lower part of the  leg
 only occasionally causes temporary engorgement of the veins of the 
OPERATIONS REQUIRED FOR VARICES.            1,3
foot, and as M. Colles is a gentleman entitled to confidence, I shall
take an opportunity to make trial of his method  upon some  cases
that may offer.
 ^ II.  Excision, exsection  and incisions by the method of the an-
cients, or J. L. Petit, could be  practised upon the legs as well as
in any^ other region.  The same remark applies to the ligature and
exsection.   Vesicatoriesemployed, it is said, (Chir. des Hdpitaux
t. II., p. 392.   Hugier, These de Cone.,') in St. George's Hospital^
London, would require no special directions in  these cases.
  III.  Transverse  Section.—In order to  divide the veins of the
lower limb by the most simple process, it would be necessary that
the legend thigh should be in a state of relaxation.   The surgeon
then seizes the vein in a fold of the skin above its swollen portions;
holding this fold by one of its extremities with  the thumb and fore-
finger of one hand, while an assistant raises the other extremity in
the same manner, it is divided transversely by inserting the point
of a straight bistoury near its base and under the vein, and in such
manner that the  back of the instrument should be turned towards
the limb.   Performed in this way, the operation is prompt and but
little  painful.   To  arrest the bleeding a considerable degree of
pressure is required upon the lower end of the cut vein.  Balls of
lint should be  applied directly, or upon linen spread with cerate at
the bottom of the wound ; without that the  continuity of the vein
might be re-established and the  object of the operation defeated.
  There are no points upon  the leg where  this section cannot be
performed.  If the varices belong to the  system of the  external
saphena, we are to  look  for the  trunk of this last in the neighbor-
hood  of the ham.   It is  well to remark  (Huguier,  These, p.  35)
upon this subject  that the external saphena is often composed of two
principal branches: one, ascending, which belongs to the leg , the
other, descending, which comes to it from  the  posterior region of
the thigh, which branches unite  to  form a  common  trunk in the
popliteal space.
  When, on the  contrary, the -varices  depend upon  the internal
saphena, it is below the knee and opposite to the  pes anserinus and
above the inner condyle of the femur that its section is to be made.
For greater security, also, it would be advisable to divide each di-
lated vessel upon different portions of the leg.  Without that there
would be reason to  fear  that  the  innumerable anastomoses of the
veins of the whole limb would ultimately reproduce the varices.
  B.  New processes.—All the new processes applied to varices of
the legs may be referred to acupuncture, the  ligature, or local com-
pression.
  I. Acupuncture.—The researches  which I made in 1829, (Read
to the Institute, the 27th of December, 1830,) having proved that
it required only to keep a foreign body  lying transversely through
a vessel for some days to effect its obliteration, it was very natural
that acupuncture  should be soon  applied to the treatment of varices.
This method which M. Fricke and M. Grossheim (Jour, des Conn.
Med.-Chir., t.  II., p. 221, 1834) were the  first to put in practice
upon the living human subject, in cases  of varicocele, is divided at 
14
NEW ELEMENTS OF OPERATIVE SURGERY.
the present time into two processes, that of M. Fricke and that of
M. Davat.
   a. Process of M. Fricke.—M. Fricke has not confined himself to
pure and simple puncture; if he perforates the vein with a needle
it is in  order to insert into it a thread in the manner of a seton.
For that purpose the vessel is grasped in a fold of the integuments,
as if it were with the view of performing the transverse section, or
we hold it firm by placing the fore-finger and thumb upon its sides.
Then with a needle  armed with a simple thread we transfix it from
one side to  the  other.  In order to be more sure of obtaining in-
flammation we may pass in this manner two or three setons through
the same vein at intervals of a few inches.  The operation is re-
peated  in this manner on each of the venous trunks that we wish
to obliterate.  If we  attack  the trunk of  the saphena vein at two
different  points below  the knee, and at two  other  points on  the
thigh, it will generally be rendered unnecessary to transfix the other
veins of the leg, unless the system of the external saphena should
also be implicated.
  Each seton should then be tied separately and moved in the vein
morning  and evening until inflammation has supervened.  We  are
generally enabled to remove them from  the second to the fourth
day.  A deposit  of plastic lymph is now effused in the neighbor-
hood, the walls of the vein inflame, and it soon becomes impossible
for the  blood to flow there.  If the inflammation is developed too
rapidly, or  becomes too  intense, we first  remove the threads and
then reduce it by  the ordinary means, but only in moderation so
long as it continues  to be local.
  M. Fricke has written to me (13th of November, 1835) that the
treatment of varices by threads or setons has always succeeded with
him, and that in his hands it has never caused serious accidents.   I
have myself made trial of it  on twelve patients: the veins became
inflamed in  all.   Eight of them had local symptoms only, and  left
the hospital apparently cured ; three others were seized with inflam-
mation which extended along the veins from the foot to the upper part
of the  thigh, and which taking on the character of a phlegmonous
erysipelas, terminated in large purulent collections:  numerous in-
cisions in the leg; ham and thigh became necessary, and these cases
caused me 'much alarm.   I will add that one  of them came back
to me  eighteen months afterwards, and that his varices had re-ap-
peared.   Moreover  the internal saphena which had been perforated
by the threads was itself again dilated.   The twelfth was still more
unfortunate ; he  was a butcher's boy of extreme timidity, but also
in  excellent health. Symptoms of internal and external  phlebitis
and angioleucitis soon supervened, ending in death at the expiration
of eight or ten days.
   Since  this  accident I have  no longer indulged the thought of re-
peating  the essays  of M. Fricke who, however, in his letter, spoke
only of varicocele.   Two reasons  combine to  induce us to reject
this process:  1.  It is impossible  that the inflammation which is
thus designedly  created should not sometimes become diffused  and
purulent; and then all the dangers of internal phlebitis and puru- 
OPERATIONS  REQUIRED FOR VARICES.
15
lent infection present themselves before the eyes of the practitioner;
2, on the- supposition  that the operation occasions no serious acci-
dent, and that it effects the obliteration of the vein, it is next to cer-
tain that the circulation will frequently ultimately  re-establish it-
self in the  vessel  and defeat the result of the operation.  It is a
process, in fact, which has nothiug to recommend it but the promp-
titude and facility of its manipulation.
   b.  Process  of M. Davat.—M. Davat, from researches of which
he  published  a summary in 1833 and 1834, (These No. 93, Paris,
1833.—Arch. Gin. de Mid., 2e  ser., t. II., p.  5,)  was led to the
conclusion that to  cure varices with certainty,  it was necessary to
adopt the following mode:—A  pin is  first passed under the vein
and through  the  skin from one  side to the other.   Raising up the
vein by embracing this pin by its two extremities, the surgeon pro-
vided with a  second  needle, transfixes the vessel  itself, from the
skin towards the deep-seated parts, penetrating thus underneath the
first  pin, in  order  to pierce  again through the same vein from the
deep-seated parts  towards  the skin, in such manner that the two
metallic  stems cross  each  other at right angles.   A thread then
passed under  their extremities  serves  to retain the  whole in its
place.  This  process, which  was not put in practice on the living
subject until after 1835, and which M. Norris, (Philadelphia Med.
Examiner, April  1838,  Exp., t. II., p. 112,)  says he  has made
trial  of  with  success  in  America, is invariably successful,  accord-
ing to the author, and  never produces serious accidents.   In the me-
moir of M. Davat, however,  there  are facts which  disclose the
danger of this method, and in the case of a man upon whom it was
performed at the Hotel Dieu,in 1837, death  was the consequence,
(Landouzi, Journ.  des Connaiss. Med.-Chir.,  1838, p. 97.)   We
cannot indeed understand how a pin left through a  vein, would not
produce  phlebitis  as  soon as the presence of a thread, and every
one knows that phlebitis is the principal danger in all the operations
performed for varices.
   If  this process, however, is a little more difficult and embarras-
sing  than that of M. Fricke, it ought also to be more certain in its
result.   The two pins, crossed, necessarily cause the ligature which
passes under them to give a curve to the vein and to have a ten-
dency to interrupt its continuity.   There is, therefore, less chance
of relapse by this method than with a simple seton.   [M. Velpeau,
in  a  letter to the Academy of Sciences of Paris, in vindication of
his claim of priority  for his method of  treating varicose veins and
varicocele, and a  copy of which has been transmitted by the Pro-
fessor of La  Charite  to Dr.  Mott and myself, thus expresses him-
self under the head of varices and varicocele; It  was in the year
1840 that M. Davat  (of Aix) alleged that I had  availed myself
of his process for the treatment of  varices.   This_process  consists
in  the passage of a pin underneath the vein we wish to obliterate,
then  of  a second  pin which crosses the first at a right angle, and
which twice  transfixes  the vessel through and through and in the
direction of its length.
   I never (says M. Velpeau) employed the process of M. Davat, 
16
NEW ELEMENTS OF OPERATIVE SURGERY.
and I never made any claim to its invention, although the two ele-
ments of which it consists are evidently based upon my researches
on the subject of the acupuncture of veins, published in 1830.   The
proof that my  process for varices does not belong to M. Davat, lies
in this, that this physician himself speaks of it as follows in a me-
moir published by him in 1836,  (Traiti Curatif des Varices) :—
  " M.  Velpeau, at La  Pitie  and La Charite  at  Paris, and  M.
Franc, at  the  hospital of Saint  Eloi at Montpellier, have employed
a method which, though as simple and innocent as mine, appears
to us to be far from possessing the same efficacy.  Already^ in our
first  trials, though  we occupied ourselves but very little with this
mode of compression, because we were aware that it had been pro-
posed  by M.  Velpeau, (Midecine Opiratoire, 1832,)  we  made
known some experiments which were but  little favorable to it,"
(p. 2.)
  And further, (p. 20) :  " to the process of M.  Velpeau there is m
my opinion these objections, viz., its uncertainty unless the constric-
tion  is made  with  a sufficient degree of  force and constantly, and
because, in the  contrary case, of its being attended with as  much
danger as the  immediate  ligature."
  We  thus  see (says M. Velpeau) that M. Davat, far from claim-
ing this process, does himself attribute it to me,  quotes it from me,
and repudiates and denounces it five or six years after I had pub-
lished it.  T.]
  II.  Compression.—Process of M. Sanson.—Taking his idea from
a process used for varicocele, and of which  I will speak further on,
M. Sanson (Brioux, These No. 282, Paris, 1836,) has proposed a
sort of clasp or forceps, by means of which  he has attempted to ob-
literate the varicose veins of the legs.   This forceps which the au-
thor (Boinet,  Gaz. Mid. de Paris, 1836, p. 84.) appears to have
often  used with  success, is not to bear on  the vein itself.  To  ap-
ply it  we endeavor to draw the vein into a fold of the integuments
and place the bite of the instrument immediately below it.   It re-
sults  from this, that the  vein is compressed by the skin which per-
mits itself to be drawn and pulled backwards by  the pressure of the
forceps.  What I have said of the return of the disease, after  the.
use of the seton or pin, sufficiently shows that this kind of com-
pression, though simple and  attended with  but little danger, can-
not have  much efficacy.  For  which reason, I have not thought it
necessary to make trial of it.
  b. Process of the Author.  The ligature upon varicose veins is
as I have said, one of the most ancient methods.  But if we adopt
what Paul of Egina, and those who have described it formerly,  say
of it, we ought first to incise the teguments  in order to lay bare or
isolate the vessel.   In this manner, the operation is as painful and
as serious, as  by  the  different processes  of excision or incision.
At the present time, we have  in use other kinds of  ligature.
  Having devised my process in 1830,1 first tried it upon animals,
and confined myself in the first edition of this treatise to make only
casual mention of it.   I employed it for  the first time in 1833, at
the hospital of La Pitie for varices of  the  legs ; since  that  time I 
OPERATIONS REQUIRED FOR VARICES.
17
have  performed it on more  than a hundred patients.  M. Franc,
(These de Montpellier, Mars, 1835,)  who on his part thought that
he was the author of it, also extols its simplicity.
  1.  First Stage.  This process is performed  with a pin for each
vessel.   It is advisable that  this pin  should be strong though  well
sharpened, and with a large but smooth head.  A strong and well-
waxed thread is also necessary.  After having seized  and  raised
up the varicose  vein in a fold of the  skin, we cause an assistant to
hold one of the  extremities of this fold, while we stretch  the other
ourselves.
  2.  Second Stage.  The  parts being thus arranged, and the vein
completely pushed above the fingers, which should try to touch be-
hind it, the surgeon  transfixes the whole cutaneous fold with the
pin, in  passing it under the  nails of his two  fingers.   The vein is
then situated astride the pin, which it crosses at a right angle, with-
out having entered its interior.  We thus proceed upon two or three
points of the saphena above  the knee, and upon all the veins which
arc found dilated  along the leg or on the foot.   It may be necessary
to use eight, ten, or even fifteen pins,  successively on the same limb,
though the insertion of two or three is often found quite sufficient.
  3.  Third Stage.   In order to complete the operation, a noose of
thread  must be passed upon each of the pins, in order to strangu-
late upon  them as  firmly as possible the  veins to be  obliterated.
At first, I crossed this  thread in the manner of a twisted  suture,
as in hare-lip ;  but  having found how difficult it was to obliterate
the vein, so as to prevent a  return, I thought it advisable to adopt
another mode.   At the present  time, and  since the  year 1837,1
place the ligature circularly under the extremities of the pin, which
an  assistant is charged with raising up, while I strangulate the tis-
sues  forcibly behind it.   I  thus obtain three constrictions which
bear  on three points of the vein, one which the  pin  effects from
behind forwards, and the two others which are produced by the
superior and inferior border of the circle represented by the thread,
and which act from the skin towards the deep-seated tissues.   For
greater certainty still, I wait until the constriction has mortified its
way through  the small pacquet of tissues included in the thread;
which  happens in the space  of from ^ix to twelve or fifteen  days.
If, about this  period, the eschar  does not  come  away of itself, I
remove the pin and also the ligature, being well assured that at time
the vein is certain to have closed.                         ,. ,  .
   4.  Fourth  Stage.  It is not  the insertion of the pins which is
painful  in  this operation ;  but it is  the application of the ligature
which seems to produce in some patients an acute degree of suffer-
ing  Nothing can be more  simple than the phenomena which fol-
low ; often they are limited to the mere mortification of the  pelo-
ton of  strangulated  integuments, and  unaccompanied  with any
marked inflammation.  Livid-colored phlyctense, supervene, ana
the skin takes on a darkish or muddy tint.  An inflamed line which
 afterwards becomes purulent and ulcerated forms under the liga-
 ture.   The eschar  is then isolated  and separates as in  a burn or
 contusion, and  leaves exposed a sanious wound, which is cleansed
    Vol. II.                    3 
18           NEW ELEMENTS OF OPERATIVE  SURGERY.
and  cicatrized afterwards  in  the manner of ulcers  or ordinary
wounds.   Often also a red, painful kernel, having the appearance of
phlegmon, developed about  each pin, at the  same  time that the
strangulated vein becomes swollen and hardened and is transformed
into a solid cord above and below.   It sometimes  happens that the
inflammation  proceeds  on to suppuration, and gives rise to true
abscesses.
   [Mr. Erichsen is in the habit of placing a piece of wax  bougie
upon the vessel, and then applying the twisted suture around the
pin,  and  over the bougie.  He  has also found it useful to make
a sub-cutaneous division of that portion of the vein included between
the pins, as recommended by Mr. Lee.   This division is made after
coagulation of the blood  has taken place, and, as he asserts, it in-
sures the obliteration of the  vessel.   G. C. B.]
  5. Fifth Stage.  The pins having been once  placed, the operation
requires no dressing, and so long as there is no acute inflammation
we may allow the patient to  get up and take some exercise.   At  a
later period it may be required to use leeches or topical applications,
emollients, or resolvents ; and so also when the pins  are removed,
each region that they  occupied must be treated as a small abscess
or burn.   It is unnecessary to add that immediately after the ope-
ration the point of each pin should be snipped off by means of a cut-
ting nippers,  or a pair  of stout scissors, and  that  to  prevent our
wounding the fingers in applying them, it is advisable to  make use
of a thimble or a piece of  thick linen.  These precautions would
be unnecessary, if we had pins with the heads well rounded, and
of a metallic quality sufficiently solid to allow of their being well-'
sharpened and reduced to a small size.   (See on this subject: Hou-
el, Bulletin de Thirapeut., t. XIII., p. 145 ;  Dupresse, Journ. Heb-
domad., 1836,1.1., p. 257 ; Bulletin de Thirapeut., t. II., p. 59-62,
t. XIII., p. 108, Septembre, 1837 ;  Journ. des Conn. Med.-Chir.,t.
III., p. 20 ;  also May or June, by M. Helot ; France Med., t.—, p.
56 ; Brioux,  These No. 282, Paris, 1836.)
  6. Whenever the veins are rolling and moveable  under the  skin,
the operation which I have described  presents no  difficulty ; but it
not unfrequently happens  that we find them too  closely  adherent
against the inner side of  the tibia, the dorsum of the foot, and the
neighborhood of the malleoli, to allow of our raising them in a fold
of the  skin.   In that case, we must insert the  pin  almost perpen-
dicularly upon one of the  sides of the vein, then incline  it so as to
slip its point  underneath, and make it come out from within out-
wards, upon the other  side.   The  pin in such  case should possess
considerable  strength;  otherwise, we  should soon find its two ex-
tremities bend or raise up under the pressure of the ligature, espe-
cially when  using the circular constriction in preference  to the
twisted suture.
   7. A precaution also to be attended to, in all the processes to be
employed for the cure  of  varices, is that which relates to the posi-
tion in which the patient should be placed at the time  of the  ope-
ration.  In order that the veins may attain their  full  size and be
rendered prominent, it is advisable that the limb  should  be held in
a pendant position.   If the teguments are pliant, and the sub-cuta- 
OPERATIONS REQUIRED FOR VARICES.
19
neous tissue but sparingly supplied with fat, this  position  will not
interfere with our obtaining a grasp upon the veins, or in anv wav
incommode us in the application of the pins.  In individuals  how-
ever, who are fat, and in whom the skin  is tense, the  case is very
different.   The veins in such persons lie close against the aponeu-
rosis  and the  bone, and it  may be impossible to grasp them in a
fold of the integuments.   In such cases, we  select with care the
points where the pins are to be placed, while the patient is in the
vertical position.  We then place him  in a recumbent posture, and
while the limb is in  a state of semi-flexion, pinch up, between the
thumb and fore-finger, the  vein, which is  recognizable under the
skin by its form, resembling that of a cord, as if it were a woody
substance.  I should remark, moreover,  that it is best to begin by
strangling the vein around the upper pin, as the nervous filaments,
which might possibly be included in this upper ligature,  would
render the pain of the others less acute.
  8. The application of a ligature to the veins, by  entwining  it
around a pin, is an  exceedingly  simple  operation.—one that pro-
duces no more pain than any of the others, that  all patients bear
without any inquietude, and one which  any person has it  in his
power to perform.  As it is one also which mortifies and  destroys
a portion of the vein, it ought to bo as effectual  and complete as
any of those that have been made trial of  up to the present time.
The object of all surgeons, in this matter, is to obliterate the vein
operated upon ; but  the process of  the pin  accomplishes this result
with as  much certainty as excision, and in a  more perfect manner
than acupuncture or  local compression.  With  respect to dangers,
I have as yet made trial of no method  which is attended with fewer
than this.  Out of more  than one hundred  patients, upon whom I
have  employed it, not one  has  died.   I  may add, also, that not
one of them was exposed to any real danger.  The  worst  that did
happen, was an external phlebitis and a phlegmonous kernel.
  The only objections that might be made  to it, are, that of incur-
ring the risk of passing the pin between  the integuments and the
vein, and thus completely frustrating the object in view; also that
of allowing in some  cases the vein,  at a later period, to reacquire its
permeability, where  the strangulation has not been applied at a suf-
ficient distance.  But these inconveniences belong, in a still greater
degree,  to acupuncture  by  the process of M. Fricke, and also  to
the method of M. Davat.  The  different  modes of incision, also,
are not  free from these objections.
  Adopting my process for the treatment of varices, M.  Liston says
he has succeeded in  removing the  pins  at the  end of forty-eight
hours.  I am the more astonished with this result, because  expe-
rience has taught me that  ten  to fifteen or eighteen days were
really necessary effectually to obliterate the vein thus strangulated.
Varices have been treated successfully by  M. Melvin, (Encyclogr.
des Sc.  Mid., 1839, p. 275,) by means of the pins and the twisted su-
ture.  Apprehending that the strangulation, whether by my  mode
or that of M. Davat, might not be sufficient to obliterate the veins,
M.  Bonnet (These,No. 5, Paris,  1830) combines cauterization  by 
20           NEW  ELEMENTS OF OPERATIVE SURGERY.
potash to the treatment of varices by pins.   The process of M.
Gagnebe, (Achiv. Gin. de Mid., Mai, 1839, p. 30,) which I explain-
ed in 1832, and which consists in passing a thread around the vein
under the teguments, by  a simple puncture of the skin, has, it is
said, succeeded in the hands of M. Ricord, ( Gaz.  des Hdpit., 1*
Juin,1839.)
  c. Process of M. Reynaud,—A surgeon  of Toulon, \\i. Rey-
naud, (Gaz. Mid., 1837,)after  modifying the process by  the  liga-
ture which I have described above, adopted, in some of his cases,
the following  method :  Passing a  needle, with a thread properly
waxed, under the vein and through  the skin, he proceeds to tie the
two ends,  and to fasten them by a bow-knot upon a roll  of diachy-
lon plaster, or a small graduated compress.  This appears to be the
indirect (mediate) ligature which Chaumete (Exchirii. de Chir., p.
278) and Lombard, (Plaies Recentes, etc., p. 549,) employed, and
of which these authors had already given an imperfect description.
As the thread may be untied at pleasure, it allows of being again
tightened  every day or other day until the vein is divided.  There
is no doubt that  we may succeed by  operating  in  this manner;
but the obliteration of the veins by this mode of division is so diffi-
cult, that there is always danger of their continuity and circulation
being re-established.  The process by the pins, which is at least as
simple and as easy, and  which also allows of increasing the con-
striction at pleasure, appears to me to be still preferable.
   C. I must  not, however, terminate this article, without adding,
that such processes are still too new to enable us to judge of their
comparative value, with a full knowledge of the causes.
   On the  other hand, practitioners should bear in mind that varices
of the legs are far from always yielding to these modes of cure.
Thus, though one of the dilated veins may be  obliterated, three or
four others will soon reappear.   Owing to the branches of the ex-
ternal saphena communicating with those of the internal saphena,
and the superficial veins  anastomosing  with those that are  deep
seated, the venous system of the abdominal extremity represents  a
vast net-work, whose circulation it is  next to  impossible to inter-
rupt, and which, whatever  we may do, will always render the
complete  success of these various  operations exceedingly problem-
atical.
   [Varicose  Veins.—The mediate or indirect  application of the
 ligature to varicose veins, the saphena and spermatic for example,
 as lately much commended by Dr.  Pagani, ] Gazetta Medicade Mi-
 lano, November, 1844 ; see also Cormack's Lond. & Edinb. Month.
 Journ.  of Med. Sc, Feb., 1845, p. 140,) and  which consists, after
 passing the ligature by a curved needle  under the raised vein and
 fold of the skin as above described, in  tying  the  knot on a small
 rouleau of linen, placed on  the skin,  is a very  ancient practice
 revived, so far as relates to this indirect pressure on an artery, (See
 this present vol., also vol. I.)  In varicose veins, the pressure thus
 sought for externally is equally well, if not more completely and
 effectually obtained by the sub-cutaneous, and, as it may be called,
 the sub-venous methods,  combined,  as practised by M. Velpeau. 
               OPERATIONS required for varices.            21

Through  means  of direct linear pressure,  sub-cutaneously ex-
ercised by the pin fro.m within and outwards, and  the  correspond-
ing pressure from the circular threads externally, embracing the
head of the pin, our purpose of the gradual division and cicatriza-
tion of the vein is much better fulfilled.
   Varicose Veins in the Pudenda.—Death by Hemorrhage.__The
pudenda themselves are not free  from a varicose enlargement of
their veins, which in one case, related by Dr. Hesse, (Medicinische
 Zeilung von Preuss.,  Verein No.  48,  Nov. 30, 1842; also,  Cor-
mack's Journal, Feb. 1843, p.  158—159,) proved fatal by sudden
and excessive hemorrhage, near the termination of a fifteenth preg-
nancy.   The Ceserean operation was performed a  few months after
the death of the  mother, but the child was also dead.   The uterus
appeared to be ensanguined, and in the left labium, which was large
and flabby, there was  an opening  of  about half an inch in length,
froin which  black tar-like blood  was  readily expressed.   This
opening led to numerous venous canals, both laterally and inwards,
deep into the perinaeum.  The husband informed Dr. Hesse that
his wife had long labored uuder a  great enlargement or swelling of
the left labium,  which, as it appears, was nothing more than an
enormous varix.   T.]

                       § II.— Varicocele.

   The  word varicocele, employed, like that of kirsocele or cirso-
cele, to designate the dilatation of the veins of the scrotum, though
applicable to every tumor formed by veins,  is,  however, exclu-
sively  confined, at the present time, to the dilatation of the  veins
of the  spermatic cord.   Varicocele, though a very  common disease,
and noticed principally between the age of fifteen and that of forty,
that is, during that period of life when the genital organs possess
all their activity, is almost all confined to the left  side.   It is rare,
however, that serious  consequences result from it.  The  swelling,
inflammation, suppuration, and atrophy of the testicle, which some
authors have attributed to it, do not  happen in one in a hundred,
perhaps in not one in a thousand cases ;  and I can  scarcely compre-
hend how  modern surgeons should have so far misconceived this
subject, as to consider a disease dangerous which, in 99  cases out
of 100, constitutes bul a slight infirmity.  The usual inconvenien-
ces are only a slight uneasiness, a  drawing-down  pain in the  loins
and in the groin or scrotum, together with a slight numbness of the
testicle.  To which I  may add, that an immense  majority of per-
sons who are affected  with it, may have it all their lives without
being aware of it.
  These preliminaries being  established,  we shall be  enabled  to
understand to what extent varicocele may be subjected to surgical
operations.
  A. Ancient Methods.—Ml the old processes which I have pointed
out under the article of varices in general were  applied formerly
to varicocele  itself.   Cauterization with slender-pointed rods of
iron, and with  chemical caustics were made use of at the time of 
22           NEW elements of operative surgery.

Celsus, (De Re Med., lib. VII., cap. 32.)  The ligature, excision,
incision, and  extirpation, which also had their partisans, are like-
wise mentioned by Celsus.   Pare (Liv.  VIIL, chap. 18) proposes
that after having'passed a double ligature underneath, we should
fix one of the threads at the upper and the other at the  lower part
of the varix, in order to incise the veins between the two ligatures,
and afterwards to dress the entire wound as in the  case of an ordi-
nary varix.  Pare (Liv. XIII., chap. 30) expresses himself to the
same effect about varices of the legs.   Cumano (Mouton, Diet, des
Scien.-Med., t. V., p. 261) had recourse to extirpation as weU as
ligature upon the varicocele.  After having made a long incision
through the integuments and penetrated to the cord, this surgeon
isolated the tumor which  he tied above and below  before  excising
a large portion of the scrotum.  The upper ligature came away on
the twentieth, and the lower on the thirty-fifth day; but the wound
was not completely cicatrized before the  fiftieth day.
  I.   Like Celsus and Paul of Egina, Delpech, (Lancette  Fran-
caise, t. III., p. 24,) laid open the scrotum, exposed the cord, iso-
lated it, and tied  or incised  its veins.   By this  method he cured,
it is  said, six  cases  out of seven; but abscesses  and  sometimes
death  were  the  consequences.  It is  also  known that Delpech,
(Gaspard, Theses de  Montpellier, 1832,) who sometimes  confined
himself to introducing and  securing a  piece of sponge under the
dilated veins with strips of adhesive plaster, was assassinated by a
patient upon whom he had thus operated.
  II.   M. Warren writes to me that he has often  excised or tied
varicocele with success, and  M. Moulinie (Bulletin Med.  de Bor-
deaux, 1833, p. 57,) who has no  apprehension of incising the tis-
sues even from the inguinal  ring to the lower part of the  scrotum
in order to tie  the dilated veins  of the cord,  and to  divide  them
above, maintains, as does also M. Rima, (Gaz. Med., 1737,  p. 234,)
that  this mode is still preferable to all others.   In  fact it seems
very clear to me, that the  accidents which have been imputed to
all these methods have been singularly exaggerated ;  that inflam-
mation and  abscesses of the scrotum are, with  some rare excep-
tions, all the results that they can in any case produce.  If, there-
fore, Dionis, and in our own time, Boyer, (Malad.  Chir., t.  X., p.
233,) and all discreet surgeons have rejected  them,  it is less  on
account of their real danger, than because of their  insufficiency,
or the benign character of the disease.
  III.  As to the proposition  to  lay bare the cord, in order to tie
the spermatic  artery, which M.  Bell approves  of, and some sur-
geons (Arch.  Gen. de Med., t.  XIX.,   p.  461, 462, 614,)  have
practiced, which M. Maunoir has performed for sarcocele or to ex-
cise a portion of the vas  deferens, as has also been done  by MM.
Morgan, (The  Lancet, 1828,  Vol. I., p. 251,) Lambert and Key,
(Ibid., Vol. II., p. 476 ;) it is an operajfton the propriety of which
we have no need of discussing at present while treating of varico-
cele.
   IV.  Castration, which is an operation that Celsus  reserved for
cases where the  testicle itself was the  seat of varices, and which 
OPERATIONS REQUIRED  FOR VARICES.               23
Boyer (Malad.  Chir., t. X., p. 234) also sanctions where varico-
cele becomes in reality a serious disease, cannot in the present day
be indicated in any presumable case, except that of complication.
  V. In fact, if surgery  were to confine itself to the ancient pro-
cesses, it were better to abandon varicocele to itself, and to mode-
rate its  development  and inconveniences  by means of topical as-
tringents and  good suspensories.  The exceedingly rare cases in
which it manifestly has  a tendency to produce disorganization in
the testicle, would  be  the only ones which would justify the con-
scientious surgeon in having recourse to such operations.
  B. New Processes. In devising the new processes of which I have
already  previously spoken, surgeons  at the present time had vari-
cocele chiefly  in view.   The processes, now six in number, are
those of MM. Davat, Fricke, Breschet, Sanson, and  Reynaud, and
J;hat of my  own.   Based  upon my researches, on the acupuncture
of veins, they have come into practice  in the following order :—
  My experiments made  in 1829, were published in 1830, (Gaz.
Mid.' de Paris, Janv., 1831; Lancette Francaise, Janvier, 1831;
Journ. Hebd.  Univ., t. I. et II.)  M. Davat made his known in
1833, (These  Citie, 1833,) and it appears to have been in the be-
ginning  of the year 1834 that M. Fricke introduced his mode into
practice.  M.  Breschet  (Gaz. Mid. de Paris, 1834, p. 33,) com-
municated his to the Academy of Sciences in January, 1834.   Mine
had already been  applied to the human subject about the close of
the  year 1833.  It was  not until 1835 or 1836 that M. Sanson
(Boinet, Gaz. Mid., loc.  cit.,) proposed his forceps.  Finally, in
the  year 1837, we have the process of M.  Reynaud, (Gaz. Mid.,
de  Paris, December, 1837.)  These processes, though originating
from a  common source, differ so much from each other, that there
is no necessity of discussing their priority.
  I. Process "of M. Fricke.—In order to perform the operation pro-
posed by M. Fricke, the  patient is placed  on  his back, unless it
should be  advisable that  he should be kept in the erect posture or
upon his knees for the purpose of  increasing the dilatation of the
veins.  The  surgeon then proceeds immediately to search for the
principal varices of the cord.   Having seized them with the thumb
and forefinger of the  left hand, he inserts through them an ordi-
nary needle, or as M. Fricke advises, a needle made expressly for
this purpose, and armed with a single thread.  If the vein is long
we pass the  needle through it a second time an inch higher up or
lower  down, and we  do  the same with each of the other  veins
whose size  appears to be enlarged.   The threads remain there in
the form of setons for one, two or three days.  We then remove
them in order to prevent too active an inflammation.  During the
time  the patient remains in bed the  scrotum is supported upon a
small cushion  and kept covered with resolvent or emollient  appli-
cations, according as the inflammation should appear to be more or
less active.                                           •,
  This  process, which M. Fricke  had already employed success-
fully upon 38 patients when he wrote me in 1835, appears to be
liable  to a number of  objections.   In inflaming the interior of the 
24           NEW ELEMENTS  OF OPERATIVE SURGERY.
 veins which  penetrate directly into the abdomen, it incurs the risk
 of producing  a phlebitis which it might not be possible to control
 and which might speedily  prove mortal.  Moreover varicocele is
 never constituted of a single vein, and the tissues of the scrotum are
i. too moveable and  too  supple to enable us to be  perfectly assured
 when we have placed setons in the veins, that we have perforated
 all  of them and that  none have escaped.   In fact the circulation
 might  evidently be re-established in some of the veins themselves
 that have actually been transfixed, and thus allow the varicocele
 to be reproduced.                                     *•
   So also the  needle  may  miss  the veins we wish to hit, the per-
 meability of those it has traversed may be afterwards re-established,
 and  if phlebitis should supervene it is of course  exceedingly dan-
 gerous.   This then is a process which should be rejected.
   II. Process of  Davat.—M.  Davat, like  the surgeon of Ham-
 burg, first seizes  the veins  of the  cord  with  the  forefinger and
 thumb  of the  left hand.  He  then  inserts under them a first pin
 transversely, then  a second through the vein in such manner as to
 make it pass under the first pin before its point emerges on the op-
 posite side, so  that  we form in this manner a cross, one of  whose
 branches twice transfixes the vessel.  If some of the veins at first
 have escaped  they are treated in the  same  manner.   Nothing re-
 mains but to introduce  a sort of ligature under the pins so as to
 strangulate the  vessels.  It does  not, however, appear that  M.
 Davat has yet applied his process to the treatment of varicocele.
 He has hitherto employed it  only for the veins of the leg; but it is
 liable to the same objections as that of M. Fricke.  Nor should
 we  have more certainty of transfixing all the varicose veins of  the
 cord with the pin than with a needle or seton, and it is  evident that
 one  of these  bodies  exposes as  much to  internal phlebitis  as the
 other.   The  only  advantage in the process of M. Davat might be
 in thus associating a sort of external constriction with acupuncture,
 the  possible  chance of strangulating  the veins  which have not
 been pierced, and perhaps, also, of thereby restraining the progress
 of the phlebitis.  It is, however, singular that M. Davat who had
 used my process alone in the year 1831, as the first  stage of  his
 own, (Petit, Journal de Med. et  de Chir.  Prat., &c, 1831,) has
 since persisted in rejecting it as insufficient."   (These citie, p.  24.)
  III. Process  of M.  Breschet.   M.  Breschet  employs neither
 setons nor pins  (Gaz.  Med., 1834, p. 33) for the cure of varico-
 cele.  The method of this surgeon consists in strangulating all the
 dilated veins  together  with the envelopes of the scrotum, by the
 the branches of a species of forceps.   This forceps designed after
 the manner of that which Dupuytren contrived to remove the salient
 angle of the intestine in artificial anus,  has undergone modification
 by  M.  Landouzy,  (Jour, des  Conn. Medico-Chir.,  Mars, 1838,)
 which renders it at the present day exceedingly simple.  To apply
 it we commence by isolating the veins in the cord  as  completely as
 possible from the vas deferens and spermatic artery.   Placing the
 extremity of  the  branches  of the instrument between these two
 orders  of bodies, we immediately appoximate them together  by 
OPERATIONS REQUIRED FOR VARICES.
25
  means  of a  screw or ring so as to compress and embrace the varicose
  bundle only.  The whole is thus left in place and the patient kept at
  rest.  The  compression is afterwards increased each day, until it is no
^  longer possible for vitality  to be maintained in the portion of tissues
*  which has been strangulated.  The forceps is not to be removed except
  with the eschar.   The  loss of substance which  results from this, and
  which in the first process of  M. Breschet sometimes exceeded two inches
  in length, leaves a wound  which gradually diminishes and cicatrizes
  after the lapse of six weeks  or two months.
    With any kind of  forceps whatever  applied upon  these principles
  we  necessarily interrupt  the  continuity of the veins, and as  they are
  all strangulated, we have thereby a fair prospect of effecting a radical
  cure of the  varicocele.  M. Landouzy  (Journ. des  Conn.  Midico-
  Chir., 1838, p. 88) avers  that more than 100 patients  have been cured
  in this manner.  The  forceps  of M. Breschet  however is annoying to
  the patient; an eschar so  extensive endangers  erysipelas, phlegmon,
  and  abscesses in the  scrotum, while there results from it an enormous
  ulcer of great length and difficult to heal.  Nor can we  perceive why
  phlebitis might not occasionally  be  produced by  it, or why the testicle
  and the generative function  have less to apprehend from this operative
  method than from the others.   It is certain that some of the patients
  who have submitted to it and have come to consult me, make great com-
  plaints against it.  Moreover this process  with all its apparent simplicity
  has much analogy in fact to  that of Cumano ; and if it is to be regarded
  as one of the most  efficacious, there is room at  least to hope that we
  may discover others that are more simple.
    [M. Sedillot states in his Traite de Med. operatoire, Vol. I, p. 295,
  that he is acquainted with a young man, whose scrotum is covered with
  deep and extensive cicatrices made by  Breschet's forceps, and yet the
  varicocele is not at all diminished.   G.  C. B.]
    IV. Process of M.  Sanson.—Being  desirous, above all things, of
  avoiding the danger  of phlebitis, M. Sanson proposes to  obliterate the
  vein by the  concretion of the blood, much rather than by an actual in-
  flammation.   The forceps he uses is so constructed that the extremity
  of its points  exercises a compression- stronger than  the rest  of its
  branches.  It results  from this  that the varicose bundle is found to be
  confined by it in  a fold of the integuments, and compressed only to the
  degree  required to prevent  the blood from  passing  through it.   This
  fluid having ceased to circulate, solidifies, contracts, adhesions, and ul-
  timately blocks up completely the strangulated veins.   As, by this meth-
  od, we have neither eschar nor wound, the process of M. Sanson would
  be infinitely superior to that of M. Breschet if it was equally effectual;
  but I am convinced that it would not enable us to procure a permanent
  obliteration of the veins.  So long as the vein has neither been divided
  nor inflamed in its interior, the blood which closes it has a tendency to
  be re-dissolved ;  gradually it becomes fluid, and in a short time we find
  that the  channel of the vessel is reopened.  Something,  in fact, more
  effectual is required to obtain a radical cure of varicocele.   I have seen
  but one patient who had  been treated by this kind of forceps : he was
  a student of medicine,  and  the varicocele, at the end  of two  months,
  had resumed its former size.
     Vol. II.                  4 
26
NEW ELEMENTS  OF OPERATIVE SURGERY.
   V. Process of M. Reynaud.—When we wish to adopt the method of
 M. Reynaud, we gather together, as in the processes above described,
 all the varicose veins in a fold  of the integument, in order that we may
 introduce behind them a strong ligature by means of an ordinary curved
 needle, which pierces the skin  twice.  For greater security it would be
 advisable to pass in this manner  two  ligatures at about an inch  apart.
 T\ e then tie them firmly upon  a small graduated compress, a piece of
 linen, a rouleau of diachylon or a dossil of lint; and in order to be able
 to relax or tighten them at pleasure, we fasten each of the ligatures by
 a simple bow-knot.   It  happens necessarily  that  the ligature, by the
 constriction which it produces, divides the strangulated  veins from be-
 hind forwards.   After  that takes place, it is to  be removed, and this
 completes the  operation.  There is nothing more to do than  simply to
 dress the wound which results from it, and to await the cicatrization.
   The process of M.  Reynaud  has more simplicity and despatch, and
 less danger than that of M.  Breschet;  and I have no doubt that it may,
 and will  often, succeed.  Nevertheless,  the section of the veins by a
 single ligature, is too nearly analogous to their division by the bistoury,
 not to incur the danger of the re-establishment of their continuity, and
 the reproduction of the  varicocele.   By means, also, of the intervention
 of the small cushion recommended by  M. Reynaud, the  section, and
 likewise the obliteration of the veins, must necessarily be much retarded
 and difficult  to effect.   Nevertheless, this  process is one  of the best
 that has been devised.
   [Prof. Gross has reported in the October number of the Amer. Journ.
 Me I Sciences,  1848, his method of  treating varicocele, which consists
 in making a vertical incision through the anterior part of  the scrotum,
 and separating the enlarged veins from  the accompanying  duct, artery
 and nerves.  A needle  is then  passed beneath, and a ligature applied
 over the veins with great firmness.   The wound is closed, and at the
 end  of  24 or  36  hours, when the blood is  sufficiently   coagulated
 the veins are divided by a subcutaneous incision.  The result in numer-
 ous cases in which he has adopted this method, has been most gratify-
 ing.   G. C. B.]                                             &    J
  VIProcess of the  Author.-Struck,  like most  other practitioners,
with the uncertainty or the dangers presented by the ancient modes of
treating varicocele, I asked myself the question in 1830, if it mio-ht not
be possible to substitute for them the method which I had made trial of
 on animals, with the view of obliterating the vessels.  The conclusion
I had arrived at, that a pm, needle, thread, or any  foreign  body what-
 ever left at rest from one to four days transfixed through a vein, arrest-
 ed the circulation there with as much certainty as a ligature,  naturally
 led me to try the processes  which  MM. Davat and  Fricke  proposed at
 a later period.   But^ recoiling before the  dangers  of phlebitis and puru-
 lent infection, I conjectured that the venous bundle, strangulated  upon
 a pin, might not be less efficacious, while at the same time it would be
 a protection against such results.
  a. Position  of the  Patient.—The patient may either stand in the
 erect posture, rest upon his  knees, be  seated, or  lie down.   This  last
 position, preferable in every  other respect, has the inconvenience of not
 permitting the  varicocele to be  so prominent.  It is necessary that the 
OPERATIONS REQUIRED FOR VARICES.              27
scrotum should have been previously shaved.  The surgeon commences
by identifying the vas deferens, which, situated in the rear of the cord,
presents itself there under the form of a hard, elastic and regular stem
of the size of a crow's  quill, and  the  compression of which  causes a
pain similar to that produced by any pressure upon the testicle.
  b. FirsJ, Stage.—Having satisfied himself upon this point, the upper
part of the scrotum is seized behind, while care is taken that the thumb
and  forefinger have a  firm hold  upon  the vas  deferens, and  that the
vein in front  remain free.   With the thumb and  forefinger of the other
hand we then draw towards us, and isolate the venous bundle while  ap-
proximating it more and more to the integuments, in such  manner that,
being thus temporarily transformed into a sort of membrane placed edge-
ways (de champ) on the side of the scrotum, it encloses the veins in  its
anterior margin, and the vas deferens in its posterior border.  The  fin-
gers remaining fixed between these two borders, serve as a point of sup-
port for the passage of  the pins.  An assistant seizes and holds one of
the extremities of the  tegumentary fold between the two orders of or-
gans mentioned, while the operator holds the opposite extremity.
   c. Second Stage.—Having besmeared the point of the pin with some
unctuous  substance, the surgeon inserts it transversely under the veins,
and as near as possible to the anterior portion of the cutaneous border,
and passes immediately a noose of thread under its extreme points.  An-
other pin is placed in the same manner, at the distance of an inch from
the first,  and the operation is terminated.   Although we may, if  neces-
sary, commence by the pin above, I would advise, nevertheless, to in-
sert that  below first, since it is always  easier to.find at  this place, the
space which  separates the veins from the vas deferens, than it is in the
vicinity  of the ring.   It is,  moreover, important  to  avoid  the  two
extremes, of placing  them too high or too low, or too near or too far
apart: if too near the  testicle, the lower pin  might pierce the  tunica
vaginalis, and give rise to a purulent inflammation, or an abscess  in this
small sac; if too near  the ring, we  might run the risk  of not entirely
separating all the veins  of the cord, and of allowing  some  of those
behind to escape ; if  too near together, the two  pins  might ultimately
form but one wound, which would then be  too large and too difficult to
heal;  to place them at a greater distance apart than I have recommend-
 ed, would require them to be fixed too near the testicle below, and too
near the inguinal canal above.
   d  Third  Stage.—As I have said in the  article Varices, I have long
been in  the practice  of strangulating the veins  upon the pin,  as in the
suture for hare-lip; but in the fear of not effectually  obliterating  the
vessel, I  have adopted  the plan of employing circular strangulation lor
varicocele, as well as for varices in general.  An assistant consequently
seizes the pin by its two extremities, and raises it with  sufficient force.
If he  is  afraid of pricking himself, or if the operator  requires more
room, the fingers of the assistant  may be replaced by an engne  with a
double blunt hook.  In whatever manner the pin may be raised up, it is
necessary to flatten down on the sides the tissues  which it embracesi   A
 cord of  two or three threads waxed together,  is immediately  placea
 first above, and then brought below the pin.   Its two portions being pass-
 ed like a simple knot, one over the other, are then drawn together witn 
28             NEW ELEMENTS OF OPERATIVE SURGERY.

force, in order to strangulate circularly all the parts behind  the  pin,
which latter by this means projects forward, drawing with it a noose ot
vessels'.  The point of the pin being snipped off by means  of a cutting
nippers, the operation is finished.  It is also a matter  of little  conse-
quence whether its head is turned in this or that direction.
  e. Fourth Stage.—We may, if so disposed,  withdraw the pins atthe
end of five or six days, and then leave the wound to cicatrize ; but it is
more secure to wait until all the strangulated tissues are separated under
the form of  an eschar.   During that time, the patient may  go about and
pursue his ordinary mode of life.  If the inflammation should be mod-
erate, it is not even necessary to make any  topical application  to the
scrotum.  After the fall of the eschar, the  ulcer which results from  it
should be treated like a burn in the fourth degree.  The whole  of the
treatment by this mode lasts nearly a month, and the eschar comes away,
or may be removed, from the tenth to the twentieth day.
  /. Fifteen patients, (September, 1838,) affected with varicocele, have
been submitted by me to  this operative  process;  they  have all been
cured.   There are four of them whom I have  seen repeatedly, and one
of these was operated upon in 1834.   They have not the  slightest ap-
pearance of a return of the disease, and in none of them  did  internal
phlebitis occur.   I have twice seen abscesses form in the vaginal tunic,
and that when I have placed the lower pin too far down.  In two others,
the cord assumed considerable development and hardness about the lig-
ature, which was caused in one of the  cases by violent excesses  in  his
diet, and in the other, probably, because I have deemed it advisable, for
greater security, to strangulate the tissues again on the thirteenth day.
These accidents, which were unattended  with any other results, were re-
lieved without sensibly prolonging the period of the final cure.  One pa-
tient only, a young man who was almost an idiot, and who  left  the  hos-
pital at the moment when the inflammation had  reached its highest inten-
sity, because I insisted that he should stop jumping all day in the court-
yard and drinking to excess, went off  without my ever being enabled to
know what became  of him.
  g. In fine, I can conceive nothing more simple than this process.  The
operation, while it is exceedingly easy, is finished in a  second of time,
and causes scarcely the slightest pain.   If we  remove  the constriction
as soon as the veins  appear to be obliterated, the patient may be free  by
the eighth day.  If, to be better assured of a radical cure, we wait until the
strangulated tissues are detached, there will be no room to doubt of  its
efficacy.  It is a method, therefore, more convenient in its application,
both for the patient and the surgeon, than that of M. Breschet.  As to the
accidents it may cause, they are evidently the same as those of any other
mode of strangulation : in this respect  it is proper to arrange this method
in the same  class with  those of MM. Reynaud, Sanson, and Breschet.
A thrust of  the pin and a turn of thread constitute the whole operation.
   [Prof. Mussey has been very successful  with the following operation,
the account of which we copy from the Trans.  Amer. Med. Association,
Vol. III. p. 377.  In a recent interview with  Prof. M. he informed us
that he had employed it in nearly forty cases, with the happiest results.
The hair having been removed from the affected side of the scrotum, the
operator separates  the spermatic vein from the vas deferens, and holds 
OPERATIONS REQUIRED FOR VARICES.
29
it^ firmly in a fold of the integument, on the outer side of the scrotum,
with the thumb and finger of one hand, while with the other Jie passes
a straight  needle, having a  blade  one seventh of an inch wide,  with
sharp edges and a long  point, its broad  surfaces looking upwards and
downwards, armed with waxed saddler's silk, through  both layers of
the integument from before backwards, on the inner side of the vein,
from an inch to an inch  and a third  below the abdominal ring.   The
thread^being drawn in, the  fold of the integument is raised from the
vein, till the punctures are brought into apposition on the outer side of
the vein, when the needle is brought back through the same punctures ;
both  legs  of the ligature now hang anteriorly, while the vein  is in-
cluded in its loop.  A surgeon's knot  is now made and tied firmly upon
the vein.   The wide and sharp edged blade of  the  needle makes an in-
cision through which the ligature sinks down upon the vein, leaving the
integument free.  The ligature, composed of two threads of the silk, is
strong enough to admit of being drawn very tight;  the  tension is kept
up for a full minute or more  before the reef or square knot is made upon
the surgeon's knot.   When the ligature is made thus tight, he had not
known the  pain to last  more than five  minutes.  With  the use of chlo-
roform, the patient can scarcely be said to feel pain at all either during
or  after the operation.   He applies collodion  to the punctures, which
seems to diminish the tendency to redness and thickening of the integu-
ment in their neighborhood.   The scrotum is supported  in a bag truss,
and the patient kept in the horizonta^osition for two  or three days,
and directed to take  light food.  There is generally but little  swelling
resulting from this operation,  never  enough to require  stronger  local
anti-phlogistic treatment than a compress  moistened with  water.  The
ligature comes away ordinarily within the month.  G. C. B.]
   VII. None of the modern  methods of compression  appear,  up to
the present moment, to  have  been followed by formidable accidents ;
while those by acupuncture, or incision  of the veins,  have frequently
caused death.   A fundamental difference,  then, exists  between  these
two orders of operative  processes.   By compression, either as M. Rey-
naud understands  it, or with the forceps of M. Breschet or M.  San-
 son, or by the mode that I prefer,  the coats of the  veins  inflame upon
 their exterior only; and their walls being  held  for   a  considerable
 length of time in contact,  become  adherent, and  ultimately  blended
 together, before the  purulent  secretion has had time to establish itself
 upon their interior surface.  It is altogether the reverse in acupuncture
 or incisions. 'Here  the pathological  process  which  it  is designed to
 bring about, establishes itself at the first—not on  the  external, but on
 the internal surface of the vein ; from whence  it follows that the pus,
 if any is formed, may mingle with the blood and infect  the system.  I
 should, however, remark, that internal phlebitis of the  scrotum, sper-
 matic cord, and penis, which I have often observed under circumstances
 disconnected with  varicocele,  has never been  followed  by that train of
 symptomf of  poisoning which accompany  it  every where else.  Can
 there be,  in those regions, a particular arrangement of nature to prevent
 purulent  infection; or  were not the  cases, observed by  me, those ot
 exceptions to the general rule ?   Certain  it is, that the  puncture ot the 
30
NEW ELEMENTS OF OPERATIVE SURGERY.
  veins of the cord does not  appear to have been attended, in the hands
  of M. Fricke, with those internal accidents which it has frequently giv-
  en rise to when it has been  applied to the veins of the limbs.
    [A solution of gutta percha in chloroform has been  highly recommend-
  ed, for the purpose of giving support to the  parts, and in mild cases,
  collodion might doubtless be occasionally employed with benefit.
                                       3   F  J          G. C. B.]

       [Varicocele—Obliteration, Ulceration and Wounds of
                             Veins, &c.

    J. L. Petit (Du Varicocele, et de sa Cure  Radicale,  par le Docteur
 J. Helot, Archiv. Gen. de Med., Sept, 1844, p. 3) mentions a case of
 varicocele  in which the bunches of dilated veins  of  the cord and scro-
 tum, had acquired in their aggregate volume the size of  a child's head !
    In regard to atrophy of the testicle which  some have asserted to be
 a consequence of varicocele, the observations of MM. Breschet, Landou-
 zy and  Helot (Loc, Op. cit., p. 5) only go to show that the testicle
 on the side affected is softer and somewhat diminished in size.   Another
 constant symptom according to M. Landouzy  (Op. cit.)  is an abundant
 cutaneous  exudation from the side of the scrotum affected, and  some-
 times  also  a species of eruption, says M. Helot, on the corresponding
 part of the thigh, (lb.)
   The general  opinion  enterta^Jed, and which is corroborated  by the
 observations of  MM.  Morgagni, Sir  Astley Cooper, &c,  and also by
 those of our author, M. Velpeau, (Vid. text  supra,) that  varicocele is
 far more frequent on the left than right  side,  because on the right side
 the spermatic vein enters the vena cava ascendens in a direction almost
 parallel  with the axis of the vessel, i. e., with the course of the  blood,
 while the left spermatic vein  empties into the emulgent at a right  angle,
 i. e., in a direction perpendicular to the current  of the  blood  which
 comes from the  loins, is contested  by M.  Helot.  So  also  does this
 author  deny the alleged predisposition to varicocele on the left side,
 because  of  the compression made on the  operative vessels on this side
 by the stercoral matters accumulated in the iliac portion of the  colon
 as  Callisen (t. II., p. 112) and J. L. Petit  pretend.  The ccecum, ac-
 cording to M. Helot  (Loc. cit.,  p. 11,)  ought to  have a similar effect
 on the right side, in which location however varicocele  is exceedingly
 rare.   In relation to the pressure of these faecal matters on the  vetns
 of the cord, their effect too, says  M. Helot, ought to be more pernicious
 when the patient is in a horizontal position,  the reverse of  which is the
 fact.  Besides, a  collection of these  matters and constipation  are not
 common in young men, who are the most frequent subjects of varicocele
 He nevertheless  admits  the  prevalence on the left side, but  confesses
 his ignorance  of the  cause.   Delpech even denies that varicocele is
 observed among young men, except in rare instances.  M. Helot asserts
 that he is satisfied from the observations he  ha3  made at Ld*Charite
 under MM. Velpeau and Ricord, that it occurs most frequently between
 the ages of 10 and 35, which agrees with the experience of M. Landouzy,
 (Loc. cit., p. 13.) Varicocele consists more, M. Helot  thinks, in the
abnormal development of the venous branches  than in the dilatation of 
operations  required for varices.
31
the principal trunks.   He  does not  consider it proved by any means
that  masturbation and  excessive  venery are a frequent cause of this
disease, nor that it is more  frequent in hot climates ; since M. R. Mar-
jolin  in his  Thesis (1837) establishes  the fact that 60 out of every 100
in  France  have it to a greater or less degree.   M. Helot also doubts
with  M. Ricord if blenorrhagic epididymitis  be a common cause of
varicocele.   It is true however, he thinks, that varicocele as M. Blandin
asserts (Diet, de Med.) may be transmitted by an hereditary predispo-
sition.   A diagnostic mark is the power of separating with the fingers
each  of the varicose  cords, which  are semi-fluctuating, knotty, and re-
sembling a  bunch of leeches, all upon, but distinct from, the testicle.
He disapproves altogether of preventive surgical operations, and advises
to leave the disease to itself or a suspensory.
   The great point is to know when to operate and when not—nor should
an operation ever be undertaken except in a case of extreme necessity
which very seldom happens.   The annoying  pain  must be subdued by-
palliatives,  and is no more a reason for a surgical  operation than the
pain  of corns is for amputating the toe.
   When palliatives fail, and  the  tumor is enormous, and  the pain so
intolerable  as to disable the  patient from attending  to his pursuits, and
where the accidents are serious and imminent, there  only is an operation
 justifiable.
   In  a case where a varicocele of inconsiderable size but of long stand-
ing, in  a gentleman of education and otherwise  of sufficient moral firm-
ness,  had by the continuance of pain greatly impaired his general health,
and  caused a permanent melancholy or hypochondria, Dr. Mott at his
earnest  solicitations  was induced to  remove the testicle on the  side
affected, which  brought about a radical cure and entire restoration of
strength and spirits and general health.
   Process  of Rolling up the  Veins, a New  Process for the  Cure of
 Varicocele,  proposed by M. Vidalde Cassis.—M. Vidal, having adopted
the process of M. Reynaud, modified it  in the following manner : a thread
of silver was passed by  means of a needle behind the spermatic cord in
its fold of skin, and kept well separated from the vas deferens.   This
thread was  knotted upon a small  roll  of bandage acting as a cushion  ;
a canula was adjusted above the knot which  answering to the stick of
the old artery compressor, served from time to time to increase the
constriction, or to diminish it when the pains were too severe.  Towards
the 15th day all the veins were cut by the  thread, and to remove this,
all that was necessary was to wait for  the ulceration of the integuments,
or to  divide the cutaneous bridgfe under which the ligature was situated
   After employing this mode for some  time he abandoned it as objection-
able because of its not effecting a perfect cure, but on the  other  hand
exposing to a return of the disease; since  it interrupts  the  venous
circulation at a particular point only of  the spermatic cord, so that the
circulation may thus be re-established in the obliterated veins.   He now
proposes the  following  method,  (See  account of his memoir, Bull, de
Thirap., Mai, 1844.—Archiv.  Gin. de Med.,  Sept.,  1844, p. 108, Ac.)
  1. A [strong] silver thread is passed behind the cord by means of a
needle,  as in the process of M. Reynaud as modified by M. Vidal.
  2. Another silver thread [of less size] is passed in front of the cord 
32
NEW ELEMENTS OF  OPERATIVE SURGERY.
in the same manner and through the same openings.   The venous bundle
is thus placed between two threads, under the skin, [constituting a sub-
cutaneous ligature.   T.]                                      . .
   3. The two threads are twisted together at each of their extremities;
" as this torsion is continued the two threads are more and more tightened,
and tend to form a cord which makes a certain degree of  resistance. ^
   This metallic  cord, in turning on its axis, makes  traction during its
movement of rotation, upon the parts included between the two threads
which compose it.   The veins are by this means  rolled  up  upon  this
double thread, after the manner of a rope upon a capstan.   The greater
the number of turns made the higher the  testicle mounts upward, while
the laxity of the cellular  tissue of the scrotum  favor the movement of
ascension."
   4. Finally a small roll of bandage is  placed upon  the  skin, and the
two ends of the rolled up metallic cord are fixed upon this plug by another
torsion, then  a  canula  is passed underneath, as in  the process of M.
Reynaud modified as above by M. Vidal.
   It will be better, M. Vidal says, to allow the threads to cut through
the skin, for we shall  then not only have  a division of the veins of the
cord at different  heights, but also that of the superficial veins, running
between  the  cord and the  skin, the strangulation  of which presents
another obstacle against a return of  the disease.  M. Vidal appears to
think that the radical cure  of varicocele should be attempted in all cases,
inasmuch as its continuance occasions more or less pain, and great fatigue
from exercise, and sometimes serious inflammation, atrophy  of the testicle,
impotency,  &c.  On the  other hand,  the editors  of the Bulletin  de
Therapeutique, commenting  upon this  process, think that in  a great
majority of cases patients  are made quite comfortable and free of pain,
by properly  contrived  suspensories, [See in Vol. I. of this American
Edition, a suspensory used with great advantage at the Seaman's Retreat,
New-York.   T.]  While  the surgical processes of a ligature upon the
spermatic cord are known in two or three instances (and it has happened
probably in several others,) to have caused death by phlebitis or other
accidents ;  [in one case death by tetanus.  T.]
   Considering, therefore, the general harmlessness of this disease, sur-
geons prefer  the palliative mode, or, if an  operation is to be resorted
to, they would recur  then, and  not till then, to the  processes of MM.
Gagnebe, Ricord, Reynaud and Vidal.   «
  It is due to our author,  M. Velpeau,  to say that at the  sitting of the
Paris Academy of Medicine, Aug. 6th, 1844, (Journal des Connaissances
Midico-Chirurgicales, Sept.  1st, 1844,* p. 126,) he, as one of a  com-
mission to whom the memoir of M. Vidal above-mentioned had been
referred, reported upon this  new process of enroulement de veines, in
which report it is stated that  two of the committee  had examined, at
the Hospital of Lourcine, two patients  upon whom M. Vidal had operated
with success by  his method.   The reporter adds, however,  that the
process  is not so simple as those that  are known; that it is not more
dangerous than the processes of MM. Breschet and Reynaud,(of Toulon;)
but that  it is at present  impossible  to decide if it exposes  less  to  a.
return of the disease.
  M. Curling (London  Lancet, June 15th,  1844, p. 388) has  cured 
OPERATIONS REQUIRED FOR VARICES.
33
 several cases of varicocele by  making  pressure at the  external ring
 by means of the moc-main truss, whereby the gravitation or hydrostat-
 ic pressure of the blood in the dilated spermatic veins was  prevented.
   Excision of all the lower part of the scrotum, preserving to it its nat-
 ural, oval  convexity downwards, is  another mode recently made trial
 of  for the cure of varicocele, under the expectation that  the permanent
 retraction obtained by the curtailment and diminution of this envelope,
 would effectually keep up the testicles, and ultimately by its compres-
 sion, cause the varicose venous  bunches of the cord to resume their nor-
 mal calibres.   The idea appears to have first suggested itself to our au-
 thor , M. Velpeau,  many years since, from having noticed the salutary con-
 traction  of  the scrotum produced by the cicatrix left after an  accidental
 sloughing  of the  teguments in  a case at La Charite, in which M. Vel-
 peau had operated on the varicose veins by his process with pins. How-
 ever, he accords (See Report  in the  Clinique Chirurgicale in the ser-
 vice of M. Velpeau, a la Charite, in  the Journal des Connaiss, <&c, de
 Paris, Decemb., 1844,  p. 223, &c.) the first conception and the priority
 of  the operation  of excision of the  scrotum to M. Bransby  Cooper of
 London, about the year 1840.   From seeing a case at Paris, which had
 been operated upon by  M. Cooper, though leaving a bad cicatrix, M.
 Velpeau was induced  nevertheless  to make trial of it  at La Charite.
 If,  however, we are to believe the statements in the report of M. Vel-
 peau's Clinique, as  furnished  to the Journal des Connaissances, (loc.
 cit.) but which, from  the rather acerb tone in which the commentaries
 of  the anonymous reporter, M. A. G., are couched, must be received, we
 think with  caution, M. Velpeau had  at that time, viz., up to Nov. 14,
 1844, performed this  operation  on  three  patients, in all of whom the
 contracted  scrotum had  again become elongated  by the weight of the
 testicles  and enlarged veins, in fact reproducing the disease in as bad a
 state as ever.  It is due however to our author,  to state his mode as
 it is therein  given, (loc. cit.,) of performing what he denominates the
 English  Process.  The patient being  laid on his back, the surgeon seizes
 the  lower  portion of the  scrotum, and raises it up vertically, so as to
 crowd the testicles back, which he does without any difficulty, upon the
 pubis, in order to remove them out of the way of the instrument.  He
 then stretches in  a transverse direction the fold of scrotum which had
 been just raised up, and  does this with such force, that it readily be-
 comes transparent to the light.    The  limit  beyond which the excision
 is to be  made, is  established  either  by means of the fore-finger and
 thumb of an assistant, or by two sounds, one on either side, which com-
 press the fold of scrotum between them, and are kept firm upon it by
 having their extremities made  fast.  A few  lines beyond this curved
line of demarcation are inserted at short distances  from each  other, ten
 pins; and on a line a short distance beyond these again the bistoury rap-
idlv makes the required excision, the  thread  for each pin being fastened
aro'und its extremities  the moment  after the knife has cut beyond the
point where it is inserted.   The sutured parts are then dressed with the
perforated  linen spread  with  cerate,  and  a compress ^ and  appropri-
 ate bandage.   The  cicatrization is usually  completed  in a few days.
  [Dr John Watson, thus expresses  his opinion of this operation (Sir
 Astley Cooper's) in the radical treatment of varicocele (Vid. Pract. Obs.
   Vol.  II.                    5 
34
NEW ELEMENTS OF  OPERATIVE SURGERY.
 on Rad.  Treat, of Varicocele, Amer. Journ. Med. Sciences, Oct. 1845,
 p.  317.)   " When properly performed it is  sufficiently efficacious;  it
 subjects the patient to none of the serious consequences that too often
 attend  every mode of operating that is addressed directly to the sper-
 matic  veins ; it is less  objectionable  than the operation for ligaturing
 the  spermatic  artery; it gives rise to less suffering, and is more effica-
 cious than Breschet's mode of indirect compression ; it does not inter-
 fere with the functions of the testicle, which are necessarily destroyed
 by every other mode of operating;—and, if performed sufficiently early,
 before the disease  has led to atrophy of the testicle, it may be the means
 of actually preserving the functions of this organ."  Instead of a trans-
 verse incision  at the bottom of the scrotum, Dr W. makes  it in an ob-
 lique direction, its upper angle being over the situation of the external
 abdominal ring, and its  lower angle  somewhat beyond the raphe near
 the  bottom of the scrotum  on the  opposite  side.   Union by  the first
 intention, he  thinks, is not  of the  importance supposed by Sir Astley
 and Mr. Key.  G. C.  B.]
   Pathological  Diagnosis  to  be  obtained from  Varicose   Veins.—It
 would, a priori, as it  seems to us, be a rational pathological inference
 to assert that where the venous trunks externally become hypertrophied
 on the abdomen to the extent that they sometimes do, though incompar-
 ably less so than on the lower extremities, that this  disorganization re-
 sulted  from  some  internal organic difficulty and obstruction ; the same
 as the hemorrhoidal dilatations, tumors,  and bleedings  indicate to  a
 certainty more or less organic derangement of the liver,  lungs, and
 other viscera.
  Thus we find a case related (London, Guy's Hospital Reports, Octo-
 ber, 1844,)  of a carpenter, aged 36, who, after manner excesses, was
 received into the  hospital for ascites, and in the right side of whose
 abdomen  the  superficial veins  had acquired  the  size of  the finger.
 Death  occurring shortly after abstracting a  large quantity of a clear
 greenish liquid, showed an enlarged liver, but  especially an enlargement
 of the right kidney, which was four  times its normal dimensions, and
filled with fungosities and tubercles of brownish, reddish, and yellow-
ish color; while the vena cava ascendens was filled  to the extent of 6
or 8 inches with a similar fungoid  substance, extending into the right
auricle, with  thickening and degeneracy  of the coats of the cava and
other marks of extensive degeneration throughout  the principal venous
 trunks of  the abdomen.
  Wounds of the Veins, &c.— The Lateral Sinus of the Brain Ulcer-
 ated.—Mr. Syme, in  a communication  to  M. Liston, which  the  latter
 surgeon referred to at a meeting of the Royal Medical and  Chirurgical
 Society of London, April 11, 1843, (Cormack's Journal, Oct. 1843, p.
 945-6,) states that he  tied the carotid in a boy, for bleeding from the
 ear  after  suppuration.  The patient died, and an opening was found
into the lateral sinus just above where it passed into the internal jugu-
lar.  Mr.  Bloxam(loc. cit.) has also seen a case of an abscess commu-
 nicating with a vein.
  Rupture of the Right Internal Jugular  into an Abscess.—As one of
the evidences of the necessity of early preventing or removing all pres-
sure by tumors, abscesses, &c, upon tissues so crowded as those of the 
OPERATIONS REQUIRED FOR VARICES.
35
 neck are with large arterial, venous, and nervous trunks, and other vital
 canals, as the .thoracic duct, trachea, oesophagus, &c, we may, as a suit-
 able illustration under the head of veins, in addition to what has already
 been said by the author on a still more important subject, viz., phlebitis,
 pus, and air in veins, &., instance the case  related by Mr.  Alexander
 King of Glasgow,  (Cormack's Lond.  & Edinb. Month. Journ. of Med.
 Science, March, 1843, p. 1, &c.;  the case belonged to Mr. John Brown,
 surgeon,) of death in a boy, aged four years, in consequence of an actual
 rupture of the right internal jugular into an abscess which had formed
 in this  part of the  neck after an attack of scarlatina.   This abscess was
 preceded  as  is common in scarlitina, by  an extensive tumefaction of
 the  oblique chain of sub-cutaneous lymphatic glands, extending from the
 parotid to the scapular extremity of the clavicle.   It broke of itself on
 the  16th  day, by a small opening through which the contents of the ab-
 scess were freely  evacuated, so that the  swelling  gradually subsided,
 until on the third day after  this, blood was found to ooze from the aper-
 ture in a full stream.   The walls of the abscess were very tense,  and
 the  tumor now about the  size of a  hen's egg was larger, the mother
 said, than before ; it  occasioned paroxysms of coughs and dyspnoea,
 and then became more tense and prominent.  Pressure on the carotid
 did  not alter its size, but on the tumor itself, brought on a  fit of cough-
 ing  immediately, without  appearing to displace  any  of its contents.
 The pulse extremely quick and feeble, and occasionally intermitting;
 countenance pale and blanched.   Pressure to the tumor by compresses
 and bandaging, in  order to faciliate  coagulation, was  attempted; but,
 as it brought on incessant  coughing, it was first abandoned, then tried
 again;  but the tumor continued to increase  the evening of the  same
 day the surgeon had been sent for, on account of the hemorrhage.  The
 tumor,  in  fact, now interfered so much, by its size, with  respiration,
 that the bandaging had to  be again relaxed;  but upon removing this
 altogether, in order to proceed to an examination, the  child was seized
 with a violent paroxysm of coughing, during which the anterior wall
 of the tumor gave  way to the extent of two square inches.  A thin
 coagulum, about the size and thickness of  a crown piece, was ejected,
 followed by an immense gush of blood.  "  I instantly," says Mr. King,
 " introduced the first  two fingers of  my right  hand into the opening,
 and  surrounded the fingers and the tumor with cloths, and very  little
 blood was afterwards lost, although my fingers could not get either to
 the  upper or  lower orifice, in  consequence of the lower part  of the
 tumor being  covered by the parotid  gland and sterno-cleido-mastoid
 muscle.   When my fingers were  first  pressed into the abscess, I felt
 blood, flow freely downwards from above, and propelled upwards with
 a great force, during  each forcible extirpation.   A state of syncope
followed in a few seconds, and  he expired shortly afterwards."
  Dissection  was made ten  hours after death.   The swelling had en-
tirely disappeared,  and the  skin which had previously covered the tu-
mor, had contracted in every direction,  so that 'it could hardly  be
conceived that so much distension had ever existed.  The  tumor from
the lobe of the  ear downwards was divided into two sacs,  which com-
municated very  freely.   The one extended below the digastric muscle
and  parotid gland,  and to the base of the skull; while the other had
• 
36
NEW ELEMENTS OF  OPERATIVE SURGERY.
 the  parotid  gland for its  posterior wall, the sterno-mastoid muscle
 for its external, and the platysma, fascia3 and skin for its anterior wall.
 Dividing  through  the parotid, which was sound  and healthy, and the
 posterior  belly of the  digastric,  a distinct view  of the course of the
 hemorrhage  was obtained.  Nine tenths of an  inch (continues Mr.
 King) of the external wall of the  internal jugular vein, commencing
 two  lines  below the base of the  skull and  extending downwards, was
 completely removed, as if  by a sharp scalpel.  The  external wall, and
 even  the  margins  of the  opening, were  perfectly healthy, and of the
 normal pearly white color.  The common  carotid  was also perfectly
 healthy;  so were  the walls of the abscesses and all the surrounding
 tissues.
   Remarks.—A case so unparalled could scarcely have been diagnosed
 by any one.   The attempt  at a ligature would probably have ended  fa-
 tally by hemorrhage before the lesion could have been cut down to  and
 secured above and  below it; while  compression  was  defeated by the
 regurgitation  or reflux of blood from the right side of the  heart during
 the paroxysms of the coughing.   Nor, (as  Mr. King says,)  could the
 ligature have  been applied  to the wounded vessel between the laceration
 and the base  of the skull.   Add  to  all which, the  child, had the la-
 ceration been freely exposed, would  probably have suffocated on  the
 spot, from unavoidable inhalation  of air into this large venous trunk.
 So no blame could any way  attach to the surgeons.   Professor Fergusson
 of London, (See M. Liston's recent memoir on-a variety of False Aneu-
 rism)  relates  a somewhat similar case.  In  this also no operation was
 resorted to, because of the  debility of the child, which died suddenly
 from hemorrhage.   On dissection, the blood was found to have proceeded
 from an ulcerated opening in the lingual artery near its origin from  the
 carotid.
  Such facts should indeed, as Mr. King says, impress surgeons with the
extreme danger of opening, as is often recklessly done, abscesses in the
nieghborhood of large vessels.
   Scrofulous Abscess with Perforation of  the Jugular Vein, and death.
Dr. Hoffman,  also  (Caspar's Wochenschrift,  March  30th,  1844—quo
ted in Cormack's Journal, July 1844, p. 632,) relates the case of a child
aged five, in whom scarlatina was followed by abscesses in the chain of
sub-cutaneous  lymphatic  glands,  on the  right side of the  neck, and
which glands,  on both sides of the neck from the parotid to. the  clavicle
arenas is well known, and as we  have already said, usually found in-
volved in severe inflammation and tumefaction in that form of eruptive
fever.   Though a certain suspicious tremor and bruit accompanied  the
fluctuation of the tumor, it  was nevertheless  punctured, when a copious
stream of blood immediately issued out and revealed the true nature of
the mischief.  At first the discharge was of a dirty red color, doubtless
from the admixture  of pus,  but soon changed to pure blood, terminating
in a few minutes in  death, notwithstanding the compressing means used.
The corresponding  external jugular  vein  was found perforated like a
sieve to the extent of three quarters  of an inch of its calibre, the por-
tion of the vessel above and below  this point, being also discolored
and soft.  The abscess being situated over the vein had in fact extended
to its walls and perforated them.  T.] 
OPERATIONS REQUIRED  FOR VARICES.               37
  [Dr. Geo. McLellan states in his Principles of Surgery, p. 195, that
in removing an inguinal tumor, he once divided the internal saphena vein,
which required a ligature.  He remarks that no inconvenience resulted,
although the orifice of the vein was sufficiently large to admit the ring
finger, being the largest which he%ad ever seen tied.   This surgeon has
also tied the internal jugular vein without any unpleasant effects.  Mr.
Fraser has reported in the Lond.  Lancet, July, 1848, a case of lacer-
ation of the axillary vein, in which he applied two ligatures, one above,
the other below the wound.  The case terminated favorably.   Dr. Nathan
R Smith has tied the internal jugular vein, and his patient recovered.
A report has recently gone the round of the journals, of a case in which
the subclavian vein was successfully tied by a Mr. Hinckley of Massa-
chusetts, who  at the time was a mate of a whaling vessel.   G. C. B.]
                     SECTION  SIXTH.

                       THE LYMPHATIC SYSTEM.

  The operations required by the lymphatic system are applicable only
to the ganglionic (i. e., glandular) portion of this part of the organiza-
tion.   But as on the other hand the  diseases of the lymphatic glands
which occasionally call for  surgical aid, almost all of them  present
themselves under the form of tumors, I shall have  an opportunity of
speaking of them while treating of this last mentioned class of affections.
   [M. Demarquay  has published in the  Mem.  de la Soc. de  Chir. de
Paris, torn. III. fas. 2. the particulars of two cases  of lymphorrhagia.
As these cases are  very uncommon, we copy from the Ass: Md. Journ.
Feb. 1853, the details  of one  of these  cases, with  the accompanying
remarks :
  Case 2.—This case was observed by Dr. Fitzer.   A young lady, set.
16, who had not menstruated,"and had had  crural hernia from the age
of eight years.   In 1847, she  found that she  had  on her  abdomen a
number of  small granular elevations ; she was examined by  Dr. Fitzer,
who found  a brownish stripe, three finger-breadths in width, commenc-
ing an inch below  the  umbilicus, to the left of the linea alba.  It ex-
tended to the left* and upwards, passing  between the false ribs and the
ilium, and  ended at the  dorsal vertebrae, becoming  smaller and more
transparent at this part.  The middle part of this streak was  prominent,
and was formed of about  eighteen  papillary enlargements ;  some  of
these  resembled the mamillary  papillae in men,  others those  in women ;
they were  not tender to the touch, and disappeared on pressure.   In
July,  the patient felt some pain in the situation of the streak; and on
the 31st of that month, after  returning  from  a walk, she  found that
there was escaping  a milky coagulable fluid. She estimated the quan-
tity which escaped at a quarter of a pint.  Dr. Fitzer found the ap-
pearance of the parts the same as before.   The fluid continued to es-
cape during three days.  It was milky, of a saline taste, alkaline, and
escaped from two of the largest of  the elevations which have been de-
scribed.  When one orifice was compressed, more lymph  flowed from
the other.  Dr. Fitzer cut one of the elevations with curved scissors ; 
38
NEW ELEMENTS OF  OPERATIVE SURGERY.
he was able to pass a probe  for an inch right and  left; a quantity of
lymph escaped  from this  incision.  Pressure, and the application of
alum were  insufficient to restrain the flow of lymph;  Dr. Fitzer there-
fore applied nitrate of silver.  It waf important to arrest the disease,
as the girl was losing strength, and the  pulse  was becoming weak.
The lymphorrhagia ceased, but the granular projections remained :  new
ones were even  formed, of the size of a lentil or millet-seed, while the
skin over the remaining part of the streak had become  pale, like that
of the rest of the abdomen.
   Microscopical and chemical analysis of the fluid, made by M. Schloss-
berger, left  no doubt that it was lymph.
   M. Demarquay has not  been able, after  diligent search, to find  any
records of cases of lymphorrhagia from spontaneous rupture of the
vessels;  cases of lymphorrhagia from wounds have been recorded by
Nuck, Van Swieten, and Assalini.
   Dilatation of  the lymphatic vessels  has been  observed  by Baillie,
Mascagni, Amussat, Breschet, Sir A. Cooper, Bichat, Sommering, Mor-
gagni, Beau, Ricord ; also, by Bidloo, Meckel, Rokitansky, Albers, An-
dral, Otto, and Hasse.  (Hasse's  Pathological Anatomy, " Sydenham
Society's  Translation," p.  9.)  But the facts  have  not as  yet been
sufficient to enable pathologists to determine the causes, forms, varieties,
diagnosis, prognosis, or treatment of the disease.  As far as M. Dem-
arquay knows, M. Beau is the only surgeon  who has attended to the
treatment.   In cases of dilatation of the  lymphatics of the prepuce, he
introduces a small seton into the  dilated vessel, and  removes it at the
end of three or four hours.  Obliteration is thus produced.   G. C.  B.]
                  SECTION  SEVENTH.

                       THE NERVOUS SYSTEM.

  Although most authors upon operative  surgery have neglected  to
treat of the nerves, they are nevertheless liable to a number of diseases
which often require its interposition.
  Among the affections of the nervous  system, there are two especially
which I cannot omit to treat of in this point of view ; These are  the
neuromas, and the different kinds of neuralgia.   The nature of  neuro-
mas and tumors of the nerves being  still a subject of dispute with  pa-
thologists, induces me to consign them  also to the  class of tumors.   I
shall consequently at present treat only of operations which are  admis-
sible for neuralgia, in other words of the section and excision of nerves.
  It was natural to suppose, that in  destroying  the continuity  of  the
sensitive nerves, we  should  thus prevent the transmission of the pain
to the  brain, and succeed in curing  the neuralgia.  As the nerves on
the other hand have no retractility, it was apprehended that after being
divided they might  reunite anew, and that their mere  division would
not be followed by any permanent relief.  Experience unfortunately has
too  well confirmed these  anticipations.  It was on that  account that
the idea suggested itself of destroying a sufficient portion of the nerve
to render its reunion impossible.  Caustics and the hot iron recommend- 
NERVES OF THE HEAD AND NECK.               39
        ed to carry out this recommendation have the serious inconvenience of
        making too large a cicatrix and  horribly  disfiguring the patient.  In
      .  our times the cutting instrument has generally been substituted for them.
        By means of an incision in the track  of the  wrinkles  of the skin, the
        muscular fibres or the principal vessels, we are enabled to lay the nerves
        bare at their exit from the bone, to divide them before they have <nven
        off any branch, and to remove a portion of them of the length of *some
        lines. ^ The wound cicatrizing by the first intention, the scar, after the
        cure, is lost in the folds of the skin, and the continuity of  the nerve
        being effectually destroyed, it seems impossible that the neuralgia should
        not be arrested.
           It is far  from being true, however, that clinical observations on this
        point have never contradicted the theory.   Often, and too often, the
        disease does not yield either to excision or  incision  performed in the
        very best manner, and there are numbers of persons who have been no
        more benefited by one of these operations than by the other, no more
fc       than they have  been by deepest cauterizations.  There was at the Hos-
        pital of St. Antoine, in  1829, a man of about 45  years of  age, who,
        for the space of  fifteen  years, had been affected by a tic douleureux,
        and who had undergone  successively the section and excision of  all the
        nerves of the face, but without experiencing any relief whatever.  As,
        however, more  fortunate  results  have been  stated, we may, when we
        have unavailingly made trial  of all other modes of treatment, and the
        sufferings of the  patient are  exceedingly acute, suggest to him the ex-
        section of the nerves as a last  resource, which it would be uncharitable,
        perhaps, to deprive him of in  certain cases of obstinate neuralgia.
                           CHAPTER I.

                   NERVES OF THE HEAD AND NECK.

   So common are neuralgias of the head, and so excruciating is their
pain, that it has often been proposed, when all our resources of hygiene
and pharmacy have failed, to have recourse to cauterization, or the sec-
tion  or excision of the nerves supposed to be affected.   There are, more-
over a great number of the head which it might be advantageous to subject
to this treatment.  The chief of  these, besides  the branches  from the
cranium, are  the  frontal, infra-orbitar, inferior dental, the facial and
some branches of superior dental.

               Article I.—Nerves of the Cranium.

  Many authors have mentioned neuralgias  established in the head as a
consequence of wounds, and which have  yielded only to incision or ex-
cision.  A young girl, for a long  time subject to convulsions, epilepsy,
and neuralgia of every variety, was instantly cured by an incision which
Pouteau  (CEuvrest Posthumes, t. II., p. 83, 86, 92,) made above the 
40             NEW ELEMENTS OF OPERATIVE SURGERY.
 mastoid process, the part upon which the  patient had received  a blow
 a long time before.  In another patient, Pouteau had  recourse, in  the
 same way, to three incisions upon different points of the cranium, and
 was not less successful than in the  preceding case.   The  same  author
 succeeded with a similar operation  performed upon the cranium of a
 young man, aged 24 years, who had fallen upon his head sixteen years
 before.  In these three cases, Pouteau confined himself, it  is true, to
 incision, but he tamponed the wound, and did not unite by the first  in-
 tention.

                Article II.—Nerves of the Face.

   The face is the part upon which the section or  excision of the  nerves
 is most frequently performed.  It is probably also the region where  the
 operation is least apt to succeed.

                      § I.— The Frontal Nerve.

   When we wish to derive all the advantage possible from the excision
 of the supra-orbitar nerve, we should seize it at the moment when, as it
 emerges from the supra-orbital notch, it is reflected backward  close  to
 the bone, and before the outer  and  inner anastomosing branches  are
 given off  from it, for the purpose of inosculating with the surrounding
 nerves.  In that part it is covered only by the skin, a thin lamellar  tis-
 sue of cellular substance, and some  pale fibres of the  orbicularis  pal-
 pelrarum muscle.   The artery which runs by the side of it is not of suffi-
 cient size to create any apprehension of wounding it, and in  the  neigh-
 borhood there are no other organs  that the  instrument  can  encounter.
 Should we not be enabled to identify the nerve at first, all that will be re-
 quired ft> determine its position will be, to recollect  that the groove or
 hole which gives passage to it, is situated at the union of the  inner third
 with the outer two-thirds of the upper orbitar arch, that is to  say, at
 about an inch outside of the root of the nose, and that by following the
 border of the orbit with the point of the finger, from the nasal  process
 to the temporal process of the frontal bone, we have it almost constantly
 in our power to ascertain its exaot locality.
   A. The operator, placed behind the patient, raises the eye-brow with
 his left hand, and  while an assistant depresses the lids,  he again  makes
 himself sure of the position  occupied by the diseased nerve, seizes a
 straight bistoury with the other hand, and  holding it as a writing-pen,
 directs the point upon the internal orbitar process, draws the instrument
 upwards, then outwardly, and divides all the tissues down to the bone
 to the extent of an inch, a little above, and in the direction  of the  ad-
 herent border of the eyelid; he then gently  separates the edges  of this
•"kemi-lunar wound  ; finishes the section of the nerve if it is not complet-
 ed ;  hooks up the anterior portion with a good pair of dissecting forceps ;
 isolates it, and excises a sufficient extent of  it to prevent the possibility
 afterwards of a reunion of the two extremities.
   Nothing now remains in the way  to prevent our proceeding at once to
 reunion of the integuments by first intention.  The loss  of substance
 which the nerve has undergone, gives us, so far as that is  concerned, 
                  nerves of the head and neck.                41

every security on this head.   As, however, the least infiltration of ex-
traneous fluid into tissues so flexible and so easy to become disunited, as
are those of the eyelid and orbit, might lead to purulent collections and
dangerous inflammations, it appears to me more prudent that the wound
should be left to suppurate.  We are to dress it then loosely with a plu-
masseau besmeared with cerate, or, if there be hemorrhage, we use the
perforated linen and balls of lint, and that for the first  dressing  only.
It afterwards requires no other attention than ordinary  simple  wounds,
and cicatrization is soon accomplished.
   B. In a patient who suffered horrible pain in the  orbit, from  a wound
of a lance in the forehead, M. Larrey (Clin.  Chir., t. L, ou Descot, Op.
cit.) destroyed  every symptom of tetanus by a division of the frontal
nerve;  and the same  operation has succeeded, in one  out of two
cases, with M. Warren.  Hennen  and M. Guthrie, (Archiv.  Gin., t.
XXV., p. 94:  et Mackenzie,  Maladies dez Yeux,) who, following the
recommendation of Beer, confine themselves to the simple section, have
not succeeded ; while, by uniting cauterization with it, M. Riberi (Bel-
linghieri, Arch.  Gen. de Mid., 2e serie, t. VII., p. 209) was enabled to
cure his patient.

                     § II.—Infra Orbitar Nerve.

   This   nerve  being more  deep-seated,  surrounded with  important
parts, and spreading out like a fan  upon its  exit from the  bones, is
much less easy of excision than the preceding; it is also  much less
subject  to neuralgia.  Two modes may be followed to effect the object.
   A. By the Mouth.—In  prolonging upwards for the space of an inch
the groove which unites the lip to the jaw, we traverse all the upper
part of  the canine fossa, and reach the root of the nerve, which  is found
in the direction of the first molar tooth,  at the distance  of three  or
four lines below the orbit.   The bistoury, which should be used at  first,
should  now, for the  last stage of the  operation, be replaced by the
straight scissors.  The principal advantage of this method, which was
practised by M. Richerand, and  who went  to the extent of scraping
the bone with his  instrument, is that of leaving no mark on the face;
but it has the disadvantage of allowing only of a simple section of the
nerve, when in fact it would be desirable to excise it.
  B.  By the Face, the instrument divides, from  the skin to the bones,
all  the soft parts which  compose the cheek;  and it is this, undeniably,
which makes it more objectionable, at least among persons of the female
sex.  Fortunately, however, by  following the natural  furrows of the
face, in  the place of adhering exclusively, as M. Langenbeck (Biblioth.
de Chirurgie, ou Nosolog. und Therap.) advises, to the direction of the
fleshy fibres, it is in our power to obtain a cicatrix which will scarcely
be observable.
  I.  Operative Process.—The patient should be seated, and arranged,
and  supported  as  for all other operations  performed upon the face.
Armed with a straight bistoury  and placed in front, the surgeon makes
at the bottom of the  naso-jugal furrow, that is,  from  the  groove  or a
line which extends obliquely from the ala of the nose to the middle of
the space which separates the prominence of the cheek from the  cor-
   Vol.  II.                     6 
 42             NEW ELEMENTS OF OPERATIVE SURGERY.

 responding labial angle ; he makes, I say, in this  direction, an incision
 an inch and a  half in length, commencing at the outer side of the as-
 cending process of the maxillary bone;  he divides at first the skin
 only, and  soon  after meets the facial vein, which he pushes aside out-
 wardly ; he then comes to fatty tissue ;  then to the levator labii supe-
 riors, which  he pushes  backwards and inwards;  then the  levator
 anguli oris, under the  inner border of which the nerve often lies con-
 cealed, now  makes  its appearance.  To enable the operator to sepa-
 rate all these different parts, he must use a steel grooved sound, with-
 out any cul-de-sac.  Detaching the filaments or tissues which still con-
 ceal or may conceal the nerve affected,  he finally divides it very near
 the infra orbitar foramen, and excises a portion of it, which finishes the
 operation.
   II.  M.  Warren, who has performed this operation twice,  succeeded
 but in  one case.  M. A. Berard,  (Godin, Journal des  Conn. Med.-
 CJiir., t.-IIL, p. 442,) who thought the T incision preferable, did not,
 however, succeed with it in the case of neuralgia in which he employed
 it; while M. Andre, (Hamel,  Theses, in 8vo, t.  XXV.,) for a case of
 old infra-orbitar neuralgia in a  lady  who fell  under his  care, was
 obliged to resort to deep cauterization.

                  § III.—Superior Dental Nerve.

   Being derived from  the  second branch of the  fifth pair, the nerves
 of the upper dental arcade  forbid  the  division of their trunk, when
 they become the seat of neuralgic pain ;  but it is sometimes practicable
 to attack them at the source of the disease.  M. C, from the neigh-
 borhood of Cusset, was recommended to me in 1835, by M.  Giraudet,
 now a practitioner at Tours.  For fifteen  years this patient had suffered
 from  pains in the right side of his  face,  which nothing could assuage.
 These pains commenced in the spot which is usually occupied by the
 last molar tooth. In passing my finger on  this region, I thought I per-
 ceived a slight granulation, which, when touched, immediately  caused
 a violent access  of suffering.  There existed a possibility of obtaining
 relief by excising- the region thus touched.  By  means of a pair of
long,  cutting nippers, curved suddenly and nearly at right  angles on
the borders near their cutting extremity, I embraced the whole posterior
 extremity of the margin, of the jaw, and removed it at a single  stroke.
 The pains  were soon assuaged, and a year afterwards I received from
M. Giraudet a letter, announcing the entire cure of our patient.

                    § IV.—Inferior Dental Nerve.

   The inferior maxillary nerve emerges  from the  jaw by the foramen
mentale under the boney groove which separates the alveolar processes
from the canine tooth and the first molar.
 A. Process of the Author.—Nothing is more easy than to reach it at
this point.   While with one hand  the surgeon  reverses  the lip out-
ward  and backward, he incises by means of a straight  bistoury in the
 other, layer after layer and from above  downwards, the tissues which
 are found  at  the bottom of the  maxillo-labial groove.   The  teeth 
NERVES  OF THE HEAD AND NECK.
43
 just mentioned will be his guide.  In a short time, that is, at some lines
 in depth,  he encounters the nerve, and  isolates it to the extent of
 a quarter  of an inch, by removing  from the jaw the posterior portion
 of the soft parts which cover it, and  then  excises  it in the same man-
 ner as has been said of the tfrontal nerve, and makes use of no dress-
 ing afterwards.
    B.  The bleeding however is quite troublesome  by this process, for
 which reason M. Berard (Godin, Jour, des Conn. Med. Chir., t. III., p.
 442)  preferred making a T incision reversed, laying open, the whole
 depth of  the tissues on the side of the  chin ;  it appears, also, that the
 patient operated  upon by this  surgeon was perfectly  cured.   To apply
 the red-hot iron to  the skin opposite the mental foramen, as Museux
 (Bull, de la Fac.  de Mid., t: I.) declares he has done with success, or
 immediately to destroy the nerve with caustic potash, as Andre  (Ham-
*el, Oper.  cit.) did successfully in a man upon whom  Marechal had un-
 availingly performed the section of the dental nerve, would neither be
 as simple  nor as certain as this kind of  excision.
    C.  When the  neuralgia  is  seated at  a greater depth, M. Warren
 (Journal  des Progres, t. XII., p.  270) has no  apprehension of attacking
 the trunk of the maxillary nerve  itself, and excising a portion of it in
 front of  the pterygoid muscles.   A  crucial  excision of the skin, the
 parotid gland, and  masseter muscle, enabled him to apply  the crown
 of a  trephine  upon  the coronoid process, and  by  means of a probe to
 raise up the nerve above the dental canal, and excise  about three lines
 of it  with the scissors.  The  accompanying artery was wounded  and
 tied  without  difficulty.   The  patient, who had been only temporarily
 relieved,  but not  cured by other  excisions, and who  suffered excessive
 pains, ceased to be troubled immediately  after  the operation, and has
 continued ever since in excellent health.
    On the dead body this operation is not very difficult.  In making trial
 of it, I have found it would be better to incise the parts in a semicircular
 and oblique direction from the lobule of the ear to the border of the jaw
 and front of the masseter, which latter it would be advisable  to divide,
 and to raise up its fibres from behind  forward; the trephine, applied
 upon the  base of  the coronoid process on a line with  the sigmoid notch,
 falls  exactly upon the nerve, and may  even be made to. divide it with
 the same  stroke.
    D,  If  the neuralgia were seated in a single tooth, we might, after the
 plan  of M. Fattori, (Rev. Med., 1825,  t. I., p.  294,) trephine the side
 of the alveolar process, and thus  destroy the  filament of nerve which
 is implicated.   But the  excision of the  part in such cases  is at  the
 same time more certain and more expeditious.
    [In the Appendix to the last edition, M. Velpeau inserted the follow-
 ing extract from a letter addressed to him by M. Hysern, of Madrid:
    " In June, 1834,1  operated on  D. J.  Bonavida, set. 54, attacked 11
 years before with a severe neuralgia  on the right side of the face, and
 for which other  surgeons had in  vain performed  the section of the in-
 ferior dental nerve, the extirpation of some lines of  this nerve, its cau-
 terization in the foramen mentale, and the section of  the facial nerve ; 1
  effected  the extirpation of the nerve in  the whole length of the dental
  groove of the lower jaw.  To effect this, I raised  almost the whole ex- 
44             NEW ELEMENTS OF  OPERATIVE SURGERY.
ternal  table  of the bone, in insolating it by four cuts of the saw, aided
by the gouge and mallet.  I afterwards took hold of the nerve with the
dissecting forceps, and extirpated it completely, after which I cauterized
the superior extremity of it with red hot-iron.  Having remarked that
the pains affected not only the dental tru^:, but also the  most superfi-   *
cial parts of the  lower half of the cheek,  and the corresponding half of
the lower lip, and of the chin down to the base of the jaw, where were
distributed the filaments of the nerve formerly extirpated by Professor
Argumosa, I  took away also all these soft parts, and I finished the ope-
ration  by autoplasty, according to my method, by means of the skin of
the neck and of the platysma myoides.
  " There was at first considerable relief, and the patient felt no other
than slight  pains produced by atmospheric changes.  This state lasted „
for  nearly  six months; the pains returned then with the same intensity
as before, but in the direction of the  infra-orbital plexus, the  buccal*
nerves, the lingual, and,  as it seemed to me, of the portion of the infe-
rior dental trunk which remained behind  the jaw.
  " The patient immediately  demanded another operation.  I resisted
for  some time, seeing the return of the disease; but at length, perceiv-
ing no  other  means  of relief, I yielded.  I undertook and effected the
extirpation of the infra-orbital  plexus and the buccal nerve, from the
internal face of the masseter muscle to an inch and a half in front, then
that of the  inferior dental and lingual nerves, at three to  four lines be-
low the foramen ovale of the sphenoid bone;  so that I took away more
than an inch of  the  dental nerve, and twenty lines of the lingual.
  "Having commenced by incising freely, and almost horizontally, the
cheek, from the  commissure  of  the lips to a little beyond the  anterior
border of the masseter muscle, and without interfering with that, I dis-
sected out the buccal and the inferior dental and lingual nerves, be-
tween the pterygoid  muscle and the ramus of  the jaw; then I took hold
of them with the blunt  hooks, (irignes mousses.)  I assured myself,
and  more than twenty persons present, most of them distinguished sur-
geons, also  satisfied  themselves, that it was  truly the nerves described
that I held in the erignes.   I then passed a  blunt-pointed very narrow
bistoury to their upper part, and turned the edge of it against the nerves.
In  drawing, at  the  same time, the erignes with the other hand, I was
enabled to  make their upper section, avoiding thus the internal  maxil-
lary artery and  every other vessel; I avoided, also, the internal late-
ral ligament of the lower jaw, and I finished by cutting the  nerves  at
the lower part with the scissors."
   M. Sedillot, of Strasburgh, has, recently performed the  following ope-
ration on the dental branch of the inferior maxillary nerve, for the  re-
lief of an obstinate neuralgic affection :—
   An  incision was made along the inferior border of the  lower maxilla
from the canine tooth to the anterior border of the masseter.   The soft
parts  were then divided to the bone, and a flap  raised towards the
upper part of the face, from over the dental foramen, whence the dental
branch was seen emerging in  thick and voluminous ramifications.  A
 small trephine  was then applied one inch posteriorly to this foramen,
 and  a circular  piece of bone, about two lines thick, removed.   By
 breaking up a few lamellse of bone the dental nerve was laid bare, and 
NERVES  OF THE HEAD AND NECK.
45
tht  l^T       ^f °f thf °SSe0US aPerture-   Another section of
dPntnl  fL    6  ™f +lhen  madf twr°-thirds  of a» in<* ^terior to the
dental  foramen and the operator then seized with two forceps the an-
terior and  posterior extremities of the  piece of nerve lying between
 he loca ity of the two sections.   By pulling it backwards and forwards^
its cellular  connections  were weakened, and the portion of nerve then
extracted  altogether by its anterior extremity. This isolated piece of
nerve was  about one inch and a quarter long, round, of an opaline col-
or  and presented  no striking vascularity.  The  flap was  allowed to
 •n  down  again, and  the report mentions that the patient said on the
eighth  day that  she suffered  no more pain, and  on the sixteenth the
wound was quite healed, the cicatrix being hardly visible.
  Dr. J.  M. Warren reported to  the Boston Society of Medical Im-
provement, a case  of  Tic  Doulereux which  was relieved  by  the re-
moval of a portion of the inferior maxillary nerve, after  trephining
the  lower  jaw bone.  A notice of this operation may be found in the
American Journal of Medical Sciences, April,  1850, p. 369.
  In May, 1854, we witnessed an  operation of this kind, performed by
Professor Parker.  The  patient, a female, who resided in Brooklyn, had
for 20 years  suffered the most  excruciating pain, which attacked her
even during sleep, and rendered  life almost insupportable.   In this in-
stance, the proceeding has been followed by the most gratifving results,
and as we *vere informed by Prof. P. in September, 1854, she remained
free from the tortures which she  had so long endured.  G.  C.  B.]

                         § V. Facial Nerve.

   The  portio  dura of the seventh pair, spreading out as it does, upon
almost every point of the visage, would naturally, at  first  sight,  be
supposed to be more frequently  the  seat of facial  neuralgia  than the
other nerves, and consequently it is the one  which has been often fre-
quently excised.
   A. Its temporal-facial branch, the only one which surgery has ventured
to attack, crosses the neck  of the condyle  of the jaw at the point
where the lobe of ear unites to the integuments of the face.   It is in
this place  that we  should  lay it bare.  An incision, slightly  oblique,
is made from before backwards or almost vertical, which commences at
the zygomatic  process, and terminates on the posterior border of the
jaw above its angle.   We have to divide successively the cellulo-adipose
tissue, an aponeurotic layer and some slight prolongations of the parotid
gland, before finding  the nerve,  which is separated  from the bone only
by  lamellar  and filamentous  cellular tissue.  By this method we are
sure  to avoid  the  temporal artery; and  should  the transverse facial
artery be wounded, its compression would be too  easy to make the he-
morrhage from it cause any disquietude.
  B. The  other, the cervicofacial branch, being lost, as it were, in the
parotid, presents too  many anomalies in its position,  while the trunk
itself of the facial has been considered too  deep-seated, and surrounded
with parts  too  important to think  of excising these nerves.  We may,
as I think, without rashness, appeal from this decision. 
46
NEW ELEMENTS OF OPERATIVE SURGERY.
  C.  I have often ascertained on the dead body that the trunk of the
facial nerve could be  laid bare  without danger at its exit from the
cranium and before it has.furnished  other branches than the filaments
of the mastoid, digastric, and stylo-hyoid.  For that purpose, the ope-
rator has  only to make a vertical incision an inch  and a half long be-
tween the mastoid process and the lobe of the ear;  then in coming down
to the anterior face of the osseous projection  and the corresponding
edge  of the sterno-mastoid  muscle, a depth of 6 to 10 lines, he has .to
divide, layer by layer, the teguments, the cellular tissue, and the parotid
gland, which latter is to be turned forward.  The lips being drawn apart,
we perceive the  nerve at the bottom of the wound, nearly  in the middle
of the space which separates the temporo-maxillary articulation from the
apex  of the mastoid  process, and where it seems to take a direction
towards the border of the inferior maxillary bone.  The division and
even  the  excision of it is then in  every respect as  simple  and easy as
that of the frontal, and it  is clear that his section, in itself, presents
all the security desirable under such circumstances, if it  be true also
that these different excisions of the nerves are, in fact, the actual remedy
for facial  neuralgia.   I purposely suggest some doubts as to these ex-
cisions, because the facts yet ascertained are not sufficiently conclusive
in their favor.  If, in  some cases, they have been followed by a marked
diminution, or even the entire subsidence of the pains, we have much
more frequently observed that they procured no relief, or assuaged the
anguish but momentarily.   I have mentioned  the  case of  a man who
was  subjected  to all these operations on both sides of the face, and
without experiencing any appreciable advantage from them.  M. War-
ren  had  a  patient,  in whom, after the  excision successively,  of the
frontal, infra-orbital, and  facial nerve, only  temporary relief was ob-
tained.   Boyer communicated to me a similar observation.   The  patient
in whom he excised successively the four principal nerves of the face,
though at first slightly relieved, was no more cured than the one of whom
I have spoken.   Moreover, if it be true that  the  frontal, infra-orbitar
and  mental nerves, in fact, that  all the branches of the  fifth pair are
exclusively nerves of  sensation, while the seventh pair is alone charged
with  the  office  of presiding over the muscular movements  of the face,
then  is it evident  that the section of this last can have no other effect
than  to paralyze the muscles of the face, while to the other three only,
must our attention be directed in whatever concerns neuralgia.
   [M.  Hilton, of Guy's Hospital,- has  divided the Gustatory  nerve,
with  a view of blunting the sensation of the  part in a case of  cancer
of the tongue.  The  tongue, having  been drawn out, and steadied by
an assistant,  Mr. H.  divided  vertically, with a  small knife, the mu-
cous  membrane,  and  sub-mucous tissue, for about three quarters of an
inch, over the hyoglossus muscle, and above the sublingual gland.   The
incision was continued through  the  upper  edge of  the  sub-lingual
gland, and the  nerve  exposed.   The flow of venous blood greatly ob-
scured the parts.  On dividing the  nerve with scissors, all sensation
was immediately lost  in the  anterior part of the tongue, on  the left
side, as well as in the ulcer.   One  month afterwards, the patient  re-
gained slight feeling  at the tip of the  tongue, and  the ulcer  became
somewhat painful to  the touch,  and the disease extending, destroyed 
NERVES OF THE NECK.
47
the patient about four months after  her discharge from the hospital.
The division of the nerve in this  case obviated the suffering from the
application of the ligatures which  were employed to remove the diseas-
ed mass, and Mr. Hilton asserts that it never should be omitted  when
such a proceding is  about to be attempted,  (Lond. Lancet  Am  Ed
June, 1851, p. 52.   G. C.  B.J                            '     *   "

                Article III.—Nerves of the Neck.

  Up to the present time I believe no one has undertaken the  section or
excision of the nerves the of neck.  M. H. Berard however has related to
me the case of a woman who suffered so severely in the sterno-mastoid or
carotid region, that she earnestly entreated that some operation might be
performed which might relieve her of  her distress ; a small deep-seated
tumor was perceptible which appeared to be  situated upon  the pneumo-
gastric  nerve.  This woman, however, died I believe, without having
had any thing done for  her.   Having  also  myself observed a  ner-
vous tumor in the  same region, and  which  appeared  to belong to the
great sympathetic nerve, I shall, in treating of  operations  applicable to
tumors, describe the process which is to be followed to enable us to reach
down to these nerves.  I may make the same remark in regard to what
concerns the section of the nerves of  the thorax.
  [ Mr. Fearn reported in the Prov.  Med. Sr Surg. Journal, Sept, 8th,
1847,a case of wound of the internal carotid artery, and divisionof the
par vagum, in which, after the ligature of the common carotid, the patient
lived upwards of eleven weeks from the receipt of the injury.  She suf-
fered from difficulty of swallowing, and cough, which continued  to in-
crease until she died.  G. C. B.]
   [Division of the Par Vagum on one side without causing death, and
followed by recovery.—I understand  that very recently and within a
few months, Dr. McClellan,  an eminent surgeon of Philadelphia, in re-
moving an enlarged  parotid gland from below the angle of the jaw, and
which had  extended to some  distance down into the  neck, was oblig-
ed, from  the  par vagum on that side being embedded in the tumor, to
exsect and actually take away about two inches of this important nerve
without producing apparently much inconvenience to the respiratory or
other functions.  Finding such an unprecedented  result from the exsec-
tion of  so important a nerve, which, as far as we are informed, had never
before been interfered with on the human subject, but on  the contrary
always  avoided with extreme caution ;  the  surgeon designedly left the
wound open for some days, in order that other surgeons of Philadelphia
might satisfy themselves, by inspecting it, of the truth of what had oc-
curred.   The fact is thus placed beyond dispute, that all the vital func-
tions of  this important pair of nerves may, in living man, be performed
by  one nerve alone, which could have scarcely been  anticipated from the
pathological and physiological views hitherto entertained.
  Nevertheless, Dr. Mott has always scrupulously avoided wounding or
dividing this nerve in all his surgical  operations; and  is satisfied that
such ought to be the rule in every  case where it is possible  so to do, not-
withstanding  the pathological fact  established by Dr. McClellan.  In
this case of Dr. McClellan, he thinks the functions of  the nerve, on the 
48
NEW ELEMENTS OF  OPERATIVE SURGERY.
diseased side, may have been interrupted, or to a certain extent  annihi-
lated, before the operation was performed.   Its  situation  in the  tumor
in which it was imprisoned and compressed, warrants this inference. T.]
                          CHAPTER II.

                       NERVES OF THE LIMBS.

        Article  I.—Nerves of the  Thoracic Extremities.

                       § I.— The Fore-arm.

  We may have occasion in the arm to make the division of the radial,
ulnar, or cutaneous nerves, and even that of the median nerve.
  [Exsection of the median nerve was first performed  in  America  by
Dr. Mott. Dr Darling proposes the following mode of reaching this nerve.
  "An incision, from an inch and a half to two inches in length should
be made along the ulnar border of the tendon of the palmaris longus
muscle, a little above its insertion into the annular  ligament.   The  in-
tegument, superficial facia, and aponeurosis of the  fore-arm being suc-
cessively divided,  the median nerve will be brought into view,  situated
behind, and rather towards the ulnar border of the tendon, where it may
be readily distinguished from  the tendons of the flexor sublinis by its
whiteness, or by pinching it with a forceps, when great pain will be ex-
perienced in the thumb, the index, and middle  fingers.  If the hand be
now slightly flexed on the fore-arm, the palmaris longus  may  be pushed
to the radial side, and a portion of the nerve be easily exsected.   It is
perhaps unnecessary to add, that the upper section must be made first .
  In cases where the palmaris longus is wanting, the nerve can readily be
exposed by making the incision three-eighths of an inch from the ulnar
side of the tendon of the flexor carpi radialis." This is certainly far pre-
ferable to, and much safer than dividing the trunk of this nerve, high up
in the arm, upon the inner side of the biceps flexor  cubita muscle.  T.]
  [Some two inches of the median nerve  removed by Prof.  Parker of
this city, during the extirpation of an encephaloid  tumor from  the arm,
with which the nerve was inseparably connected. The paralysis  resulting
from this occurrence, in a few weeks began to disappear, and at length the
use of  the arm was perfectly regained.   The exsected portion  of  the
nerve had doubtless been regenerated, the possibility of  which  has been
proved by the observation of Cruikshank, Haighton,  Fontana, Monro, Mi-
chaelis, Meyer, Tiedemann  Prevost and Swan.   True, the restoration  of
the functions of a paralysed limb has been otherwise explained  by  Reil,
Soemmering, Breschet and Jobert.   According to their views  of the sub-
ject, this change  is to be attributed to the influence of anastomosing
branches, rather than to a  direct union of the main  trunk of the divided
nerve,  but Meyer  succeeded in tracing the  uniting  medium, by subject- 
[
                       nerves of the limbs.                     49

ing the intermediate cicatrix to the action of nitric acid, and proved that
this medium was composed of the nervous filament itself.
  In some instances however after the division of a nerve, it seems doubt-
ful  if union  takes place in  the manner above mentioned.  An interest-
ing case  is related by Mr. Fergusson (Pract. Surgery, 3rd Lond. Ed., p.
287.) in which he assisted Dr. Simpson of Edinburgh in an  attempt, by
an  operation, to re-establish the  continuity in a divided median nerve.
In this instance, a small tumor had formed on the upper extremity of the
cut nerve, such as is seen occasionally after amputation, and its removal
required the exsection of about one inch of the median nerve. The divid-
ed  ends were brought as nearly as possible into contact, but some  years
elasped before any material increase  occurred in the  temperature and
sensibility of those parts supplied by this nerve.  On the same page he
relates another case, in which he divided the  median nerve, for the re-
lief of the pain produced by a tumor, about the size of a hazel nut,  in the
palm of  the hand, and which was supposed to be a growth  in  the sub-
stance of one of the branches of the median nerve.  The simple division,
in this case, did not effect the desired object.   G. C. B.]
   A.  Ulnar nerve.   In 1832  Lauth wrote me that he  had practised,
the excision of the ulnar  nerve three  times  in  epileptic patients;
the operation succeeded in  one  of the cases, but failed  in two others.
The  paroxysms in  the  first case were  ushered  in  by an  aura epi-
leptica, while in the others this  did not  occur.  If we wish to repeat
this  operation, whatever may be the indication, the limb should be
placed in the same position as for tying the arteries.   The  parts would
be incised in the same place and in the same manner  as for  this last
operation.   After having divided the integuments and a first aponeurotic
layer, then pushed to the inner side the flexor carpi ulnaris, and divided
a second fibrous layer, we should find the nerve in the form of a white
cord within  and a little behind the artery.  After having isolated and
raised it, we should excise from it a fragment of at least from two to four
lines in length.  If we should limit ourselves to dividing it transversely,
its two ends would soon reunite, and there would be nothing  to hope from
the operation.  In a case thus treated by M.  Cairoli, (Arch.  Gin. de
Mid., 2 ser., p. 137,) Professor Viviani saw the neuralgia  reappear at
the expiration of a few days.  In the case of  a gardener, noticed by A.
Dubois, (Descot, Affections Locales  des Nerfs, 1825,) and  who had the
ulnar nerve above the wrist divided by the cut of a pruning knife, the
 paralysis lasted but a very  short time.  Excision more formidable  than
the division as respects the paralysis which it should  seem it  ought to
 produce in the third or fourth fingers, has not, however, been always
followed by  it.  A young man had in this manner a portion of his ulnar
nerve and the corresponding artery destroyed above the wrist by an ac-
 cident.  A paralysis which continued for six weeks in the  two  fingers,
mentioned, afterwards gradually disappeared.  When I saw the young
 man  again, a year after, he felt nothing more  of it.
    [Mr  Fergusson (op. cit. p. 288) remarks:  " In an instance of pain-
 ful ulcer on the arm, a little  above  the inner condyle, I  have seen a
 portion of the ulnar nerve, supposed to be involved in the sore, remov-
 ed with excellent  effect.   The  painful open  surface which  has been
 present for many months, and resisted all  attempts at cure,  speedily put
    Vol. II.                      7 
50             NEW ELEMENTS  OF OPERATIVE SURGERY.
on a more healthy  aspect, and the operation, although it deprived  the
little finger and the ulnar side of the ring one of sensibility, was attend-
ed with all the benefit that could have been desired.  G. C. B.]
  B.  Radial nerve.  Among the examples of the section of the radial
nerve, there is one related  by M. A. Cooper, (Arch.  Gin.  de  3kd.,
1838, t. II., p. 183,) in which the operation was performed for a neu-
ralgia caused by a contusion of the thumb, and attended with success.
A similar fact is related  by M.  Wilson, (Swan, Maladies des  Nerfs,
p. 117.)   M. Teewan, another English surgeon, (Arch.  Gin.  de  Mid.,
loc. cit.,) has  been equally  successful in ordinary cases of neuralgia.
But  it was  a cutaneous  nerve and  not the radial  which M. Wilson
divided.
  The operation in such cases exacts  precisely the same precautions as
in the ligature upon the radial artery.  Except that the incision  should
be made  outside of the  track of the  artery, since the  nerve is .found
nearly in the middle of the space  which separates the outer edge of the
radius from the course of the vessel.
  As the  radial  nerve is of  infinitely  less importance than the  ulnar,
we might without any apprehension, excise a long  portion of it.  In a
young lady who was exhausted by the pain, A. Petit (Verpinet, Journal
de Med., t. X.; Descot, p. 18) effected a complete  cure in his patient
by producing a large  eschar  by means of the hot iron  applied upon a
cicatrix which included the radial nerve.

                        § II.— The  Elbow.

  The nerves which lie in the neighborhood of the  veins in  the bend
of the arm, have been so frequently charged with causing severe acci-
dents resulting from bleeding, that early attention was  directed to the
subject  of their  division.   It is an  operation, however, which has  not
been subjected to any surgical rule, and one which was no longer thought
of until M. Hamilton (Arch. Gen. de Med., 1838, t. II., p. 174) again
drew public attention to it in 1837.
  A.  The Cutaneous Nerves.—The  section of the cutaneous  nerves
has been performed by M. Watson, M. Sherwin, and also by M. Wilson
to remedy accidents from bleeding.   M. Crampton, however, in divid-
ing for this  purpose the cutaneous nerve in a young lady obtained only
an imperfect cure.
  1. Upon the supposition that we were not disposed to operate upon
the point whence the pain originated, we might find the external cuta-
neous or musculo-cutaneous nerve above the fold of the arm between
the biceps and the anterior  border of the supinator radii  longus.   An
incision, two inches in length, slightly oblique from above downwards,
and  from behind forwards, would, after  having divided the  skin, sub-
cutaneous fascia, and aponeurosis, necessarily conduct to  this  nerve,
after reaching which we should excise a portion of  sufficient length.
  II. For the internal cutaneous nerve, the incision would  require a
little more  caution on  account  of  the  neighborhood  of the artery.
Carried obliquely from the middle of the lower part of  the biceps to an
inch below the internal condyle of the humerus, it should not go below
the aponeurosis, since the internal cutaneous nerve is invariably situated 
NERVES  OF THE LIMBS.
51
at this point in the thickness of the  sub-cutaneous layer near the me-
dian, ulnar and  basilic veins.  [See  a note of Dr. Mott on wounds of
the cutaneous nerves in bleeding and the operation, Vol. I."]
  III.  The  Ulnar Nerve .—Many of  the nerves of the arm  have lon«*
been submitted to the operation of excision ; the ulnar alone however3
as it appears to me, has had this operation performed uponVt at a pre-
scribed point of its track.  The operation was performed by Delpech
(Revue  Mid., 1832, t. I., p.  80)  in  a  lady who for a long time had
suffered  from a neuralgia  which appeared to proceed from an ulcerous
affection of the  wrist.  Holding the arm in such a manner as to turn
the elbow forward, Delpech made an  incision an  inch and a half in
length, between the olecranon  and the inner condyle, over the immediate
track of the ulnar nerve.   This nerve was soon exposed to view, then
divided on its upper part, and a portion excised.  The pains immedi-
ately subsided, and  ultimately disappeared.  The  complete  paralysis
which at first took place, became reduced to a slight numbness  of "the
third and fourth fingers, which, however, retained all their mobility.
  If the excision of the radial  and  the median has been  performed
upon the continuity of the arm, as M. Richius supposes, it has been in
the case of tumors, of which I shall  speak further on, and not for neu-
ralgia.   As it is the tumor which  serves as the  guide in such cases, I
have not to discuss that subject in this  place.  The case related by M.
Larrey belongs rather to the cutaneous nerves than to the radial.

         Article II.—The Nerves of the Lower Extremity.

  The excision  of the nerves of the foot, unless they  should  be*the
seat of some nodosity or tumor, could not  be subjected to any  fixed
rules as regards a surgical  operation.  The  case is different, however,
with the nerves of the leg or thigh.

                      § I.—Nerves of  the Leg.

  There are  four nerves of  the leg which may be cut down to, and di-
vided by the surgeon, viz.:—the internal saphena, the external saphena,
the anterior tibial, and the posterior tibial.
  A. The Internal  Saphena.—If the  internal saphena should  be the
seat of violent and obstinate pains, as in two patients in whom Sabatier
was disposed to employ cauterization, nothing would be more easy than
to excise a portion of it.  We should  do this on the point itself from
whence the suffering  appeared  to  proceed, as, for  example, where a
cicatrix or ancient lesion  of the tissues was  found on the leg.  If not,
we should  seek  for the nerve  above the parts where the pains usually
existed.   We might reach the nerve by means of an incision an inch or
two inches in length made upon the track of the vein of the same name.
The nerve is almost constantly  found  upon the posterior face of this
vessel.   Nor would there  be any serious inconvenience in excising with
the same stroke  the  vein as well as  the nerve, if the surgeon should
meet with any difficulty in distinguishing the  former.   Only it would
be necessary in that case to apply a ligature  upon the lower  end of the
vein, if the  wound was to be closed  by first intention.   It is unneces- 
52
NEW ELEMENTS OF  OPERATIVE SURGERY.
sary to add that this  nerve, both on the  foot and as high as above the
knee, follows, as in the leg, the course of the vein.
  B.  The  External Saphena.—In  supposing that the suffering should
be confined to the outer part of the foot, or the lower third of the leg,
it  would be  practicable to excise the external saphena after the same
rules  which I have laid down for the internal saphena, that is, it would
suffice to  incise the integuments on the track of the vein bearing the
same  name, towards the fibular  border  of the  foot behind the corres-
ponding malleolus or outside of the tendo Achillis.  Higher up we would
not arrive  at it  with any certainty, except  by  making an oblique^ or
transverse  incision about two inches long on the outer and lower side
of the calf.  Cutting  down to the aponeurosis, we should be enabled to
recognize  its trunk, the two roots of which  unite a little higher up.
  C. Anterior Tibial Nerve.—This nerve, supplying all the dorsal region
of the foot, and traversing the whole anterior portion of the leg, may be
attacked with neuralgia, or  pains sufficiently acute to suggest the idea of
dividing it or  excising a portion of it.  Nicod (Journ. de Med., Nov.
1818) says that  the  nervous accidents caused by this nerve becoming
compressed between the fragments  of bone  in  a fracture  of the leg,
caused the death  of the patient.   The operation, besides, being attend-
ed with  a  good deal of difficulty upon the instep and the whole anterior
part of the leg, would not be entirely free from danger.
  I would, therefore, recommend it to be  performed  below and behind
the head  of the fibula, where the nerve  loses the name of the external
popliteal.   The limb, slightly flexed, should  be  turned  upon its inner
side.  An  incision, carried from the termination of the popliteal space
to the beginning of the anterior inter-osseous fossa of the leg, so  as to
follow the groove which separates the  tendon  of the biceps muscle
from  the root of the gastrocnemius exturnus, then to cross the external
and  anterior surface  of the  fibula immediately below the head of this
bone, would  perfectly fulfil our intention.   To arrive at the nerve, the
surgeon would thus  have to divide successively the skin, sub-cutaneous
fascia and aponeurosis ; separating the tissues  apart  by means  of a
sound, he would then discover the nervous cord between the gastrocne-
mius  externus, which lies  within and below, the tendon of the biceps,
which is  found above and outside with  the head of the fibula, and the
posterior  border of this bone, or of the peroneus longus muscle which
is seen  in front.  In case of difficulty, we  might without danger cut
down to the bone through the whole thickness of the peroneus itself,
so that in searching from the head of the bone to eight or ten lines be-
low, it would be  impossible not to find the nerve.  After raising it up
on a grooved sound or an erigne, it should be excised in the same man-
ner  as  we have  said of others.  Its excision at this point would have
probably saved the patient of Nicod.  Certain it is, that the patient ope-
rated upon in this manner by M. Yvan,  (Descot, These No. 233, p. 43,
Paris, 1822,) was promptly and radically cured of an ancient neuralgia
of the leg.
   D. Posterior Tibial Nerve.—The excision of this nerve could not be
performed without real danger, except between the termination of the
calf  and the beginning of the plantar surface of the foot; and it is be-
hind the  internal malleolus that  the operation would be most practica- 
NERVES  OF THE LIMBS.
53
ble, or the  least dangerous.  The leg is to be placed in demi-flexion on
its outer side.  The surgeon divides through the integuments, sub-cuta-
neous  fascia, and aponeurosis, at about  six  lines behind the posterior
border of the  internal malleolus, and to  the extent of two inches and
parallel to the  axis of the limb, in the same manner as for cuttino- down
upon  the posterior tibial artery.  Situated behind and outside°of this
artery, and in the midst of a loose cellulo-adipose tissue, this nerve is re-
cognized by its yellow color and its size and cord like appearance.  The
absence  of  pulsation, and the difficulty of compressing it, enables us,
moreover, to distinguish  it from the vessel.   Having  raised it upon a
sound, or secured  it  with  an erigne, we  should excise a portion of it
with strong scissors,  in the manner already described.
   [In the Association Medical Journal, January 6, 1854, p. 22, a case
is referred to in which Mr. Patterson  divided the posterior tibial nerve
in tetanus after amputation and other  means had been resorted to with-
out avail.  The original injury was inflicted on the toes.  After the di-
vision of the posterior tibial nerve, it  is stated,  that the symptoms were
immediately relieved, and the  patient recovered.   Mr. Murray has re-
ported a case of  tetanus in the  Transactions of the  Med.  and Phys.
Soc. of Calcutta, Vol. VI., p. 410,  which  he cured  by  dividing  the
posterior  tibial nerve.  The  disease  followed  a punctured wound  in
the foot.  Opposed to this case,  is that which occurred in the practice
of Professor Parker of this city.  He  exsected a portion of the poste-
rior tibial nerve  for  the  purpose of relieving  the  excessive pain and
tetanic symptoms arising  from a  punctured wound in  the sole of  the
foot.   The relief afforded was but  temporary, and was  rendered com-
plete  only by an  amputation of the leg.   G. C.  B.]
  In  performing this operation, Delpech  (Lancetta Francaise, t.  V.,
p. 457—458;  Rev.   Mid., 1832, t. I., p.  72)  made his incision  too
near  the  edge of the  bone; but the  skill  of  the operator easily tri-
umphed over this difficulty.  It appears that the patient recovered per-
fectly.  A fact to be  noticed here is, that the foot, at first benumbed and
almost insensible, finally regained to a great degree its faculty of motion
and feeling.   It  results, therefore, from this, that  the  excision of  the
anterior tibial nerve would not probably cause a permanent paralysis of
the extensor muscles  of the toes, the loss of the movements of extension,
and the establishment of a pes equinus, as was at first imagined.
  As  to the section  of the saphena nerves, it could only interfere with
the sensibility  of the integuments, and this, it might be hoped, would
not be of long  duration.

                     § II.—Nerves of the TJiigh.             *

  Among the nerves of the thigh, there are scarcely any other than the
great  sciatic whose excision could be attempted.
  A.  I have however read, in a volume recently published,  that a sur-
geon,  not content with having divided the sciatic nerve for a neuralgia
of the leg, tried also  to make  the section  of  the femoral nerve ; but it
was found, after death, that he had missed  it.   To say that the division
of the femoral  nerve  in the thigh ought not to  be attempted, would be 
54             NEW ELEMENTS  OF OPERATIVE SURGERY.
 entirely unnecessary, since, as  all anatomists know, it  divides itself
 into an infinity of branches, immediately upon its arrival at the groin.
   B.  As to the sciatic nerve, it is of so large a size, and it  nourishes
 of itself so great an  extent of parts, that the very idea of its excision,
 or even  of its simple  division, has in it something frightful.  The suf-
 ferings from the sciatic have, on the  other hand, a character  so violent
 and of such obstinacy in certain patients, that one  would be  almost
 tempted to make trial of anything to put an end to them. ^  We must,
 therefore, not be too much  astonished to learn that the excision of this
 nerve  has  actually been  performed,  and  that a surgeon of  Italy has
 had the courage to recommend it.
   It was in 1828, that M. Malagodi  (Arch.  Gin. de Mid., 2e serie, t.
 VI., p. 114) had recourse  to this operation  for the cure of a  neuralgia
 which  nothing had been able to relieve.   The limb was placed as in the
 operation for a  ligature  upon the popliteal  artery ;  the surgeon  then
 made a long incision,  from the middle third of the  thigh to the holloV
 of the ham.  Dividing through  the integuments, sub-cutaneous fascia,
 and aponeurosis, he soon came between the biceps muscle, which is found
 upon the outside, and the semi-membranosus, which  is  situated upon
 the inner side.   Continuing to divide the tissues layer by layer, and then
 substituting the  end of the sound for the bistoury, he soon reached the
 nerve,  in the form of  a large cord of a slightly yellowish color.
   The uppermost part of  the region of the ham should be preferred in
 such cases  : 1st. Because in this place the two branches of  the sciatic,
 if it be that they have already  separated, are still in close  approxi-
 mation to each other ; 2d. Because the popliteal vein and artery, besides
 being always deeper and  situated more within, are here much farther
 distant from the nerve than  in the hollow of the ham itself.
   After having properly isolated the sciatic nerve and passed  his finger
 underneath, M. Malagodi  performed the section of it in the upper angle
 of the  wound.    Numerous accidents ensued.  The wound  was five
 months cicatrizing ; the limb, at first  completely paralyzed, was a long
 time in recovering its  sensibility ; but it finally regained its functions,
 and the patient was, as we are told, perfectly  cured at the expiration of
 a year.
   I should not wish that this account  would induce others to undertake
 such an operation, unless in a case of necessity; nor would I even assert
 that it  could ever be indispensable ; I  would remark, only, that the case
 related by  M. Malagodi ought  to be  registered and that the question
 merits  the investigation of surgeons.
   [According to  Mr.  Erichsen (Science and Art of Surgery, p, 565)
 our author  has removed one of these  tumors  connected with the sciatic
 nerve,  without dividing the latter itself.
   Dr.  Bayard, of St John's, N. B. removed the sciatic nerve involved in
 a tumor  situated about three  inches below  the tuber ischii. It was
of about the size of a goose's egg, producing great pain in the lumbar
and saqral  regions and the whole course of the leg.  The emaciation
was  great, there  were loss of appetite, colliquative perspirations, and
restlessness.  "After the bulk of the tumor was laid bare, and the nerve
was exposed as it apparently entered into, and issued out of the  swelling,
the nerve itself was found to be  very much  thickened and enlarged; 
NERVES OF THE LIMBS.
55
it was, therefore, traced upwards as high as the tuber ischii and divided,
and downward an inch below its  popliteal ramification, and these re-
moved.  Syncope  supervened, and the state of collapse continued for
an hour, after which she gradually revived and complained of less pain
than she  had suffered  for months past.  The vital energies gradually
sunk, and the woman expired on  the sixth  day, after  the  operation,
apparently from extreme exhaustion.  The fatal termination was sup-
posed  to  arise  from a continuation of the  disease  along the nerves
within the pelvis, aggravated by the operation.  (New-York Med. &•
Phys. Journal, Oct. 1829. p. 37, Communicated by Thomas Cock, M. D )
                                                       G. C. B.]

Article III.—Excision of the Extremity of the Nervous Trunks at
           the Bottom of Ancient Wounds or Cicatrices.

  We find, among those who have been amputated or wounded, patients
who complain of excruciating pains when  any one touches their scars,
or the  end of the  stump.  The  observations of M. Larrey have shown
that the nerves, after  amputations, in becoming agglutinated together
or adherent to the cicatrix itself, are liable to tumefaction and a peculiar
change  at their extremities.   In these cases, the constancy of the pains
and their circumscribed extent, and the manner in which they are pro-
pagated, induce us to  suppose that the excision of the parts might be
calculated, in some cases, to afford relief.  It is an operation, however,
which  has hitherto never yet  been  attempted, and which it would be
difficult, moreover, to arrange under any  established  rule of operative
surgery.  M. Champion, who was tempted  to undertake it  upon the
sciatic nerve, for an obstinate neuralgia in the stump of a thigh which
he had amputated, finally gave it up.   M. Palmer (Encyclograph. Mid.,
1836, p. 41)  had a case of convulsions and agonizing pains in the stump
after amputation, but the excision  of an inch of the fibular nei^e, which
protruded from  the  cicatrix  in  a  state  of hypertrophy,  afforded but
partial relief.  I have  no other instance  at present to cite in favor of
this operation.
  Electro-Puncture  in  Neuralgia.—M. E. Hermel, (Annates  Medico-
Psychologiques, Paris, Janv., Mars & Mai, 1844.—Journ. des Connaiss.,
Paris, Juillet, 1844, p. 27—8,) as an  evidence of the successes which
electro-puncture has had in his hands, in the treatment of some of the
severest forms of neuralgia, almost all of them lumbo-sacral and sciatic,
accompanied  in some instances with partial paralysis, gives eight cases
in which perfect cures were speedily effected by electro-puncture, when
all the usual  modes of depletion, purgation, &c, were of no  avail.
  He says nothing, however, of the still more formidable and  distress-
ing forms of neuralgia, known as  tic-douleureux.   Nevertheless, he is
inspired with full confidence in the value  of this remedy, and while he
promises  to  supply  fresh evidence  thereof, meanwhile comes to these
conclusions:—1, That electro-puncture is applicable to  diopathic or
essential neuralgias ; 2, The  violence of  the  pains is not a  counter-
indication to  the employ of this therapeutic agent;  they have never in
any case been aggravated by its use; 3, The paralysis which supervenes 
56
NEW ELEMENTS OF  OPERATIVE SURGERY.
in the progress of idiopathic (essentielles)  neuralgias, yields to  the
same treatment.
   Inutility of Exsection for Neuralgia.—M. Berard, has  seen (Mal-
gaigne's Manuel de Mid. Opirat., 4th edit., Paris, 1843, p. 150,) an
infra-orbitar neuralgia, return  after having  exsected three inches of
the  nerve, and Swan has seen the  two ends of a nerve in a horse re-
unite, (lb.,) after having exsected a  segment near nine inches long!
   M. Malgaigne suggests, (lb.,)  whether it might not be  advisable
after dividing the nerve to detach both  ends by dissection, and  fold
them back on the trunk so as to form a noose, or to interpose  between
the ends a small fleshy flap from the immediate neighborhood, the bet-
ter to interrupt, when the  cicatrization  is completed over this, the con-
tinuity of nervous influence.
   M. Bonnet of Lyon, proposes in the  frontal nerve to divide it freely
down to the bone by a sub-cutaneous  incision, (lb., 151—152.)
   M. Malgaigne, for the infra-orbitar nerve, prefers also the sub-cuta-
neous section on the groove of the nerve in the floor of the orbit, after
which he tears out the divided fragment from its groove by means of a
forceps, applied to the portion  of the  nerve laid  bare, and divided a
little below the orbit,  (lb., p. 153.)   M. Bonnet makes only a sub-cuta-
neous division of the nerve, (lb.)
   Amputation of the  Fingers and Arm, for  Concussion of the Nerves
of Sense.—Amputation has been had recourse to, but without any bene-
fit whatever, in cases  for  example, where the little finger  from a mere
blow, has without any external lesion been followed by severe neuralgic
pain, and finally wasted  away.   Dr. Wigan, in a  case of this kind
in a  lady  who struck her little finger  against a garden roller, ampu-
tated it, but  finding  the  distress  continue  in  two  others, amputated
them also, with  a like unsuccessful  result.   Neuralgic pain in every
part  of the body came on, and the patient died a martyr. (Proceedings
of the Meiical Society of London,  March,  1845.—London Lancet, May
3,1845, p. 505.)  Mr. Crisp proposes in such cases, (lb., loc. cit.,)
the possible advantage of removing a certain portion of the nerve, from
the remarkable  effect known  from this kind of operation on the lame
foot  of horses.
   According  to Mr. Pilcfyer, (lb., loc. cit.)  the nerves of the organs
of sense, as of the eye, may become paralytic by pure concussion, i. e.,
by a blow without any ecchymosis or change of structure.  M. Dendy,
however, (lb., loc. cit.,)  has known a family, the  members  of which
were so delicate, that  slight pressure  on the surface produced a  kind of
thrombus.  It is difficult to determine, however, how far neuralgic  and
paralytic  diseases of  the  nerves are dependent on the influence of the
nervous centres, or on local causes.  Surgery in most such cases seems
to have less resources than internal constitutional treatment, and exter-
nal applications.
   Remarkable Ganglionic Transformation of the Nerves.—M. Serres
of Montpellier, communicated to  the Academy of Sciences of Paris,
April 3,1843, (See Journ. des  Connaiss., &c, de  Paris, Mai, 1843, p.
216,) the results  of observations  made by him upon a remarkable gan-
glionic  transformation of  the nerves  of organic and  animal life in  two
young men examined after death, one  shown to him by M. Manec, at 
NERVES  OF THE LIMBS.
57
Salpetriere, in 1829,  the  other  recently by Drs. Petit.and Sappey.
Both  had  died  of typhoid (entero-mesenterique, improperly so called
by French writers) fever.   All the  nerves of the limbs, and face, and
the intercostals and lumbar nerves, were occupied in their course by
numerous ganglionic enlargements (renflemens ganglionnaires)  of the
form and external physical characters of the superior cervical ganglion.
The  posterior  branches of the spinal nerves were  affected with this
transformation to the same degree as the anterior branches ; while the
nervous  branches of communication between these abnormal enlarge-
ments appeared to the  naked eye to be unaffected.  The number of these
ganglions was less on the  nervous  filaments of the great sympathetic,
than  on those of the  nerves  of relation  of life; but  nevertheless,  so
considerable as to entirely  change its aspect.   The nerves  that  form
the lumbar and sacral plexuses, the great  sciatic nerves, and the two
pneumo-gastric, were  those upon which  this transformation was the
most extensively  developed.   For example, the great sciatic nerves, in
their course through the upper part of the thighs, (le long de la partie
superieure des cuisses,) had acquired the  size of the  humerus, (le vol-
ume de l'humerus,) and their external surface was completely embossed
by the inequality in the size of the abnormal enlargements.
  In neither case did the  structure of the cerebro-spinal axis, present
any trace  of  alteration ; which, says M. Serres, is  another argument
against  the opinion of Gall that the spinal  marrow of man and vete-
brated  animals is of a ganglionic structure.   Dr. Petit adds that the
groove on the inner border of the ribs, for the passage of the intercostal
vessels and nerves, was increased in width and depth;  produced doubt-
less by the ganglionic  enlargement of the intercostal nerves, and which,
as well  as the inequality of development  of  these abnormal ganglions
generally, seemed to show that the  degeneration had  been a long  time
in progression.
   Nervous  Substitutions.—At the sitting of the Academy of Sciences,
of Paris, Jan. 6, 1845, (Gaz. Mid. de Paris, Janv. 11, 1845, p. 28,)
Dr.  Tavignot, in a communication on  the subject of " substitutions
veineuses," remarks that considering it now to be established  by a
great number of experiments, that when a nerve is divided, and its two
cut extremities are placed  in juxtaposition, it recovers  its  continuity,
and re-acquires its functions,  he asked himself the question, if what
took place  between the two  extremities  of the same  nerve, would
not equally happen between the extremities of different nerves when
placed in juxtaposition; to solve which problem, he undertook a series
of experiments, by which he established the following facts:— ^
  1.  If two  neighboring  nerves are included in the same  ligature,
with the view of dividing them both at the same time, there is devel-
oped between their four cut extremities a sort of nerve-like ganglion,
(ganglion nerviforme,) which is common to them, and  in which the
fibres of the two nerves and their functions  appear to be blended;
  2.  If the section of  two  nerves that  are separated but a short dis-
tance apart, is made in such a manner, that the upper extremity  of one
is placed in contact with the lower  extremity of the other, the result
is the formation of a nerve which preserves its functions entire.
  The practicability of thus engrafting one nerve upon another being
   Vol. II.                    8 
58
NEW ELEMENTS OF OPERATIVE SURGERY.
established, a route is opened for new experiments calculated to give
greater elucidation to the physiology of the nervous system.
   The fact had already been established in respect to the practicability
of uniting, or engrafting by  suture, the cut extremities of an extensor
tendon  of the middle  finger to those  of  the  adjoining  fingers, which
last thus served to execute  the movements required  of the  wounded
finger, (See Vol. I.j p. 409, 410, &c.;) but we are  not aware to what
object of practical  utility, so far as a new direction to, or channel for,
the distribution of the nervous fluid, either in neuralgia or any other dis-
oasc, this' engrafting of nerves could be  applied.  It seems to  be evi-
dent that in  neuralgic affections, as of the face, at least, which often
involve so great an extent of nervous distribution, the grafting of two
adjoining nerves in the manner described, could not afford any relief
to the disease.
  It appears that at the  same meeting of the Academy of  Sciences,
( Gaz. Mid.  de Paris,  Jan. 18, 1845, p. 46,) that M. Flourens claimed
priority  of Dr.  Tavignot, on the subject  of engrafting nerves,  having
made and published many years since a series of experiments  similar
in every respect, as to their  character and results, to those of M. Tav-
ignot.  He has thus seen effected the union of many nerves crosswise,
(reunion, croisee,) for  example, that of the superior with  the inferior
nerves,  of the brachial plexus, and even  that of the cervical  nerves
with those of the pneumo-gastric.  In  every  case  the union was com-
plete, and in  some of them there was a  perfect restoration of  the func-
tions, (Vid.  Mimoires  de V Acadimie des Sciences, Paris, Tome XIII.,
p. 14, et suiv., and the work of M. Flourens, entitled, Recherches Ex-
perimentales  sur les Fonctions du Systeme Nerveux, &c, p. 272, et
suiv.)   T.]
                     SECTION NINTH.

                     amputation of the limbs.

              Part First.—Amputation in general.

  Amputations being  the last resource of surgery, should not be per-
formed but as a desperate remedy.  Always in itself a serious operation,
it necessarily involves  the mutilation of the patient.   Nevertheless, in
cases which seem to require it, the practitioner, without forgetting that
the aim of surgery is to preserve, not to destroy, and  that we acquire
more honor in saving a limb than in skilfully performing a great num-
ber of amputations, ought  not to keep  out  of view  that it is better to
sacrifice a part than to let the whole perish, and that patients prefer life
vjWi three limbs than death with four.
  The  necessity of sacrificing a portion or the  totality of a limb  must
have been experienced at every epoch.   It would seem, however, that
in former  times this operation  was rarely undertaken.  The Hippocrat-
ists give but few details on this subject, and Celsus is the first who has
furnished  us with a tolerably accurate description  of this operation.
The ancients, being but imperfectly  acquainted with the circulation of 
amputation of the  limbs.
59
 the blood, and ignorant of the means of guarding against hemorrhage,
 must have had constantly before them the apprehension of a fatal ter-
 mination as often as the question came up of taking off a limb of any
 considerable magnitude.   On the other  hand, before the discovery  of
 gun-powder, national wars being less destructive in their tendency, nat-
 urally rendered amputation less frequently necessary than it has become
 since.  At this early period they confined themselves to the separation
 of the dead parts, without touching the living tissues, and this practice,
 which was continued among  the  surgeons of the middle  ages-, is also
 recommended by Fabricus ab Aquapendente.
   Though the ancients rarely speak of amputation except in cases  of
 gangrene or corroding ulcers, we  find, however, that they  had at  an
 early period become  aware of  the  necessity of dividing  the tissues
 above the mortified parts.   Celsus (De Re Med., lib. VII., cap. 33,)
 formerly  recommended it, and Archigenes of Apamea appears to have
 performed it frequently.  Always  alarmed at the idea of hemorrhage,
 they  invented  a thousand contrivances (at the present day  forgotten,)
 by which they  could prevent it, and thus made amputation an operation
 so terrible that many among them preferred abandoning their patient to
 certain death.   Some commenced with securing the vessels by inserting
 a ligature through the whole thickness of  the limb ; others  by strangu-
 lating the entire contour of the limb itself and sprinkling  cold  water
 upon it.   The  operation  being finished they burnt the  surface of the
 stump with a red hot iron or with boiling oil.
   Albucasis, less timid than  the others, says :—" When we  cannot pre-
 serve a limb we must cut it off as high up as the sound part since the
 death of the whole body is a greater evil than the abstraction of a limb."
 Guy ( Traict. 6, Doctr. I., chap. 8,  p. 469)  advises that we should cut a
 little above the diseased tissues, " at the place where upon introducing
 the tent  there  shall be found a resisting texture and pain.   For  that
 purpose the limb was first held  firm by the assistants ; the  soft parts
 were then  divided with a razor down to the bone; after which the lips
 of the wound  were protected by a compress  that they  might not  be
 injured by the saw; finally the surface of the  stump was  cauterized
 with red hot iron or boiling oil.
  It is not certain, however, that this  method was adopted by Guy  de
 Chauliac, for he soon after adds :—" As for myself I envelop the whole
 mortified  limb  with  a plaster, and I keep this on until the separation is
 complete, and  that it falls off of itself; which is more humane in the
 physician than  if he cut it off, for when it is cut off there always remains
 behind a grudge in the  mind of the  patient who thinks  that it might
 have been preserved to him."  (Operat. cit., p. 466.)  It is  doubtless
 this passage which has given rise to the idea that Guy strangulated the
limb or a bone  on a  line with the articulation  by means of a ligature,
in order to bring  about  its  separation, an error  which M.  Dezeimeris
 (Diet, de Mid., 2d ed., t. II.,  p. 479) has  established in the most con-
 clusive manner.
  Notwithstanding the efforts of Pare to  induce the adoption of the
ligature upon the vessels  after amputations, Pigray, Dionis and Rossi,
 still prefer the  actual cautery in certain cases ; but this barbarous prac-
tice has long since been proscribed  from surgery. 
60
NEW ELEMENTS OF OPERATIVE SURGERY.
 _  At the time of Hippocrates (Op. cit.,-p. 466)  amputation of tho
limbs was most usually performed at the joints.  This  practice pre-
vailed also among the Arabs, for we are told in their works that if the
disease  extends to the neighborhood of  the joint, amputation must  be
performed at the joint itself by means of a razor or other  instrument in
place of the saw, (Diet, de Mid., 2d ed., t. II., p. 479.)  The method of
Celsus,  though  advocated by Gersdorf of Strasburg, and  by De Cervia
a long time before, and by Maggi and some others afterwards, was how-
ever abandoned by most practitioners; insomuch so that in the seven-
teenth century Botal had the courage to  eulogise a surgeon who was in
the practice of placing the limb upon the cutting  edge of a hatchet,
fixed in a solid  position, and then letting  fall upon it from an elevated
point  another hatchet to which an  additional weight was given by at-
taching  to it pieces  of lead.  Finally, to set out from  Ambrose Pare
and Wiseman, the practice in this respect has entirely changed ; since
which time amputation of the limbs has become much less dangerous.
                           CHAPTER I.

                            INDICATIONS.

   The cases that require amputation demand the most careful consider-
ation, and  will become, it is hoped, less and less numerous in propor-
tion as the healing art advances, and the correct mode of treating dis-
eases shall be more and more diffused.

            Article I.—Limbs almost entirely divided.

   If the limb is in great part separated from the body in consequence
of the wound itself, the  idea naturally suggests itself immediately  of
completing  the  amputation.  It is  important, however, not to  decide
upon  it too precipitately; I have  shown in the  chapter on anaplasty,
how many organs we have it in our power to restore, when there had
been reason to suppose that their removal was indispensable.
   In  the  case of the  fingers when  held only by a small strip of skin,
and which reunite perfectly well, the question, as M. Champion says, has
long since been put  at  rest by all  practitioners.  I have before' me as
many as thirty  examples of this kind  gathered from the practice of
others, and  I  could^ augment the number by a dozen cases taken from
my own, among which there was one in which from the contusion with
which the  wound was complicated, it was apprehended that the attempt
at reunion would prove abortive.
  Of all these  facts the most curious is that related by Bagieu, (Exam.
de plus. Parties  de la  Chirurg., 1757, 2 vol.,  12mo,) where  a ring
finger reunited with the  nail turned round in front.   The patient men-
tioned by Forestus, (Bond, t.  III., 140, liv. 2, obs.  51,) had had the
whole hand divided with the exception of the outer and posterior por- 
amputation of the limbs.
61
tion.   In that of Charriere, (Gaz. de Santi, 1780, No. 24, p. 95,) the
four last bones of the  metacarpus had been divided by the stroke of a
hatchet, and were retained only by a small strip of skin near the thumb.
In  one of  those  of Bagieu, (Op. Cit., t. II., p. 596,) the wound went
through the entire thickness of the two last metacarpal bones.   Salmon
(De  Artium  Amputat.  rar.  admittenda, § 19, sect. 2, 1777) relates
cases in which the  right fore-fingers had been bitten by an ass, and
were nevertheless restored.  Harbicht (Bibliot. Chir. du Nord, p. 188-
189)  relates two cases where the hanwwas almost entirely cut off, in
one  of them by  a  contusion, but which notwithstanding recovered.  I
have  elsewhere cited  the observations by Jung and Hoffman.   In an-
other  case, (Mecure  de  France, 1755, t.  I., p.  202 ; planque, t.
XXVII., p. 49,) it was the wrist which was restored, after having been
almost entirely separated.  In a patient of Talabere  (Ques. et  Obs.
Chir. Prac,  These  de 1804, p. 17, § 42, Strasb.,) all the muscles of the
middle  portion of right fore-arm, the radius, and the radial and inter-
osseous arteries had been divided by a sabre-cut, but were nevertheless
restored.   An  Arm, wounded in the same manner by a bullet, was, if
we may  believe  Forestus, restored  in the same way  by J.  Carpius,
(Bonet, t.  III., p.  126, liv.  de Forestus, obs.  24,)  and Demarque
(Traiti des  Bandages, 347)  was no less fortunate in a patient who
had had the arm divided by the  cut of a pruning knife.   The surgeon,
Desire, (Bonet, t. VII., p.  528,  obs.  81,) succeeded equally well in a
similar case.   The same occurred with a wounded patient, treated by
Seeliger, (Anc. Journ. Mid., t.  LXVL, p. 356; et Bibliot.  Chir du
Nord, 116,)  though there was a considerable  destruction of the soft
parts ; and Bordenave (suppl. d la Chirurg. d'Heister, p. 50, art. 8, in oc-
tavo)  has  collected a number of facts of the same kind.   The case of
afoot, the  greater portion of which was separated, and yet reunited, is
related by  Ledran, (Consultat.  Chir., p. 61, plaie derriere le gros or-
teil jusqu'au petit.)   Cartier, (Medical Facts and  Observations, t. II.,
London, 1792,) who relates a similar case, says the wound was compli-
cated with luxation of the foot inwards, and he mentions having seen a
man aged  60, with fracture and solution of continuity at the lower part
of the leg, and which left nothing remaining but a  small portion of the
gastrocnemii or of the soleus, recover in thirty-six days.
  To understand what reliance we ought to place upon these facts, and
what  is their  actual value, I refer to the examination I have made of
them under the article on organic restitutions.

                      Article II.—Gangrene.

  Though  sphacelus formerly was the only lesion for which amputation
was  deemed necessary, it is not in reality the one which most frequent-
ly requires it, though it still constitutes one of its most positive indica-
tions.  Before this can happen, it is necessary that the gangrene should
have attacked the entire thickness of the part, and that it should at least
be  so  deep-seated  as to leave   no hope of saving the principal tis-
sues.                                                      .      . ,
  In its connection with amputation, gangrene  involves a question which
some moderns have attempted to solve in a way quite different from that 
62
new elements of  operative surgery.
 of the  ancients.  Pott and  (before him) Snarp earnestly insisted that
 we  should  always wait until the organism had arrested the progress of
 the mortification, before we should think of amputating;  otherwise they
 contend that we run the risk of seeing the gangrene invade the stump,
 and may thus perform a painful operation  when there is no necessity for
 it.  This manner of viewing  the subject, based as it is upon an accurate
 observation of facts, should  be adopted as a general, but not as an ab-
 solute,  rule.  MM.  Larrey, ^Clin.-Chir., t. III., p.  520-550,) Yvan,
 (Dissertat.  No. 425, Paris, aWXIII.,) Lawrence, (Medico-Chir.  Tran-
 sactions, vol. VI., p. 184,) Dupuytren, (Legons Orales, etc., t. IV., p.
 262-265,)  Gouraud, (Princip.  Op.,  etc. 1815,) Guthrie, Chaussier,
 (Bullet, de  Firussac. t.  XIV., p. 362,)  Labesse de Nancy,  (Archiv.
 Gin. de  Mid., t.  XVII., p. 307,) Macdermott, (Journ. de Progris, t.
 X., 235,) and Busch, have clearly shown that it is  sometimes prudent
 to  adopt  an opposite  line of conduct, and to perform the amputation
 before the  gangrene is arrested.  That this subject  may  be  well un-
 derstood, it is proper to consider separately each kind of gangrene.

                        § I.—Inflammation.

   It rarely  happens, at  the  present time, that the  surgeon allows in-
 flammation to go on to the extent of producing gangrene in the body of
 the limbs.   Deep, free, and numerous  incisions, the  liberal application
 of leeches, and large temporary blisters, mercurial ointment, regulated
 compression, and extensive  dilatations, almost constantly arrest  the
 progress of  the evil, not only under the skin,  but  between the muscles
 and  in  the  tendinous and synovial  sheaths.  The great articulations
 only would constitute the exceptions, and to these I shall return farther
 on.  Nevertheless, if the gangrene shall not have ceased, and may have
 proceeded to the extent of involving the entire thickness of the part,
 the finger or foot for example, still, if it shall  not appear to  be com-
 plicated with inflammation of the large  vessels above, there is  good
 reason for amputating ;  otherwise we  must put it off.  A  young man,
 in the year  1824, was  received  at the hospital of the  Faculte for a
 wound under the ankle, Gangrene  commences ; the limb  is amputated ;
 gangrenous patches make  their appearance on the stump, and finally
 upon the thigh.  The patient dies, and it  is found that there has been
phlebitis, together with metastatic collections of pus in the interior.

                    § II.—Hospital Gangrene.

  The species  of gray gangrene,  known  under the  name of hospital
gangrene, does not by any means always require amputation.   Ulcers
around the nails are so frequently the seat of it, as to lead to the belief
that there is a necrosis of the phalanx and necessity  of amputating the
finger.  Free  cauterization, however, of all the bleeding or  mortified
 surface, by means of the nitric acid of  mercury, or even by the red-hot
iron, has always enabled me, in such  cases, to arrest the disease and
 preserve the finger  provided the bone  was not yet  necrosed.   I have
 ascertained that the same method applies equally well upon other parts
 of the members ; but if the surface which is to undergo the transmutation 
amputation of the limbs.
63
should be very extensive, the  red-hot  iron is to be preferred, since the
application of a large quantity of the acid upon the wound might not
be unattended with danger.  Supposing  that the diseased limb should
have to be amputated, previous  cauterization, nevertheless, should not
be omitted, since  this gangrene is of a character to attack  the wound
from  the  operation  as  well as the  primitive wound.  Though Paulet
(Pierron, Thise No. 112, Paris, 1814) and others  may have flattered
themselves that they saved their patients by amputating, I have to remark
that  many of those in  whom the dressing was confided to me, at the
hospital of Tours, in 1816 and 1817, were re-attacked with gangrene
after amputation.

                     §  III.—External Violence.

  If the violence which  has  caused the mortification is a simple con-
struction or strangulation of the limb,  it is perfectly useless to wait for
the limitation of  the gangrene.  A young man, aged 24,  who had been
bitten  by a viper, strangled his leg  with a cord.   The limb mortified
and separated, and the sphacelus proceeded no farther, (Delacroix, Arch.
Gen.  de Mid., 2e serie, t. II., p. 587.)  In a similar  case, M. Petitot
(Id.,  p. 592)  amputated  above the gangrene, and  succeeded.  The
patient upon  whom Park (Excisions of Various Joints, 1805, p. 64)
amputated, after  having tied the  artery  for popliteal aneurism, also
recovered.  A young man was  attacked with  gangrene in consequence
of a contusion of  the femoral artery ; he was amputated, and recovered,
(Milang. de  Chir.,  p. 212.)   Josse (Ibid.,  p. 243)  also  speaks  of
another case, in which the  femoral  artery, wounded  by the fragments
of a fracture, brought on gangrene, and in which amputation was attended
with the same advantage.  I have  performed amputation in six ca?es
where the mortification  caused  by wounds was  constantly extending:
twice in the arm, and four  times in the thigh.  M. Erard at Saint Mi-
hiel, and M. Thomas at Revigny, have both, as M. Champion writes me,
amputated the thigh under similar circumstances ; and all their patients
recovered.  Other practitioners, however, have been less successful.
  In a fracture near the knee, one of the fragments  compressing the
popliteal vessels caused sphacelus of the leg.  M. Smith, ( Gaz, Mid.,
1839, p. 43,)  who amputated the thigh before the arrest of the gangrene,
cured  his patient.  In the  case of M. P. Eve, (Lane. Franc., t. xii.,
p. 540,) the gangrene  had  reached the thigh,  and amputation was per-
formed in a line with the  trochanters.  The cure was effected in six
weeks.   M. Morisson, (Ibid. Mid. Chir. Rev., Oct., 1838,) in amputat-
ing the thigh to arrest a gangrene  of the leg, caused by  a wound from
fire-arms, was  not less  successful.   A traumatic lesion was succeeded
by gangrene ;  the leg, says M. Malle, (Thise de Concurs,  Strasb., 1836,
p. 26,) was amputated, and the patient died with an emphysema of the
stump.   I tied the femoral artery for a popliteal aneurism, and gangrene
of the  leg supervened ;  amputation was performed  at  the thigh: in
the evening the stump became emphysematous, and on the following day
the patient died.  A similar case has  just been published by M. Lau-
chlan, (Gaz.  Mid.  de  Paris,  1838,  p. 487.)  Unless,  therefore, we
should decide  upon it, as is recommendedtby Mehee, (Plaies d' Armes- 
64
NEW ELEMENTS OF  OPERATIVE SURGERY.
 a-Feu, p. 214,) on the very first appearances of mortification, I should
 advise, in  cases of ligature of arteries or  aneurisms, that we  should
 not proceed  to  amputation until after  the  limitation of the gangrene.
   If the process of obliteration of the vessel is already going on during
 the operation, the  amputation will not arrest it, and the gangrene will
 continue.  If the process is suspended, and we do  not amputate, the
 mortification will  be arrested of itself.  The  patient of  M. Thomas
 (Arch. Gen. de Mid., 2e  serie, t. XII., p. 490) was cured  in  conse-
 quence of this fortunate  coincidence.   The same may be said of that
 of M.  Campbell, (Gaz. Mid. de Paris,  1833, p. 151 ;)  also, doubtless,
 of those  of M. Delaunay,  (Bulletin de  la  Faculti, t.  VI., p. 197,)
 Delpech, (Perecis des  Mai ad. Reput. Chir., etc.) M. Se'dillot, (Malle,
 These  de Concours,  Strasbourg, 1836, p. 25,) and M. S. Cooper.
   [Mr. Fergusson thus  states  his experience in amputating during
 spreading gangrene:
   " I have in my recollection  six  cases in  which I amputated during
 spreading gangrene, four times in the thigh ; (one of them being for a
 simple fracture of the leg, another for compound ; both close upon the
 ankle ; the third following spontaneous obstruction of a popliteal aneu-
 rism, and the fourth after ligature of  the femoral artery for a similar
 disease ;) once (being the fifth) in the leg for severe lacerated wound
 of the  foot, and once (the  sixth) at the shoulder joint for extensive
 injury of the arm.  None of these succeeded.  I might possibly in future
 resort to a similar practice, but should feel greatly inclined to wait for
 a line of  demarcation, though even here, I should not be very sanguine
 as to the result  (" Pract. Surgery, 3d Lond. ed. p. 112.)
  Mr.  Guthrie  seems to have come to a  different conclusion, as may be
 seen from the following quotation:
  " The result of amputations, after a line of separation had been formed,
 during the Peninsular war, was not favourable; it was in fact so much
the reverse, when the constitution of the sufferer was impaired by dis-
ease or was otherwise  unsound, that I was led to abandon it in many
instances, and to adopt a different proceeding" (On  Wounds and Inju-
ries of Arteries, London, 1846. p. 23.)
  Mr.  Erichsen amputated at the shoulder-joint for spreading gangrene
of the  limb and although the  infiltration had  extended as high as the
 scapula, the patient rapidly recovered.)  Science and Art of Surgery.
Lond. 1853. p. 94.)
  Mr.  Jonathan Toogood in his " Reminiscences of a  Professional
 Life"  relates two cases of amputation  in spreading  gangrene, and  in
both instances  the patients recovered.   In  one it was performed  just
below the knee, in  the other close to the shoulder-joint.  The gangrene
 in these cases was  the result of injury.   G. C. B.]

                  §  IV.—Spontaneous  Gangrene.

  Were spontaneous  gangrene always  dependent upon a diseased con-
 dition  of the large arterial trunks, we ought by no means to amputate
 until its progress has been arrested.  If the cause remains, it is evident
 that the  removal of  the  dead portion  will not prevent the remainder
 from becoming gangrenous.  *I amputated in the body of the first bone 
AMPUTATION OF THE LIMBS.
65
of the metatarsus, in a case of gangrene from old age, [gangrena senilis,]
in the  great toe.   The foot was soon  attacked, and the patient  died.
Another case had been affected  with gangrena senilis for four months.
I amputated at the knee ;  the flaps of the wound mortified, the gangrene
extended to the thigh, and life terminated on the thirty-second day.   But
I am satisfied that the vessels are not always  obstructed in spontaneous
gangrene.   Among the numerous examples I have in my possession, I
select  the  two following:—A thin, small-sized woman, aged 54, died
at the  Hospital of La Pitie, in 1833, of a gangrena senilis which  occu-
pied the whole fore-arm.   The most minute  dissection in this case did
not enable  me to detect the least degree of lesion  either in the arteries
or veins.   When I  entered upon service at La Charite, in March,  1835,
I found a patient there in  whom spontaneous  gangrene had successively
invaded the legs, the thighs, one arm, and the nose.   All the vessels
that could be identified were, nevertheless, found permeable, nor did
the heart appear to be diseased.   It is manifest that the etiology of gan-
grene requires farther investigation.  If we can suppose that the large
arteries remained permeable in the limb in the cases operated upon by
Hennen and by McCready, (France  Mid.,  t.  I., p. 96,)  in one of those
of M.  Josse, (Mid. de  Chir., p. 20,) and in  many of those  that have
recovered,  though the gangrena senilis with which they were attacked
had not become limited when amputation was performed, this condition
of things did not  exist in a great  number  of other cases.  Moublet
(Bull, de la Fac.,7e annee,p. 227)-and M. Roux, (Voyage d Londres,
p. 53,) each cite a case where the arteries were so entirely  obliterated
that no ligature became necessary after the amputation.  A fact of the
same kind is related by Ansiaux, (Clin. Chir., 2e edit., p. 278,)  and I
have collected elsewhere (Journ. Hebd. Univ.,t. I. et II., 1830,1831,)
a number of others.  Here is one of the most singular and, at the same
time, one  of the most  curious.   M. Champion writes  me:—" I have
amputated  the leg  in a case of gangrene of the leg supervening from a
slight  kick from a  horse upon the middle and  outer part of the thigh.
The patient was about 60, thin, but strong  and robust.   The mortifica-
tion presented all  the  characters of dry  gangrene ; the femoral and
popliteal arteries  indicated  no pulsation,  and I deemed it  proper to
wait until  nature  should trace out  for me the demarcation of the dis-
ease before I proceeded  to amputate, although she clearly indicated that
the external violence was the  determining cause.  None of the three
arteries emitted  blood  during  nor  after  the  operation; I  found the
posterior tibial only, to which I applied a ligature around a small plug
of wood, which, as I had no wax, I introduced  into the extremely narrow
aperture of the ossified  vessel.   The superficial soft parts alone, on the
outer  side of  the  leg, presented two  small  arteries for the ligature.
Union was  effected by the second intention, and the patient at present
enjoys perfect health.  I do not know an analogous fact, and I consider
it one that  possesses some interest for medical jurisprudence."
  I will remark  here, that the three cases that died out of the seven in
which  M. Porter (Gaz. Med. de  Paris, 1833, p.  866)  states that he
amputated  the leg for gangrene which had  not become limited, did not
die from the  effects of the  extension of the mortification.  In all of
them the stump retained its vitality, and without any trace of gangrene
  Vol. II.                    9 
66             NEW ELEMENTS OF OPERATIVE SURGERY.
up to the termination  of life.  M. Segond (Gaz. Mid., 1837, p. 523)
having  thus amputated the arm, lost his patient on the  twenty-second
day, owing, says  the author, to his having abstained from taking any
sort of aliment after  the operation.  Three  patients, on the contrary,
in whom amputation  was performed on both legs at the same time by
M. Luke, (Ibid., 1839,  p. 104,) for gangrene of the feet, the consequence
of  typhus fever, recovered.
   Unless we adopt the precept of Wiseman, that we ought to amputate
before the  appearance of delirium, in order that the patient may have
sufficient strength to sustain the operation, it is exceedingly difficult on
this subject to lay down rules.  For my own part, I regulate myself by
these principles ; if the general health is good, and the digestive func-
tions  unimpaired, if the arteries  pulsate  as  usual, and  are free from
pain under pressure, and the disease  progresses slowly, do not wait for
the gangrene to become limited ; but whether the  pulsations are per-
ceptible or not, should  the  arteries  on the  large  veins seem to  be the
seat of an irritation, of a diffused inflammation, and violent  and  con-
tinued pains, and should the pulse be irregular, the tongue  slimy, and
the bowels constipated, be not  in a hurry, but allow the  disease to be-
come arrested.
  When amputation is once decided upon in case of non-limited gan-
grene, the surgeon should always operate at a sufficient  distance from
the disease.   Without  this precaution, he would inevitably leave germs
of sphacelus within  the stump, and I do not think that any one would
then attempt union by the first intention.
  [In two cases Dj. Mott has amputated the legs, and in one instance the
thigh, for gangrena senilis, without waiting for the disease to be arrested.
The amputation of the thigh, and of one of the legs were successful.
Prof. Parker  has operated in a case, under the same circumstances,
with success.   Mr. Langstaff removed the leg of a man  seventy  years
of  age, affected with  dry  gangrene, but although  the  stump healed
kindly, the patient died from  angina pectoris seven weeks  after the
operation.  Mr. Crisp  ( On the  Blood-vessels) has given the details of
four cases in which he  operated, with success, but in these the patients
were  comparatively  young, and the line of demarcation had formed.
Dr. Pitney of Auburn, N. Y. conforming to the rule laid down by our
author of operating  in non-limited  gangrene, at a  sufficient  distance
from the disease, was  accustomed to amputate  through  the thigh for
gangrene of the foot or leg.
  Mr. Fiddes  has  reported in  the  Ed.  Monthly  Journal, for March,
1848, an interesting  case of mortification of the lower extremity, from
spontaneous obliteration of its  arteries, in a patient 23  years of age.
There  was ossific transformation of the femoral artery. Amputation
was performed first below, and  afterwards  above the knee, and Mr. F.
declares his belief that theyoung man's life was saved by his departing
from the established principle  which forbids amputation in idiopathic
mortification, so long as there is no  line of demarcation between the
dead and living parts.  His error consisted in not performing the ope-
ration in the first place above the knee.
   A most extraordinary case is  reported  in  the  Charleston  Medical
Journal, Vol. IV. p. 301,1849, in which Dr. Jarrott successfully per- 
AMPUTATION OF THE LIMBS.
67
formed amputation of the leg for  gangrene of the foot, on a negro 102
years of age!  G. C. B.]                            '        5

                         §  V.— Congelation.

   In gangrene from congelation, [i. e., from  freezing or cold.   T.] we
should  always wait until it  becomes limited, before amputatino-.  In
these cases, the disease  is entirely external,  and the vital actionDhas a
constant tendency to restrict it to  narrow limits.   If the limb is not of
large size there is no serious  inconvenience, even in giving time to the
eschars to become slightly detached.  We may amputate as near the dis-
ease as the  flaps to be  formed will admit.   The  operation has then
every  chance of success.  In 1838,1 saw a case of a peasant in whom
all the  fingers came  away in this  manner.  The excision of the head
of the bones of the  metatarsus in this case was sufficient to allow the
soft parts to cover the bones perfectly.
   M. Hysern,  of Spain, in 1829,  amputated both feet  at  the  tarso-
metatarsal  articulations.  The patient was but ten years of age, and
the gangrne (from cold) was  already limited by a regular inflammation.
The case was completely successful.
   [In the opinion of Dr. Mott, there  is, perhaps, no  seaport or  other
city in the  world, where practitioners have  such ample and frequent
opportunities of studying this  disease, as at New  York.  The long-con-
tinued severity of our winters, and the extremely tempestuous and dan-
gerous character of our coast in that season,  and our  proximity, at the
same time,  to hot latitudes, and the immense extent of our commerce
with such  latitudes, whether with the West Indies, South America,
Africa, or the Asiatic tropics and China, render this affection one of
the commonest occurrence every winter among the crews of vessels ar-
riving from such  countries upon  our coast,  who being prevented, by
violent storms and contrary  winds, from entering  our ports, are thus
imminently exposed to every variety of frost-bitten limbs.  It is particu-
larly noted, that the crews of what are called  wet ships, or such as dur-
ing this perilous coast-navigation frequently ship  seas, generally escape,
as their  feet are almost constantly immersed in water  on deck, and
therefore in a temperature above the freezing point.  This casualty of
inflammation of the extremities ending in gangrene, and resulting from
exposure to cold, is, as we have said, of such frequent occurrence, that
its treatment is exceedingly well  understood in all our hospitals, those
being the places where  nearly all this class of  patients are received.
Dr.  Mott coincides  with the general observation  of practitioners in
saying, that not only the phalanges of the toes and fingers, but all the
metacarpal  and metatarsal  bones, and  the entire foot, and  frequently
both feet or both legs or arms, are, after the limitation of the gangrene
is well defined, amputated under such circumstances and almost inva-
riably  with  perfect success.  For it must be remembered, that  this
species  of gangrenous inflammation is of  the  mildest and least malig-
nant kind, generally occurring in young and healthy seafaring subjects ;
that it is disconnected, for the most part, with any constitutional taint;
and is purely a local affection.  In addition to the observations^ Dr.
Mott, I may  remark, that I noticed it frequently while I was Physician to 
68
NEW ELEMENTS OF OPERATIVE SURGERY.
 the  Seamen's Retreat, Staten  Island, (New York,) and that it occurs
 to me here, as not irrelevant, to refer specially to a case of a sailor in
 the  prime of life, in whom, by the malpractice of the official  person
 under whose care he had  previously fallen, there was established, by
 the  prolonged and unmedical  application of poultices, a permanent or
 chronic gangrene of some  months, in all  the  phalanges  of  the  toes.
 These bones successively  rotted out under  the  system of poulticing,
 and when he was brought to the Retreat, his feet presented  the case of
 two stumps with red  flabby granulations, and the anterior extremities of
 the  metatarsal  bones protruding out beyond the  flesh to  the distance
 of an inch or more, and having the appearance of black burnt brands,
 or ends of beams in the framework  of a  building half consumed  by
 fire.  These necrosed neglected projections were  clipped off  by a pair
 of common strong nippers, close to the sound flesh, and until  the fresh
 bleeding surface of the healthy portion of the bones was reached.  The
 effervescing cataplasm of bark, yeast, charcoal, and alcohol, was applied
 for a few days, followed by adhesive straps, bringing the flesh  well and
 firmly in  every  part over  the ends  of  the  bones, which,  with tonic
 treatment internally,  rapidly completed the  cure.  T.]

                              §  VI.

  Deep burns are in the same relation with congelation, and should be
 subjected  to  the same rules.   I have  amputated immediately above the
 elbow in  a woman whose fore-arm had been burned up to the humerus,
 and the operation succeeded very well.   In the case of a soldier, (Del-
 atouche, Oper. cit., p. 45,) amputation was performed above the carpus
 and tarsus in all the  four extremities for gangrene from cold.
  [Mr. Spence, of Edinburgh, has reported  in the Monthly Journal, for
February, 1848, an interesting  case of amputation of the arm for  the
 secondary effects of  a burn.   The arm presented an almost continuous
ulcerated  surface, which was  discharging  profusely,  and  had reduced
the patient, a girl eleven years of age, almost to a skeleton.   The ope-
 ration was the means of saving her life.   G. C.  B.]

                              §  VII.

  When  a traumatic lesion is  the cause of the accident, when it pro-
 ceeds from the rupture of an artery or the division of the vein and prin-
 cipal nerves of  the limb, or from mechanical strangulation of the part;
 when, in fine, mortification does not seem to be connected with any gen-
 eral  lesion or any internal or concealed cause, we cannot perceive what
 great advantages are to be obtained by procrastination.  In such cases
 the gangrene is  to be considered as a cause  of gangrene, and as soon as
 it is well established the patient cannot be otherwise than benefited by
 a speedy removal of  the mortified parts.
   If the gangrene on the  other hand arises from the spontaneous ob-
 literation of the artery or principal  vein  of the  limb, it  is  perfectly
 clear that the amputation will not prevent it from extending.  Success
 then depends upon chance ; and under such circumstances prudence re-
 quires that we  should wait.   Everything,  therefore, depends  upon our 
AMPUTATION OF THE LIMBS.                   69
accurately  distinguishing these two classes of circumstances from each
other.
                        § VIII.—Aneurisms.

  For  aneurisms and wounds of large  vessels we now have means of
success more  simple than amputation.  If Fenelon (Bagieu, Examen
de plus. Qu. de  Chir., t. I., p. 141) who died from the immediate effects
of a puncture  of the femoral artery, in the presence of the surgeons of
the court, had lived a century later, his wound would have inspired but
little disquietude ; and it is surprising that the preacher whom M. PL
Portal (Clinic.  Chir., t. I. p. 181) speaks of should have escaped from
becoming the victim  to a similar accident.  The ideas of Petit and Pott
on this subject are rarely applicable to the presenytimes, and cannot be
adopted except in cases where the gangrene is imminent or  already es-
tablished.   Aneurism of itself does not necessarily involve amputa-
tion of the limb unless the tumor be too voluminous and has caused de-
generation to  the surrounding parts to such depth that  the  ligature to
the artery which is  the seat of it presents not the slightest chance of
success.  When secondary  hemorrhages, after  applying the ligature,
have supervened from ossification of the arteries ; or when  the princi-
pal  nervous trunks  have been divided or the vein closed at the same
time with  the artery ; when the muscles shall have become  softened or
disorganized in any manner whatever, the articulations also  in  the
neighborhood involved, and the bones  friable and more or less complete-
ly  destroyed; aneurism and  arterial  diseases may then have no other
resource than amputation.   It  was for these reasons that it was found
advisable  to disarticulate the arm  in a case at the Val-de-Grace, in
1812, and  that  M. Auchingloss recently found himself obliged to recur
to the same operation for an arterial lesion in the hollow of the axilla.
I have stated above what we  have to expect from amputation when gan-
grene  has  attacked  the limb after the operation for aneurism.   If M.
S. Cooper has been successful, it is because the mortification of the limb
had less tendency in his case to extend itself upward, than in that  of
M.  Lauchlan and mine.
   [Mr. Syme has twice amputated  at  the shoulder joint in desperate
cases of axillary aneurism, and we have already alluded to the proposi-
tion of Mr. Fergusson to amputate at this joint for aneurisms seated  on
the  subclavian artery, instead of tying  the latter  on the tracheal side
of the scaleni muscles.   G.  C. B. J

              Article IV.—Fractures and Luxations.

                                §1.

   Compound  Fractures  are  among the accidents which most  frequent-
ly require  amputation of the limbs.   To justify this, however, it is ne-
cessary that the injury  should be accompanied with serious lesions of
the soft parts.
  A. When outside of the articulations, and so long as the artery, vein
and principal  nerves are not ruptured, and the muscles preserve a por-
tion of their continuity, it is advisable to delay.   If fragments or splin- 
70
NEW ELEMENTS OF OPERATIVE SURGERY.
ters of bone are detached and buried in the midst of the tissues, they
are to  be removed.  If either extremity of the  fractured bones pro-
trudes outside and we cannot reduce it in spite of  the dilatations which
sound  practice authorises, it is  proper  to remove it  by the saw, (see
Exseclions.)  Even  though the muscles be contused and reduced to a
pulp, it does not, therefore  follow, provided the  tendons of some  of
them  remain uninjured and the circulation of the fluids below the frac-
ture is  not interrupted, that the limb should necessarily be sacrificed,
especially if it is an upper extremity.
  Three adults having fractures of this description were cured without
amputation in 1829  and 1830, at the hospital of St. Antoine while I
was in service there, though two of them, suddenly seized with delirium,
tore off the dressings^ and marched into the hall, on the sixth or eighth
day from the accident.  I saw a young man at the hospital of Perfec-
tionnement who had  nearly all the muscles of the anterior and inner
side of the arm and the skin on this part also stripped off and lacerat-
ed,  by  an  injury from a spinning machine, and who, though he  had at
the  same  time  the  radius  and ulna fractured in two or three places,
finally got well and saved  his  limb.  In private practice we  should
never  lose sight of these facts ; that, with  care  and  proper  regimen
and all the resources of a judicious treatment, it is rare that compound
fractures immediately require amputation.
  A woman, thrown from a carriage, had the left leg crushed ; the bones
and centre of the limb were reduced to a pulp,  the livid color which  ex-
tended to the thigh, and the  swelling and tension, joined with the slight
degree of pain that the patient complained of, induced the assistants to
propose amputation.  Seeing no wound  of the skin, I applied a ban-
dage and resolvents.   No accident supervened, and the cure took place
as in a simple fracture.  Another woman came into La Charite, who had
been crushed in a diligence;  amputation seemed urgent, and I was sent
for.  The right thigh which was mashed, as well as the knee, was trans-
formed into a sort of bag of bones, and  as moveable  as the limbs of
Punchinella.  An enormous effusion of blood occupied its whole extent,
but the skin was only excoriated.   The compressing bandage, and after-
wards the starch dressings  were  applied, and everything went on as
well as in a simple fracture.
  B. I have seen  so many of these cases that they never now  give  me
any alarm, and I never amputate  under  such  circumstances, not even
though  the fracture  implicates the large articulation.   In  throwing
herself  from the fourth story, a young woman fell on  her feet  before
striking her forehead upon the pavement, and  crushed the tarsus  and
the inferior extremities of the bones of both legs.  I  found the tibio-
tarsal regions completely reduced  to a pulp, while the fracture  of  the
cranium precluded at first all idea of amputation.   This woman  was
submitted to the treatment with the starched bandage, and was perfectly
cured.
 .  But if the soft parts are extensively crushed and lacerated down to
the bones, the question assumes another  aspect.   Wherever the injury
involves an extensive articulation, the foot,  knee, hand and elbow  for
example, amputation  is then  to be preferred.   In  the lower limbs it
should be performed, even though the joints are not laid open.   In  the 
AMPUTATION OF THE LIMBS.
71
arm, on the contrary, it is rare that fractures complicated with wounds
and lacerations of the soft parts, do not admit of preserving the limb,
provided the articulations are uninjured.   A man was admitted into the
hospital with the humerus comminuted.   The  muscles  were ruptured.
The skin open in two places appeared filled with pulp.  The arm already
emphysematous, was tumefied as high up as the shoulder.  An abundant
hemorrhage took place, but still  the artery was felt at the wrist.   I
applied the immovable  dressing,  and the patient recovered without any
accident.   A  woman  similarly  situated, and  who  had  refused  to
undergo amputation, had recovered in  the  same way a few  months
before.
  C.  We  must  not, however,  in  these cases  go too  far.   In the
lower extremities especially these grave  injuries but too often  require
amputation.  Of three  patients in this state  received at the hospital of
St. Antoine, and in  whom I was  anxious to save the leg, two died in
the course of a few days, and the third owed his preservation to ampu-
tation  performed on the fourteenth day on account of gangrene.  It is
true that a fourth, though immediately  amputated, nevertheless died on
the seventh day ; but in him there was so little  vital  action after the
operation, that he was  scarcely conscious of what was done to him.
The  emphysema, which is sometimes added to the  other complications
of fracture, even from  the first day, and  before  the appearance of any
symptom of gangrene or inflammation, is  one of  those accidents which
under  such circumstances  most  emphatically  indicate  amputation.
Though no person  has hitherto pointed  it  out, I have  noticed  it in
six cases, and three out of the five in whom the leg was the  seat  of
the disease, died.  Against the numerous facts stated by Bardy (These
No.  176, Paris, 1803)  and De la  Touche,  (Sur VAmputation, 1814,
Strasbourg,) to show that in cases  of comminuted fractures with lacer-
ations of the soft parts, amputation is scarcely ever necessary, M. Bintot
(These No. 306, Paris, 1827) has adduced others not less conclusive,
going to prove directly  the reverse.

                        § II.—Dislocations.
       w
  Dislocations, complicated with laceration  of the soft parts, are some-
times followed by symptoms so formidable and appalling, that they were
at an early period placed amongst the cases that imperiously  require
amputation.  The remark of an  army  surgeon, which made so vivid
an impression  on the mind of J.  L. Petit, and which was to the effect,
that  every dislocation  of the  foot, with  laceration  of  the integuments
and protrusion of the bones externally, was fatal unless amputation was
performed immediately, has unfortunately since that time been but too
often confirmed.  The  agonising sufferings which come  on when the
inflammation sets in, the gangrene  which  is frequently the consequence
of it, and which nothing can check, and the most excruciating torments
terminating in death, which  last seems alone capable of arresting the
march of the disease, have been deemed to be reasons quite sufficient to
justify the surgical law upon this subject.
  Experience  has, nevertheless, demonstrated that this rule has nu-
merous exceptions ; which J. L. Petit himself has taken the  precaution 
#
72
NEW ELEMENTS OF OPERATIVE SURGERY.
to point out.  M.  Laugier, (Thise No. 51, Paris,  1828,)  M. Arnal,
(Journal Hebdomad. Univ.,t. I., II., III.,) &c, have also furnished addi-
tional evidence of this fact.  If the laceration is not  excessive; if the
bones are  merely luxated without being  broken; if the  nerves and
principal vessels are not ruptured; if, in fine, gangrene should not  ap-
pear inevitable, we should replace the parts, exsect  the bones, or have
recourse-to dilatations, and not at first proceed to amputation, except
under an  opposite condition  of things; that is, where the  teguments,
tendons, ligaments and capsules of the joints  are extensively lacerated,
the bones and soft parts at the same time both torn and crushed, or vio-
lently contused, and the articulation too much implicated or of  too little
importance to be saved without the risk of danger.
  A. As to the election which is to be made in these cases between exsec-
tion and simple reduction, this is  shown by the state  of the parts.   In
the upper  extremities, says M. Champion, I prefer simple reduction to
exsection, because  this latter is so frequently followed by  anchylosis.
Exsection, whatever may  be the  locality of the luxation, becomes ab-
solutely necessary wherever  the  extremities of the bones are denuded
of their periosteum, and dry  and shattered.   In  twenty-six  of these
cases collected by M. Patry, ( Thise No. 289, Paris, 1837, p. 26,) from
La  Motte,  Coligny, Dupuytren, A. Cooper,  and Thierry,  three  only
died.  In the foot, even reduction may be  preferable ; though the for-
midable accidents which follow wounds with luxation of the tibio-tarsal
articulation, would induce me to adopt, with M. Champion, exsection to
simple reduction, if the latter was attended with  the least difficulty,
seeing that  the  removal of the extremities of the bones is so  powerful
a means of preventing the accidents of inflammation.  Of seven cases
thus treated, and which are related by Deschamps, Hey, Moreau, Cooper,
de Bungay, MM. A. Cooper, Josse and Bintot, one only proved  fatal.
At the knee, however, amputation  should be preferred to all other means,
and exsection should not  be attempted except in persons who are not
obliged to get their living by some  severe and laborious occupation.
I will return  to this  subject  farther on, in treating of amputations in
particular, and of exsections.   Among these cases, [of reduction.   T.J
though  there may be some who will die that might have been  raved by
amputation, there will be a much  greater number who will survive and
preserve their limbs.
  B.  A remark  to be attended to here is this, that  whether we have to
treat a fracture or a compound dislocation, should amputation become
necessary, we must, as in cases  of non-limited gangrene, perform it
very high up.   I  cannot  understand how Lassus, (Pott,  Traiti  des
Fractures, 2e edit., p. 181) should have said that it is better to remove
the contused parts on a line with the fracture, than to go to the trouble
of sawing the bones above it.  It  is so seldom, under such circumstances,
that the fractured bone is free from all  cracks, and  that  the cellular
tissue, aponeurosis, and muscles  are not disorganized at  some inches
above the  apparent lesion, that there  would be real  danger if we did
not amputate higher up.  A slater had his foot crushed  by the wheel
of a carriage.  I amputated the leg after the expiration of a few hours,
and I performed the operation at  three inches above the malleoli, after
having asked myself the question, from  the contusion appearing so cir- 
AMPUTATION OF THE LIMBS.
73
cumscribed, if it would not have sufficed to have taken off the foot at
the tarsus.   The  mortification of a part of the tegumentary ruff, and
the livid color from extravasation, which soon attacked the sub-cutaneous
tissues of the stump, showed us that lower down, the operation would
have  failed from  the  effects of the gangrene.  In another patient the
leg was shattered at its lower  third.  I amputated below the knee at
six inches above the apparent lesion.   Death ensued, and enabled us to
ascertain  that  the contusion extended  under the skin up to the thio-h
especially on the outside.   A third patient was more fortunate ;  though
the leg only had been injured by the wheel of a diligence, I amputated
the thigh ; nevertheless, strips  and pieces of mortified collular tissue
ultimately  sloughed off from the  stump.  The same rule applies  to
those cases where the contusing body has separated the  limb from the
rest of the economy, or so to speak, has itself performed the amputation.
If,  under such  circumstances, we do not also remove with the wounded
parts themselves, all the neighboring tissues which have been injured by
the blow, we may be  prepared  for gangrene of the integuments, dif-
fused phlegmon, and mortification of the cellular tissue,  together with
denudation of th,e  bone.
   [Some five years since we treated a case of compound  dislocation of
the elbow, with rupture of  the brachial artery, and preserved the limb.
Though anchylosis exists  at  the elbow joint, still the boy has a use-
ful arm.  We are  at present treating a case, of the same kind, in which
we hope to save the arm.   We  have been  compelled to  exsect  the
cordyles and lower  end of the humerus, together with the lower end
of the radius, and the  prospect of saving the limb, now some six weeks
after the accident, is good.  G.  C.  B.]

                  § III.— Wounds from Fire-arms.

  No wounds more frequently require amputation than those from fire-
arms.   It is not that the  projectiles lanced  by powder   have in them-
selves anything of a poisonous nature, as some surgeons have supposed,
since  the  time of A.  Ferri, or  as the vulgar are  also  too  prone to
believe ; but because they lacerate, tear, contuse, or cut into the tissues
they traverse or strike.
  A.  A ball, or biscaien,  a grenade,  or the bursting of a  bomb  or
howitzer, carrying away a part of the thickness of the limb, including
the vessels with it, requires amputation; while a similar wound effected
by a cutting  instrument would not, perhaps, make it necessary to have
recourse to such mutilation.  If  the same missiles had struck the body
of the arm or thigh so as  to reduce  the muscles to a  pulp, without
breaking either the skin or bones, still amputation would  be necessary,
unless the attrition  should be exceedingly circumscribed, and the vas-
cular and nervous  trunks uninjured.
  B.  Wounds complicated with fractures in an especial manner, indicate
this extreme alternative.  In the joints, if the destruction is considerable,
there is no time for delay.   A difference of opinion among practitioners
exists only where the joint is not greatly exposed, and where the osseous
extremities have merely been  traversed or fractured  by a ball.   In
these cases we must be governed by  the  circumstances, thus :—where
  Vol. II.                      10 
74
NEW ELEMENTS OF  OPERATIVE SURGERY.
we have it in our power to pay every necessary attention to the patient,
and the ball has merely passed through the wrist, elbow, instep, shoulder,
etc., fracturing the articular extremities without lacerating the tendons
and other soft parts; ought  we  not then to endeavor to save the limb ?
On the contrary, on the field of battle, in hospitals crowded with  the
sick, and when some fatal epidemic is  prevailing, and we  can neither
obtain quiet nor  repose, nor those assiduous  cares  which are  so indis-
pensable, and  where the fracture, too,  is complicated with splinters of
bone, and the ligaments, synovial  tissues and  tendons are bruised and
torn, amputation is more advantageous to the patient than temporization.
   M. Labaslide,  ( These sur les  Blessures par Armes-d-Feu,) desirous
of sustaining the  principles of Bilguer, has, it is true, collected quite a
great number of  examples  to  prove  that such wounds at the wrist, el-
bow, foot and knee, have not always  rendered  amputation necessary
for the  recovery  of the  patient.   Similar cases  noticed at the Maison
de St.  Cloud,  among the wounded of  July, as treated by Dupuytren,
have been  published by M.  Arnal,  (Journ. Hebd., 1830—1831. t. I.,
p. 385; t. II., p.  497 ;  t. Ill, p.  5, 33.) Faure, Percy, Lombard, and
Leveille  (Soc. Med. d' Emulat, t. V., p. 192—234,) have also  reported
analogous cases ;  but how many reverses might we not oppose to these
unhoped-for successes!
   [It is stated in  Dorsey's Elements  of Surgery, Yol. II., p. 313, that
Gen. Scott of the United States army, recovered from a gunshot wound
of the  shoulder joint attended  with fracture and destruction  of the
head  and adjacent parts of the humerus, and a wound of the axillary
artery, and that he  preserved a useful  arm.   G. C. B.]
  C.  The  gardener of  the  director of one' of the theatres of the ca-
pital, had a part of the metacarpus and fingers  carried away  by a
musket which  burst in his right hand.   He was brought to the St. An-
toine, and  begged me to save the thumb and fore-finger, which were
left; I yielded to his solicitations.  Serious  symptoms supervened and
death was  not prevented by the amputation  of the arm  fifteen days
after.   One of the wounded of July  had his heel perforated by a ball,
and the tibio-tarsal articulation laid  open on its  posterior and outer
part.   As there was not much destruction of the parts, we were desirous
of preserving  the l,imb.  On the 18th  day the patient died.   Another
patient  also admitted into La Pitie, had a large wound with fracture
of the elbow, and an opening into the point.   Amputation  was not per-
formed, and the patient  perished like  others, from the effects  of puru-
lent infection.   A young man in my service* had the osseous extremities,
of the  articulation of the knee  obliquely traversed by a ball, at the
taking of the H6tel-de-Ville ; there  were no  splinters nor any lacera-
tion of the soft parts.   After a month's care we were compelled never-
theless, to  have recourse to amputation of the thigh, which did not
prevent death  from  taking  place  thirteen days after.  It is, to say the
least, probable, that had amputation in some of these cases been per-
formed at the very onset, life might have been saved.
   D.  It is not in the neighborhood of the complex  articulations only,
that wounds from fire-arms, accompanied with fracture and with lesion
of the synovial cavities are so dangerous; they are scarcely  less for-
midable in the middle portions of the long bones, especially in the low 
AMPUTATION OF THE LIMBS.
75
 er extremities.  Thus a simple ball, which breaks at the same  time the
 tibia and fibula, and detaches also a certain  number of splinters, is al-
 most always a case for amputation.  Where  there is one patient, under
 such  circumstances, who  refusing to  be operated upon, gets well with-
 out amputation, there are  ten that die if the soft parts are at all injur-
 ed or violently contused.
   E.   The  Thigh.—In  the thigh the  indication is much more  positive.
 Ravaton says, if  we do  not amputate,  this fracture almost always
 proves fatal.   Schmucker maintains, that in cases of this nature, only
 one  patient is saved out of seven.  Lombard holds the same language,
 M.  Ribes,  (Gaz. Med.  de Paris, 1831, p. 101,)  who  has seen none re-
 cover, gives the history of ten  cases, in whom  the utmost  care  could
 not prevent a fatal issue,  and mentions, also, that at the Hotel des  In-
 valides, in  an aggregate of 4,000 cases, there was not a single patient
 that had been cured of  this kind of wound.  M. Yvan pointed out two
 to him in 1815, in whom,  however, fistulous  openings formed, and who
 ultimately  succumbed from the  consequences of their fracture.  I no-
 tice that M.  Gaultier de  Claubry, (Journ.  Hebd.  Univ., t. V., p. 479 ;
 Journ.  Gin. de Mid., t. LVII.,) formerly a surgeon of  the  Imperial
 Guard, is on this point of the same opinion as M. Ribes, and that in the
 army of  Spain almost all  the soldiers  that  had fracture of the  thigh
 died unless amputation had been performed immediately.  Out of eight
 treated by M. S.  Cooper after the battle of  Oudenbosh, one only sur-
 vived, and he never was enabled to make much use  of his limb.   Percy,
 Thompson, MM. Larrey,  Guthrie, and J.  Hennen, express  themselves
 nearly in the same terms, and the events of July, 1830, enabled most
* of the surgeons attached to the hospitals of Paris to recognize the truth
 of this melancholy prognosis.
   Though  one of the cases of wounds of this  kind was saved by M.
 Lisfranc, at La Pitie, and another by  Dupuytren, I  had not the same
 good  fortune; there was  but one only received in my wards, and the
 fracture appeared to be  quite simple ;  nevertheless we could not prevent
 death, which put an end  to his sufferings  on the  38th day.   Somme,
 (Journal. Hebd. Univ.,  t.  I.,  p. 221,) during the events at Antwerp in
 Oct. 1830, cured 2 cases  out of 8, without  amputation.  Lassis,  (Gaz.
 Med. de Paris, 1830, p.  322,)  and other surgeons of Paris and Brus-
 sels, have  published other cases not less  fortunate;  but we  must not
 forget, that among us, in  Belgium, even where  we have had it in our
 power to bestow the same attention that we  habitually do to patients in
 private practice, the  instances  of success  have, nevertheless, been ex-
 ceedingly rare, and the limb saved has generally been so deformed, that
 its loss would scarcely have proved a greater source of affliction to the
 patient.  It is to be  remarked,  also,  that a  fracture of the thigh is so
 much the more dangerous in  proportion to its proximity to the middle
 portion of the bone, both because the splinters and  fragments  shivered
 off are more common in that part, and also on account of the number,
 arrangement, and force of the muscles.
   It  is painful, without doubt, to mutilate a  patient, in whom the limb
 might have been preserved;  but the argument drawn from  certain
 unlooked-for  cases of recovery, in patients who had refused the opera-
 tion, has it, in fact, all the  value usually  accorded to it ? Admitting that 
76             NEW ELEMENTS  OF OPERATIVE SURGERY.
in ten  persons  wounded in this manner, four are cured ; it is certainly
a good deal.   But in submitting all of them to amputation at the begin-
ning, is it not to be presumed that two-thirds of them at  least would
have been saved ?  I leave it to conscientious men to decide whether the
saving of the life of two or three  persons  in  the  vigor of age, is not
preferable to a deformed limb, which  can  only  be saved, perhaps, in
four cases [out of  ten,] and at the risk of a thousand dangers.
   [Among the most common causes, at the present  day, of  amputation,
is  the crushing produced by railway carriages  in passing  over limbs.
These injuries seem to  be of a peculiar nature, and it is only of late that
they have attracted that attention from  surgeons which they deserve.
Dr. John Watson, of  the New-York Hospital, has so happily describ-
ed this class of injuries, in a communication to the Editor of the New-
 York  Medical  Times, November, 1853, that we feel tempted to insert
his remarks in this place.   After detailing some cases, he proceeds:
"  It is apparent that  the crushing effect of railroad  injuries, among
the  deeper  tissues of a limb, is usually out  of all proportion to the
apparent  amount  of injury  on the integuments; and  that, from  these
deceptive circumstances, attempts are often made to save limbs, which,
from the first, are so far disorganized as to leave no chance  of their re-
covery.  And  again, even where the knife is employed early, and car-
ried through tissues   which,  to appearance, still retain their healthy
structure, inflammatory reaction which follows, is occasionally so severe
as to lead to gangrene ; which, if not arrested, may necessitate a second
operation at some point higher up; or  result in high  irritative fever,
and, finally, in the death of the patient.  The primary amount of injury #
is not in proportion to the later consequences that too frequently  result
from it.   The surgeon, looking at a foot with  one or two  of the  toes
crushed, may, perhaps, dismiss all solicitude ; and yet, before he is aware
of the true aspect of the injury, the whole is changed, and the case has
assumed  the gravest character;  inflammation  has crept  up deeply
beneath the fascias of the leg—the tension of the tissues interferes with
the circulation; the deeper  structures are deprived  of their vitality,
and the whole limb is  implicated in the diseased action.
   The part crushed, if of limited extent, may slough, and leave the sur-
rounding soft part with force sufficient to carry on the process of  repar-
ation.   But, too often, the gangrene is not thus circumscribed ; and the
disorganizing tendency, with or without reaction, takes a wider circuit.
But where inflammatory reaction is fairly  established, it may be with
force insufficient to lead to fibrinous effusions, or be otherwise perverted,
so as not to establish a wall of plastic lymph at the outposts of the dis-
eased tissues.  The morbid  effusions, and  the  fluid detritus of the de-
composing mass, are then allowed to work upwards by infiltration, or to
be carried upwards by absorption, so as to poison all the tissues in the
neighborhood, and vitiate the whole of the circulating blood.  The limb
now falls into putrilage, and the constitutional symptoms are of corres-
ponding severity.
   The process of reaction, with, or without the  spread of the disease
among the deeper tissues, leads, also to diffuse inflammation of the skin.
This may assume the form of erysipelas, or be mistaken for it.  In many
instances, it is only such in appearance.  It corresponds with it, however, 
AMPUTATION OF THE LIMBS.
77
in this, that in neither of them is there  any barrier set up, by the effu-
sion of fibrine, against the spread of the disease.   But the condition of
the skin now under consideration has a closer connection with that which
always accompanies subfascial inflammation, than with any form of true
erysipelas.  In the latter the cause of disease is  situated  either in the
skin, or in the cellular tissue forming part of the  common integument,
beneath this ; whilst in the other, every vascular tissue of the limb  is
equally involved, or if any be the last to suffer, it is usually the integu-
ment itself.
   The spread of ecchymosis from extravasated blood, in these cases, is
generally extensive, giving the greater part of the limb—especially in the
track of the larger vessels, and among parts where the cellular tissue is
lax—a deep purplish discoloration.   But in many cases, the blood in the
various tissues, muscular, cellular, and tegumentary—without  having at
all escaped from its proper vessels—coagulates in the capillary veins ;
and  there, losing its color as  well as its  vitality, it gives to the  deeper
structures a dry and withered, purplish  appearance, and to the skin a
dusky or dingy-brown color ; and when the  tissue of the skin itself  is
otherwise implicated, and disposed to fall into gangrene, a pinkish brown
color.  These changes in the color and condition of  the skin, from their
disposition to extend, are also often taken for erysipelas; and, as I think,
erroneously.  In some cases, the coagulated blood thus  situated, is re-
dissolved, and carried off, so as to restore the tissues to their normal ap-
pearance.  I have, in more than one  instance, carried the amputating
knife through muscular and cellular tissues, as well as through the skin
in which this condition of the blood in them was demonstrable  ; and yet
these cases have done well.  But the extensive diffusion of  this brownish
discoloration is usually an unpropitious symptom;  and the pinkish dis-
coloration is  always a  more formidable  appearance than the other.
They usually come on early, within two  or three days after the primary
injury;  and are not to  be confounded with the discoloration which
results from ordinary ecchymosis.
   The constitutional symptoms resulting from these  accidents, it is not
my purpose to dwell upon.  They  are such as  usually  attend other
local injuries of equal severity.
   The practical deductions, then, from the  foregoing observations, are,
that the amount of injury from railroad  accidents  is  apt to be  under-
estimated ;  that the  shock is often  such as to  destroy  the vitality of
parts in the neighborhood of the tissues first  hurt; and  that, if  the in-
jured parts are to be removed, the sooner the  operation  is performed
after reaction, and the greater the care of the operator to keep at a re-
spectable distance from the immediate line of disorganization, the better
for the safety of the patient."  G. C. B.]

                Article VII.—Various Affections.

                                §1.

   Necrosis and caries also, either in the middle part or in the  articular
extremities  of  the  bones, find their last resource in amputation.  To
justify this, however, it is necessary that the evil  should be extensive, 
78             NEW ELEMENTS OF  OPERATIVE SURGERY.
 ancient, and  accompanied with sufferings and  suppuration which are
 exhausting to the  patient; that it should  occupy a joint or large  sur-
 faces, and be surrounded  with  fistulous ulcerations or deep-seated de-
 vastations in the soft parts ;  that the bone  should be diseased through-
 out its whole texture, if it is in the continuity of the  limbs ; and  that
 we cannot count upon any  reproductive action from the periosteum: but
 it is important, in such cases, not to forget that the organism possesses
 great  power, and that art, at the present day, has at her command the
 means of removing the bones in part, without removing the limb,  pro-
 vided the soft parts are in  a condition to be preserved, (See Trephining
 and Exsection.)

                    § II.— Cancerous  Affections.

   Spina ventosa, osteo-sarcoma, and colloid, hydatid and  erectile de-
 generations,  affecting the  bones,  also  frequently require amputation.
 These  affections are of such  a malignant character, that we deem our-
 selves  particularly fortunate in being enabled to destroy them effectually,
 even at the sacrifice of the part  in which they are seated.  Unless they
 should  occupy an  exceedingly  superficial, long, or small-sized bone,
 easy of excision, we should not hesitate a moment about amputating.   If
 the soft parts are also implicated in the degeneration, amputation becomes
 a case Of necessity.  It is the same with fungus hsematodes, as soon as it
 is found impossible to extirpate it in its totality, without altering the
 continuity of the bone or bones of some important regions of the limbs.
 M.  Hervez  de Chegoin (Journ. Hebd.  Univers.,  t.  II., p. 117)  has
 clearly  established, that extirpation,  or amputation, where practicable,
 is the  only effectual  remedy—for example:  for sanguineous fungoid
 tumors, made  up  of  heterogeneous  tissues and  encephaloid matters,
 and  when  they have  reached to a certain depth in the organ—except
 that we must  take care not to confound them with simple  erectile tu-
 mors, which at the  present day  are cured by much  milder means.  As
 to cancers, properly so called, it is not required that they should have
 penetrated to the bones before we proceed to amputation.  If they are
 large and immovable, and go deeper  than the integuments, and  impli-
 cate the aponeuroses, muscles, vessels and  nerves, we should compro-
 mise the life of the patient by attempting to  preserve the limb.  The
 greatest misfortune in all these  cases is, that  amputation  itself is  no
 certain security, always, against a return of the disease.   A young man,
 in other  respects in exceedingly good health, came to La Charite  for
 an enormous fungus haematodes upon the calf of the leg.   Through fear  I
 concluded to amputate at the  femur ;  but the  wound of the  stump had
 not  yet healed, when the disease  had  already invaded the remaining
 part of  the thigh.
  [At a meeting of the Pathological  Society of London, May 2, 1854,
 Mr. Fergusson, in reporting a case of  medullary cancer of the femur in
 which he had performed amputation through the bone, and not at the ar-
ticulation, remarked, that he  did not agree with the  rule ordinarilv
laid  down  in such  cases, to disarticulate the  bone, as his  experience
had taught him that the medullary  cavity is very rarely affected by ex-
tension of malignant deposit.  (Lond. Med.   Times Sr  Gazette. Mav
1854, p. 556.)   G.  C. B.]                                         * 
AMPUTATION OF THE LIMBS.                   79
                               § III.

  Nor do exostoses and fibrous tumors, whether of the species elephan-
tiasis or otherwise, unless  they should be exceedingly voluminous  or
should have compromised the general health and destroyed the natural
functions  of the  part, or cannot be  taken away separately  and com-
pletely  distinct from the bone,  and from the neighboring Organs most
essential to the maintenance of life in the rest of the limb,  absolutely
require amputation.

                      § IV.— White  Swellings.

  Numerous  observations have shown that white swellings yield more
frequently than had been generally imagined, to the resources of a judi-
cious therapeutic, and that we  should not, so long as the caries or sup-
puration of the articular surfaces is not clearly established, have recourse
to the removal of the limb, until we have exhausted  upon the disease
all the  means that our judgment enables us to suggest.   The  phrase
white swelling is, moreover, one of too  vague an import, at the present
day, to have any value as an indication of amputation, (Jeanselme, Arch.
 Gen. de Mid., 1837.)  It is upon the character of the disease and  of
the  tissues affected, and not from the  title of white swelling, that we
are to make up our judgment upon the  propriety of amputation in dis-
eases of the joints.  If the capsule has  been  for a long time filled • with
pus ; if there are fistulas existing about  the joints, and the friction made
on the surfaces leave no doubt as to the  extent of the necrosis  or caries ;
if, also, the ligaments and surrounding fibrous layers are  destroyed,
and  an ichorous fluid  escapes in large quantities, and a fungoid or fatty
degeneration has involved the synovial  membrane and most of the soft
tissues; if the limb be atrophied  both above  and below, and is luxated,
or«has a tendency to  become so ; if, in a word, it is manifest that the
bones  and the cartilages have  been for  a long  time the seat of a deep-
seated, destructive alteration in the parts; then is amputation indicated:
though  the  cure, even where all  this mischief exists, does  sometimes
ultimately take place in the articulations, especially in those of the
fingers.
                      § V.—Suppuration.

  Unless suppuration should  derive its source from some disease in the
bones, it rarely happens, whether it be of long standing or recent, su-
perficial or profound, or is ever so abundant  that it renders amputation
absolutely necessary.    Regimen,  judicious  medication, incisions and
suitable  dressings, ought  to  be sufficient to dry up its source.  In the
contrary case, we should look for the cause in the general  condition  of
the patient, or trace it to some internal lesion; in which case amputation
would but hasten the  progress of the disease.  We admit the dangers
of those suppurations  which sometimes  invade the greater  portion of a
limb, and are  ordinarily  the  result of inflammation of the synovial
capsules,  the tendinous  sheaths, or inter-muscular  tissue; and every
person has been enabled, on this head,  to make observations similar to 
80
NEW ELEMENTS OF  OPERATIVE SURGERY.
those of Lecat, (Proprietes des Nerfs, p. 202.)  But as these dangers
are not always present, as death is not always  their  inevitable  result,
and as it is practicable to make successful resistance against or entirely
to prevent them in a good number of cases, suppuration of the soft parts,
without degeneration of the  bones, ought not to be ranged among the
indications for amputating the  lhnlR.  I have, moreover, had  an op-
portunity  of witnessing three patients on whom it was performed, and
who sank  as  rapidly, or more so even, than  they would have done had
they not been operated upon.  In  the two  first a suppuration, which
numerous  incisions had not  been able to arrest, occupied  almost  the
whole of the Jore-arm ; in the other, the evil, which did not approach
so near the  wrist, had reached to above  the elbow.  They  were all
amputated at the arm, and they died before the fifteenth day, with pur-
ulent deposites in  the viscera.  In fine, if the  suppuration is  purely
local, and the  destruction of the tissues slight, amputation is  not in-
dispensable ;  and should it be kept up by constitutional  disease, it will
not succeed.

                              § VI.

  Corroding  ulcers, lupus, and  phagedenic  sores, of the  legs, which
formerly constituted  one  of  the principal indications for  amputation,
do not in  reality require it, or do not exact it at least, but in  a very
small number of cases, as  when the skin is  destroyed and the muscles
laid  bare, to  a great extent  around most of the limb  ;  nevertheless, it
is proper that  the patient should desire the operation, and that he should
be convinced that there is  no  hope of curing him by any other mode.

                              § VII.

  In  Tetanus, for which M.  Larrey, (Clin.  Chir., t.  I., p. 27 a 131,)
M. Del  Signore (Arch. Gin.  de Mid., t. II., p. 298)  and some  others
have had  the courage  to  employ it, is it possible that any advantages
could be derived from it ?  Would it not rather be aggravated than cured
by the removal by the limb ?   I am aware that a man from the country
was saved in  this manner by  Dubois, that Levesque-Lasource (Bull, de
la Fac. de Mid., 7e  annee,  p. 100) has published a similar  fact, and
that we find here and there  in  periodical publications other examples
of success obtained in the  same  manner.  Nevertheless two of  the pa-
tients operated upon by M. Larrey died notwithstanding the amputation,
and the state of the third leaves the matter in doubt as  to the real nature
of his  disease.  If in itself the wound which has caused the tetanus
should be  of so serious a nature as to justify an extreme measure, the ac-
cess of  this frightful disease would without doubt weigh in the balance
as a determining motive.  But in other cases I should be so much the less
disposed  to follow the example of  our celebrated  military surgeon, in-
asmuch as amputation  is, as  is  known, in itself a potent cause of the
very disease for which it is here proposed to employ it as a remedy.
   \_ Amputation for Tetanus.—As illustrative of this subject the following
facts may be useful:—
   Sir Geo. Ballingall (Outlines of Military  Surgery, Edinburgh, 1844) 
AMPUTATION OF THE LIMBS.
81
gives an important fact which he  derived  from Deputy Inspector Mar-
shall, to show that the statements touching  the  production of tetanus
by  punctured  wounds have  been greatly exaggerated.  Out  of one
hundred cases of arrow wounds at Ceylon, (East Indies,) Mr.  Marshall
did not, even in the heat of that climate, which as we see in all tropical
countries, constantly predisposes  in  all diseases, to complications of
tetanus, trismus, spasms, convulsions, Ac, meet with a single case of
tetanus!
  Dr.  Casper of Berlin  (vid. Casper's Wochenschrift—also Journ. des
Connaissances, &c, Paris, Aout, 1844, p. 74) relates the case of a man
aged 35, who having had a corn removed from the little toe of the left
foot by too deep an incision, continued notwithstanding the pain which
ensued to do his duty  as a domestic where he was  employed, until he
had to take to his bed.   M. Casper found the patient complaining of no
other symptom than the pain in the part from whence the corn  had been
extracted, and in place of it a vesicle filled with blood, the  foot also
being swollen throughout its whole extent.   In a  day or two  came on
difficulty  of swallowing,  stammering,  and  difficulty  of  articulation,
though preserving all his  mental  consciousness perfectly.   Tetanus
followed with death  the same evening.  Pus  was found effused under
the integuments, and the mucous bursa over  the  articulation was filled
with blood ; but no lesion was discovered on the branches of the fibular
nerve which are distributed to the  toes.
  Dr.  Aberle (Jour, des  Conn. Mid. Chir., Paris, Nov., 1844, p. 208)
relates an instructive case in which it finally became necessary  to ampu-
tate the medius finger for a wound from a splinter (echarde) under the
nail, which the patient, a female aged 22, had supposed she  had ex-
tracted.  The  paroxysms  of tetanus which had continued  daily for
weeks, and  which were  kept under  and ultimately reduced  to one a
week by repeated small enemata of .equal parts of spirits of turpentine,
olive oil, and mucilage of gum arabic finally returned  with all their force
and induced the patient to  consent to the operation.   Immediate relief
was obtained, but to the dismay  of all it was  found that though the
wound on the point of the finger had cicatrized a portion of the splinter
(echarde)  was  found buried in the nerve I  The  patient recovered
completely.
  Mr.  Miller, Professor of  Surgery in the University of Edinburgh, in
a case  of traumatic tetanus  (Cormack's Lond.  and Edinb.  Monthly
Jour, of Med. Sc, Jan., 1845, p. 22, &c.) in a girl  aged 7,  from in-
jury to the right middle  finger caused by a cart wheel passing over it,
and in which case  unequivocal tetanic symptoms  developed themselves
on the 20th day after the  accident, in trismus and   pain of the jaws,
opisthotonos, rigidity of the upper extremities and  abnormal  muscles,,
immediately on the day of their apppearance performed amputation at
the  metatarso-digital articulation.  The case was   then treated with
large doses of the cannabis Indica,  (Indian hemp,) sometimes to 301
drops of the tincture (equivalent to three grains of the resinous extract)
every half hour, together with bags of cold ice to the upper part of the
spine.   He places much reliance on Indian hemp, as from his experience
in this case its extraordinary anti-spasmodic and narcotic effects, though
it may be comparatively  useless as an anodyne  in ordinary  cases of
  Vol. II.                    1] 
82             NEW ELEMENTS OF  OPERATIVE SURGERY.
disease, are wholly exempted from the objections to opium, morphine,
aconite, &c.  For instead of constipating the bowels it creates an inor-
dinate appetite, (especially  in convalescence,) which enabled  the Pro-
fessor during the treatment,  which however was prolonged to two months
before the tetanus  was  subdued, to adminster constantly a supply of
wholesome nourishment (strong beef tea)  to replenish the exhausted
excitability  necessarily caused by such severe and morbid  exercise of
the muscular power of the  whole system  of voluntary  muscles.   He
recommends also careful attention to evacuation  of the bowels,  but
above all early  amputation of the injured part upon its cardiac aspect.
To show the power of the cannabis Indica in controlling muscular spasm,
and the extent also to which morbid muscular power is developed in
tetanus, it may  be remarked that large as the doses were on this young
and slender girl, none of its unpleasant effects were  produced.  Dr.
O'Shaughnessy, from what he saw of the virtues of  the Indian hemp in
India  in tetanus,  was  induced to commend  it strongly to  the notice of
British practitioners, (See British and Foreign Medical  Review, July,
1840, p. 225,) and it is worthy of further trials after those of Mr. Mil-
ler given above, as a valuable adjunct to early amputation—instead of
the disturbing  herculean  doses  of opium,  wine, alcohol, &c, formerly
in vogue in tetanic affections, especially in traumatic tetanus.   T.]

                              \ XII.

   The bite of rabid animals is also, in the estimation of some, a case
for amputation.   M. Calloway  (Clinique des Hopitaux,t. I., p. 16) had
no qualms about taking off in this manner the arm of a person who had
been bitten in the hand, and who, by the way, died nevertheless of hy-
drophobia in eight hours after.   At farthest we should never think of it,
except for a finger  for example, unjess the wounds are so extensive,
complicated and deep that we  cannot cauterise or in any other manner
excise their whole track ; the amputation also should in  such cases be
performed immediately, as in a lady  whose case was transmitted to me
by M. Champion ; for after the absorption of the virus  has  once taken
place, how can it be of any utility ?

            Article  VI.—Amputations of Expediency.

  Anchylosis, complete or incomplete, deformities of different sorts,
ancient ulcers that are incurable, or where the cure is not  permanent,
or any annoying condition whatever of certain parts of  the limbs, often
induce patients to demand relief from them at whatever sacrifice, though
their life and general health  are not in any manner endangered.
  As a general  rule, a discreet physician ought, in such cases, to resist
the entreaties of persons who consult him.   There is evidence, in fact,
to show that the operations which are denominated those of complaisance
terminate  sufficiently often in an  unfortunate way.   In 1821, there was
received into the Hospital of St. Louis, a man of robust make, in the
vigor  of age, and in  other respects enjoying the most flourishing health
but with the firm resolution of having his thigh cut off for an anchylosis
of the knee, which obliged him to use a crutch.  After having remon- 
AMPUTATION of the  limbs.
83
strated with him in every possible way, and traced out to him as black
a prospect as could be portrayed of the  dangers to which he would be
exposed, M. Richerand finally  acceded to his entreaties ; the amputa-
tion was one of the most simple ; no local accident supervened ;  but an
ataxic fever, which  soon supervened, ended, nevertheless, in death on
the fifth day.   Pelletan cites a  similar fact.  I saw some quite as strik-
ing at the Hospital of Tours, from 1815 to 1820, and M. Gouraud, then
surgeon-in-chief of that establishment, finally came to  the resolution,
as Dupuytren did afterwards, of giving a flat denial  to these pressing
requests of patients.   In 1825, a countryman who had been an old sol-
dier, annoyed at having a large leg, and carrying a dry  ulcer  behind
the malleolus, presented himself in the wards of the School of Medi-
cine with the idea of having his  limb  amputated.   It was in vain that
M. Roux  endeavored to alarm  him, and to make him feel the  rashness
of his project;  nothing could  shake  him.  The operation  presented
nothing peculiar ; the first days  went off as well as could possibly be
desired ; but constitutional symptoms  supervened, and the man died at
the end of the week.
   What is worse, amputations  of the  least importance in themselves,
those of a finger or toe for example, have not unfrequently been follow-
ed by similar results.
   In 1829, there was received in the  Hospital of St. Antoine, a shoe-
maker whose left fore-finger had been for a long time held  firmly  and
immoveably fixed upon the palm of the hand.   I operated upon him,
and this patient, who did very  well at first, and  finally recovered, was,
during fifteen days, so severely affected, that on  two different occasions
I thought there was no hope  for him.  A young  peasant girl came into
La Charite to have an amputation of her left fore-finger, which was  re-
tracted backwards, and adherent to the dorsum of the metacarpal bone ;
she died of phlebitis and of purulent peritonitis on the eighth day after
the operation!
   Nothing is more common than examples of this kind, and there is no
practitioner who has not had occasion to see them.   From thence  has
arisen a question among modern observers which the  ancients seem
never to have thought of: ought a practitioner to limit himself to sim-
ple explanations ?  Is it not his duty positively to refuse to perform
operations which are not indispensable  ?  At Paris, many surgeons have
answered  negatively, and violently oppose those who amputate under
such  circumstances.   For myself, I find the question  badly stated, and
here is  another  one  which may be  brought into consideration.  Does
humanity  allow that we should  condemn a man to carry  forever an  in-
firmity which renders  life a burden, merely because that in the attempt
to get relieved of it, he may be exposed to more or less serious dangers  ?
If that were  the case, we should  never  interfere with  lupus, nor  tu-
mors of any kind which are developed upon different points of the body;
for they are rarely dangerous in themselves, and the  operations we are
obliged to employ to remove them may give rise to formidable accidents,
or even cause death.
  Far be it from me to justify those who are in haste  to  perform ampu-
tation of the limbs for lesions which do not absolutely  require it, and
for simple annoyances, and merely  because the  patients wish to be re» 
84             NEW  ELEMENTS OF OPERATIVE SURGERY.
lieved of them ; but I would ask if it be not conformable to a sound sur-
gery to have recourse to it for deformities which we cannot otherwise
get rid of, when those deformities are of a character to destroy the nat-
ural uses of an  important part of the body, to give rise to pains, and to
make them a source of  trouble and continual suffering, and when the
patient also has decided upon it, and maturely reflected upon the con-
sequences which may result from his determination ?
  Dominique de Aric, (Governor of  Amiens,) (Essais Historiques sur
Paris, par  Sainte-Foix, t. V., p. 108,)  in 1586, having had the fleshy
portion  of his  leg  crrricd  away,  and being thus incapacitated, from
mounting his horse without experiencing the most acute pains, went into
retirement for three years.   Hearing  that Henry IV.  required the ser-
vices of all his subjects, he caused his leg to be amputated, sold a part
of his property, went to find his prince, and  rendered him signal ser-
vices at the battle of Ivry, and on many  other occasions.   Can he be
blamed ?
  A captain of marine having  lost his foot, had the leg cut off  near the
knee, because, says Pare, (CEuv. complet.,liv. XII,chap. 29,) he found
it too long.   Villars, as cited  by Briot,  (Hist, de la  Chir. Milit, p.
185,) did  the  same.  Ought Sabatier to  cast  reproaches  upon  these
practitioners, he who so long  felt the  embarrassment of too long a
stump to the leg ?   I would not like Odier (Man. de Mid. Prat., p.
362,) go to the extent of amputating the fore-arm for a simple neuroma,
nor for an anchylosis of the wrist, which caused no pain, nor for a false
articulation, unless  under circumstances  altogether  peculiar ; but I
should decide in favor of it in the following cases.

                    § II.—Anchylosed Fingers.

  Whether deformed, flexed or  extended, straight or deviated, an an-
kylosed finger is not  only a useless  organ, but a perpetual source of
trouble, pain and accidents.   If there be no other remedy, amputation
is allowable.  I have performed it seventeen times, and of these, fifteen
of the cases were cured.

                   § II.—Supernumerary Fingers.

  Without being as annoying as those that are ankylosed,  supernume-
rary fingers  are  enough so to justify their  removal.  I have  amputated
them  on the thumb and little finger, and the little toe, and have had
no reason to regret doing so.   I saw—it is now twenty-four years since
—a child  of four days  old, who had seven fingers  on each hand ; the
thumb and little finger  were  double; I amputated them successively,
and  united by first  intention.   In 1837,1 amputated,  writes M. Cham-
pion, the two great toes that were double upon the child of  the preced-
ing case, and I  separated apart the middle and ring fingers, which had
been  united at their two sides.   In conclusion, I do not  know  what re-
mark to make of the case of a double thumb,  in a child of 3 years, am-
putated at the  joint by Ch. White, and which was reproduced to the
extent of  causing W. Bromfield to amputate  it a second  time, which
however, did not prevent its reproduction again ! 
AMPUTATION OF THE LIMBS.
85
                 § III.—Prominent or angulated toes.

   Whatever may be the deviation of any one of the three middle toes,
it is rare if they are at all prominent  that the person does not experi-
ence pains, and an extreme degree of annoyance in walking or wearing
shoes.  In such  cases, should  the  patients demand it, I  amputate.   I
have performed it on five persons, two of whom were  students of  medi-
cine, and  although  in one of these it was followed by some accidents,
they all got well.

                 § IV.—Ankylosis of the Large Joints.

   So long  as there  is a chance of curing ankylosis, of assuaging  the
pains, or of putting the patient in a condition to walk, though it should
be with crutches, I decline  an amputation of the  limbs properly  so
called ; otherwise I am governed by circumstances.  A man from Prov-
ence who, in consequence of  successive inflammation of the  joints, had
the hips, knees and feet  ankylosed  with the legs  and thighs  bent into
a serpentine  direction, so  as to be unable to  stand  erect,  or to seat
himself, or lie upon his side, obliging him thus to pass his life upon
his back, sought  in vain at Lyon, Nimes, Avignon and Toulouse for a
surgeon who would amputate  his two thighs, and then came to Paris with
the  hope of  attaining  his  object.   I, like the  others, at  first refused.
" Though  a cripple, I  might  then, said he  to me, be enabled  to occupy
myself and live.   But  as I  now am I do not exist.  Amputation you say
might  kill me ;  that is  not so certain.  Besides I suffer, and I do not
wish to live if I  am to remain as you see me.   Therefore I leave here
either my legs or my body !"   The two amputations were attended with
complete success, and he returned as happy as a god !
   [The following curious case is deserving of a place in connection with
that related  by  our author.  It was  published in  the the New-York
Journal of Medicine, May, 1853.
   The case related  by Dr Purple, is that of a young man, a native of
Virginia, who, at 22 years of age, had his back broken by the fall of a
tree, which he was in the act  of felling.   The result of the accident was
the immediate  loss of  motion and sensibility in all parts below the fifth
dorsal vertebra, and of voluntary  power over the bladder and rectum.
He recovered, however, from the immediate effects of the accident, and
regained a  fair amount of his  former health, but the paralysis continued,
though the  paralyzed parts  were as plump and warm as ever.   He gain-
ed his livelihood  as a pedlar, and spent nearly  all his time lying on his
back in the vehicle in which he travelled from one place to another.
   In  1851, six years  after  the  injury, he presented  himself to our
County  Medical Society, and requested the amputation of his lower ex-
tremities.   He  insisted upon its performance with his wonted resolution
and  energy.   His reasons  were, that  they  were a burdensome appen-
dage to  his body—causing him much labor to move them, and that he
wanted the room they occupied in his carriage for books and other arti-
cles for peddling.  These reasons were not sufficient to induce a major-
ity to  consent  to an amputation, as, independent of  the horrors of so 
86
NEW ELEMENTS  OF OPERATIVE SURGERY.
extensive a mutilation for such reasons, there were fears that the vitali-
ty of the vegetative existence enjoyed by these limbs was such as might
endanger a healthy healing process.
   The patient, nothing daunted by our reasoning, firmly resolved to cast
off the  offensive  limbs  as  a useless  burden on  the  rest of his body,
sought  other  counsel, and succeeded in getting bis wishes gratified.
Both limbs were amputated near the hip joint without the slightest pain,
or  even the  tremor of a muscle.  The stumps healed readily, and no
unfavorable symptoms occurred in the  progress of a perfect union by
the first intention.   In this mutilated condition he was unable  to move
his pelvis  in the slightest manner without the greatest effort by the aid
of his hands.
   He then resumed his former wandering life, and travelled over this
and portions of the adjoining States,  until May, 1852, when he was ar-
rested in this village by  his last disease,  which suddenly terminated
his life.
  He died with  all the symptoms of the disease of  the digestive func-
tions  consequent  upon  his bacchanalian propensities, to which he had
been  strongly addicted since the injury.  He was very excitable, and
the smallest quantity of spirits irritated the  brain to the utmost frenzy.
His  irritable characteristics  were unbounded, and although he was in
the most  helpless condition, he was converted from a man of a mild
and amiable disposition to one of the  most irritable of the human fami-
ly.   His energy, his  force of character, and his mental powers, gener-
ally were very much increased by the narrow limits in which his sen-
tient powers were confined.
  Mr. James, of Exeter, in his valuable paper  On the Causes of Mor-
tality after  Amputation of the  limbs, Part II.; in the Frans.  Prov.
Med. Sr Surg. Association, Vol. XVIII,  p.  330, thus expresses his
opinion  on amputation for useless limbs: " My own record contains but
few cases of the  kind, none of which  appear to have proved fatal; and
I am much inclined to think, from the present examination and a care-
ful consideration of the subject, that  little risk is incurred.  The limbs
are wasted ; there is no active disease.   The time, the  season, and the
place may be selected, and in all these respects such operations stand
apart from many others.  He there gives  a summary  of  11  cases in
which he has operated ; these  were as follows:—Thigh, 7 ;  Leg,  3 ;
Arm, 1; Total, 11;  and all successful.   G.  C. B.]

               § V.— Ulcers with Loss of Substance.

   In  consequence of extensive burns, gangrene, phlegmonous erysipelas,
or old ulcers, it may happen that the integuments throughout the whole
circumference of a limb are destoyed, together with the aponeurosis and
some of the muscles, to such extent as  to render cicatrization  forever
impossible.  If the patient desires  it,  amputation  is applicable here
also; but in all  such  cases I wait for  the  patient  himself if  he is an
adult and has his reason, or in the contrary  case for his parents, to de-
mand the  operation.  I do not  decide  upon it but at their entreaties,
and after having  pointed out to them all its dangers and chances. 
AMPUTATION OF THE LIMBS.
87
                           CHAPTER II.

                       PRELIMINARY CAUTIONS.—

                 Article I.—Counter-Indications.

   Before amputation is performed  it  is not only necessary that the
disease which requires it should be one that cannot  be cured in any
other manner, but  also that we be enabled to remove  the whole of the
disease, and with a rational prospect of saving the life of the patient,
(Malle, Contre-lnd. aux Opir., Strasb., 1836.)

                                §1.
                                                         •
   When the  disease is a cancerous affection, it is important to make
ourselves assured that  there  exists no germ of it in the viscera.  If a
diseased condition of the  lymphatic glands is observable at the upper
part of the limbs, and that the color of the skin, the  state of the res-
piration  and digestion, or any other symptom whatever indicates that
the disease is not confined to  the  surface, amputation is useless  and
would only serve to hasten the development of lesions analogous to
those we desire to relieve.

                                §11.

   Pulmonary phthisis,  necrosis (Mehee, Plaies df Armes-d-Feu, etc.)
caries of the vertebral  column, (Lassus, Fract.  de Pott, p. 181, 1788,)
abscesses from congestion, any organic lesion of the heart, liver, stom-
ach, or  genito-urinary  passages, &c., extreme  prostration, intestinal
ulcerations in considerable  numbers  and of long  standing, coincident
or not with a colliquative  diarrhoea, are, unless in a  case  of urgency,
(see Vol. I. of this work,) so  many positive counter-indications, (Dela-
touche, Dissert sur V Amputation, Strasbourg,  1814.)  In fine, in  all
eases where in  the  removal of a limb we  leave in the organization a
disease of  such gravity that  death will almost inevitably  follow, we
ought to  abstain from the operation.  When it is for a scrofulous, syph-
ilitic or rheumatic affection, we have to apprehend  that it will  soon be
reproduced in other parts of the limbs, and may oblige us, if we pro-
pose to follow it up, to perform  successively a number of amputations.
We ought, therefore, in such cases to have at least a strong reasonable
prospect of being enabled to limit the progress  of the general  disease,
in fact to retard its advancement and ultimately to extirpate it effectu-
ually.  Prudence, for example,  does not permit us to amputate a limb
affected with rheumatic or  syphilitic caries or necrosis, if other parts
and  some of the articulations are already the seat of swellings, pains,
and other primary symptoms of a similar affection.
   [When tubercular disease of the lungs coincides, as is frequently the
case, with that of a joint, amputation is generally regarded as an unjus-
tifiable operation.  'The diseased joint in these cases is supposed toact
as a safety  valve, warding off or keeping in check the internal affection. 
88
NEW ELEMENTS OF OPERATIVE SURGERY.
 But, as Sir Benjamin Brodie remarks in the last edition  of his  work
 " On the Diseases  of the  Bones and Joints," visceral disease, which
 was  previously in a state of inactivity, may  assume a new form, and
 make rapid progress under the depressing influence  of the articular
, malady, and under these circumstances an amputation may prolong life,
 perhaps  for several years.  He  relates a  case in point.   A  young
 woman, affected  with strumous disease of the joint, had also a trouble-
 some  cough, purulent expectoration, <fec. on which  account Sir Benja-
 min did not deem an operation advisable.   As the pain became  insup-
 portable, the  patient earnestly  implored him to amputate the limb, to
 which he finally consented with reluctance.   The stumps healed readily ;
 the pulmonary symptoms soon "subsided, and  four or five years after-
 wards she was in good  health.  M. Nelaton, in his Elemens de Pathol-
 ogic  Chirurgicate," torn.  II. p.  227.) refers  to a case in which M.
 Velpeau amputated, notwithstanding M.  Andral and several other phy-
 sicians had diagnosed  tubercular  disease  of  the lungs.   Two years
 afterwards the patient  was in the most perfect health.   The testimony
 of Mr. James, of Exeter, is to the same effect.   G. C.  B.]

                               § III.

   In  regard to scrofula, however, it had been for a long time noticed
 that the removal of an important part from the body was often followed
 by a favorable  change in the general health  of the  patient; that after
 the cure debility has been succeeded by manifestations of strength, and
 of the most flourishing health.  This is a change which we may readily
 comprehend :  an  abundant suppuration, protracted  pains, and a disor-
 ganized condition of the articulations, constitute a morbific cause cal-
 culated continually  to impair the  functions, and  cannot fail of keeping
 up in the economy a sufficient degree of disturbance to impede the de-
 velopement  of the  natural resources of  the system.  In removing,
 therefore, this  real  cause of suffering and danger, it  is very natural
 that the health should afterwards be re-established ;  that nature ceasing
 to be disturbed and  embarrassed in her efforts, should then be enabled
 to suppress less serious  lesions, and to preponderate over a morbid pro-
 cess whose principal source has been destroyed.

                             § IV.

   One of the first questions to decide is  to know if there are really any
 internal diseases existing, and to ascertain their nature, for if these be
 incurable amputation is  inadmissible.  The  next question is to determine
 the source of the mischief, for if this be  external  then amputation is
 formally indicated, but  if elsewhere, the contrary.  As often as a local
 affection is the result of general  disease, we must entirely  subdue this
 latter before thinking of removing the former, which, according to cor-
 rect practice, does not allow of amputation until it becomes  reduced to
 what exists of it externally.  A minute examination of the patient be-
 fore  coming to a final decision, is  so much the more important, inasmuch
 as most of the diseases which require  amputation rarely  fail of pro-
 ducing a reaction to a greater or less  degree upon the  internal organs, 
AMPUTATION OF THE  LIMBS.                  89
 and of thus  giving origin in the viscera to  abscesses, tubercles, ulcera-
 tions, indurations, and  numerous other morbid  determinations, whose
 exact appreciation or detection is far from being always an easy matter.

                              .   § V.

   It is well  nevertheless to remark  that the debility which is found to
 exist in certain patients, is not in itself an absolute counter-indication
 to the operation.  All  observers know that it is not in  the  strongest
 subjects, and those who have the  greatest appearance of health, that
 amputations succeed best.  A certain degree of exhaustion  produced
 by protracted pain, even diarrhoea itself when it is not kept up by any
 internal organic lesion, are in general favorable rather than unfavorable
 conditions.  It would seem  that in  the first  case  the  organization in
 possession of its whole forces, revolts at the mutilation which it has
 suffered ; while in the other, the affection upon which it had exhausted
 all its resources, being removed, it has no other  task to perform but to
 dissipate the subsequent disorders which it  was not in its power to pre-
 vent.
                                § VI.

   When we  have under consideration recent traumatic lesions, there
 may be a number of serious  wounds in the  same patient.   Ought we
 then to amputate ? and if there are several limbs to be removed, should
 all  this be done on the same day ?   Bagieu relates that in a man who
 had both legs crushed, it was decided upon to remove the one most in
 jured first;  but that by mistake the other was taken off and the bad
 one got^vell!  I amputated  the  leg of a man who had just fallen from
. a second story.   He died on the fourth day with a laceration of the
 liver.  In another case  of wound it was proposed to  amputate both
 legs; I objected to it.   After  death it was found he had twelve ribs
 and  six of the vertebrae  fractured!  If the two  hands or two feet are
 the only parts wounded, we may amputate them immediately.   Though
 the accompanying wounds are not in themselves mortal, still we should
 amputate.   If other  parts seem too seriously compromised, then wait
 and do not amputate  immediately.

               Article II.—The Period to  Amputate.

   In the last century surgeons were  zealously occupied with  the  ques-
 tion whether after severe wounds by fire-arms or otherwise, it was bet-
 ter to operate immediately or to wait for  the constitutional  reaction.
 Faure, (Prix de  V Acad., t. II., p. 337, et  Mem.  de V Acad, de Chi-
 rurgie, t. II., p. 323, 1819,)  Boucher, (Mini  de V Acad, de  Cliir., t.
 II., p. 199, 1819,) Bilguer, (Abus de V Amputation des Membres, fyc,
 traduit  par  Tissot,)  Leconte, (Prix de V Acad.  Roy. de Chir., t. III.,
 p. 357_367,) Schmucker, (Richter, Biblioth. Chir., t. IV., p. 1,) and
 De la  Martiniere (Mini, de  V Acad, de Chir., t. IV., p.  133) particu-
 larly  discussed this question  during the controversies that took place.
 And although almost every surgeon since that period has treated of it,
 no one has yet been enabled to come to an absolute decision.
    Vol. II.                     12 
90
NEW ELEMENTS OF  OPERATIVE SURGERY.
                               §1-

  The partisans of immediate amputation, among whom we must reckon
Van Gescher, (Necessiti de V Amputat., &c., 1767, in Dutch,) Fabre,
(Differents Points de Physiol., p. 279,) Briot, Prog, de la Chir. Milit.,
p. 189,) M. Durand, (These No. 198, Paris, 1814,) M. Jacquin, (These
No. 54, Montpellier, 1831,) and M. 0. Gouraud, (Demonstr. des Prin-
cip. Opirat., 1815,) maintain that immediately after the wound the
patient is  found in the most  favorable conditions  possible.  There  is
then, say  they, no fever,  suppuration or inflammation  ; the affection  is
entirely local; while at a later period the swelling of the limb, often
gangrene, a violent reaction, tetanus, and  a  thousand other  accidents
may cause death  before we have  the opportunity to  amputate.   Even
though  this primary reaction may be calmed, the copious  suppuration,
and the  separations of the muscles and the  fistulous passages  which
may have been established  together with the  induration and disorgani-
zation of the tissues, ordinarily render the operation of a  more serious
character.
                               §11.

  To  sustain their position,  the partisans of consecutive amputation,
among whom are to be  ranged, Mehee, (Inutiliti  de V Amputat. des
Membres, Paris, 1800,) Lassus, (Trad, du Traiti  des Fract., de Pott,
p. 181,) M. Delatouche, (Amputat. dans les  Cas de Fract., etc., Stras-
bourg, 1814,) and Leveille, (Soc.  Mid. d' Emul., t. V., p. 192,) main-
tain, on the contrary, that  in the first moments  the organism is too in-
tensely disturbed, and under the control of a commotion too violent  to
admit of the  possibility of. success from any operation whatever, and.
above all that we run the risk of sacrificing limbs which it would have
been easy to have preserved ; whilst after having combated  the first
symptoms, should amputation become necessary, we have at least noth-
ing to reproach ourselves with.
  Besides that  the question under this  form  is misplaced, the two
opinions,  taken literally, appear  to be equally remote  from  sound
practice.  When  amputation  becomes absolutely indispensable, there is
no doubt that it is better to  perform it  promptly than to put it off, and
Faure, himself, (Prix de VAcad, de  Chir., t.  III., p. 337,  edit. 1819,)
who defends with so much zeal  the cause  of consecutive  amputations,
does not take opposite ground to this opinion.  Bagieu (Exam, de plus.
Quest, de Chir., t. I., p. 137, 12mo.) and Leveille  have in this respect
gone much farther than him.  On the contrary when there is any chance
of saving  the limb, and its destruction is not inevtitable, we may tempo-
rize and resist the general symptoms, reserving our decision to amputate,
after the reaction is subdued, to those cases only in which we cannot
obtain a cure by any other means.

                               §111.

  On examining the  subject more  closely, it is also evident  that Faure
has not treated the question, in a proper point of view.  It is true  that 
AMPUTATION OF THE LIMBS.
91
his ten cases of wounds all of them  had fracture ;  the first, the  ninth
and tenth, in the leg ; the second in the thigh ;  the third in the knee ;
the fourth and fifth in  the fore-arm; the sixth in  the humerus;  the
seventh in the metacarpus ; and the eighth  in the heel; but the wound
from the fire-arms was not sufficiently serious in any  of them to extin-
guish all hope of saving the part.   In regard to these  cases the diffi-
culty was  to know  whether  amputation  was indispensable, and not
whether it should be performed at an earlier or later period.   The result
about which this surgeon made so much noise, does not therefore in  any
manner prove that amputation, when once admitted to be necessary, is less
dangerous after than before the access of the general symptoms.   We
may, in fact, deduce  from it a totally opposite conclusion.   What, in
truth, did he gain by thus  temporizing ? Nine out  of his  ten  patients
were reduced to the necessity of losing a limb, and that after five  or six
weeks of severe suffering, and running the greatest danger of losing their
lives.  To say that if they had been  amputated  immediately they would
not have recovered is altogether a gratuitous assumption.   Reason, on
the contrary, shows that these men who had such strength to' resist  so
many causes  of death, would have been much better  cured if they had
been operated upon at the beginning, and their recovery would probably
have  been  completed, when,' by the method of Faure, they  were still
under the anticipation of the operation.

                               §IV.

   In admitting that secondary operations succeed better than immediate,
the Academy of Surgery have  evidently been  deceived.  Against  the
calculations of Faure, which maintain that the success  is in proportion
of three to one, we may at the present time oppose the experience of a
multitude of  reputable persons, who have observed directly the reverse.
Dubor (These, Strasb.,  1803.   Larrey, Clin.  Chir.,t. III., p.  518)
affirms, that in the  American  war, the French  surgeons, by deferring
amputations, lost almost all their patients, while the Americans, by am-
putating immediately, saved almost all theirs, without scarcely, an  ex-
ception.  In  the affair at Newbourg,  Percy  (Gouraud, Oper. cit., p.  8)
performed ninety-two immediate  amputations, and cured  eighty-six of
them.   M. Larrey (Ibid., p. 8) cured  twelve out of fourteen.  Out of
sixty wounded in  the naval action of Jan. 1, 1794, and who were am-
putated immediately, two only died, (Fercoc, Lctlre d M. Larrey, Clin.
Chir.,t. III., p. 515.)  After the battle of  Aboukir, the eleven soldiers
mentioned by Masclet, (Lettre d M. Larrey, Clin. Chir., t. III., p. 517,)
who were amputated in the first twenty-four hours, got well, while three
others amputated eight  days after, died.  The English surgeons assert,
that after the battle of Toulouse immediate amputation  succeeded in
thirty-seven cases out of forty-eight; while in those  in whom the am-
putation was  deferred, twenty-one died out of fifty-one.  At the attack
upon New Orleans, the proportions were still more favorable, for  out
of forty-five  amputations of the first kind, seven only perished, while
out of  seven  of the second, two only  were cured.  We learn also that
after the battle  of Navarino, out of thirty-one  immediate amputations,
M. del Signore (Archiv.  Gin. de Mid., t.  XXL, p. 298) lost but one; 
92
NEW ELEMENTS OF OPERATIVE SURGERY.
while out of the thirty-eight that he amputated in the twelve following
days, he saved but twenty-five.

                               §V.

  Finally, the events of 1830 enabled us to corroborate the same  facts
at Paris.  One hundred amputations were performed, thirty-four at the
Hotel Dieu, fifteen at La Charite, twenty at Gros  Caillou, thirteen at
Beaujon, six or seven at St. Louis, four or five at the Maison de Sante,
three at the Nccker, one at the Hospital of the School of Medicine, one
at St. M.'ry, and five at La Pitie, and in all these places it was observed that
immediate was more successful than consecutive amputation.  Almpst
all of the first kind succeeded, while a great majority of the other kind
had a fatal issue.  The service of M. Roux, the wards of M.  Larrey,
of M. Richerand, M. Marjolin, andDupuytren, gave  proof of this asser-
tion, though with the last the difference was less marked. The two cases
also at La Pitie, in whom I deferred the amputation, died.  Nevertheless
Somme, who after the battle of Antwerp, performed five immediate and
three consecutive amputations, lost two of the first and saved the three
last;  but what a difference was there also in the gravity of the wounds !
In Holland, M. Kerst, who has decided for consecutive amputation, be-
cause of sixteen amputated in the first  twenty-four  hours, eight  died,
while of twenty amputated after fifteen to twenty days, four  alone per-
ished—and who  admits no other  cause  of the difference of reshlt in
these two series than that of the period at which  the amputation was
performed—finds a sturdy  antagonist in M. V. Onsenort, who, though
a countryman of M. Kerst,  gives  the  preference to immediate  amputa-
tion.
  Though secondary amputation should even succeed as often as it fails,
it would be no reason for giving it the preference ;  it  would be requir-
ed, moreover, (and which is not the fact,) that immediate amputation,
in itself, should  offer  fewer chances of success.  The fundamental ar-
gument  of the  partisans' of temporization, to wit, that a multitude of
mutilated persons would have been  enabled to save their limbs, if the
surgeon  had  delayed, is, as I have already said, more specious  than
solid; for we can reply to them, that a goodly number  of the other
cases would  be living with three limbs, if, in delaying the operation,
they had not suffered them to die with four.

                              § VI.

  Though experience had not spoken, who  could be  made to believe
that a simple, regular, and smooth wound, could be  more  dangerous
than those wounds from fire-arms which, accompanied with fracture of
the  bones and  crushing of the soft parts,  require amputation ?  The
pain, too, of the operation, can that be weighed in the balance along
with those that patients, not  amputated, every day  suffer, and which
are  reproduced upon the  slightest movements, or  from  examinations
of the wound, dilatations, and the  numerous  incisions we are obliged
to make  to extract  the splinters, moderate the  inflammation, or  give
egress to the morbid discharges ?   In fine, who would have the  temerity 
AMPUTATION OF THE LIMBS.
93
to maintain  that, in  this last condition, the wounded patient is not a
thousand times more exposed to phlebitis, purulent infection, tetanus,
and all the different kinds of visceral inflammation, than if an amputat-
ing wound  had been substituted for the serious lesions he was suffering
under ?                                                           °
  And,  after all, it is not at the present day that the doctrine of im-
mediate  amputation has been promulgated.  Surgeons  like Lecomte.
Thompson, Hennen, MM. Larrey, Gouraud, and  Guthrie, in opposing
the ideas of Bilguer, Faure,  Hunter,  Percy, Lombard, and Leveille,
have done nothing more than  to confirm  or to  establish, beyond the
possibility  of dispute,  the justice of the assertions  of Duchesne, who
wrote at Paris in 1625,  and also those of Wiseman, Le Dran, &c.
  The advantages of this practice being now undoubted, the only question
is to know at the  very first whether an amputation is or is not neces-
sary ; which excludes it then  from  the category of the diagnosis or
indications ?  It is from having been constantly  wandering from this
point, that the question  has remained so long undecided, and that it so
frequently becomes the subject of controversy.

                              § VII.

  Upon the whole, therefore, amputation  should  be performed immedi-
ately ; that is, in  the first  24 hours, and before  symptoms of reaction
have commenced;  in a word, as soon as possible,  so long as there is no
other chance of curing the patient.   The stupor and insensibility which
are observable in some cases of wounds, is not by any means a positive
counter-indication.  A  Swiss, whom I saw at the Hospice de  Perfec-
tionnement, July 27, 1830, with the  thigh  shattered  from a ball, and
who I advised should not be  operated  upon, was  amputated by M. P.
Guersent, and did exceedingly well.  We are not to abandon any cases
but those that seem to be without any resource.   It  is for  the  skilful
surgeon  to  decide what are  the  accidents which  require  delay.  In
doubtful cases, we defer ; but if afterwards  amputation  becomes indis-
pensible, we should be aware of the  fact that it scarcely ever succeeds
if performed during the severity  of the  symptoms, when the affection
is not completely localized, and signs of phlebitis  or  infection have
made their  appearance.  It is then especially that the viscera and all
the functions  should be thoroughly  examined, seeing that the reaction
which we had hoped to have had it in our power to subdue, often leaves
in the system purulent depositions which would be certain to endanger
the success of the operation.  These various remarks are as much ap-
plicable also to amputations rendered necessary  by causes other than
those of fire-arms, as to those of  which we have been speaking.
  [When to Amputate.—Sir George Ballingall (Outlines of Military
Surgery, Edinburgh, 1844,  p. 337) makes a remark of great value,
which, though it appertains  more exclusively to  military surgery, has
now (in the present frequent and dangerous  use of fire-arms  in our
own country, on all occasions, civil as well as military, as in street-fights,
broils, &c.)  become of every  day practical value, though  apparently
hitherto overlooked.   It is the well-established fact  that, in gun-shot
wounds from balls, there  is  generally  an  extensive  comminution and 
94
NEW ELEMENTS OF OPERATIVE SURGERY.
splintering of the bone, which is split and shivered, cracked and frac-
tured, in all directions—chiefly,  however, longitudinally, and  not un-
frequently to the distance of six inches, as in the tibia, <fcc.   Numerous
specimens of these are in possession of Sir  George Ballingall, and he
deduces from it the rule in  practice, that  full allowance should always
bo  made, in cases of this kind, for the  extent of this comminution,
when about to amputate or exsect, or where the joints  are laid open.
The comminution, and also the calibre of the aperture, as is well known,
are always greatest at the place-where the ball makes its exit, (lb.)
  This Surgeon, also, presents some rather  new, and certainly important,
rules, as gathered from his  great  experience, both  in military and civil
hospitals,  in relation to the time when amputations should be performed.
He is satisfied that, in  civil hospitals, primary amputations, i. e., those
that are performed at once and before reaction  has commenced, do not
do so well as in military hospitals ; and the distinction he makes,  founded
on the different action of  the moral causes in these two different states
of circumstances, seems to us  perfectly just.  Thus, the soldier is or-
dinarily of far more robust health,  and not only comes perhaps out of
a filthy barrack-room into a clean, airy, well-regulated and uncrowded
hospital, which thus improves his tone of health and increases his chances
of cure, but has his mind at rest also as to his situation after amputation,
as he knows  a pension is then provided for him.   Different is  the con-
dition of  the labourer, for example,  from the  country, who,  from a
perfectly pure air, immediately experiences the  deteriorating influence
upon his health, on entering a  civil  hospital in a city, (as is remarked
also by our author, M. Velpeau, see vol. L, supra,) and as is familiarly
known, however clean and well-regulated  the hospital may be, is almost
always attacked under this  change of his customary food, air, &c., with
a species of febricula or,  perchance, fever, which Sir G. Ballingall ap-
propriately denominates a seasoning, and which he says, notwithstanding
the reaction which is superadded to this  by the amputation itself, should
not deter  us, in most cases, from  proceeding at once to the  operation,
and thus take our chances for a favorable  result from  this combination
of the symptomatic and house fever  together.   But few surgeons, how-
ever, would  venture  to go so far.  Dr.  Cormack (Lond.  Sr  Edinb.
Month. Journ., Dec. 1844, p. 1046) thinks  the patient should be allowed
first to go  through his  seasoning fever, especially if there has»been a
rigor.
  As to what are  called intermediary amputations, in contra-distinction
to primary and secondary, i. e., those during  the existence of the con-
stitutional reaction, they  are  compulsory, and not  the  time of choice
which any" surgeon would prefer.
  Secondary  amputations, however, or those performed after the inflam-
matory and febrile action  have subsided, and when suppuration has com-
menced, are,  as is well  known  and  as  has been  fully discussed in the
text of our author, (M. Velpeau,) always preferred, by some surgeons,
to those that  are called primary.
  Sir G.  Ballingall  thinks the relative proportion of deaths and suc-
cesses, from both  primary and secondary  amputations, and an accurate
statistic also of the  co-operating influences, such  as those of  the air, 
AMPUTATION OF THE  LIMBS.
95  •
climate, constitution, the moral effect of victory or defeat upon an army,
&c, would throw valuable light upon this subject.  T.]

  Article  III.—Of the  Place where  the Amputation should be
                               PERFORMED.

  All amputations  have been divided into two great classes : those that
are performed on the body of the limbs, take the name of amputations
in continuity, the others are nothing more than disarticulations, and are
distinguished  by the  title of amputations in contiguity.  Amputations,
moreover, are performed in a place of election, or one of necessity, ac-
cording as the practitioner is free or forced by the disease to act on one
point rather than another.   Upon this subject we can scarcely lay down
other than extremely uncertain rules, for there are none of them that are
not liable  to numerous exceptions.  Thus, it is  not  always correct to
maintain that we ought to perform as far from the trunk, and remove as
little of the parts, as possible ;  or that  we should make choice of the
place that is smallest, and is the least bulky.

                               §1.

  It is the same with the  rule which prescribes, that we should always
amputate above the diseased tissues.  Fatty degeneration by no means
exacts the removal of the parts involved in it, since it may be of some
advantage to  preserve them ; being the usual result of an alteration in
hard parts, this as well as the fistulous passages and the purulent tracks,
disappear  as  soon  as the cause has been removed.  It is sufficient, in
such cases, to make the  section of the  bone above the part where this
itself has undergone an alteration, without being at all disquieted by the
state  of the soft parts, especially  if the  case under treatment be the
thigh or the upper  extremity.

                                §11.

  On this subject, the nature of the disease is to be considered as well
as its seat.  If the question be  that of immediate amputation in conse-
quence of  shattering or extensive damage to the limbs, or wounds from
fire-arms, or gangrene, inflammation, and  suppuration  still  advancing,
or cancerous tumors, the  instrument should be carried as high up above
the apparent seat of the evil as  the importance of the organ will allow.
If, on the contrary, the disease which requires amputation is a gangrene
defined, a necrosis, caries, suppuration, fracture,  compound  dislocation,
wound of  an artery, a division from a cutting instrument, or a strangu-
lation, and that the morbid process which has resulted from it, is purely
local, and  has no disposition to  extend  higher up, we may, without any
impropriety, take away that part only which has  been actually disor-
ganized.

                                §111.

   After  traumatic  lesions, it is  generally  advised to  amputate  at the 
•  96
NEW ELEMENTS OF OPERATIVE SURGERY.
articulation, or in the continuity  of the bone  above it; the accidents
which, under such circumstances, supervene  after  amputation,  being
most  usually imputable to the fissures which  extend sometimes to the
spongy texture of the upper articular extremity of the bone which has
been  broken.   M. Kerst remarks that the fissures is always made in
the direction  taken by the projectile.  Following this indication, he has
also, in  cases where the wound has been made from above  downward,
been  enabled to  amputate  successfully  at the distance of  some  few
inches only above it.

                    Article IV.—Preparations.

                                  §1.

  The attentions, physical or moral, which we should give to the patient,
the preparations to which it is proper he should  submit before an ampu-
tation, are the same as for every important operation, and  vary, more-
over,  according to an infinity of circumstances.   Any time, season,
hour of the day or night, may be selected for the  performance of am-
putations, as well as for every other operation of  urgent necessity.   Gen-
erally, however, the  morning is preferred if we are  allowed to delay,
and this because it is more easy to watch the patient during the remain-
der of the day, than if he had been operated upon  at nightfall.

                   § II.-Dressings, (vid. Vol. I.)

  The instruments required to perform amputations that are the most
complicated, are a tourniquet, a garrote, a pelote provided with a handle,
or other  articles  suitable to arrest temporarily the current of blood in
the limb ; knives of different lengths, a straight bistoury, a convex bis-
toury, a saw with spare blades, a dissecting forceps, curved and straight
scissors,  cutting  pincers, erignes, suture needles, and a  tenaculum.
For the immediate dressing, we require single, double, triple, and quad-
ruple  waxed  threads,  of which the ligatures  of  different length and
thickness are to be formed; strips of adhesive plaster, lint in the rough,
in small  balls  and plumasseaux, (see Vol.  I.,) long, square, and also
other  shaped  compresses ; bandages of linen, and sometimes, those also
of flannel.  We must also have agaric, [or spunk  or  punk.   T.]  spon-
ges, and  warm and cold water  in different vessels ;  a small quantity of
wine, vinegar, and cologne water ; a taper, with coals, in a chafing-dish,
and a few cauteries, upon the supposition that they may be required.
  A. Among  these objects there are some which  demand every atten-
tion from the surgeon.   Thus the length of the  knives should be in
proportion to the  size of the limb which is to be removed.   Those of
Wiseman and many of the ancient surgeons had  the form of a sickle,
for the purpose of dividing at once as much of the soft parts as possible.
These curved knives, in general use for many  centuries, and which are
still employed by M.  Onsenort for disarticulating the shoulder, have been
entirely laid  aside since the  time  of Louis, who clearly  pointed  out
their inutility and disadvantages.   At the present  day  they  are  made
perfectly straight, terminating  in  a blunt, wide point.  Others, on  the 
                    AMPUTATION OF THE LIMBS.                   97

contrary, are rounded at their extremity.   There  are  some, also, that
are made very sharp at the  point, having  at the  same  time but little
breadth.  M. Weinhold, (Bull, de Fir., t. I., p. 140,) who in order to
complete the whole amputation with  one  instrument, invented a knife-
saw, (couteau-scie,) has just been surpassed  by M.  Cazenaud, (Riv.
Med., 1838, t. II., p. 442,) who possesses a citexciseur by which limbs
are amputated at a single stroke, as was already  done at the time of
Botal !  The best amputating knives, however, are those whose  cutting
edge is  slightly convex, as recommended by Lassus, and whose width is
a medium between the knives adopted by the members  or pupils  of the
ancient  Academy  of Surgery, and those  of some modern surgeons.
Their point is neither too acute, nor is it rounded  off square, so that it
does not become necessary to give to their heel a salient angle in front
of the handle which sustains them.
  B. The saw is an instrument which  has undergone still greater varia-
tions than the knife.  It is important that it should have so much weight,
as to require only to be drawn upon the bone, at the time it is in  action.
Its  blade should be properly made tense immediately before the  opera-
tion, have a slight  degree more of thickness at the teeth than near its
back, and a range  sufficiently  prominent to enable it in penetrating  to
have a free and easy movement.   This range is  given to it by the man-
ufacturer in disposing  of the teeth alternately to  the right and left.
M.  Guthrie recommends arranging these teeth upon two parallel  ranks,
so that in one their points incline forward, and in  the  other backward,
in order, he says, that  they may penetrate as well in advancing as in re-
ceding.   This modification is not adopted  with us.  The  saw used  in
England since the time of Pott and Hey, being  very light, is more  easy
of management, but to  be well-handled, it exacts more practice than the
French  saw.  The one that Brunninghausen (Operat. cit.) claims to be
the inventor of before Heine, unites according to the author, the qualities
of the ordinary saw with the advantages of that of Pott.   The turning
saw of M. Thall (Achiv. Gen.  de Mid., t. I., p. 268,) is  still  of less
importance.  This, however, is not an essential matter in an amputa-
tion.  In cases of necessity, there is no kind of  saw,  that may not
serve our purpose.  Victor Moreau performed his first  exsection of the
tibia, in 1788, with a  joiner's  saw, and M. Neve was compelled, M.
Champion  writes me, to make  use of the same tool  for  an exsection
upon the body of this bone.
  Be that as it may, it is well  in the order of regular surgery, that the
saw should always have one or two spare blades ; this is a rule which Fab-
ricius of Hilden was induced to adopt, from having been forced to leave
an amputation unfinished, until a second saw could be procured for him,
to replace the one he had broken.  As to the other  articles of the dres-
sings, I shall return to them in speaking of their  special  applications,
or of amputations in particular.

                   § III.—Position of the Patient.

  In hospitals, we generally carry the  patient  to the amphitheatre, or
to  a  ward specially appropriated for operations,  (See Vol. I.)  We
there place him upon a table more or  less elevated, and provided with
  Vol. II.                      13 
 98            NEW ELEMENTS OF OPERATIVE SURGERY.

 mattresses  and  folded sheets,  in  certain cases, he is simply  seated
 upon a chair properly arranged.   Out of public establishments, we may
 also select a particular locale, but in  general, we operate upon  a bed
 or a chair in the sleeping apartment.

                               § IV.

   The assistants (Vid. Vol. I.) should each of them have  a particular
 duty assigned to them, and that properly understood beforehand.  One
 of them is charged with compressing the artery.   For this purpose we
 generally select the strongest and tallest, or the one who  has the most
 coolness and intelligence.   A second embraces the limb near its upper
 part, in order to draw up the flesh.  The third  supports  and fixes the
 part that is to be removed.  A fourth is charged  with  handing the
 instruments, as they are required.  Others  seize hold of those  various
 parts of the body, whose movements might interfere with the operator.

      § V.— To suspend the Course of the Blood, (See Yol. I.)

   Amputation of the limbs  is the operation in which there is the most
 imperious necessity of provisional hemostatic means.  All that  I have
 said of these means, and of the  mode of using them, (vid. the preced-
 ing and present vol.,) must be borne in mind here.  Compression with
 the fingers or hands does not prevent our having  recourse to the gar-
 rote or tourniquet.  " The  garrote,  (saysM. Champion,) is my favorite
 means of suspending the course of the blood, because it succeeds better
 than any other, and because it benumbs the limb."  In a feeble subject
it  becomes a matter of  consequence to prevent even the loss of a small
quantity of blood; in the country, and where assistants cannot be had,
it  becomes indispensable ;  and is also a preventive precaution  against
 consecutive hemorrhage when we are separated some leagues from  our
 patient.  "I have seen," says the same practitioner, " the only assistant
 who was  capable of compressing the femoral  artery with a pelote, in a
 case of amputation  of  the  thigh, faint  away during the  operation, so
 that the patient would have been exposed to the  greatest  dangers, if I
 had not taken his place."   The perforated plate of the garrote exposes
 the ligature to be cut by its edges and I prefer a piece of strong leather.
 Loder says a single tourniquet is insufficient when the extremities  are
 thin ; otherwise we should  have  to make too violent a pressure.  The
 garrote, properly applied, in no  way  interferes with  our preserving a
 sufficient quantity of skin to unite the wound.
   [Mr. Guthrie states (Comm. in Surg.)  that he has rarely applied a
 tourniquet  since 1812, and that few persons have performed more formid-
 able operations under more difficult circumstances.   He regards the use of
 this instrument as injurious in amputations at the hips or shoulder joint,
 and remarks that it should  not be used in less dangerous  cases, provid-
 ed sufficient assistance can  be  obtained.  G. C. B.] 
AMPUTATION OF THE LIMBS.
99
                         CHAPTER III.

                       OPERATIVE METHODS.

              Article I.—Amputations in continuity.

  Amputations in the continuity  of the  limbs, which were overlooked
in the time of Hippocrates,  and almost the  only kind  since in use,
during a long succession of ages, are still, at the present time, the most
common ; they are performed in three  different ways, but principally
by the circular, or flap operations.

                    §  I.— The  Circular Method.

  When we amputate by the circular mode, we have to look successively
to the division of the skin, the section of the muscles, that of the bones,
the hemostatic means, and the dressing of the wound.
  A.  Division of the skin.—Celsus, (De Re Med., lib. VII., cap. 33,)
Archigenes, (Collect, de  Nicetas,-p. 156,)  Gersdorf, (Sprengel,  His1.
de la Mid., t. VII., p. 314,)  Pare and Wiseman, (Chirurg., etc., Vol.
II., p. 220,)  as  Louis,  (Mem. de VAcad, de Chir., t. II., p.   248,)
Dupuytren, (Lemons  Orates, t. IV., p. 298,) and many others have done
since, divided the  skin and  certain muscles  at the same stroke.   It
appears  on the contrary,  that Maggi (De Vuln. Bomb, et Slop., etc.,
1552) drew it up at  first to sufficient extent to be enabled  afterwards
to cover the surface of the stump with it.  This precept, nevertheless,
was rarely followed in ancient times, and it  is to J. L. Petit, (Malad.
Chir., t. III., p. 136,) to whom  the  credit is due of having caused it
to be adopted.
  I. After having circularly  divided the cutaneous envelope of the limb,
Petit caused it to be drawn up by an assistant, or did it himself,  to the
extent of almost two fingers' breadth.  Cheselden adopted the same  mode,
and nearly about the same time.
  It was Alanson, (Practical Observations,  etc., 1779,) as it  seems
to me, rather than Brunninghausen, who was the first  that  advised to
dissect it, and turn it back from  below  upwards, after the manner  of
a kind of ruff, as M. Richerand, (Nosogr.  Chir., etc.,) and many other
French surgeons have done,  at a later period.  MM.  Guthrie, (On
Gun-shot  Wounds,  &c.,  1815,) Graefe, (Normen fur  die  Ablosung
grosserer Glieder, etc., 1812,) &c., are  of opinion that we may, without
any impropriety, divide the aponeurosis  and some of the muscular fibres
at the same stroke ;  that we  are thus more sure of thoroughly dividing
the skin, and that this  membrane  then retracts  with  more facility.
Hey (Observ. de  Chir., edit. 1814) and Langenbeck (Biblioth.  Chir.,
et Nosol. und Ther.) are of a contrary  opinion.
  II.—But what advantage is there in avoiding with so much pare, the
periphery of the aponeurosis 'and muscles ?   Whether the knife  pene-
trates a little more or a little less, so long as the teguments are divided
through  their whole thickness,  the  remainder of the operation is ren-
dered thereby neither more nor  less  difficult.  Surgeons who, like Hey 
100
NEW ELEMENTS OF  OPERATIVE SURGERY.
and  M. Brunninghausen, (Nouv. Biblioth. German., t. II., 1821,) pre-
fer to have the stump completely covered by the skin, have laid it down
as a  principle  that we must first measure the circumference of the limb,
in order to preserve two  inches of the integuments, as, for example,
when we are to have a wound of four  inches  in width.  Lassus (Mid.
Oper., t. II.)  says he has followed this practice with success.
   IH-—In my opinion, precautions so  minute  are utterly useless.  The
best  plan, when it is not our  intention  to cut  down at once to the bone,
is to  divide with the amputating knife the different cellulo-fibrous bridles
which attach the external  envelope to the subjacent parts, while at the
same time an assistant, or the operator, draws it back with considerable
force towards  the upper part of the limb.  The pain is less acute, and
the skin preserves a thicker lining than when turned up like a.ruff, and
nothing is easier than to raise it in this manner to the extent of two or
three inches.
  To effect this division the  hand of the operator is passed under the
parts, and in describing an arc he brings the knife upon  the  anterior
surface  of the limb.  It is unnecessary to follow  here the  advice  of
Mynors, (Practical  Observations on   Amputat.,  Src,  1788,)  that  we
should incline its cutting edge  from below upwards in order to divide
the integuments by a sloping edge, (en  biseau.)  They are to be divided
perpendicularly, while we draw the knife from its  heel to its point,
making thus as complete and regular a circle as possible.  The hand is
first  turned  in pronation, and  gradually comes into  supination, as it
passes from the inner  side of and  then underneath the limb.  If we
prefer  making this incision at  one stroke,  the  hand  turns insensibly
upon  the  handle  of the  instrument so as to  become  gradually placed
into  forced pronation in terminating the operation.  By this means we
avoid that disagreeable and  fatiguing  twisting backwards of the wrist
that  most surgeons  make who do not wish to repeat their incision.
With practice  it is very easy to cut in  the manner I mention; but I can-
not see what great inconvenience there would be after having  divided
the skin upon the inside, outside and  underneath, to withdraw the in-
strument, as a  great number of French surgeons do, in order to re-apply
it in front to unite by means of a second cut the two  extremities of the
first  wound.   However, this is  clearly a matter of option and  not of
necessity.
   B. Division of the Muscles.—The  section of the muscles more par-
ticularly is the point which seems to have occupied the attention of ope-
rators for a century  past.  At the time of Celsus the knife was carried
a little  higher up than the dead parts  (des parties mortes;) the integu-
ments and the whole thickness of the  muscles were divided by the first
cut; then the  deeper muscles were detached and raised up in such man-
ner  that the bone might be sawed a little higher up, and these  muscles
afterwards be  brought back upon the  wound.  This  precept of Celsus,
which Pare ((Euvr. Complit.,\\Y. XII., ch. 30, p. 339)  and Pigray
 (Epitome, p. 128—129) seem also to have adopted, was for a long time
neglected; and Wiseman, J. L. Petit,  and  Cheselden, in making  the
 division of the soft parts at  two separate incisions, appear to have also
 themselves forgotten it.
   I. It was Louis who clearly  pointed out that the cone-like  shape of 
AMPUTATION OF THE  LIMBS.
101
  the stump, an almost constant result of the ancient methods was owing
  much more to the retraction of the muscles than to that of the skin.
  He therefore advised that the muscular layers should be divided by two
  successive  cuts.  With the first incision Louis divided the integuments
  and superficial muscles, causing them at the  same time to be  drawn
  back  with as much force as possible, so as to favor their retraction by
  every means in his power.   The deep layers were  divided by a second
  cut; after which he made the section of the bone in the ordinary manner.
    II.  Le  Dran  (Operations, etc., p. 556) says: "With one stroke I
  divide the integuments and one half the thickness of the muscles ; I
  then immediately cause the skfei and  flesh  to be drawn back as much as
  possible, and make a second incision in a circular direction and upon a
  line with the skin where it is drawn back  and divided.  By this last I
  cut none of the skin, but only  the muscles  down to the periosteum."
  This process has much resemblance to that of Pigray (Epitome, p. 128,
  in 12mo, 1615)  or Celsus, and differs also as  we see but very little from
  that of  Louis.  But it is this last  author to whom the  credit is due of
  having made its importance appreciated.
,    III. Valentin  (Recherches  Critiques sur la Chir., p. 135) in  his
  Critical Researches on Surgery, conceived that in order to  divide  the
  muscles it was necessary to put them successively in a state of extension
  at the moment when the knife was about to be applied to them ; so that
  in the thigh for example, while the instrument was making  its circuit,
  the limb, in adopting rigorously the rule of Valentin, would  have to be
  thrown  first backwards, then outwardly, then forwards, and  finally in-
  wards.  This whimsical  recommendation  has not had and ought not to
  have any partisans.
    IV. That of Portal  (Acad,  des Sicence.  t. CXXXVIIL, p.  693, in
  12mo, Ann. 1777) who reversing the precept of Valentin, recommends
  that in dividing the flexor muscles*he limb should be held in the utmost
  degree of flexion possible, and in a state of  extension  for the division
  of the extensor muscles, has not met with any greater success, though
  according to the  author, Marechal made use  of it at the hospital of
  Strasbourg.
    V. Desault ((Euvres Chir., t. II., p. 547) combined the  methods of
  Petit and Louis, that is to say, he recommended with the first of these
  authors  first to  divide and draw back the skin, and with  the second to
  divide afterwards the superficial muscular  layer on a line with the skin
  as drawn back, and to begin the section of the deep muscles at the line
  where the first had been retracted.
    VI. After having dissected and turned back the skin, Alanson di-
  vided the whole of the muscles with a single  stroke of the knife, taking
  care to direct the  cutting edge of his instrument obliquely upwards,
  and to carry  the point  of it still more obliquely around the bone, with
  the  view of obtaining a hollow cone whose base  should be at the peri-
  phery of the wound.  M. Langenbeck opposes this mode of proceeding,
  and Wardenburg, in maintaining the impossibility of forming a hollow
  cone, by following implicitly the process of Alanson, says that the knife
  held obliquely will of necessity take a spiral instead  of a circular di-
  rection.   Loefler and Loder on the other hand  endeavored to show that
  it was an easy matter to correct this tendency of making a spinal inci- 
102            NEW ELEMENTS  OF OPERATIVE SURGERY.
sion.   It would appear that MM. Langenbeck and Graefe upon this point
have misconceived the  process of the English surgeon.   In fact Dupuy-
tren constantly employed this process at the Hotel-Dieu with the great-
est success.  In order that the knife when  carried obliquely may not
deviate from the circular  direction, it suffices to hold the handle-prop-
erly, in proportion as the blade penetrates.  Alanson moreover had ob-
served that it was principally by means of its point that we hollow out
a cone through the muscles.
  VII.  In the process of  Dupuytren an  assistant forcibly draws back
the soft parts ; the operator holding the knife by the mode of Alanson
then divides the skin and the whole thiclwiess of the muscles with a  sin-
gle stroke ;  he then immediately brings back the instrument held in the
same  manner, upon the base of the fleshy cone which is left upon the
bone by the retraction of the  superficial muscles.  This is done with
extreme rapidity, and the  result  of the process is the formation of a
perfect  hollow cone, which apparently is exceedingly favorable to the
union of the wound.
  VIII.  Bell  (Cours de  Chirurg., trad, par Bosquillon,) after  having
divided the skin in the manner of J. L. Petit, and the muscles accord- t
ing to the  method of Wiseman, passed  his amputating knife between
these  latter and the bone,  in order to divide their adhesions to the  ex-
tent of  about two inches, and in this manner to raise them with greater
facility.
  IX.  All  these processes have undergone other modifications which it
is unnecessary to enumerate.  The brevity of the text of Celsus has not
prevented us from  discovering  in  this author the origin of the process
of Petit, Louis and Bell, and even that of Dupuytren; but if it be ques-
tionable  that  any  surgeon at that epoch followed a method at all com-
parable with those which are adopted in our days, it is not so with that
which Pigray describes in the following manner:—" After having drawn
the skin back  with the two hands, we must cut all the muscles around
the limb above the disease; we  then, with a split compress, raise up the
divided muscle in order  to  saw  the  bone as high up and as near the
flesh as  possible.  The hemorrhage being arrested by caustics, astrin-
gents  or the  ligature, we bring  back  the skin in order to adjust it in
front of the wound by two stitches of suture placed across it.
  X.  What is remarkable in all these processes, in appearance so  dif-
ferent, is this, that when closely examined the most of them lead to  the
same  results.   Whether  the  skin and  superficial muscles are divided
with  the first  cut  and the deep-seated  muscles with a second incision
after  the manner of Louis ; or we adopt, on the  contrary,  the rules laid
down by  Dupuytren; or whether the section of the soft parts be made
in three stages, as Desault recommends, or in the manner Alanson made
this division, or as Bell  advises ; so long as we take care to favor the
retraction  of the muscles, the  bone is laid bare at two, three and four
inches above the point where the incision commenced.  The division of
the muscles in amputations, in conformity with either this or that mode,
is  therefore a  matter  of  much less importance than some people sup-
pose.
   XL  The process of Bell found, in 1829, a new champion in M. Hello,
(These  No. 258, Paris, 1829,)  formerly a naval surgeon, who recom- 
AMPUTATION OF THE LIMBS.
103
mends that it should in every case be substituted for the process of hol-
lowing  out  the muscles  (i. e., the process of the hollow cone.  T.) and
it  is  the one M. Champion usually adopts.  In the trials I have  made
of it, it has in reality appeared to me that the muscles thus detached re-
adhere with greater facility upon the front part of the bone, and that they
could be more readily put in contact and kept approximated face to face,
from the bottom to the borders of the wound, than by any other method.
The only  difficulty  is that the operative process is a little longer and
not so easy.
  XII. With the view of preventing too great a shock upon the system,
Faure (Encycloped. Method. Mid., t. II., p. 210) seriously proposes to
take  off the limb by  a succession  of  operations in three, four or five
times  for  example, at 4 to 5 days apart;  the first section to comprise a
fourth of the circumference of the part, I suppose;  some days after an-
other  fourth to be  divided  and  so  on to the conclusion.   Faure even
asks  the question  whether it would not  be advisable to allow the first
wound to cicatrize before proceeding to the second!
  XIII. The author.  The most rational, surest, "and the most general-
ly applicable method is as follows :—The skin is divided with the first
cut without endeavoring too scrupulously to avoid the subjacent parts.
An assistant raises it up while the surgeon divides the bridles which at-
tach  it to the aponeurosis or muscles, to the extent of  two to three fin-
gers' breadth.  The knife now applied on a line with the refracted skin,
passes  circularly  and perpendicularly  through all the muscles down to
the  bone, or at least sufficiently near the bone for  the superficial layer
to be completely divided.  The assistant  again forcibly draws back the
parts, and  the  surgeon, with  a second cut, divides all the fleshy fibres
of the deep-seated layer, at the point where this layer passes under the
retracted  extremities of the muscles that were first divided.  Whether
the knife  be held  obliquely or perpendicularly makes no difference in
the final result; whether we go immediately down to the bone or mere-
ly to the deep-seated  muscular layer is all the same.  In both cases,
however, we have to make a second division of those fleshy fibres most
adherent to the bone and  at two or three inches above the place of the
first division.  I divide the tissues perpendicularly, in order to obtain a
cleaner section and a less extended traumatic surface.
  C.  The  section of the muscles  being completed, we raise them up-
wards by means of a retractor.   Formerly they  used  for  this purpose
bags of wool or linen, or pieces of leather, and even of metal.  Fabri-
cius of Hilden,  Gooch, Bell, and Percy have severally  extolled these
objects ; but at the present time we require only a simple split compress,
with two tails for the thigh and arm, and three for the leg and fore-arm.
The undivided portion of this compress is drawn back upon the posterior in
preference to the anterior portion of the muscles, as M. Graefe recom-
mends ; while its two free  extremities are crossed  and turned back in
front; the assistant who embraces the  whole with  the two hands thus
draws the soft parts backwards, to protect them from the action of the
saw.   It is requisite, moreover, that this split compress, to which some
surgeons, smartly reproved for it by Petit, have objected on the pretext
that it interferes  with  the  action of the saw, should be made of strong
linen and wide enough to extend beyond the sides of the wound. 
104
NEW ELEMENTS OF  OPERATIVE SURGERY.
  I. Before proceeding farther, most surgeons recommend dividing and
carefully scraping the periosteum.   It was with the back of their great
sickle  that  Pare and Wiseman  effected  this denudation.  Since  that
time the bistoury or the edge of  an ordinary  knife has been  preferred
for  that purpose.  Some with Graefe  perform this from above  down-
wards ; others with Brunninghausen detach the  periosteum in this man-
ner from below upwards, or like M. V. Onsenort, form a flap with it in
order to bring it down afterwards upon the section made by the saw.
  II. All those  precautions are useless as Alanson, MM. Guthrie and
Cooper, and before them J. L. Petit and Ledran, had  already pointed
out.  The motive in recommending them was to obviate the increase of
pain, or to prevent tetanus, exfoliation  and  inflammation of the bone
as well as the suppuration of the surrounding parts ; as if the periosteum
could have  the  least to  do with the  production of such phenomena!
When it has been carefully separated, one of two things must happen :
1, The  saw is applied a little  higher up than  the  surgeon is  aware
of, and  then it is the same as if  no regard  was  paid to it; 2, the saw
is in reality applied to the denuded portion of bone, and in this  case it
would  be strange if there should not remain higher up a small portion
which has been deprived of its envelope.  In fine, if the surgeon attains
the  object he has in view, the precaution is injurious, and if he fails, it
is, to say the least, useless.  He must confine himself,  therefore, to de-
taching carefully the fleshy fibres with "the knife or the bistoury.
  D. Section  of the Bone.—Having done  this, he embraces the  limb
with his left hand, placing the thumb immediately above or below the
point which is to sustain the action of the instrument.  The  saw, held
in his right hand, is applied perpendicularly ; we first move it rapidly
with short cuts  until it  has worked itself a passage; afterwards, we
draw it through the whole extent of its blade, pressing only moderately
upon it.  So long as it has not yet made its way through the thickness
of the bone, we may move it with rapidity ; but  as soon as it has  nearly
completed the section, we must proceed with the utmost degree of cau-
tion.  It is at this moment  that the two assistants who are holding the
two opposite portions of the limb, must redouble their attention in order
to keep these in their  natural direction.   If the  assistant who  holds
the  diseased portion, lowers it, the bone almost unavoidably breaks be-
fore being entirely cut through ; if he raises it, on the contrary, the
progress of the saw will  soon be arrested, and the operation thus ren-
dered more difficult.   It is necessary that the operator should make
himself familiar  with handling this  instrument, and when he  uses it he
should take  care not to incline it either in one  direction or the other.
By  attending to all  these  precautions, the  bone is usually  sawed  off
neatly.  Nevertheless, if any points or roughnesses remain  upon  the
extremity, they should be immediately removed with the cutting forceps,
as is usually  done, or what appears to me  preferable, by  means  of a
small saw, or when they are of considerable length, by using the same
saw which has  served for the  amputation.  The  edges of the  sawed
bone are usually quite pointed and sharp.   Some practitioners, indeed,
as  MM. Graefe and Hutchinson, have  advised that these should be
smoothed down  with a file, or with  the cutting  edge of a strong, short 
AMPUTATION OF THE  LIMBS.                 105
 scalpel, but this practice has rarely been imitated by other operators.
 Theory and observation unite, in fact, in showing its inutility.

                      § II.— The flap operation.

   The flap operation which  Sprengel (Histoire de la Mid., t. VII., p.
 316)  and Gagnier (These de Holler, 1734, t. V.)  seem disposed to as-
 cribe  to Celsus, to Maggi and other ancient surgeons, such as Pare and
 de Hilden, was not, as it is  generally believed, proposed  for the  first
 time by Lowdham, in his  letter to Young, in 1679.  We shall  see far-
 ther on, that Leonidas and Heliodorus describe it  with sufficient clear-
 ness.   It consists in cutting at the expense of the soft parts one or two
 flaps, which enable us to close the wound immediately and completely.
 After Lowdham, this method was extolled and variously modified, by
 Verduin of Amsterdam, in 1696 ;  by Sabourin, of Geneva, in 1702 ;  and
 by  Morand, De la Faye, (Acad.  Roy. de  Chir., t. II., p.  243,)  and
 Garengeot, (Ibid., t. II., p. 261,) before the middle of the last century.
 At  first opposed by Koenerding, (Sprengel, Oper. cit., t. VII, p. 318,)
 countryman of Verduin, and by Heister and many others, it was  soon
 defended again by  P.  Massuet,  (Amput.  a  Lamb. Paris,  1751,)  Le
 Dran, Ravaton, and Vermale.   Since  then, O'Halloran, Dupuytren,
 Roux, Guthrie, Klein, Kern, Langenbeck, Larrey,  and a multitude  of
 other surgeons, have frequently had recourse to it.   Its history presents
 two epochs  that  are  quite  distinct; one  that  comprises all that  was
• said of it in  the last century ; the other, that which belongs more espe-
 cially to the  present time.
   A.   Appreciation.—Lowdham  (Young,  Currus  Triomph. e tereb.,
 1679  ; Mem. del1 Acad. Roy. de   Chir., t. II., p. 244,) maintains that
 the flap operation is more prompt and less painful, and that it exposes
 less to tetanus and hemorrhage than circular amputation, that it renders
 the ligature  upon  the  vessels useless, prevents exfoliation, obtains a
 rapid cure, and allows of an extremely easy adaptation of an artificial
 limb.
   There is a considerable number of these advantages that  experience
 has not corroborated.  In the first place we  cannot see how  the  flap
 amputation can be less painful or  be  more certain to prevent tetanus
 than the circular method.   Exfoliation is a rare occurrence, instead of
 being constant, as it was then believed to be.  As thejtertificial limbs
 are not to be applied upon  the  apex of the  stump, it is a matter of in-
 difference in  this respect,  whether the amputation  has ieen performed
 by  one method or the other.  In fine, it is easy  to perceive that we can-
 not dispense  with tying the vessels, and that  the wound scarcely  ever
 cicatrizes without suppurating for a greater or less length of time.   Its
 immediate reunion, however, is  an incontestible  advantage; and did not
 the improvements of the circular method allow  of  our  accomplishing in
 most  cases the same result, there is no doubt that the flap operation at
 the present day would have been generally preferred.  We must allow,
 also,  that it generally enables us to avoid with facility the projection of
 the bones and the conicity of the  stump, and to preserve as much of the
 soft parts as  are necessary to uniting  without traction the widest  and
 deepest kind of wounds.
   Vol. II.                    14 
106            NEW ELEMENTS OF OPERATIVE  SURGERY.
   B.  Processes.—The flap  amputation is  performed by  two general
methods, the one from without inwards, the other from within outwards.
In one we divide from the skin to the bones, while in the other, we com-
mence by thrusting the knife through the limb, so as to cut  the flap from
the root to its free border.  If the first mode is more regular and sure,
the second is more rapid  and brilliant.
  From without inwards, it is well to begin  by dividing the integuments
with a single stroke ;  we then cause the assistant to  draw them back,
in order that with a second cut we may effect the division of the muscles
a little higher up.  In proceeding in this manner,  it is easy to  give to
the flaps the form and dimensions desired,  but  the operation  requires
several stages, and is not as rapid.  If we plunge through  the flesh, at
first the point of the instrument, in danger of striking against the bones,
often  wounds parts that we should have  preferred to avoid, divides ir-
regularly  certain  tissues whose exact (nette) section is  a  matter of
some  importance, and does not always allow  of our cutting flaps as thick
as they should be  for the  object  we  have in  view.   Nevertheless, this
mode  of operating has found in our times, especially in dissecting rooms,
and among those who practise  upon the dead body, numerous and intel-
ligent partisans ; but it is scarcely ever  employed, any more than  the
preceding mode for amputation in the continuity.
  In  conclusion, too much importance, as I think, has been  generally
accorded to the flap operation.  The wound which  it causes  has neces-
sarily a much greater extent of surface  than if  it was  circular.  The
muscles which this mode deems it so  important to preserve, are exposed'
to various accidents.  If they should be attacked with inflammation,
they  suppurate most  abundantly, absorb the fluid like a sponge, and
favor  to a remarkable  degree purulent infection  and  phlebitis.  On the
other  hand, they  scarcely  ever  become  adherent  to the  apex  of the
stump in the centre of the cicatrix.  By whatever mode we may proceed,
it is the skin which finally becomes united to the cut surface of the bone,
and the side of the flaps through means of the  retraction of the  angles
of the wound, favors to a greater degree than  any other method  the
protrusion of the bone.
  C.  The flap method moreover  presents a number of distinct modifi-
cations.  Lowdham,  Verduin, Labourin, M. Guthrie, and M.  Graefe,
confine themselves to a single lower flap, which they bring up in contact
with the bleed|jfc  surface..  Vermale recommends  cutting one on each
side, and to mase them by plunging  the knife down to the spot where
the bone is to k| sawed.   That we may  not be  deceived  in  regard to
the length, he  proposes, before we commence, that we  should mark out
with a red thread the point of  departure and the point  where  we  are
to terminate.  Ravaton and Bell, with one stroke of the knife, divide
circularly  the skin and the  entire thickness  of the  muscles ; another
incision, which strikes upon the bone in front and behind, in a direction
parallel to its axis, then allows of the separation  of the two flaps, which
are dissected  off  and raised up  immediately after.  The process of
Vermale is at present the only one, or almost the  only one, employed,
even for the formation of a single flap.   The mode of Ravaton ought
not, in fact, to be  followed.  The circular incision  which it first makes,
is altogether so much loss.  The flaps cut out in this manner, square, 
AMPUTATION OF THE LIMBS.
107
have too much thickness at  their apex, and interfere to a considerable
extent with their immediate  union.  When, on  the  contrary, they  are
cut with slanting or bevilled edges, they adapt themselves to each other
accurately, even though we neglect the rule laid down by Mynors, that
the skin should also be divided in a very oblique direction at the expense
of its deep-seated layers.
  D.   Two flaps should be preferred when we have it in our  power to
give them nearly the  same degree of width and thickness, whereas, if
we are unable to give to either one of them the proper dimensions, it is
better  to cut  one only.  If  the wound or the disease  which compels us
to amputate should leave considerably more sound tissue on one side
than on  the other, and-has thus in some degree indicated the character
of the flaps in advance, we should avail ourselves of it.  After  having
completed  the section of the bone, we then equalise the fleshy parts in
order to cover the stump with them.  Nevertheless, it becomes necessary
in this last case, in order  to close the wound, that the flap, if there be
but one of  them, should have considerable length, and that it should be
bent almost to a right  angle and submitted to compression and tractions,
which  nevertheless endanger the success of the operation.  With two
flaps, on the  contrary, one  in front and one behind, as M. Walther
(Rust's Handbuch der  Chir., t. I., p.  609) advises, the bleeding sur-
faces are adjusted to each other without the least difficulty.
   E.  Kirckland, who excises  the two angles of the wound, and M. Lar-
rey, who confines himself  to slitting them afterwards to the extent of
half an inch, make in  this manner a sort of flap operation out of the cir-
cular method.  M. Sedillot  has  remarked that in most of the methods
of disarticulations in which a flap is cut in terminating the operation, the
knife  almost always  encounters a difficulty in getting below the bones
that are to be removed ; the angles of the wound moreover being stretch-
ed and bridled, are thus jagged  and cut to a greater or  less depth by
means  of the instrument.  To avoid this inconvenience, M. Sedillot in-
cises at first about a third of the extent of the flap with the heel of the
knife or bistoury, and afterwards  experiences no  difficulty in finishing
the operation without  injuring the angles of the wound.  In the continu-
ity of the limbs, at the thigh, the upper part of  the leg, and at the arm
or fore-arm, M.  Sedillot cuts two small, short, rounded flaps, which are
then raised up to complete the operation by the ordinary processes for
circular amputation.   We  thus unite  the advantages of  wounds with
double  flaps to those  of circular amputation, the  bones being covered
over in a proper manner, and prevented from projecting  at the Sngles
of the wound.   I have recently, says the author, applied this method to
the fore-arm, and obtained the most satisfactory  results.  We shall see,
in describing amputations in particular, what are the cases which do not
admit of this mode of operating.  M.  J. Cloquet has suggested  that in
certain cases, after having cut through the skin circularly, it would be
better, instead  of dividing the other soft parts  in the same manner, to
plunge the knife between them and the bones, in order to cut from with-
in outwards as in the  flap method.   Finally, Dupuytren, M. Larrey, and
others have frequently endeavored to combine the ovalar with the ordi-
nary flap operation, by commencing with the division of the skin from
without inwards, and  terminating with  the division of the muscles from
within outwards. 
108            NEW ELEMENTS OF  OPERATIVE SURGERY.
                   § III.— The  Ovalar  Method.

  The ovalar method, though more recent than the two others, and already
described in the commencement of this century by Chasley (Rust's Hand-
buck  der Chir.,  t. I., p. 59o) and M.  Lan^enbeck, (Theses de Paris,
1803,) and by Lebas, (Bull, de la Fac. de Mid. de Paris, t. V., p. 417
—420,)  who explains it in a memoir, upon which Beclard reported to
the Society of the Faculty of Medicine, and afterwards by MM. Guthrie
and Richerand, for certain kinds of amputation only, was not in reality
introduced  into  practice until in the year 1827, by M. Scoutetten, (De
la Mith. Oval.,ou  Nouv.  Mith., etc.,  Paris, 1827.)   According  to
this last  surgeon, its great advantage consists in always allowing us to
cut from  without inwards, that is, from the superficial to the deep-seated
parts, as  in the circular method, and of preserving also a sufficiency of
the flesh and soft parts to  enable us with  ease to bring  the lips of  the
wound into coaptation, as in the flap operation ; so that it occupies, as
he says, the middle  ground between the two other methods, and is  the
link which either separates or unites them.  It is certain, that by  the
ovalar method, we  obtain  a neat  and regular division ;  that for  the
most part, we may preserve a sufficiency of tissues to undertake imme-
diate reunion ;  and that there are but few  points upon the limbs to
which it  is not applicable, unless it be in the  continuity of such as pre-
sent length  enough to make the circular or flap method easy and sure.
Its  distinctive characteristic is to form a wound of an ovoid shape, as
already pointed  out by  Lassus, in 1793, M. Chasley, in 1803, or 1804,
and  M. Langenbeck, in 1809, and on which account M. Scoutetten  has
given it the name which I have retained.  It consists of two  processes
which  differ but  little  from each other.   In the one case, which is  the
most ancient, the operator begins by circumscribing a triangular flap in
the form of an inverted V, a little under the place where he proposes
to use  the  saw or to disarticulate  the  bone.   After  having depressed
the summit of this triangle, and separated the two lips of the  wound,
he passes from above  downwards, or from one side to the other, using
the saw in amputations at the continuity, and the  knife in cases of dis-
articulation, grazing the posterior and deep-seated surface of the bone,
and  terminating by uniting the two first incisions at the base  of the V,
where the vessels had been preserved.   M. Scoutetten  prefers giving
at the  very  first a perfectly oval form to his incision ; except  that he
takes care in passing under the plexus of vessels  and nerves and near
the point which is to form  the larger extremity  of the oval, to go no
deeper at first than the tegumentary  tissues.  This is no farther impor-
tant than that it gives a little more regularity  to the incision.   The oval
method has the advantage of uniting all that is most approved of, both
in the circular and flap  processes.   I have frequently used it, but shall
examine  it more  in detail in the chapter on Amputations of the Joints.

           Article II.—Amputation in  the Contiguity.

  The perusal of the works of Hippocrates teaches  us that there was
a species of amputation at  the joints, sometimes practised among  the 
AMPUTATION OF THE LIMBS.
109
ancients.   Galen and Heliodorus also  speak of it  in  sufficiently clear
language.  The Arabs themselves were not ignorant of it, and Sprengel
is evidently in an error when he says that, from the time of the Greek
writers down to Munnicks, nobody  makes any mention of it.  Guy de
Chauliac states positively that, " if the disease invades the immediate
neighborhood of the joint, the limb should  be taken off at the  joint
itself, by means of a razor  or other instruments, and without sawing."
Nor has Pare passed it over in silence.  Fabricius of Hilden, speaks of
it as a common process ; and Pigray thus expresses himself upon  this
subject: " Some start objections to cutting in the joint itself, or near it,
because of the  nervous parts, nevertheless, the dangers from these are
not so very great: / have seen  many such (amputations) which  have
done well.'1'' The labors of Ledran, Morand, Heister, Brasdor, and Hoin,
therefore, have done no more than to revive this  operation, by dispel-
ling the prejudices with which the physiology of the  middle  ages  had
invested it.  It is performed like amputation in the continuity in three
principal ways, but more especially by the flat or the ovalar method.  We
shall see, farther on, however, that  the circular method is perfectly ap-
plicable to it, and that this  ought, in  a large  number of cases, to have
the preference.
   The  advantages of disarticulation  are, that it is more prompt and
easy than amputation in the body of the limbs ; that it does not require
the section of the bones, is more favorable to immediate union, and en-
ables us to preserve a longer stump.  Its  disadvantages, at least in a
larger number of cases, are : that  it lays bare extensive osseous or car-
tilaginous  surfaces ; that it obliges us  to carry the instrument upon the
thickest parts of the  bones, which  are least  abundantly supplied  with
soft parts, and to make use  frequently of tendinous or synovial tissues
for closing the wound ; and  that it also makes a solution of continuity,
somewhat  irregular:  but it is not true, other things being equal, that it
endangers, more than amputation  in  the  continuity, as had been for a
long  period thought, nervous symptoms, tetanus, abscesses, purulent
collections, and symptoms of general reaction.  It  requires but few
instruments, and no necessity of  such  complicated dressings as are de-
manded in amputation  in the continuity.  A  knife or simple bistoury
are generally all that are needed to perform every step of the operation.
So also have we less  to fear  from the  conicity of the stump, the projec-
tion of the bones, or the retraction of the muscles.  As  the soft parts
are but slightly displaced, the adhesion  of the  flaps  is  obtained  with
facility, and the inflammation proceeds  no farther than is requisite to
secure immediate union.  The  division   acting only on the skin, the
cellular and fibrous tissues and some of the attachments of the muscles;
inflammation, abscesses, and constitutional reaction, are in general but
little to be apprehended.  Though very large in appearance, the wound
has in reality but very little  extent; because the cartilaginous surfaces
at the bottom of it, being deprived of all  sensibility  and wholly inert,
take  no part in the process of suppuration or inflammation.  M. Kerst,
professor in the military hospital of instruction at Utrecht, prefers, as a
general rule,  disarticulation to  amputation in the continuity, because
from the last we have to apprehend traumatic fever of a pernicious (per- 
110
NEW ELEMENTS OF OPERATIVE SURGERY.
nicieuse) and  intermittent character, together with inflammtion of the
veins in the sawed bone.
  The dread which prevailed among  surgeons of the last century, of
wounding the inter-articular cartilages, exposing them to the  air, and
touching them with the instrument, is  at the present day  entirely  dis-
pelled.   In place of all those precautions formerly recommended in order
to avoid the articular surface, which constitutes the bottom of the stump,
some modern surgeons go to the extent  of advising that it should be
wounded expressly.  For example, M. Gensoul ( These No. 109, Paris,
1824)  is of the opinion of Richter and Bromfield, that in  scarifying it
with the point of the knife, we have  a better prospect  of cicatrization
by the first intention.  This practice,  adopted also by some surgeons of
Paris, and which is attended with no inconvenience, seems, nevertheless,
to be sustained upon a position which is far from being demonstrated. In
fact, it is incorrect to say, with Beclard and many others, that after ampu-
tation in the contiguity, [i. e., in the joint, vid. supra. T.] the smooth face
of the cartilage does not unite  with the flaps, but remains free even after
the final cure, unless by some means or another, inflammation  has  been
excited.   This can only take place  by exception.  Whether the instru-
ment comes in contact with it  or not,  it nevertheless contracts, and that
speedily, firm  adhesions with the tissues  that cover it; and it is as use
less to sprape it  with a scalpel  as to  cauterize it, in the manner  prac-
tised in the  time  of Heliodorus.  If the agglutination is not imme-
diate, the cartilaginous  surface,  acted upon by the cellular  granula-
tions which are formed upon the bone, soon detaches itself,  sometimes in
fragments, sometimes in large pieces, at other times in the  form of a
shell, and soon completely exfoliates, leaving exposed a vermillion-colored
wound, which afterwards cicatrizes with great facility.  In the contrary
case it does not  perceptibly change  its appearance ; it only  loses its
polish and becomes rugose, but a molecular action soon developes itself,
erodes, and insensibly dissolves it, until it has totally disappeared.  Con-
stituting the true epiderm of the bones, and consisting of a simple an-
histe tissue, it cannot, with the attributes that  belong to it,  exist any
longer than while the articular movements are preserved.   As  soon  as
the living tissues rest permanently upon it, the  vitality  of the bones,
properly so called, begins to act upon it  and  to  destroy it, by creating
the cellulo-fibrous deposition, which is the base of every sound cicatrix ;
unless in its  actual state of cartilage, it becomes  agglutinated to the
soft tissues, by becoming, as M. Champion thinks, organized and blended
with them.  By one mode or the other, the tendons, aponeuroses, nerves
and vessels ultimately become firmly adherent  upon the  extremity  of
the stump, so much so, that the patient is enabled  to move it with  as
much facility after the cure as before the operation.
   When the  articulation is surrounded with a large capsule, it is well
to  remove as much of it  as possible with the  bone, without however
 giving ourselves any great uneasiness about such part of it as may re-
 main.  In place of leaving the tendons hanging out of  the  wound, they
 should on the  contrary  be cut off as low down as possible,  that  their
 presence may not  interfere  with the immediate  union.   The incision
 into the fibrous  and  synovial sheaths, as recommended by Garengeot
 and  Bertrandi, with the view of preventing their inflammation and the 
AMPUTATION OF THE  LIMBS.
Ill
formation of purulent collections, is useless, and should not be practised
unless there are particular indications for it.
  The fistulas which  sometimes follow amputations at the joints, are
owing either to some point of the cartilaginous surface  which has not
exfoliated or become adherent to the flap of the soft parts, continuing
to exude synovia; or to one or more of the  tendinous  sheaths which
have not closed, furnishing fluids of  the same nature in quantities suffi-
cient  to  become an impediment to the agglutination  of  the tissues.
These difficulties are in general very  easily overcome, and almost always
without any serious consequences, by means of compression, stimulating
injections, cauterization, &c.  Moreover, amputations in  the continuity
are by no means absolutely exempt from such accidents.  If, therefore,
in amputating below the articulation we can remove all the  disease, and
at the same time preserve a sufficiency of tissues to close  the wound,
amputation in the continuity ought to have the preference ;  on the con-
trary  it is better to amputate at the joint than to go above it.   On the
other  hand, if in amputating at the  articulation  we should incur the
risk of not removing all the disease, we should renounce it and  carry
the' instrument higher up.   When in amputating in the  continuity we
are obliged to make the section of the bones*too near the  great synovial
cavities,  disarticulation is the^eferable  course.  The danger of  puru-
lent arthritis is then too.imminent not to justify the immediate  sacrifice
of the joint.   All these questions, moreover, have been  judiciously ex-
amined by M. Sedillot, (These de Concours, 1836.)  In conclusion, the
extirpation of the limbs is not more dangerous than their  amputation,
properly so called, and it is the extent of the disease and the  functions
of the organ to be removed, which are to influence  the  surgeon in his
preference for one of these methods over  the  other, in  the particular
cases  that present.

                   Article III.—The Dressing

                      § I.—Hemostatic Means.

  To  prevent the flow of blood after amputations, is one of those indi-
cations which has most engaged the  attention  of surgeons  at  every
epoch ; and what I have said of hemostatic means in treating of opera-
tions in general (vid. Vol. I.) are especially applicable to amputations.
  A.  At the present day we are no longer under the necessity of re-
commending to surgeons  the remedy eulogized by Galen,  of  one  part
incense and a half of aloes with  the white of an egg ; nor the mush-
room  nor puff-ball vaunted by Van Horn, and  revived  by Vurtz, (La
Chirurgie, p.  36;)  nor Fowler's powder, nor  hog-excrement, nor the
powder of burnt agaric  mentioned  by Charmetton, nor the thrusting
the  arm into the bowels of  a cock opened alive, after having cut off the
wrist, as  did that brute mentioned by F. Platter, (Bonet, t.  III., p. 145,
liv. 4, obs. 25 ;)  nor the animal oil of Dippel given internally by Schulze,
(Rondelai, Hemorrh. Internes, p. 90.— These de  Paris, in  8vo.)   The
hemostatic bladder, used by Gersdorf, ( Chirurgien d' Armie in  German,
p. 63,1527,) reintroduced  by Wiseman and afterwards by Fabre, (Es-
sais sur  divers Points de Physiologie, p. 160,  lllO.—Recherches des 
112
NEW ELEMENTS OF OPERATIVE SURGERY.
Vrais Principes de V Art de Guerir, p. 531,1790,) and on one occa-
sion made trial of on the fore-arm with success by Frescarode (Fabre,
Recherches, &c., p. 278,  1783) are  equally  useless.   Nor has  the  re-
union of the wound by flaps and compression, which answered the pur-
pose with Verduin and Sabourin, and which  Kock has so much eulogiz-
ed, ar-d  Smith  employed, any  longer to be discussed, even though  we
should combine with it  like Garengeot (Mem. de V Acad, de Chir., t.
II., p. 180 ;  and torn. V., p. 263) a ligature on the  principal  artery.
It is effectually the ligature or torsion that we must  have recourse to
after amputations, unless  in cases  altogether  of an exceptional nature.
  B. It was for a long time thought advisable to include a certain por-
tion of  tissue in the ligature upon each artery.   If Fabre is to be  be-
lieved, Oper. cit., p. 278, 1783,)  it was Ferrand who first resorted in
amputations to direct ligature upon  the artery.  The author of a thesis
upon surgery at that time also made the same remark.  Desault (Journ.
de  Chir., t. IV., p.  203)  according to Bichat (Eloge de Desault, par
Bichat,  p. 43) had  recourse to  this  means, Louis  being  present, at  the
Bicctre  in 1779, and before any other modern.  Pouteau (Ancien Journ.
de Mid., t. XLVIIL, p. 440, 1777) recommended also that the artery
should be isolated on each side the ligature, in order to prevent accidents.
Nothing analogous to this is in practice m the present day.  The tena-
culum of Bromfield under this  point of view has naturally  carried us
back without any disadvantage to the time of Avicenna; the artery is
to be denuded, that is, stripped of the flesh that invests it, says the cele-
brated Arab, (Guy de Chauliac, trad, de Mingelouseaulx, t. I., p. 112 ;
Des Plaies,ch.TV., Quatrieme  Facon d'arreler le  Sang;) we then
seize hold of it with a small hook, draw it gently outward, pass under
it a thread of silk, and then tie it with a firm knot.
  In order not to entrust to an inexperienced assistant the direction of
the ligature, Brunninghausen (Expir. et Obs. surVAmput.— Gaz. Mid.
Chir. d'Ehrhart, 1818,  et  Nouv. Bibl.  Germanique, t. II., 1821, p.
51) makes use of a small fork with blunt points, by means of which he
passes the thread above the artery, until the assistant  has tightened  the
knot  outside of the wound, and  in a horizontal  direction.   As large
as well  as small arteries  are to be tied, the author has had constructed
a double instrument, the  branches of which separate  farther apart on
one side than on the other, so that by means of the narrower  extremity
we may also bring up to  a level with the wound the  arteries that have
retracted too deeply,'and likewise separate  them  from the nerves and
other parts with which they may be united ; but the spring forceps  de-
scribed  in  the article  on  torsion,  (vid. Vol. I.,) and the pinces-porte-
nauds,  as contrived by MM. J. Colquet and Colombat,  would be much
preferable, if under such circumstances there should  be any necessity
of  a particular instrument.
   The  ligatures  required,  also  sometimes amount to  a considerable
number.  Loder (Bibl.   Germ. Mid. Chir., trad. France., t . II., p.  94)
relates  that he was obliged in a case of  amputation  of the  leg in an
infant, to use sixteen before he could effectually arrest the hemorrhage.
In another case he used  nineteen, and several smaller  arteries were in-
cluded  in the same ligature.  The  first case  recovered in twenty-five
days ; but in  the other  the flap, on removing the dressing on  the fifth 
AMPUTATION OF THE LIMBS.
113
day, was found to have become detached.  In other  cases  there is no
hemorrhage, and the ligature is  inapplicable, for  we  find no  arteries,
(Taxil Saint-Vincent, Jour. Univ. des Science, Mid., t.—, p. 324.)  I
have  elsewhere detailed (Jour. Hebd. Univ., t. I. et II.) numerous ex-
amples  of this kind.  Zinc  (Chalmail, Recherches sur les Metastases,
p. 265) has  seen this in the  fore-arm, Chalmail (Chalmail, Op. cit., p.
265)  in the arm; Leveille, Briot, and all army surgeons have frequently
made the same remark, (Gaultier de  Claubry, Jour. Gin. de Mid., t.
XLVIL, p. 238.)  It is necessary that the ligatures should be very firm.
Morand (Opusc. de  Chir., t. II., p. 268) on one occasion found that all
the ligatures handed to him snapped, the threads, according to the au-
thor,  having wasted away  from their  being so old. After  this nothing
is more embarrassing than ligatures that are too long ; fifteen inches is
enough for each.
   The blood arrested at first may afterwards reappear.  Tetu (Recueil
de Mid. et  Chir.  Milit.,  t. XXIL, 3 Nov., 1827) amputated the  fore
and middle fingers with the  corresponding  metacarpal bones ; in spite
of the ligatures the hemorrhage was  renewed an hour  after, and a liga-
ture upon the deep palmar arch became indispensable.  Sometimes he-
morrhage takes place from the end of the bone. In a case of this kind
A. Petit (Acad, des  Sc, Paris, 1732, Mim., p. 39) succeeded with lint
in the mouth  of the vessel.  Hevin (Pathol, et  Thirapeut., t.  II., p.
40) used  with advantage  a  plug of  wax.   In Loder's case of 19 liga-
tures, (Obs. Mid.   Chir., Jena, 1794, dans Bibliot.  Germ., t.  II., p.
94,) the blood issued copiously from  the medullary  canal of  the bone
of the leg.   To arrest it he was obliged to use eau d'arquebusade.
   We may be obliged to tie the veins.   I have, says M. Champion, had
to tie the femoral vein  which was throwing out blood in jets, in  a case
of amputation  of the  thigh, performed upon a man who had become
excessively nervous from  fear of the  operation, and  who, after it  was
performed, experienced prolonged paroxysms of suffocation.  The same
thing has  occurred to me on three occasions ; the  ligature of the veins
therefore-after amputation, as I have  already said, does  not appear to
me so dangerous as has been asserted.   [On  the method of tying ar-
teries, &c, see Dr. Mott's remarks at the  conclusion of this section of
M. Velpeau's work, supra. T.]

                 §  II.—Disposition of the Wound.

   Being  now secure against  hemorrhage, (vid.  Vol. I.,) the  surgeon
has to attend to the dressing.  It is now  that  the great question  of im-
mediate or secondary union presents itself.  From the time that Lyon
(Alanson,  Manuel Prat,  de  VAmput.,  1765)  suggested to Park the
idea of bringing the parts  in contact  upon the centre of the stump, to
obtain union by the first intention, and that Alanson brought the practice
into vogue ; from the time when, in accordance with  the English sur-
geons and the flap method, M. Maunoir made himself the champion of
it, immediate reunion has become so  generally  adopted that it is had
recourse  to after almost every kind of amputation.   But I have else-
where (see Vol. I.) treated of this subject  too much at length, and its
advantages and inconveniences, as well as of the different sorts of dres-
  Vol. II.                   15 
114
NEW ELEMENTS OF  OPERATIVE SURGERY.
sings applicable to amputations, (see same  volume,) to make  it neces-
sary to recur to it in this place.   I shall not, therefore, speak of it again
except  when  treating  of each  amputation in particular.   Surgeons,
however, have not confined themselves to the adoption of these different
methods separately ; it has been  proposed  by some persons to blend
them and to combine many of their stages with the view of profiting of
the advantages of some and protecting ourselves from the inconveniences
of others.
  It is in this manner that O'Halloran (New Method of Amput., 1765,)
adopts the following modification, which, in his opinion, ought to concil-
iate  the suffrages of all in favor  of Lowdham's  mode  of amputating.
Instead of depending upon  compression to suspend the hemorrhage, he
advises, like Garengeot, that we should tie  the arteries  with  care, and
in order to be sure of having no serious difficulty at the stump, he pro-
poses that the dressings should be flat, that the flap  should  be left to
suppurate for eight or ten days ; and that we should then, as  soon as it
is covered with cellular granulations, raise it up and  adjust it properly
to the  rest of the wound.   White (Cases in  Surgery, etc.,1770) and
Paroisse (Opuscules de  Chir., 1806) assert that they  have  practised
this mode in a great number of cases and with  the most perfect success.
For my own part I am convinced, from  the trials I have made of it for
the purpose of secondary immediate union, that with us it has not been
properly appreciated,  and that in  a great number of cases it possesses
incontestible advantages, (see Vol. I.)   What O'Halloran added to the
process of Lowdham,  Beclard proposed for that of Vermale, when the
flaps are formed of tendinous parts, fibrous and synovial sheaths.

              Article IV.—Consecutive Treatment.

  The  patient being  carried to his bed must be placed there in a com-
fortable position;  a hoop is made use of  to sustain the weight of  the
bed  clothes, and  to hinder them  from pressing upon the stump, which
latter is to be placed gently upon a cushion or upon a sheet foLded in the
manner of 2, fanon (vid. Vol. I.)

                   § I.—Position of  the  Stump.

  It is the practice invariably to have this part slightly raised, in order
that the muscles may be relaxed, and also according to some persons
for the purpose of counteracting the tendency  of the fluids to gravitate
towards the wound.  There are in fact some advantages from it in this
point of view so long as there is no suppuration.  But in the contrary
case we evidently  thereby favor inflammation along the inter-muscular
cellular passages, the denudation of the bones, phlebitis, the formation
of abscesses and purulent infection.  The wisest course therefore is to
follow  the advice of Hippocrates and Alanson, that is, to leave the stump,
should  the form  of the limb admit of it, upon a horizontal  plane, and
even to place  it upon an inclined one, as  soon  as  the suppuration is
about to be established. 
amputation of the limbs.                 115
                   § II.—Immediate Medication.

  A spoonful or two  of pure wine might be proper to relieve the tor-
por  or 'sinking  temporarily produced by the operation ; during the re-
mainder  of the  day we give a few spoonfuls of some anodyne and mild
anti-spasmodic potion;  and for a drink, infusion of linden, violet, pop-
py, &c, sweetened  with syrup.  Except in patients who have been de-
bilitated by  long suffering, abstinence at first, in the opinion of most
surgeons of  Paris, should  be  rigidly adhered to.  According to  them,
the-most that is  admissible is a little diluted broth, until the general re-
action has taken place.   This is a practice which I have  renounced for
many years past.  If the patient has an appetite, and the constitutional
reaction  is moderate, I  give  him  broths  the first day, a potage on the
day  after,  and put him on the fourth part of his usual food on  the
fourth or fifth day.  Unless it be the thigh or leg that has been operat-
ed upon, I  change the patient as little as possible from his ordinary diet,
and treat him as a convalescent.                      •

                               §  III.

  Furthermore, the regimen after  amputations ought to be the same as
after acute diseases, and all the greater  operations, (see Vol. I.) If the
patient is  robust and  sanguine, and the operation has been performed
for a  recent injury, and there has not been much hemorrhage, conges-
tion of the fluids  is to be feared, and we  may resort to bleeding and
depletives.   In  France, the importance at this time  of diminishing the
volume of the  blood to prevent internal inflammation, and the dangers
of general reaction, has been greatly insisted upon.   In Germany, Eng-
land, and America, however, many operators follow an opposite course.
Kock, on the very first days, allowed his patients coffee, wine, and even
meats.  M. Benedict affirms  that  the  bleeding, instead of preventing
accidents, favors their developement.  It is those who are the strongest
and  are the most saguine, who best resist, he says, morbific causes, and
in whom inflammations  are most easily cured.   Therefore, the more we
debilitate persons amputated upon, and the more they are bled, the more
are they disposed to become sick, and the more dangerous and difficult
to treat  are  the inflammations with which they are attacked. The se-
vere dieting and the copious bleedings, prescribed by some persons, and
immediately  after  amputations, only  become really  serviceable at the
moment when incidental  diseases and  local inflammations make their
appearance, (see Vol. I.)
  [Dr. F.  Pauli, of Leipsic, in his  Untersuchungen und Erfahrungen
im  Gebeite der Chirurgie, 1844, makes some valuable observations on
amputations,  in thirty of which performed by himself, only two patients
died.   Of these, 12, were  of the tiiigh ; 8, of the leg; 4, of the arm ;
and 6  of the  fore-arm.   In nervous and excitable patients be has found
opium of great service, and a nutritious diet forms an important part of
his after treatment.
  M.  Guersant performs at the Hopital des Enfants some 18 to 20 am-
putatious annually, and it is  stated (Gazette des Hopitaux, No.  54, 
HO           NEW ELEMENTS OF  OPERATIVE SURGERY.

1851) that 9 out  of 10, recover.   In 1S50, he did  not  lose a single
case.  He uses chloroform,.and orders a good nutritious diet after the
operation.   Vid.  also, Am.  Journ.  Med. Sciences, Ap. 1852, p. 532.)
Mr. James of Exeter, in his remarks on the causes of mortality after
amputation of the limbs, to which we have already referred, recommends
a generous diet after this operation.   His observations upon this point
commend themselves to the common sense of every reader.  G. C. B.]

                              § IV.

  In  ordinary cases, the first dressing should not take place  until at
the expiration of seventy-two hours, or of four days, or even sometimes
five or six, as recommended by C. Magati and Monro,  and  as still prac-
tised  in Spain.  In general, patients have much dread of  it.  Once, in
fact, it was to them  a formidable affair.  No precaution  was taken to
prevent the adhesions of the lint and compresses to the bottom or sides
of the wound.  Being performed upon  the next or the second day after
the operation,#and consequently, before suppuration was established, it
was  calculated to  produce such severe pain as to leave an impression
upon the  minds of the patients as fearful almost as that of the amputation
itself. In this respect, patients of the present day are agreeably disappoint-
ed.   The  pieces of linen besmeared with grease, which Bromfield (Al-
anson, Man., etc., p. 33) was the first to introduce into practice, or the
strips spread with cerate always render easy the separation of the other
portions  of the dressing.  At the end of three or four days, the natu-
ral  moisture and exudations from the wound have destroyed the  adhe-
sions  which would have necessarily produced some traction, so  that the
first dressing causes no more pain than the subsequent  ones.  We should
be on our guard, therefore, against  imitating those busy-bodies who are
found even in hospitals, and who, under  the idle pretext of seeing what is
going on in the stump, wish to have the dressings removed on the first day.
We should not, however, hesitate  in  removing them  if any accidents
supervene, such as  violent pains in the wound, erysipelas, swelling or
hemorrhage.   In summer, or when  the  bandage becomes saturated, and
emits much smell, it may also be proper on  the first or second days, to
remove all the pieces which do not bear directly upon the wound, (see
Vol. I.)
  In  dressing, an  assistant  takes  charge of the  stump, which he sup-
ports gently with  his  two hands, taking care not to give it the least
sudden movement.  The  bandage  and compresses, impregnated with
blood and other fluids, are for the most part, glued together and  hard-
ened by drying, to such degree, that their removal  sometimes  becomes
a matter  of considerable difficulty.   In  such cases, if by saturating them
with warm water we do not succeed in softening them we must cut off
the  turns with a scissors.   These  first pieces being detached, we wet
the lint freely with water, and remove only the  outer pieces, should
they still adhere too firmly.  As soon as the wound is  uncovered, it
should be washed ; we do this by squeezing gently warm water  upon it,
and afterwards cleansing it with fine  linen or small balls  of lint; after
which, the dressing- is re-applied as at first, to be repeated every day in
 the same manner. 
AMPUTATION OF THE  LIMBS.
117
  If immediate union has been attempted, and  no special accident has
supervened, we defer to a still longer period this first dressing.  Never-
theless, as it  is rare that the  agglutination at the first is complete at
every point,  it is likewise a rule to cleanse the  stump on the third,
fourth or fifth day.   If no suppuration makes its appearance, and there
should be no  reason to believe  that there are sinuses forming or appear-
ing, we should avoid meddling with the lips of the wound ; at most, it
is allowable to remove one of the strips of adhesive plaster to replace
it immediately by another.  In the contrary case, and when the plasters
have become  loose, they should be removed in succession, and the puru-
lent and other matters, by means of gentle pressure, be encouraged to
make  their way  outwardly.   To  detach  these strips, they are to be
raised successively  from their extremities towards the  apex of the
stump, on which point they are not to be separated  until at the end of
the dressing ; otherwise, were we to take  them off from one side to the
other  without stopping, we should run the risk of destroying the adhe-
sions  which at this time  are too feeble to  sustain the  least  degree of
traction.

                              §V.

  The ligatures ordinarily do not come away before the eighth or tenth
day,  and  after they have, by means of ulceration,  completely  cut
through the artery they embraced.   It would, therefore, be improper to
endeavor to force them away at an earlier period.   But as soon  as they
delay coming away  beyond that time, there will be some advantage m
pulling upon them a  little as often as the  dressing is removed.   Their
retention is owing to their having having been caught in some sinuosi-
ties, or from  the  knot having  imprisoned  some fibrous  lamellae as  well
as the artery.  Their separation, moreover, is the more  speedy  in  pro-
portion as  their application  has been more directly made upon the  ves-
sels.   Everything induces to the supposition that their presence ceasea
to be useful after the second or third day, and that there would be no
impropriety at this time in disembarrassing the wound of them, provid-
ed  the thing  was easy of  execution.  I have seen them  after amputa-
tions of the arm or leg, come away  on the third or fourth  day without
any inconvenience.   Bonfils,  (These de  Strasbourg,) who  maintains
that after the sixth  day  we should hasten their  separation, proposes
even that we should subject them to a sort of permanent extension ; to
carry  out  this object, which MM.  Kluge (Bull,  de Fir.,  t. X.)  and
Law (Ibid., t. XII., p. 234) have  proposed to lay down as an axiom,
they  recommend that the knot should be tied  outside  and upon pieces
of  sponge.   That we may not  have  to resort to what J. L. Petit (Ma-
lad. Chir., t. III., p. 196) did who was obliged to divide at the bottom
of  the wound a ligature  that did hot come away, and in order to avoid,
also, drawing forcibly upon them at every dressing, as soon as the in-
flammation has subsided, as is  recommended  by  Alanson, (Oper. cit.,
p.  76,) M. Pierron (These No. XII., Paris, 1824) proposes that we
should subject them to a permanent torsion, which is to be  increased
daily ; but it is not often that surgeons of the  present  day require any
such means. 
118
NEW ELEMENTS OF OPERATIVE  SURGERY.
                     Article V.—Accidents.

   The accidents which may succeed to amputations of the limbs are im-
portant and  numerous.  Some of  them occur  at  the  moment of the
operation, and the others at a greater or less distance  of time after-
wards.

                    § I.—During the Operation.

   A.  Hemorrhage.—In feeble subjects the loss of blood during the ope-
ration is a thing calculated to give rise to serious consequences. It takes
place  sometimes before  we have had an opportunity  to tie the  vessels,
either because the tourniquet has  been loosened or displaced, or from the
assistant not  making the compression properly, or  because unexpected
difficulties present themselves in seizing hold of the arteries.   It is to
avoid  these difficulties that a suggestion has been made to place a liga-
ture upon the principal artery of the limb before commencing the inci-
sion of the soft parts.   M. Blandin gives an example of this practice,
which is still  followed at the Hospital of Beaujon, by M. Marjolin.  M.
Guthrie and some others have thought it more  advisable  to tie the arte-
ries in proportion as they are cut.  When the ligature is impracticable,
our art posseses no other resources than mediate or immediate, and late-
ral or perpendicular pressure.
   [Dr. Sayre amputated the leg of a patient whose  femoral artery had
been tied by  Dr. Mott  some 15 years previously.   In this case, in con-
sequence of the numerous anastomosing branches  which  had become
developed in consequence of the operation on the femoral  artery, twenty-
three  required the ligature.   G. C. B.]
   But there is another  kind of hemorrhage, to which these means are
not applicable : I mean hemorrhage from  the veins, and which, never-
theless, is in some persons exceedingly  abundant and sometimes alarm-
ing, being produced by the temporary compression preventing the blood
from  returning to the upper part of the trunk, or caused by some ob-
struction in the respiration.   To arrest it, some persons have  proposed
to apply a ligature on the principal vein.  Monro, Bromfield, Hey, and
M. Guthrie are  of  this opinion.   With us, we generally  proceed in a
different manner.  We remove immediately  everything which can pro-
duce any obstruction in the course  of the blood through the limb.   The
patient is directed to make long inspirations, and the difficulty subsides
almost immediately.  I have already remarked, that a ligature upon the
veins  has nothing in it alarming, and that, in persons who have been
amputated and who are already too much  enfeebled, we must have re-
course to it, if the other means do  not promptly succeed.
   [Dr. Bullen has particularly adverted to the frequent occurrence of
venous  hemorrhage, in aged  people, in whom  the  lower extremities
have  been for a long time the seat of chronic inflammation.   In such,
he remarks, the veins are sometimes very large, and varicose, and after
an amputation  may give  rise to a copious  hemorrhage.  To restrain
this is sometimes a matter  of great  difficulty, and in addition to the
means recommended by our  author, he recommends that the limb should 
AMPUTATION OF THE LIMBS.
119
be elevated, and the limb  bathed with lotions  impregnated with alum.
The limb should also be exposed to a current of cold air.   T.]
  B.  The syncopes  and swoonings which result from the hemorrhage,
or the pain, or from the fright which the operation sometimes causes to
the patient, require scarcely other than moral means, a spoonful of wine
when they are anticipated, cold water, vinegar, or Cologne-water, thrown
in the face or held to the  nose, and  all the other means  generally re-
sorted to under such circumstances, and which require no further detail.
  C.  Spasms.—It is not  uncommon, immediately  after the operation,
to see the stump take on a trembling which it is difficult to restrain—a
sort of convulsive or spasmodic movement, which  also requires some
attention.  Under  such  circumstances we endeavor, suddenly and  as
strongly as possible, to divert the attention of the patient, and to inspire
him with courage;  we  make him  seize  hold of his leg himself at its
upper part, or, should it be thought more  advisable, cause this to be
done  by an assistant, with both hands, until the dressing is  finished.
In general, this  symptom  continues but a short time, and  disappears in
a few minutes.   It is generally relieved by compressing the muscles with
force  upon two different circles of the stump.  Nevertheless, if it should
seem  disposed to continue, the stump, as soon as the patient is in bed,
should be secured by a sheet or by a napkin, folded in the manner of a
cravat.  It is then  also that some of the  preparations of opium are
particularly indicated.
  D.  After being  placed in bed, some patients  complain of acute pain.
This  pain, which  in some is nothing more than the smarting of  the
wound, which subsides  in a few hours, is increased in others so as to
cause them to cry out, and to be under strong nervous excitement.  We
should then saturate the dressings with narcotic liquids ; for example,
decoction of marsh-mallows with laudanum, giving at the same time
powerful doses of opium  internally.  When patients refer their pain,
as is very common, to the  limb  they have lost, we must  recur to  the
same  treatment; but we must expect to see this  symptom return for a
long time, and even after the entire cure of the wound.

                    § II.—After the  Operation.

  A.  The accident, which  still engages our attention the most  after an
operation, is hemorrhage,  which is sometimes caused by our not having
tied some of the more important arteries,  or by some of the ligatures
having become loose, or, more frequently than is thought, by a kind of
irritative exudation  going on from  the  surfaces of the  wound. After
the third or fourth day is passed, it is rare to have any other hemor-
rhage  than  this, unless  the threads  have too rapidly cut through the
arteries by ulceration, or that there exists that remarkable condition
of the system which Otto,  Buel, Krimer, (Malle, These de Cone, 1836,
p. 36,)  Lobstein, (Anat. Pathol., t. I., p. 211) and so many others,
have related examples of,  and the peculiarity of which is, that the most
trifling incision is followed by an incessant hemorrhage.  Why hemor-
rhage  should  occur aftert he eighth or tenth day, it is  difficult to say.
Petit, Bromfield,  Guthrie, and other practitioners, however, have seen
it occur at the expiration  of  three weeks, a month, or even later.  In 
120
NEW ELEMENTS OF OPERATIVE SURGERY.
 one of my patients, after amputation of the thigh, it came on after the
 twenty-third day.  The case is related of a patient operated upon by
 M. Roux, (Diet, de Mid. et Chir.  Prat., t. IT., p. 213,)  in  which it
 did not  appear until  at the end  of two  months.  The inflammation,
\ which may seize upon the coats of the vessels in the deep-seated tissues
' of the stump, and the suppuration which surrounds them at the bottom
 of fistulous  passages, can alone  account for this  species of perforation.
 Hey and Hennen maintain that consecutive hemorrhage frequently pro-
 ceeds from  the  retracted skin  strangulating  circularly the subjacent
 tissues, and especially  the venous canals ; and that it  is from this last
 mentioned class of vessels that the blood comes.  This opinion,  in my
 view, appears to be far  from being well-founded.  When the blood es-
 capes from the veins, it is to be much more frequently imputed, as Pou-
 teau remarks, to too  unequal or powerful a  compression made by the
 bandage  upon the stump, than to  the  retraction of the skin; in that
 case, it is.only necessary to remove  the dressing and  re-apply it more
 methodically, and the hemorrhage ceases immediately.   Another species
 of hemorrhage, which appears to have been first indicated by M.  Gou-
 raud,  is that which comes from the bones in consequence of their  being
 in a state  of necrosis ;  at every moment the blood is observed rising up
 between the living and dead  tissue ; compression,  plugging, nothing
 stops it—nothing but the exsection of the altered part can subdue it.
 The swelling of  the stump, attended  with a  considerable degree  of in-
 flammation,  causes a hemorrhage, which may be suppressed in various
 ways: 1st, By saturating all the dressings with cold water, which is to
 be frequently renewed ;  2d, By applying the tourniquet or garrote per-
 manently upon the principal artery of the limb.
   [ Dr. Tripler,  of the United States army  has reported in the New-
 York Journal of Medicine, July, 1849, a case of secondary hemorrhage
 after amputation of the  shoulder-joint which was successfully treated by
 a compress and roller to the wound.  Dr. Campbell, of Montreal, relates
 in the Medical Chronicle, July 1853, a case of  secondary hemorrhage
 after amputation at the shoulder-joint which  was arrested  by compres-
 sion at a distance from the bleeding point upon its cardiac aspect.   The
 following  details of this case are of interest  :
   " Every thing progressed  favourably till  the 14th  day, the wound
 having almost completely united, excepting for about an inch near its
 centre, where the ligature from the axillary passed out.  On  the  after-
 noon of this day an alarming  hemorrhage  occurred.   The  gush was
 sudden, and the stream large, and it certainly would have proved rapid-
 ly fatal, had not pressure been  promptly applied  by   Mr.  Sinclair, the
 acting apothecary ;  as it was, several pounds of blood were lost.   At a
 consultation  of  the staff of the hospital, it  was determined instead
 of performing deligation of the  subclavian at  the  outer border of the
 scalenus anticus muscle, or opening up the wound and  attempting to se-
 cure the bleeding axillary, to try  the  effects  of compression  with the
 horse-shoe tourniquet of Signorini.   From the tilting  upwards of the
 clavicle, the anterior pad of the instrument was placed below that bone
 over the spot where the subclavian was felt pulsating upon the first rib,
 the posterior pad being applied to the dorsum of the scapula.  From
 the tendency to slip upwards, it was found  very difficult  to  keep the 
AMPUTATION OF THE  LIMBS.
121
instrument in its position ; but with the assistance of the pupils  attend
ing the hospital, compression was maintained pretty  steadily for five
days, and then suspended, as it became irksome to the patient, and all
tendency to hemorrhage seemed to have ceased.  This state of affairs
continued till the 21st day, in spite of the frequent disturbance occasion-
ed by a diarrhoea, which had troubled the  patient  more or less for a
week previously, and which was found very unyielding to treatment.  At
9 P. M. on the evening of that  day, arterial hemorrhage again broke
out. while the patient was in the act of describing a peculiar sensation
which he then experienced,  and which had also preceded the former at-
tack, as if something fluid was trickling from the shoulder to the points of
the fingers ; only a few ounces of blood were lost, as the house surgeon,
Dr. Reddy, immediately reapplied the compressor, with a broad leather
pad under the posterior limb of the instrument, to diffuse the pressure
over  a  large  surface, and a bandage which  retained  it  securely in its
place.  The  compressor was worn  after the occurrence of the  second
hemorrhage for three weeks, until the ligature had come away, and the
stump had completely cicatrized.  The  pressure was  borne with great
fortitude by the  patient, who left the hospital about two months after
his admission, perfectly restored to  health, and has continued free from
any return of the disease up to the  present time."  G.  C.  B.]
   After having found all  these means fail, whatever may be the cause
of the hemorrhage, we may undress  the wound and  proceed in search
of the bleeding vessel.  As it  is rare, in  consequence of the changes
which have been effected throughout the whole  extent  of  the wound,
after the  fiist twenty-four  hours are passed, that this last-mentioned
means would succeed,  we  have then no other resource than to apply the
agaric or sponge, as recommended  by White and Brossard, upon  the
point from whence the blood issues,  to lampone (i. e. to plug) the wound,
in whatever way it  may be done,  till the hemorrhage  is arrested, to
make use of the apparatus invented by Petit, or to have recourse to di-
rect compression  upon the gaping vessel, by means  Of  small plugs of
linen or  lint, sprinkled with rosin,  and held on by the fingers of assist-
ants, who  are to be relieved successively for several days;  or we shall
have to  establish a sufficient degree of compression upon the track of
the artery above the stump,  by one of the means which I have elsewhere
described, (see vol. I. and the present volume.)   In a case where the
arteries were  ossified, (Acad, des Sc, 1732, p. 536,) it was found ne-
cessary to make compression in this manner for the space of four days.
In  a patient, however, who, after amputation of the leg, was attacked
with  repeated hemorrhages after  the thirteenth  day, I succeeded, by
means of the tourniquet of Petit, applied to the thigh for the  space of
three days.
   A last  resource, should it be practicable, consists in laying  bare the
principal artery and tying it above  the  wound.   M. Roux, Dupuytren,
Delpech,  Somine and Ghidella have done this  successfully.  M. Arnal
has given a recent instance  of this kind, and I have in citing these cases
also related others, (see this present volume.)  J. L.  Petit would  have
made trial of it, had not the debility of his noble patient deterred him,
(Malad.  Chirurg., t.  III.,  p.  164.)   Pelletan (Clin.  Chir., t. II., p.
275) moreover formally recommends it, and I cannot perceive how Du-
   Vol. II.                16 
122
NEW ELEMENTS OF OPERATIVE SURGERY.
  puytren, M. Roux, Delpech or  M. Guthrie can claim this suggestion for
  others.  It is after all a means which may fail like  the  others.   In a
  case, related by M. Blandin, and in some others mentioned by M. Guthrie,
  this ligature applied as it is after the  manner of Anel, did not prevent
  the flow of blood  or ultimately save  the  patients from death.   If the
  vessel which bleeds should be surrounded with soft parts we could  also
  circumscribe it with a stroke of  the bistoury at the bottom of the wound,
  and by passing a ligature upon  this groove immediately close the vessel,
  as was once practised with success by M. Sanson, (These de cone, etc.,
  1836.)  We should do' wrong, however, to rank among  hemorrhages
  that oozing which, upon the first or second day, rarely fails to wet  and
  soil the dressings  and linens, and sometimes to go through  the  whole
  thickness of the cushions.  Though it  should  be pure blood  and  not
  bloody serum, we have no reason to be at  all under any  apprehensions
  unless the patient  has become  thereby enfeebled.  As a general rule,
  while the force of  the  pulse is sustained and  the paleness of the  face
  does not increase, cold ablutions and the tourniquet, if any thing  at all
  be required, will be found quite sufficient.
   [Mr.  Guthrie's immense experience as a military surgeon gives  to his
  remarks upon this  subject the most  weighty authority.   The  success,
  however, which followed compression  in the hands of Drs. Tripler  and
  Campbell, shows that ligature of the artery above the bleeding point is
  not always  indispensable, secondary  hemorrhage occurring  after  am-
  putation at the shoulder joint.  We quote from Mr. Guthrie's Commen-
  taries in Surgery, p. 64, the following instructions :
   " In the irritable and sloughing state of stump alluded to, haemorrhages
 frequently take place from the small branches, or from the  main trunks
 of the arteries, in consequence  of  ulceration ;  and it is not always easy
  to discover the bleeding vessel,  or  when discovered  to secure it on the
•face of the stump; for as the ulcerative process has not ceased, and the
 end of the artery which is to be secured is not sound, no healthy action
 can take place, the ligature  very  soon cuts  its  way through, and the
 haemorrhage returns as violently as before, or some other  branch gives
 away;  and under this succession of ligatures and haemorrhages the patient
  dies.
   " Some surgeons have in such cases, preferred cutting down upon the
  principal artery of the limb, in  preference to performing another ampu-
  tation, even wnen  it is practicable  ; and they  have sometimes succeeded
  in restraining the haemorrhage  for a sufficient  length  of time  to  allow
  the stump to resume a more  healthy  action.  This operation, although
  successful in some  cases, will generally fail, and particularly if absolute
  rest cannot de obtained^ when amputation will  become necessary.   The
  same objection of want of success  may be made to amputation ; and on
  a due comparison of the whole of the attending> circumstances, the ope-
  ration of tying  the artery in most  cases is to be preferred in  the first
  instance, and if that prove unsuccessful, then recourse  is to be had to
  amputation ;  but this  practice is by no means to be followed indiscrim-
  inately.  The artery ought to be secured  with reference  to the  mode
  of operating, as in aneurism, but the  doctrines of this  disease  are  not
  to be applied to it,  because it is still a wounded vessel with an external
  opening.
'•;- -&- 
AMPUTATION OF THE  LIMBS.
123
  " To obviate all difficulties, the part from which the bleeding comes
should be well studied, and the shortest distance from the stump carefully
noted at which compression,on the artery commands the bleeding; and
at this spot the ligature should  be applied, provided it is not within the
sphere of the inflammation  of the  stump.  In case the haemorrhage
should only be restrained by pressure above the origin of the profunda,
and repeated attempts to secure the vessel  on the surface of the stump
have failed, amputation is preferable when the strength of the patieni
will bear it, to tying the artery in the groin.
  " When haemorrhage takes place after amputation at the shoulder-joint,
it is a most dangerous occurrence.   An incision should then  be  made
through the integuments and across the great pectoral muscle,  when the
artery may be readily  exposed, and a ligature placed  upon it without
difficulty anywhere below the clavicle.
  " If the state of the stump in any of these cases depend upon the bad
air of the  hospital, the patient "had better be exposed to the inclemency
of the weather rather than be allowed to remain in  it.
  " In crowded hospitals, haemorrhages from the face of an irritable stump
are not unfrequent, and often cause a great deal of trouble and distress.
It is not a direct bleeding from a vessel of sufficient size to be discovered
and secured, but an oozing from some part of the exposed granulations,
which are soft, pale  and flaccid.   On making pressure  on  them, the
haemorrhage ceases, but shortly after re-appears, and even becomes dan-
gerous.  This haemorrhage is usually preceded by pain, heat, and throb-
bing, in the surface  from which it proceeds.  There is irritation of the
habit  generally, and a tendency to direct  debility.   The  proper treat-
ment consists in the removal of the  patient to the open  air, with an
antiphlogistic regimen in the first instance,'followed  by the use of quinine
and acids ; cold to the stump, in the shape of pounded ice or  iced
water ;  with occasional styptics to suppress the immediate  bleeding.
Escharotic and  stimulating applications should be  used with  caution."
                                                        G. C. B.]
   [B.  Conicity of the Stump.—Since the labors  of J.  L.   Petit and
Louis, the cone-shaped form of the  stump, an almost inevitable result
of the mode  of amputating formerly, has become a rare occurrence.
By immediate reunion, when that does not  fail, we  almost  constantly
prevent  it.   It rarely occurs now except sometimes  after  the  union by
suppuration.  Imputable entirely to the retraction  of the muscles, it is
in the power of the operator to prevent it, unless  the cure  should be
complicated with some unexpected  difficulty.  The processes of Petit
and Brunninghausen, which consist in bringing the  skin only  upon the
stump, are deemed less efficacious than those of Louis, Alanson, Desault
and Dupuytren, or than all in fact which  consist in cutting the muscles
adherent to the bone much higher up than the free muscles, but this is a
question for future consideration.   On  this subject we must  not forget
that the muscles retract in some persons much more than in others, and
much more so in proportion as their fibres  are longer, or have  been
farther divided  from their  point of origin, or are more irritated, or
slower in uniting and incorporating  with the  cicatrix ; nor  must ^ we
moreover  confound their  primitive with  their secondary  retraction.
The shortening which immediately succeeds their section, is not in fact 
124
NEW ELEMENTS OF  OPERATIVE SURGERY.
 the only one that takes place;  we often see the muscles, especially in
 patients possessing much strength and embonpoint at the time of the oper-
 ation, but who become debilitated soon after; we often, I repeat, see the
 muscles draw themselves to a great distance within their sheaths, aban-
 don the bones which they at  first completely  covered, thus  rendering
 conical a stump which at the first dressing had the very largest kind of
 excavation.   One of the means which contributes most to prevent  this
 accident, is the care which the surgeon takes at each  dressing to adjust
 the bone accurately to the centre of the stump.   In this respect the  flap
 operation has the objectionable inconvenience of favoring the slipping of
 the parts towards one of  the angles of the wound.  It is  therefore then
 a matter of much importance to  preserve a sufficiency of  tissues  in  that
 part towards  which  the  bone has a natural tendency to incline, either
 by means of the action of the  muscles or the habitual direction of the
 stump.
   After the operation we counteract the  retraction of the muscles, by
 applying to the stump the moderately  compressing  bandage  of the an-
 cients, as modified by Aitken, (Essays on several important subjects in
 surgery, 1771,)  Alanson, Louis, and M.  Richerand ; arranging  it in
 such manner^ that instead of pushing the flesh backwards, like the cape-
 line censured by  Decourcelles, (Man. des Operat., p. 372,) all the  por-
 tions of the dressing on the contrary concur in brihging it forward; we
 are also to dress the wound as lightly as possible, avoiding every thing
 which can irritate it, or cause it to suppurate or retard  its union ; ad-
 justing the stump in such manner  that it may constantly  repose be-
 tween  flexion and  extension, and all its muscles remain in a state of
 relaxation.   The projection of the bone, however, is to  be apprehend-
 ed notwithstanding  all this, should the periosteum  proceed to suppura-
 tion, and the pus  detach the muscles of  the stump, or if any  serious
 affection should  in  the first  eight  days after the  operation take .such
 hold of the system as materially to  interfere  with the healing process
 going on in the wound.
   C.  Protrusion of  the bone.—The  protrusion of the bone after ampu-
 tations, whatever may be the cause, is always a grievous  inconvenience.
 When it is slight and simple and without denudation we  should not, M.
 Gouraud says, meddle with it.  Nature will elaborate her work in ulti-
 mately removing the cicatrix by bringing the skin over the apex of the
 stump.  If the patient is corpulent he will often find that this conicity
 will partially disappear, and present no obstacle to the employment of
 an artificial limb.  When it exists to a greater degree, there is nothing
 but the natural exfoliation or exsection which can give relief.
    I.   Spontaneous   Separation.—If the bone is not denuded, necrosis
 will not take place; and we should be in an error to wait for its exfoli-
 ation, as advised by Lassus, (Trad,  des  Fract.  de Pott,-p.  181, 2o
 edit.) Pare, therefore, who made use of excision, was right, (Lib.  XII.,
 chap.  35.)  Unless this were done, the osseous  cone would, in the thigh
  especially, be in the way in applying an  artificial leg, as in the cases
  mentioned by Veyret and Alanson, (Opir. cit., p. 49, 50,192, obs. 20,)
  and as I have also myself seen.   This projection of the bone, moreover,
  is the cause  of  incurable ulcerations.  The soldier mentioned by Sal-
  mon, (De Art. Amp. rar. adm.,  § 9, sect. 2,) and who had both his arms
t 
AMPUTATION OF THE LIMBS.
125
amputated, is an  example of this, to which I could myself add a multi-
tude of others.
  The articular  extremities take a longer time  to exfoliate than the
body  of the bones; thus Smucker (Bibl.  Chir. du  Nord, p.  57) was
obliged to exsect them in a patient whom he had amputated at the wrist.
In a similar case, Reisenbach (Trad, par Masuyer, t.  I., p. 218;  Bibl.
du Nord, p. 82) felt himself obliged to remove the lower  extremity of
the radius because it did not seem disposed  to exfoliate.  The heads of
the bones of the  metacarpus in  a man who  had had all the fingers dis-
articulated, having  remained  for  ten  months withojit exfoliating, I
deemed it my duty, in order to secure the closure of the Wound, to per-
form the operation of exsection.
  II.  Exfoliation, which was formerly  considered unavoidable after an
amputation, is  at the  present time  deemed only an  incidental result.
As it is extremely tardy in being brought about, requiring thirty, forty,
and  sixty days, and even  three  and four months, to  be completed, we
should not, except in a very small number' of cases, leave this process to
nature.  The red hot  iron, chemical caustics, as the nitrate of mercury
for example, and which was frequently  employed, down to the  present
times, and  even as late as by Sabatier,  do not in any  degree accelerate
it.  It is much better to confine ourselves to gentle movements with the
forceps, to  be  repeated at each dressing, and  directed upon the pieces
of dead bone as soon as they become moveable.  It is well to recollect,
however, that this eschar  sometimes disappears without any apparent
exfoliation.  An adult whose leg was amputated at the hospital of  St.
Antoine by Beauchene, had a necrosis at the angle  of the tibia, which we
could feel  with the probe, the wound closed over it, and at the expira-
tion of a month  a  small abscess made its  appearance ; I laid it open,
and a limpid, reddish pus flowed out, but there was no  more necrosis,
and the cavity  soon" cicatrised permanently.  In another case where the
whole stump had become involved in suppuration, I had for a long time
before my  eyes the extremities of the fibula and tibia, of a chalky and
slightly yellowish color, rough and sonorous in fact, completely necrosed;
gradually they disappeared under the flesh, the cicatrization took place,
and in four months the cure was complete.   Bones, then, that have been
laid bare by pus, are not absolutely doomed to exfoliation.   I have now
seen more than fifty  cases, in which the bones of the cranium, nose,
jaws, fingers, and toes, the fore-arm and leg, and the humerus and thigh,
were  bathed in pus and divested of their periosteum, and which, never-
theless, recovered without any perceptible exfoliation.   [This is a valu-
able  remark of the author, which is fully  borne out by the experience
of Dr. Mott and  most  practitioners  who have been familiar with syphi-
litic and mercurio-syphilitic cases, more especially with the latter.  We
have  noticed this fact in an  especial manner, at the Seamen's Retreat
Hospital, in deplorable  cases from those murderous,  drenching saliva-
tions  for syphilis, to which sailors are  exposed in the  hands of adver-
tising  empirics,  as well as of empyrical  physicians.   In  such  cases,
where the energies of the  system have not been too  much prostrated,
we shall find, by wholesome, generous diet, good air, and the mild altera-
tive treatment with sarsaparilla, and iodine internally, and lotions of chlo-
rine externally, with strict  attention to drawing as forcibly together as 
126
NEW ELEMENTS OF  OPERATIVE SURGERY.
 possible the lips of the wound, by adhesive plaster, whenever dressed, and
 which should be as at long intervals as possible,—that the granulations,
 even on the  frontal  parts of the  cranium  where the  teguments are so
 thin, and on  the  sharp  edge of the  tibia or ulna, where  they are  yet
 thinner, will, as our author has well described it,  shoot out gradually
 over the white, dry, rough,  denuded surface  of the  bone,  and  finally
 close the wound perfectly without the slightest perceptible exfoliation,
 unless the constitution be greatly vitiated and  prostrated, or the loss of
 substance in  the  soft parts be over the size of an inch in diameter.
 The word necrosis, however, as used by the author, to express this con-
 dition of the bone, expresses, as it seems to us,  too much ; for  an  ac-
 tual death of the bone cannot, as we conceive,  have  taken place in these
 denudations.  In fact, the natural, healthy, organic state of the parts,
 notwithstanding the loss of the periosteum, cannot  have been sensibly
 changed, but the normal action only suspended, and not destroyed.   No
 doubt, in former, as well  as  in modern times, this curious phenomenon
 of tenacity in the vital principle, had been noticed, but (though often ob-
 served by others) not, as we are aware, correctly described  by any one
 before Prof. Velpeau.  T.]
  III.—The exsection of the bones and of the stump, which caused so
 warm  a  debate in the ancient academy of surgery,  is described  by
 Sabatier as a simple, easy, and but  slightly painful operation ; by  others
 as a second  amputation, often more dangerous than the first.  When it
is to be done, we should  perform it so high up as not to be  obliged to
do it again, or endanger  another  conicity.  We may conceive, more-
over, that where the integuments and  superficial muscles are far remov-
ed from the apex of the stump, it cannot fail to be otherwise than pain-
ful ;  while on the other hand, if the saw is to be used only at some lines
above the dead parts or portion to  be  removed, it becomes an operation
of the least importance.
  After  immediate union especially,  purulent inflammation, should it
supervene, will sometimes attack the  periosteum, which will then sup-
purate and become detached ; the  bone is then denuded, and soon mor-
tifies, either throughout its whole  substance, or only in a more or less
 considerable  portion of it.   At other times, the disease begins  in the
internal  texture of the bone, which renders the  accident so much the
 more serious.   M. Moulinie has shown me a sequestrum of this kind,
 of more  than six inches in length,  and which comprised the entire cir-
 cumference of the femur.   One of those which I took from the humerus
 was  over three inches.  The first indiction to be  attended to in such
 cases is to dilate and divide, by  means of the bistoury, everything  which
 appears to interfere in the least degree  with the free egress and discharge
 of the pus and other morbid  matters; after which we should endeavor
 to limit the extension of the mischief, by applying expulsive compression
 from the upper part of the limb down to near  the wound.   We may
 then wait for the exfoliation.   In other  cases, after the evil  has ceased
 to extend itself, we have recourse to  exsection, or  repeat the amputa-
 tion a little  higher up, as in operating for conicity.  If all the tissues
 should be sound, perhaps there would be some  advantage in imitating
 Wie^-and, who, in  such cases, makes  two  semilunar, lateral  incisions
 with°the convexity downwards, at  a certain distance  from the borders 
AMPUTATION OF THE LIMBS.
127
of the wound, and of greater or less length, according to the  size, and
the greater or less  degree of conicity in  the amputated limb.  These
incisions which comprise the skin only, or the skin'and superficial mus-
cles, are made in such a manner as to avoid the vessels  upon which a
ligature might be rendered necessary.   The  teguments  being thus de-
tached,  are  then  brought up and united in front of the bone by means
of adhesive plasters or the suture.
   C.  Hospital Gangrene, frequently among the sequelae of amputations,
is one of the worst complications that can happen.   As soon as it has
seized upon the stump, or involved the integuments  and muscles to a
certain  extent, and that the bone has become denuded, and topical ap-
plications and caustics have been tried in vain, amputation above the
neighboring articulation, and if that be not possible, immediately abote
the limits of the disease, is one of the last resources we have to oppose
to it.   M. Gouraud  obtained  many unexpected cures from it, both in
the army and at the hospital of Tours, where I myself was an eye-witness
to them.   Percy,  MM. Willaume,  and Desruelles,  also  adopted this
practice, and I do not think we should hesitate in  following it under
the conditions  which I have pointed out, that is to say, when, in spite
of the cauterization with the nitric acid of mercury, and even with the
red-hot iron, the gangrene continues to advance.
   [Gangrene.  Hospital  Gangrene.—The  vitiated  condition of the
atmosphere in crowded  hospitals, barracks, on shipboard in transports,
camps, &c, depends upon the abstraction of oxygen or rather its dis-
placement by carbonic acid and nitrogen, and the exhalation of various
other deleterious gases, &c, from the  skin and alvine and urinary ex-
cretions, &c.  This will not only predispose to, but generate a new and
malignant principle, or morbific virus which will manifest itself in fevers
of a putrid and ataxic and adynamic type, in the degeneration of ulcers
and wounds into hospital pourriture or gangrene, and in  such  degrada-
tion or diminution of all the vital forces as to diminish  the  chances  of
success in, or give a fatal termination to, diseases or operations of every
kind.   Thus Sir  George Ballingall (Remarks on Schools  of Instruc-
tion for Military and Naval Surgeons, also  his Treatise on Schools  of
Naval and Military Surgery,  3d ed., Edinb., 1844) remarks that when
military  hospitals are .over-crowded, too long occupied, or filled  with a
relay  of fresh cases  immediately after the  removal of the  old, results
the most fatal are the consequence.  In March, 1837, after an action,
the surgical hospital at San Telmo afforded a striking example of  this.
" There  were thus," says Mr. Allcock, (London  Lancet, 1840—41,)
" 1041 patients in the hospital of the legion, calculated to accomodate,
with due regard to health, 800 ;  the chief press of the extra numbers
fell upon the surgical hospital of  San Telmo."  The following  gives
the melancholy result:—Of 17 primary amputations there were only
two recoveries ; of 4 intermediary, all died  ; of 3 secondary,  only one
recovered, making a total of 24  cases of amputation and  only  three
recoveries.
  M. Ollivier, of Paris, has satisfactorily established by personal inocu-
lation on himself (See his late  work on Traumatic Gangrene) what
was in our opinion long  since familiarly known, that the matter of  hos-
pital  gangrene is  contagious and  will reproduce  itself.  Sponge has 
128
NEW ELEMENTS OF OPERATIVE SURGERY.
been, according to Sir  Geo. Ballingall, (Op. cit.,) ascertained to be a
direct vehicle of this, contagion, by the careless and culpable use of the
same sponge to cleanse the ulcers among the sick of a regiment station-
ed at Feversham, England, as related  by Deputy  Inspector Marshall,
(lb., and Cormack's London  Sc Edin. Monthly Jour., Dec, 1844, p.
1040.)                       ^
   Some  persons have  on this account gone so far  as to propose to dis-
card sponge altogether as a detergent, from the difficulty of cleaning it,
and  this has been actually done in some English hospitals, (Cormack,
ib., p. 1041,) and surgeon's lint substituted.
   We cannot agree with Sir G. Ballingall that venesection can  ever
scarcely  be admissible  in  cases of hospital  gangrene;  unless it be in
vefy rare instances  in  young robust  subjects in whom the purulent in-
fection has produced such violent perturbation in the cerebral and cir-
culating functions as  to have caused for the time being in the early stage
a violent inflammatory  febrile reaction, spasms, convulsions, local en-
gorgement, &c.
   Bleeding in Mortification.—There are  cases, says Sir  B.  Brodie,
(Medical Times, March 1, 1845,) where bleeding and purging will ar-
rest  the  mortification  and cure the patient as in robust habits—not so
in persons whose constitutions are broken down by mercury, intemper-
ance, &c, with  small,  weak, frequent pulse, anxious countenance, &c.
Thus you find  these two classes of patients where a neglected chancre,
has resulted  in mortification of the penis.  In the one where  bleeding,
not stimulation, is required, an  artery perhaps  while the physician is
hesitating will spontaneously inflame, and after  the discharge of a pint
of blood  an immediate amendment takes place by nature's unaided ef-
forts.  T.]
  D. The inflammatory enlargement of the stump, sometimes shows it-
self in the form of  simple erysipelas, at other times under the charac-
ters  of erysipelatous phlegmon.  In  the first case, if the skin only is
affected, the adhesive plasters are frequently the cause of it, either be-
cause they have been  drawn too tightly over  the  wound, or because
they contain too great a proportion of matters of an irritating quality ;
we have then nothing more to do than to remove them, and to dress the
inflamed  surfaces for a few days with emollient cataplasms.  In the sec-
ond case the accident is of a much graver character and merits the most
serious attention.  The phlegmasia rapidly  extends itself; the muscles
and  skin  are  soon  dissected by the pus; the subcutaneous tissues and
the  cellular prolongations sometimes go on to mortify and slough off in
large masses, an ataxic or adynamic fever supervenes and the patient's
life  is placed in peril.   Union by second intention is not often followed
by such accidents; which is one of the strongest objections urged against
the rigid partisans of union by the first intention.
   As soon as theee symptoms become manifested they must be vigorous-
ly combated ; they are mitigated sometimes  by uncovering the whole
 wound  so  as to dress it flat, and by  applying leeches to the stump and
 then cataplasms; but when such means are  unsuccessful, or when they
 are too late, I know of nothing more efficacious than deep and numerous
 incisions.  In 1828  I had occasion to use the flap operation for an am-
 putation of the leg.  The whole thickness of the stump soon became 
                    AMPUTATION OF THE LIMBS.                  129

the seat of an extensive phlegmasia ;  erysipelas and purulent collections
already occupied the lower third of the thigh.  The stupor and  other
adynamic symptoms  went on  with  a frigthful rapidity.  I  considered
the patient lost beyond all hope.  Beauchene, who thought otherwise,
made from eight to ten deep  cuts upon different  inflamed portions of
the skin.  From  that time the symptoms began to subside and the pa-
tient recovered.  It is against this erysipelas also with a greyish tint,
and which so often terminates  in gangrene in  persons who have been
amputated, that M. Larrey advantageously employs the  actual cautery.
The hot  iron applied with a certain degree of force upon the inflamed
surfaces, so as to  imitate  the  branches of the fern or the nerves upon
the laurel leaf for example, or other  figures, certainly did wonders at
the Hospital of the  Guard where I have witnessed the most extraordi-
nary results from it.
   Suppose the disease should, after having given rise to numerous gene-
ral phenomena, again  become circumscribed to the part, there often re-
sults from it that denudation of the bone, and those fistulous burrowings
with  that conicity of  the stump, which can only be cured by a second
amputation.   "Experience  has  taught me,  says M.  Gouraud, that
wounded  persons sustain amputation  of the stump better than that of
the limb, and that the success of the former is more probable than that
of the latter. Of ten persons upon whom I performed it in 1814 and 1815,
nine  were cured."  Instead  of attacking  the whole stump, the phleg-
masia is limited sometimes to the cellular tissue surrounding the vessels,
and especially the sub-cutaneous veins ; there will then soon be found
along  the track of these canals, small  purulent collections and abscess-
es, which are to  be  opened  in good  season, should not antiphlogistic
means or compression have prevented their development.
   E.  Purulent Infections.  Phlebitis.—The veins often become inflam-
ed, either in themselves  alone, or  concurrently with  the  surrounding
parts.   Here  as elsewhere Phlebitis  is exceedingly dangerous.  The
symptoms of adynamy, putridity and  ataxy that  are soon developed,
are almost  always followed by death; so that this becomes one of the
most  formidable  of the accidents that  can present themselves after am-
putations.   The dangers  which it involves, imputed  even down to our
own times to inflammation propagated up to the heart, depend as I have
shown (see Vol. I.) upon a totally different cause.  Purulent infection
which is  so often complicated with phlebitis, is another accident whose
dangers are precisely similar.   It is true that the researches of M. Monod
and M. Reynaud, tend to  prove, that the inflammation of the medullary
tissue  of the  bones  participates also in the production of those symp-
toms  which  are  generally ascribed to  phlebitis and infection from pus ;
but this is  a question which requires new investigations, and I am of
opinion that on  this subject  persons  have had their minds1 warped by
preconceived theories.
   F.  Cystitis.—We are  often, says M. Gouraud, obliged to  apply the
catheter to persons who have been operated upon, and many observers
have made the same  remark.  Whatever may be the primary  cause of
it, it is no less certain that cystitis  is  by no means an uhfrequent eon-
sequence of amputations, and especially of amputation of the abdominal
extremities; we must be prepared for this inflammation upon  the least
   Vol. LI.                    17 
 130           NEW ELEMENTS OF OPERATIVE SURGERY.

 appearance of trouble in the  urinary passages.   It  is useless  to  say
 that when this affection menaces  blisters ought to be proscribed ;  but
 M. Blandin is evidently deceived in imputing it to this therapeutic agent,
 for it is observed where no preparation of cantharides has been made
 use of; as I saw  in the  case of a woman whose thigh was amputated
 by M. Roux, in 1820.  For more ample details on the accidents we have
just enumerated, and upon tetanus  and every other disease that can be
 complicated with the results of amputation, I can refer only to treatises
 upon pathology properly so called, and to the article (see Vol. I.) upon
 operations in general.

      Article VI.—Organic Changes produced by Amputation.

   As  has been  noticed by all surgeons, very remarkable changes after
the removal of a limb, sometimes take place in the person who has been
operated upon, changes which  relate either to the stump itself or to  the
constitution in general.

                           § I.—In the  Stump.

  The muscles, vessels, cellular tissue, aponeuroses, tendons and bones
themselves, undergo  at the place of their section, a transformation of
such character, that all their parts are  blended together in their union
with the cicatrix, and  consist at that place only  of layers or fibrous
cords, more or less dense and more or less distinct; the stump which
had wasted at  first, afterwards becomes the seat of a more active  nu-
trition, increases in size, and  finally at the expiration of an indefinite
period of time, attains in this  respect the  volume nearly of the root of
the other limb.

                  §  II.—In the rest of the  System.

  Persons  amputated upon, acquire a remarkable  embonpoint, and an
augmentation  of  energy in the  organs of digestion, circulation  and
reproduction ; the vital fluids compelled to circulate  within  narrower
limits, increase the activity of all the functions, in  the same way as  the
intensity of a light becomes more and  more vivid  in proportion as we
concentrate its rays.   The tendency is to the formation of the sanguine
temperament.   The salutary efforts of nature to remedy this too great
plethora of the system, are manifested according to the age and sex in
epistaxies, hemorrhoids, more abundant menstruations, a greater frequen-
cy of  stools, and more  copious perspiration and secretions.   Garengeot
therefore advises in order to prevent this plethora  and crowding of  the
blood, that patients who have had a limb amputated, should  from time
to time be bled, that they should reduce their nourishment one quarter
part during the first year, and abstain  from violent exercises.   A  sol-
 dier in the army of the Eastern Pyrenees had his two thighs amputated
 and recovered  perfectly.  The activity of all  the  viscera, particularly
 the stomach, increased to a singular degree.   In a short time this man
 acquired a corpulency the end of which  it was impossible to foresee.
The stools in fact were nearer together without however any perturbation 
AMPUTATION OF THE LIMBS.
131
of the belly.   But the immobility to which this double mutilation sub-
jected him made his  plethora itself a disease.  A species of carriage
was procured.  This passive  movement did  more harm than good, be-
cause it favored digestion more than transpiration and the other excre-
tions.  This unfortunate person finally sank under the burden of san-
guineous plethora.  " I have seen hundreds of such cases, says M. Gour-
aud, and they appear to me every way worthy the attention of physicians."
I have myself seen a young soldier in whom  it became necessary to
amputate  in succession a leg and both arms, also an employe in a bureau
who had had his thigh taken off, both of whom by the plethora which
ensued, fully confirm  the observations of this practitioner.

             Article VII.—Prognosis of Amputations.

   Amputations have always been  considered very  dangerous, and they
are so in reality.  Nor can anything be more  uncertain  than  the con-
sequences which may result  from  them.  Welschius (Bonet,  Corps de
Mid., t. IV., p. 312) says, that out  of five persons  amputated whom
he saw at the Hotel Dieu, four terminated fatally.   Out of twenty-nine
operated upon by M. Baudens (Gaz. Mid. de Paris, 1838, p. 346, 347,)
or  his assistants at  the expedition to Constantina, twenty-four  died,
while out of twenty others amputated by M. Pointis (Ibid., p. 448) at
Bougie, during the space of four years, not one perished  !  M. Warren
has lost eight out of forty at  the Hospital at Boston, while M. Chelius,
(Arch.  Gin.  de Mid.,  2e serie,  t. IX., p.  229,) at  Heidelberg, has
saved twenty-seven  out of twenty-nine.  The English surgeons, who
maintain  that a greater proportion of persons  amputated die  in France
than among them, attribute it to our mode of dressing ; but in examining
the fact in itself,  M. B. Philipps has  recently read a paper  (1838) at
the Med.-Chirurgical  Society of London, by which it appears that^the
mortality  in persons  amputated is at  least  as great  in  England as in
Franco.   At La Charite, I have in the course of one year lost but two
out of twenty-six.  In the preceding  year I had lost six out of twenty-
one, and in following year I lost four out of nineteen.   A young surgeon
of Philadelphia maintained that in his  country persons do not  die from
amputations as they  do  with us.  Upon returning to America, he as-
certained  that six  died out  of  twenty-four.   M. Mott writes : " Our
amputations at New-Yorjt are rarely followed by death ; I cannot recall
to mind, at present, but four cases  of amputation which have  thus ter-
minated.  I have amputated two legs and a thigh for gangrena senilis,
without waiting for the disease to  be arrested.   The amputation of the
thigh, and one of the  two amputations of the legs, were  followed with
success.   Union by the  first intention more frequently occurs at New
York than in  France.  I have remarked that  in America, the inflam-
mation which  follows operations is altogether of  a healthy character,
whilst at Paris  there  is  more irritability than  true  inflammation.   We
must  ascribe  this difference to our climate, and to the constitution of
our countrymen.  If our operations are followed by more considerable
inflammation, and by a more  intense fever/our inflammatory diseases
are also  more  acute  than those that are observed in France."  It is
well to  remark, that in their communications, MM. Warren, Gibson, 
132
NEW ELEMENTS OF OPERATIVE SURGERY.
Paul Eve, and some physicians of Philadelphia, hold precisely the same
language as M. Mott on this head.  A pupil of the Hospital  of Lyons
considered himself fortunate in saving twelve  out of seventeen, and M.
Laborie (Bull, de Thirapeut., t. XV., p. 165) eulogizes a kind of dres-
sing by which only four are lost out of every eleven.
  An opinion has gained ground among physicians, that in the hospitals
of Paris we lose  one in every two or three patients ; but this  is  not
generally  true.  As to myself, I have lost but one in every five  or six.
It is, besides, impossible in this loose way to form  a correct opinion of
the mortality of amputations.   Success or failure in these cases depends
more  than anything else, upon the nature of the lesion which requires
the operation, the acccuracy of the diagnosis as to the  condition of  the
viscera, the importance of  the limb to be amputated, the circumstances
and the precautions connected with the patient, and the hygienic means
and consecutive treatment employed ; therefore, when patients  die, is
it from the amputation, or in spite of the amputation ?  Other things,
moreover, being equal, amputations  are more dangerous  in  hospitals
than in private practice, under an extreme than in  a mild temperature,
during epidemics than in an ordinary healthy condition of the atmos-
phere, in men than in women, in old men more than in  adults, in adults
more  than in children, in the lower  rather  than in the upper extremi-
ties, and near the trunk  more than at a distance from  it.   I ought also
to remark that amputation of the fingers has to me  appeared more dan-
gerous than that of the toes, and that the former  in  itself, is not less
hazardous to life than amputation of  the arm.
  [The favorable influence of our intense summer heats in promoting
union  by  the  first intention, was strikingly  confirmed to Dr. Mott by
what he observed also in Egypt, during his visit to that country.  The
somewhat similar climate  of the valley of the Nile to our own  during
the summer, and its often long-continued, and parching heats, have
nevertheless,  he observed, a  most remarkable  and salutary effect  in
accelerating the cure of all surgical operations  by adhesive inflammation
—a result favored, also, by the spare sinewy make and dry fibrous tem-
perament of the Arab, resulting from the character  of their climate,
their food, and their active habits.   The same beneficial results which
an elevated and dry temperature produces upon the processes of adhe-
sive inflammation, seem to be derived also, says Dr. M., from the tonic
power of intense cold during our protracted winters.   T.]
   [We are indebted to Mr. Samuel  Fenwick,  Lecturer on Pathological
Anatomy at the Newcastle-upon-Tyne School of Medicine and Surgery,
for by far the most elaborate  papers which have yet  appeared on the
general mortality of amputations.  They may be found  in the Edinburgh
Monthly Journal for October  and November, 1847, and January and
February 1848.  We quote the following table : 
AMPUTATION  OF THE  LIMBS.
133
                      TABLE  I.

GENERAL MORTALITY OF AMPUTATIONS OF THE LIMBS.
Hospital or Authority.
 Number
of Ampu-
 tations.
Number
  of
Deaths.
 Average
Mortality
  Period
 in i&iich
Performed.
            Civil Practice.
Liverpool Infirmary,
Liverpool Infirmary—Mr. Halton,
Liverpool Northern Hospital,
Edinburgh Infirmary,
Glasgow Infirmary,
Glasgow Infirmary,
Six Scotch Hospitals,
Newcastle Infirmary,
Royal Berkshire Hospital,
Chester Infirmary,
University College Hospital,
Guy's Hospital,
Great Britain—Mr. Phillips,
Collected from various journals—Mr. Phillips,
Notes of various surgeons—Mr. Phillips,
Various surgeons—Dr. M. Hardy,

    Total of British Practice,

Massachusetts General Hospital,
Pennsylvania Hospital,
America—Mr. Phillips,

    Total American Practice,  •

Germany—Mr. Phillips,
France—Mr. Phillips,
Hotel Dieu,
Hotel Dieu,
Hospitals of Paris^-Malgaigne,
Paris—Gendrin,
Paris—D upuy tren,

    Total of Continental Practice,

    Total of Civil Practice.

          Military Practice.
Army at Algiers,
Baron Percy,
New Orleans,
Naval Action of  June 1st, 1794,
Bombardment of Algiers,
British Army in Peninsula,
British Army at  Thoulouse,
Military Records—Alcock,
British Legion,

    Total of Military Practice,

Total of  Civil and Military,
43	3
96	18
61	31
276	100
155	47
24	3
229	54
27	5
21	9
66	10
36	4
233	53
308	76
107	28
364	83
2046	624
67	15
79	22
95	24
241	61
109	'26
203	47
35	17
178	104
552	300
63	23
59	15
1199	532
3486	1117
63	17
92	6
52	12
60	8
59	24
842	289
100	31
74	6
109	55
1451	448
4937	1565
1 in 14 33
  "  11.66
  "   5.33
  "   1.96
  "   2.76
  «   329
  "   8
  "   4.24
  "   5.40
  "   2.23
  "   6.60
  "   9
  "   4.39
  "   4.05
  "   3.82
  "   4.38

1 in  3.09
lin
4.46
3.59
3.95
1 in  3.95
1 in
4.19
4.31
2 05
1.71
184
2.73
3.93
lin  2.25

1 in  3.12
lin
 3.71
15.33
 4.33
 7.50
 2.45
 2.91
 3.22
12.33
 198
1 in  3.23

lin  315
1834—1836
22 years.
1834—1843
3^ years.
1794—1839
1841—1846
1842

1838—1845
1838—1841
1835—1841
1843—1845
1840—1842
1836—1842
1836—1841
1834
1837—1840
   Add to this  number 151 from  the  Pennsylvania  Hospital, and  154
from the New-York  Hospital  not included in the  above, and we have 
134            NEW ELEMENTS OF OPERATIVE SURGERY.
5242 cases.   Then with 88 additional fatal cases, we have 5242 ampu-
tations and 1653 deaths, or 1 in 3.15.
  The following is Mr. Fenwick's estimate of the mortality which may
be expected in 500  ampntations  of the limbs, according to the results
in the civil hospitals of Great Britain :
	Number	Proportion to 1 Proportion	
	of	total number in 500 Am-	
	Deaths.	of Deaths.	putations.
Shock, Exhaustion and Delirium,	23	lin 6	} 27.82
Gangrene of Stump,	7	" 19.71	
Secondary Hemorrhage,	4	" 34.5	3.89
Tetanus,	4	" 34.5	3.89
Erysipelas,	6	" 23	\
Visceral Inflammation,	21	" 6.57	
Diseased Viscera,	6	" 23	>80.62
Purulent Deposits,	29	" 4.75	
Phlebitis,	20	" 6.9	
Phlebitis and Purulent Deposites,	5	" 27.6	>
Diarrhoea and Hectic,	12	" 11.5	J 12.07
Bed Sores,	1	" 138	
	138		
  From the statistics  collected from British and Continental hospitals
and other authorities, it appears that of 869 amputations of the thigh,
376 were fatal, or  1 in 2.31.  Of the  leg, in 534 amputations, 209
died, or 1, in 2.55, and  at  the knee joint, of 10 cases, 8 died, or 1, in
1.25.   Of 58 amputations at the shoulder-joint, 27 were  fatal, or 1, in
2.14.   Of the arm, in 317  cases, 118 died, or 1 in 2.81.   In the fore-
arm, of 181 cases, 19, died, being 1 in 9.52.
  As to the influence of the duration of the disease for which  amputa-
tion is  performed, Mr. Fenwick concludes that so long as  the life of the
patient is not placed in immediate danger by his disease,  we shall best
consult his interest by deferring the operation, since, besides giving
him a  greater chance of a natural recovery, the  amputation  will be
more  successful, and  less time will be required to heal  the wound in
case it be eventually  required.  Age seems to exert an important influ-
ence upon the results of an amputation.  Whilst most successful when
performed  for  disease on persons between 5 and  20 years of ao-e  the
chance of recovery, according to Mr. Fenwick, of those under 5° years
of age is comparatively  small.  After  the age of  30, the mortality in-
creases, until the commencement of old age, when the danger usually
becomes less.   The influence of the  season on the  results  of amputation
is shown in the  greater mortality  which  occurs during the months of
April,  May,  and June.   The  lowest  mortality occurred  during  the
summer months.
  The influence of anaesthetics on the mortality following amputations
has been most  ably investigated by Professor  Simpson  of Edinburgh
(Monthly Journal, April, 1848.)
  He found that 23 in 100 died after  amputation of the thigh, leg or arm 
AMPUTATION OF THE LIMBS.
135
performed  upon patients in an anaesthetic state, whilst 29 in every 100
died when not subjected to this influence.
  The fourth 'volume  of  the  Transactions  of the  American Medical
Association, contains the Report of a Committee appointed to examine
the question of the propriety of using anaesthetics in surgical operations,
and in the  analysis of  this Report made by Dr. Sargeant of Philadel-
phia, and published in the American Journal of Medical Sciences, for
April,  1852, we find a different estimate of their value upon the results
of amputations.   From the statistics of the amputations performed in
the Boston, New-York and Philadelphia hospitals he  found that the
mortality, when  performed for injuries, with anaesthetics, was 1 in 2* ;
for diseases, 1, in  4| cases.   Without  anaesthetics for accidents, 1 in
3||;  for  diseases, 1 in 6|.   For further remarks  upon  this subject we
would  refer the  reader to Dr. Norris'  Statistical Account of the Cases
of Amputation performed at the Pennsylvania Hospital from January
1, 1840,  to January 1,1850, published  in the American Journal of the
Medical  Sciences, July, 1854.  G. C. B.] 
13$            NEW ELEMENTS OF OPERATIVE  SURGERY.
   SECOND  PART.

AMPUTATIONS IN PARTICULAR.
                          CHAPTER I.

                      THE UPPER EXTREMITIES.

  The upper extremities, exposed by their uses and their relations with
external agents to every kind of injury, frequently require amputation.
The principle in regard to them, is to take  away from them as little as
possible.   The small portion which is preserved rarely fails to be still
of some service.  We thus amputate  separately the fingers, the several
bones of the metacarpus, the hand  alone, the wrist, the fore-arm in its
continuity, and  at its articulation, the  arm  at  different  points  of its
length, or at its union with the shoulder, or the shoulder itself.

        Article  I.—Partial Amputation of the Fingers.

  The amputation of the fingers, though but  slightly  mentioned by the
ancients, must have  been  had recourse to by them in a great number
of cases, and at the present day is very frequently performed, and in a
great  variety of modes, whether we limit ourselves to the removal of
one of the phalanges only, or take away the whole, whether we ampu-
tate in the continuity of the bones, of which they are made up, or pre-
fer doing it at the articulations.

                         § I.—Anatomy.

  The fingers, composed of three pieces of bone articulated in the two
anterior phalanges  in  the manner of a hinge, and at the metacarpal
phalanx by  enarthrosis, are, moreover,  composed' of tendons, fibrou3
grooves, synovial sheaths,  arteries,  and  nerves  of considerable size,
and also of a cutaneous covering, distinguished on its anterior  surface
by remarkable characters.   It is upon their palmar face that are found
the two flexor tendons and  the fibro-synovial groove, in which they
glide.  One of these tendons is attached at one extremity to the articu-
lar projection of the third phalanx, and at the other to the metacarpal
phalanx by means of a simple fibrous bridle.  The two  layers of the
other  flexor, on the contrary, are attached to the  sides of the middle
phalanx.   As all the flexor tendons are  gathered together in the hollow
of the hand  before they reach the wrist and the fore-arm, nothing can
be more dangerous  after amputation of the fingers, than inflammation
of their sheaths.  From their synovial  sheath, terminating in a cul-de-
sac only, on the anterior surface of the metacarpophalangeal articu- 
AMPUTATION OF THE UPPER  EXTREMITIES.
137
lations of the two or  three  median  fingers, operations performed  on
the thumb or little finger are thereby rendered yet more dangerous.
From the cellular  tissue being accumulated in front in  form of a cush-
ion, this part is  generally selected from  whence to obtain  soft parts to
cover the stump after an operation. From their dorsal surface being more
convex, it would be rendered more difficult to cut out in that part a flap
of sufficient width  and  thickness.   From the two arteries that run along
their  sides, lying  so close to the  bones, compression upon them  may,
without any  difficulty, be substituted for the  ligature.   The  two pha-
langeal articulations have this about  them remarkable,  that being sup-
ported on their  sides by two very strong ligaments, and in front and
behind by tendons  of considerable strength, they cannot be divided but
by means of certain  precautions.  The pulley which their head termi-
nates in, and the small  cavities separated by a crest which are found
upon the posterior extremities of these phalanges, are  also important,
to be  noted  in enabling us  to guide the action  of the bistoury with
security.
  The skin in these parts possesses  peculiarities  which are of so much
the more importance, that these are nofr ordinarily  effaced  by its morbid
condition.  In the midst of a considerable number  of folds  and wrinkles
which are found  upon its dorsal surface, there  are  three which must be
particularly recollected.  One which is perfectly transverse, corresponds
almost always with the line of the articulation; the second, convex behind,
lies over the union of the head of the posterior  phalanx with  its body ;
while the  third,  convex forwards, has the same  relation to the anterior
phalanx.  The palmar surface of the articulation  of the third phalanx,
is directly underneath, or at farthest, at  the distance of a line in ad-
vance  of  the  transverse groove which  is alone found upon  the skin
at this part.   The  same  may be said  of the middle articulation,  in
respect to the deepest  and  most clearly  defined line in the integuments
which surround  it.  The metacapo-phalangeal articulation, surrounded
like the preceding, by  two lateral ligaments, and  flexor  and extensor
tendons, has, moreover, in front of it, or upon its sides, the termination
of the lumbricales  and  inter-ossei muscles, and the trunk of  the collateral
arteries which bifurcates only a short  distance further in advance.   As it
is upon the head  of the  metacarpus that the phalanx  turns, this latter, dur-
ing flexion, is almost entirely concealed under the  former, which  alone
forms the  projection which is seen in the knuckles.  These articulations
are not upon the same  line.   The transverse groove on the palm of the
hand  which corresponds to the  articulation of the fore and little finger,
is situated many lines farther back than that of the two intermediate fin-
gers.   The best mode  of striking upon them is  to look for them at ten
to twelve lines farther back than each inter-digital commissure; by which
arrangement, also, the  cushion of their  palmar surface serves for an
excellent  flap to cover  completely the head of each matacarpal  bone
when we remove all the fingers.

                        § II.—Amputation.

   In former times, the  fingers were always amputated in the continuity •
of their phalanges.  In the time of Fabricius of Hilden, they  were re-
   Vol. II.                    18 
138
NEW ELEMENTS OF OPERATIVE SURGERY.
moved by a cutting forceps, gouge, chizel, or some other similar instru-
ment, operated upon by strokes of a mallet.  At a later period, the saw
was  substituted for these, which, in addition to their  clumsiness, had,
says Fabricius of Hilden, (Bonnet, Corps  de  Blvd., p.  516,) the incon-
venience of splitting the bones and giving rise usually  to  very  serious
consequences.   Verduc,  Petit, Garengcot, Sharp,  and most modern
surgeons, opposed  this manner of proceeding ;  so  that, for a long time
past, amputation of the fingers in the continuity  was abandoned.  The
operation, it  is averred, is more difficult, and that the portion of the
phalanx which is left can  be  of no  use.   Upon  this  subject, it would
seem to me, they have gone too far, and  that it is better, as  Le Dran
(Operat., t. I., p. 308) and MM.  Guthrie and S. Cooper think, k> saw'
through the phalanx where it is practicable, than to extirpate it entire: in
the fingers there is no part which has not its uses and importance.  M.
Graefe occasionally has no hesitation in still employing the chizel and
hammer, (Rust's Handb.der  Chir., t. I., p.  620.)  A young military
surgeon, M. Moreau (Gaz Mid de Paris, 1836, p. 93) has  specially
pointed out the advantages of amputation in the continuity of the phalan-
ges, and 1 have  often had occasion to confirm in  practice the opinion
which I first  expressed upon this subject.
  A.  Amputation  in the  Continuity.—We will suppose the  disease to
be confined to one  of the  two last  articulations.  It is clear that we
cannot remove it entirely, without dividing the  posterior  phalanx at a
certain distance from the diseased articulation, and that  the remainder
of the bone cannot fail to prove serviceable to the patient.   We may
moreover perform this operation, either by the circular  or  flap method.
  I.   Circular Method.—In the first  mode, the integuments  are to be
divided as near as  possible to the part  affected ; we  then push them
backwards, in order to divide the tendons and effect  the  section of the
bones by means of a small  saw, or,  what is better, by a good  cutting
forceps, at three or four lines farther back than the point where we com-
menced the incision.
  II.   The Flap Method.—In the second process,  we may  confine our-
selves to a single  flap, which it  is better to cut in front,  or, doing as
Heliodorus formerly did, (Nicet, de Lus  qua Digit, accidunt, p. 159,)
we may, should the soft parts not make it objectionable, make  two flaps,
giving them a little less length to each.  Reunion, also,  by the first inten-
tion, should be attempted  in both cases.
   B.  Amputation in  the Contiguity.—I.    Circular Method.—The
skin is  divided  circularly at three lines in front of  the  articulation.
The assistant pulls it back, in order that we may be  enabled to divide
the extensor  tendon  higher  up,  and enter between the  phalanges on
their  dorsal surface, after having divided the lateral  ligaments.  It is
not until the  bistoury comes out on the palmar surface, that the section
of the flexor tendons is accomplished.
   This process  which was followed a long time ago,  described by Ga-
rengeot,and  recommended by Sharp, Bertrandi, (Opirat.  de  Chir., p.
504,) Leblanc,  (Operat., t.  I., p.  308,) and  Lassus, Med.  Opir.,-p.
545,) and* which  has been generally adopted in England, is quite as
good as any other, and  allows of  a ready facility of  union by the first
intention. 
AMPUTATION OF THE UPPER EXTREMITIES.
139
  II. Flap Method.—A Process of Garengeot.—Flaps of the same
length, one dorsal, the other palmar. Garengeot, ( Opir. de Chir., t. III.,
p. 436) recommends that we should adopt for amputation of the fingers
the method of Ravaton, or  what is better that of Heliodorus ; that is
to say, that we should make two  lateral  incisions united in front by a
circular  incision; that we  should dissect  off the two flaps thus made
and raise them up to a level with the articulation  before dividing that,
and that we should then unite them by first intention.
  b.  Process  of Ledran, (Opirat.,p.  576.)—Two flaps,  one to the
right, the other to the left.—In the place  of making two  flaps, one in
front and the other behind, Le Dran  makes them on the side, and gives
them a semi-lunar form ; this is the  process  lately described anew by
M. Maingault, and very  properly condemned by M. Blandin.
  c.  Process of  Laroche (Encyclop.  Mith., part Chir., t. I., p. 108,)
or of Loder, (Rust's Handbuch der Chir., t.L, p. 635,) attributed to M.
Lisfranc.—A  Palmar Flap only.—The skin is divided at about the dis-
tance of a  line in front of the transverse fold on the dorsum of  the fin-
ger in order to be enabled to penetrate the  articulation  at  the first
stroke.   The lateral  ligaments are also immediately divided by inclin-
ing the  bistoury  first to one side then to the  other.  The  articulation
being completely separated, we  have nothing  more to do than to cut
out a palmar flap of sufficient length  to close the wound perfectly.  The
operation by this mode is performed in an instant.  The cicatrix being
turned towards the dorsal surface of the finger is, it is said,  more favor-
ably situated than when in front; a very questionable advantage certain-
ly,  and one that is more than counterbalanced by the risk of having the
phalanx denuded  posteriorly.  Besides the  disease does  not  by any
means always  permit us to  obtain a flap of sufficient length.
  d.  Process of M.  Lisfranc.—The  diseased finger is placed in supi-
nation ;  the bistoury is inserted transversely and flatwise in  front of the
palmar line, between the soft parts and the phalanx, the palmar surface
of which is grazed in order to obtain a flap  similar to the preceding,
and which  is then raised up; the joint is then divided from before back-
wards, without leaving any posterior flap.  This process is  not as good
as the preceding  one.
  e. Process described by Laroche, (Encyclop. Nith. part. Chir., 1.1.,
p. 108,) and adopted by M. Walther, (Rust's Handb., t. I., p. 625).  A
dorsal flap only.   When the disease does not  admit of our forming a
flap in front, (i.  e.,  a palmar flap,) we may divide the skin at one line
in advance of the palmar furrow, and thus arriving at the fibrous groove,
tendons, articulation and lateral ligaments, finish by forming a flap from
the dorsal  surface of  the finger which has  been amputated. The cica-
trix being  less exposed to  view  and to the  action of external agents,
offers, it is seen,  some advantage,  as Laroche  says, (Encyclop.,  p.
108,) to people of  condition; but in  persons who work  in the fields,
it exposes  to painful  contact with hard bodies, which an infinity of la-
borers are  obliged to seize with the  hand.  It is  therefore  from neces-
sity and not from preference  when  we are  obliged  to operate in this
way.
  /.  The  Usual Process.—Two Flaps.   MM.  Richerand,  Gouraud,
(Handb. der Chir,, 1.1., p. 625,) &c, recommend making  two semilu- 
140            NEW ELEMENTS  OF OPERATIVE SURGERY.
nar flaps, one dorsal and the other palmar, and each from three to four
lines  in  length.  This  process, modified  in the following manner, ap-
pears to  me to be of a more general application, and fully as secure and
as prompt in its execution as any other ; I proceed to  describe it more
particularly:—
  g.   Process of M. Rust, (Princip.  Opir., etc., p. 84.)   The Palmar
Flap  longer than the other.  The operator seizes the  diseased  finger
and gently flexes it as he draws it towards him, while an assistant sup-
ports  the upper  part of it, flexes the other fingers or  separates them
from the  first, and fixes the entire  hand in pronation.  He then with
a narrow bistoury, held in the first  position, passes it  from one side to
the other through the entire track of the  anterior fold of the skin, and
cuts out a small semilunar flap, with its convexity towards the nail; the
divided teguments are drawn back by an assistant; the bistoury ascend-
ing with  them, traverses  the joint as it  divides the  extensor tendon,
and cutting the lateral  ligaments to the right and left, passes between
the articulating surfaces, and arrives at  the  anterior ligament.  The
surgeon  then directs the cutting edge of his  instrument forwards to
make it  glide upon the palmar surface of the phalanx, which he has
just disarticulated, and to form a flap of from four to six or eight lines
in length.
  h.  The anterior  (i. e., the  palmar) flap is the one to be principally
depended upon, though  the  other is not without its use.   That it may
not be too short, and in  order that we may at  the same time give it the
necessary length, I think with  Delpech, that it is more prudent before
terminating  its section,  to take the measure of it, so to speak, by rais-
ing it  upon  the articular surface which it is  destined to cover.  All
these  processes, however, enable us to obtain  our object.  The trials I
have  made  of them have  convinced me  that we may to a certain ex-
tent, adopt any of them indifferently; that the preference to be given
in such cases, depends much more  upon the  pathological  condition of
the parts or the fancy of the surgeon, than upon the absolute value of
the operative process.
  At  all events, the amputation of  the phalanges is an easy  operation.
It is certain, however, when we can control the choice, that the mode I
have just described, and that  which comes under the circular  method,
areto.be preferred.  The  others will not be necessary, except where
we are obliged  from the condition of the  soft parts to cut the flap en-
tirely from one only of the two phalangeal surfaces.
   C.  Dressing and subsequent Treatment.  The operation having been
completed by one process or another, it rarely  becomes necessary either
to tie or twist the arteries.   The blood, after the amputation of the pha-
langes stops of itself, or by  means of  gentle pressure.   If, however, we
should prefer using  the ligature, each thread  should be afterwards ar-
ranged at the corresponding angle of  the wound.  The two flaps, care-
fully brought together, are kept in contact by one or two strips of adhesive
plaster, which embrace the stump in the form of a noose, and are carried
back to the wrist upon  its dorsal and palmar  surfaces.  A perforated
linen  besmeared with cerate, a little  dry lint, a soft  compress and  a
narrow bandage to adjust the whole, complete the dressing.  In respect
to regimen, a light diet for two or three days, and afterwards  nourish- 
AMPUTATION OF THE UPPER EXTREMITIES.
141
ment somewhat diminished in quantity and less succulent than usual, are
the only restrictions to which the patient is to be subjected.
  D.  Accidents.  Provided the  patient keeps his hand in a sling, it is
not necessary to confine him to his bed, unless accidents  should  super-
vene.   The best method, however, in these cases, of preventing any
complications, or remedying them when they do occur, is  to  establish a
uniform and  regular compression, from the fore-arm to the  wound, in-
cluding therein the hand, which is to be well protected on its two sur-
faces.
  If unfortunately, purulent  inflammation should  seize the  stump, we
must  hasten to remove the bandages, and to substitute emollient cata-
plasms  in  their place,  and  endeavour to check the disease  by leeches,
mercurial unctions, or even deep incisions.  This inflammation, from its
propagation  along  the  synovial membranes  becomes one of  extreme
danger, and together with phlebitis renders amputation of the phalanges
as formidable  almost as  that of the arm, especially amputation of the
thumb, fore finger, and little finger.  As  we  are not obliged in the last
[i. e.,  the third]  phalanx, to open so completely into  the tendinous
groove, the operation here is attended with much less  danger than in
the others.   I will  add that  I  have in three cases of amputation of
the phalanges, obtained  complete and immediate union, without any sup-
puration.

                § II.—Amputation of a whole finger

   Some  surgeons, and  among others, Lassus, (Mid.  Opir., p. 543,)
have laid it down as a precept, that when the middle phalanx is diseased,
the first should also be  removed at the same time; since, say they, this
last, when preserved alone, remains immovable, and becomes  much more
embarrassing than useful.   To remedy this inconvenience, which he ex-
plains by saying that, after the removal of the second phalanx, the flex-
or tendons are deprived of every kind of point d'appui,  and are inca-
pable of acting on  the  first  phalanx, M. Lisfranc (Coster, Manuel de
Mid.  Opir., 1823) has conceived the singular  idea of making at first
one or two incisions in  front of the metacarpal phalanx, to  traverse in
this manner  the whole  thickness of the soft parts, in order  to promote
inflammation of the tendons and their previous adhesion to the surround-
ing tissues ; but this would be making two operations instead  of one, and
as I have said  elsewhere,  (Anatom. des  Rigions, t.  L,  1825, first
edition,) and as has been well remarked by M. Scoutetten since, (Arch.
Gin. de Mid., t. XIII.,  p. 54,) the object which M. Lisfranc has in view
is naturally accomplished by the  fibrous bridle  which attaches one of
the flexor tendons to the first phalanx of the fingers.  Even though this
anatomieal arrangement should not exist, we should not have  to fear the
immobility mentioned by Lassus.  After the cure, the  tendons invari-
ably become  fixed to the neighborhood of the cicatrix, if  they no not to
the bone itself, so that nothing hinders them from  flexing or extending
the root of the amputated finger.   On the other hand, observation proves
that these fears are purely theoretical.   All the  patients I  have  seen,
who have  had the two last phalanges removed, have used  the first per-
fectly well, and would have been lothe to have had it sacrificed.  It is not 
142            NEW ELEMENTS OF  OPERATIVE SURGERY.
proper, therefore,  to amputate the whole of the first phalanx, unless
the disease has extended so far as to make it absolutely necessary.
   Considering that  after the operation "the  two  collateral fingers are
found widely separated by the head of the intervening metacarpal bone,
Dupuytren preferred amputation of  this last bone in its • continuity to
simple disarticulation of the finger.  If the  patient incurred no more
risk by one mode than the other, or if  the head of the  metacarpal bone
did hot ultimately become narrower, (s'aplatir,) so as to permit a nearer
approach of the two neighboring fingers, we might adopt this process
which  M. Champion and many other  modern practitioners have sanc-
tioned, and which the English, M. Larrey says, (Clin.  Chir., t. III., p.
609,) employ  to prevent inflammation in the  fibrous  structure of the
hand,-  but  this is entirely the reverse, and the  surgeon ought not to go
beyond the metacarpo-phalangeal articulation, unless he is compelled to
do so.
  A. Circular Method.—The disarticulation of the fingers is  performed
only by the flap or  oval  method.   The  circular, carelessly  described
and adopted by some authors, by Leblanc (Pricis des Opirat., etc., t.
I., p. 328,) among others, and recommended also by M. Cornuau, ( These
No. 71, Paris, 1830,) is attended only with  inconveniences, and  ought
to be rejected.
  B. Flap Method.—I. Process of Sharp.—After having made a  cir-
cular  incision  upon  the root of the finger in front  of the commissure,
Sharp (Opirat. de Chir., p. 390) proposes that we  should make  ano-
ther upon each side in order to form a dorsal, and afterwards a palmar
flap, before  proceeding  to  the  articulation.  This  is a mode which is
inherently defective,  and which no one ought to follow, notwithstanding
the modification which Rust (Handb.  der  Chir., t.  I., p.  621)  has
given to it.
  II.  Process  of Garengeot,  (Operat., t. III., p. 431.)—The root
of the finger, at first  isolated down to the articulation by two lateral
or parallel incisions, is afterwards laid bare upon its dorsal surface by
a semilunar or transverse incision.   There is then nothing left but to
divide  the extensor tendon  and the  sides of the  capsule, in order to
separate the joint and remove the finger, while  terminating by the sec-
tion of the flexor tendons and the skin which covers them.  This  is the
process described  by Bertrandi, (Traiti des Opir., p. 504,) Leblanc,
&c.  The one that many  moderns  have  substituted for it differs  only
in this, that the extremities of the  two  lateral divisions  are made to
join upon the dorsal  and  palmar surfaces of the articulation, in place
of being united by a transverse incision.
  III.  Process of J. L. Petit—(Malad. Chir., t. III., p.  208.)   The
root of the finger, circumscribed by two semicircular  incisions  which
include its commissures  and  are prolonged  obliquely in converging to
become united behind on the dorsum  and in front of the hand, is first
laid bare down to the articulation, which is opened and then  separated
from one side to the  other or from before backwards.
  IV.  By  Puncture.  In place of dividing from the skin  to the  bones,
as in the preceding  mode, we  may, as Rossi (Mid. Opirat., t. II., p.
235) proposes, plunge in  the bistoury from the dorsal to the palmar
surface, in order to cut out successively the two flaps from within out- 
AMPUTATION OF THE UPPER EXTREMITIES.           143
wards and from behind forwards, that is, from their base to their apex ;
but this is a process wliich has no advantage over the others, and which
makes a less  regular  wound than that of Petit, of which in fact it is
only a repetition reversed.   M. Plantade (These de Montpellier, 1805)
proposes,  after having formed in this manner the first flap, that  we
should  divide the joint and  finish as in the following  method, which is
somewhat less objectionable.
  V. Process of Ledran, (Opirat.  de  Chir., p. 577,) or of M.  Gou-
raud, (Princip. Opir., p. 83,) improved by M. Walther, (Rust's Hand-
buch, t. -I., p. 622,) and attributed to M. Lisfranc, (Malgaigne, Man.,
etc., p.  304.)  The assistants seize the hand turned in pronation, and
also the sound fingers, holding them  apart  from the median line while
they keep them extended.   The  operator  seizes  the diseased  finger
with his left  hand and  exerts some movements upon it in order to be
the better enabled to identify the articulation.   Holding  the  bistoury
in his right hand in the first position he directs its heel upon the dor-
sum of  the articulation, or commences even at four or five lines beyond
that, and  dividing the skin reaches the middle of the  commissure upon
one  side ; depressing the wrist he prolongs the incision in the same di-
rection  nearly up to the groove which transversely crosses the palm of
the hand  in front of the joint.  The  cutting edge of  the instrument is
brought back upon the convexity of this semicircular  wound, to divide
from before  backwards the  remainder of the soft parts  down  to the
articulation, which is laid open  upon the side by turning  the edge  of
the instrument transversely into it as soon as it reaches behind the head
of the phalanx ; while we are dividing the joint and the aid is drawing
the  skin  gently back towards  the wrist to the right or to the left, we
reverse the finger as though we were in the act of luxating it.   Divid-
ing  the extensor and flexor tendons at the moment the assistant is
drawing upon the teguments in an opposite direction in  order to pro-
tect them from the action of  the bistoury, the surgeon finishes the ope-
ration  with a second  flap, similar to the first, but cut in the direction
from without inwards, and from  the metacarpus to the interdigital com-
missure on the opposite side.
  VI.  To give greater length to the flaps, Garengeot and some others
recommend to commence the first and terminate the second flap at some
lines in front of the commissures.   Others propose that their apex
should be cut off square, and  not  made pointed as they generally arc.
It has  appeared to me that  by approximating the root of the fingers
with some degree of  care, we may very easily  bring the two sides of
the wound in contact, without having recourse to the above precautions,
which  however have no other inconvenience than  that of exposing the
skin to  become  turned  back upon itself and to render  the  operation
somewhat more difficult.
  When the first incision is  made, it is well, in order  to run no risk of
going beyond the head of the bone and to avoid all kind of groping in
the dark,  to search with the fore-finger  for the internal tubercle of  the
phalanx which is to be removed; which is moreover an  easy  matter,
as it is the first projection we meet with behind.
  I would recommend that the first incision should be prolonged nearly
a half an inch beyond  the  articulation, because we can then  divide 
144
NEW ELEMENTS OF OPERATIVE SURGERY.
 with much greater ease all the fibrous tissues which surround it with-
 out interfering with the other lip of the wound, and because we shall
 bo more easily enabled by this means to cut out the other flap in a reg-
 ular manner.
   When we have  adopted the precaution  of grazing the sides of the
 phalanx and of not passing  beyond the head of the metacarpal bone,
 the trunk of the collateral arteries will  generally be found to have es-
 caped ; there are but two vessels which  bleed,  and  which  can  be tied
 or twisted if they do not stop  of themselves.
   The process of Ledran  is the most rapid  of all, and has no other
 disadvantage than that of not  always allowing us to give the same reg-
 ularity nor exactly the same form to the last flap as to the first;  in this
 respect the method of Petit is preferable to it,  and  does not merit the
 censures which some persons have bestowed upon it.
   C. The  Oval Method.—The hand of the patient, the assistants and
 the operator are arranged as  in the  preceding  process : we commence
 also in the same manner.
   I. Process of M.  Scoutetten.—The surgeon seizes the affected finger
 with his left hand, and gently flexes it while  holding it  slightly apart
 from the others, and then commences  the incision upon the dorsal sur-
 face behind the articulation, with  the heel of the bistoury which he
 gently brings forward to the border of the commissure, and comes round
 with it upon the palmar surface of the finger, by cutting exactly upon
the semicircular line which separates it from the hand, properly so  called ;
 arrived at the opposite border, he  reconducts the  bistoury  to  the an-
 terior or phalangeal extremity of the wound, and brings it back obliquely
to the metacarpus to unite the two extremities of the incision.  Without
leaving the part to be severed he widens the lips of the  wound as much
 as possible, divides the  extensor  tendon,  then  the  lateral  ligaments,
increases the flexion of the finger in drawing  upon it as if in order  to
 dislocate it, reaches  its palmar surface by passing the bistoury through
 the articulation, and finishes by dividing the flexor tendons  as  well  as
 the soft parts which connect the phalanx to the cellular cushion of the
 hand.
   II. In the place of following the palmar groove of the  finger, on ar-
 riving at its commissure, it is more convenient to make the second  inci-
 sion immediately in the same manner as the first.  We then disarticulate,
 and proceed for the rest of the  operation in the  mode just described.
 We have thus circumscribed a V incision, and the wound does not  present
 the form of an oval until after the operation is finished.
   III.   In  the ovalar  method we rarely divide the common trunk of
 the collateral arteries.  Provided we have not  given too  much width
 to the  point of the flap which is to lie removed  with the  finger, [i.  e.,
 the point or angle on the dorsal surface 6f the hand immediately behind
 the articulation where the two incisions meet, or where they commence,
 if we adopt the modification of M. Velpeau above.  T.] the two lips of
 the wound may be brought together with ease and reunion effected with
 more facility and certainty by this than by  any  other  method.  It is
 therefore the process which ought to be generally adopted ;  and it pos-
 sesses so much the greater advantage that it  does not require the skin
 to be sound to so great an extent as in the others.  The  wound which 
AMPUTATION OF THE UPPER EXTREMITIES.
145
 results from it, leaving the palmar  cushion  untouched, offers in fact a
 surface one half less in extent than by the flap method, and its regularity
 always renders coaptation easy ; but to perform it well, it is necessary
 to be intimately conversant with  the anatomy of the parts, and to have
 had much practice with the  operation, and its  repetition on the dead
 body.

       §  III. Amputation of the four Fingers at one Operation,

   Some ancient authors, with various  works  on military surgery, and
 many theses written at the commencement of the present century, show
 that the amputation of all  the fingers at one operation had been  already
 practised.  In a case where the fingers of both hands had been mutilated
 by  the bat of a cotton dresser, I had an opportunity of putting  in practice
 at the same time all the known methods, and of  obtaining flaps from all
 the sides  of the fingers, either to give  length to  the stumps, or take ad-
 vantage of the facilities offered by the soft parts intended for covering
 the bones.  In 1804, I was so fortunate as to have  it  in my power to
 prevent amputation at the  wrist in a young lady who had all  the fingers
 burnt except the thumb, which  remained sound.   The  cure was pro-
 tracted, but the  results were  of immense  importance to  the patient,
 (Champion, Private Communications.)  The cases, however, which de-
 mand this  kind  of operation may be readily  conceived without the
 necessity  of pointing them out in  detail.   The crushing of  the parts,
 a projectile from a cannon, congelation, or  any  thing which would at
 once  disorganize  the four appendages of the hand are of this nature.
 Nevertheless as the cases are rare, where all the fingers are destroyed
 up to their metacarpal articulation, and no farther than that point, there
 must  be but few occasions where the operation is called for.
  A.  The hand and the fore-arm being held in the  same manner as for
 amputating  a single  finger,  the operator having  seized hold  of  the
 fingers which he is about to  remove by placing his  left thumb  trans-
 versely upon their dorsal surface, and his left fingers upon their palmar
 surface, gently flexes them and directs  the assistant to stretch the skin
 by  drawing it backwards; he then with a straight  bistoury makes a
 transverse incision slightly convex in front, and  from six to eight lines
 below the extremities of the metacarpal bones, taking care to  commence
 at the fore-finger if he is operating" on  the left hand, and at  the little
 finger if on  the right hand.  This first incision exposes the extensor
 tendons in front of the articulations.  As  soon as the integuments  are
 properly drawn back the surgeon opens into the articulations, and divides
 their  anterior ligament.  Nothing more  remains for him to do than to
pass in front of the head  of all the  disarticulated  phalanges a narrow
knife, with which he  cuts  from behind forward a large semi-elliptical
flap, whose limits  are naturally marked  out by the groove which connects
the  palmar surface of the  fingers  with that of  the hand.   The same
knife  might  serve also for the dorsal incision ; but  as it is necessary to
pass successively over projections and depressions, the bistoury is much
more  convenient.
  B.  In order to prevent the protrusion of  the flexor tendons we must
divide them upon a line with the  articulation before finishing the flap.
  Vol. II.                  19 
146
NEW ELEMENTS OF  OPERATIVE SURGERY.
 For this purpose it would  be better, perhaps, after the dorsal  incision
 has been  completed, to cut out the palmar  flap as  M.  Caillard ( These
 No. 307, Paris, 1833) proposes, before proceeding to the disarticulation.
 In  order  to make the  circular incision, M. Cornuau  (These  Xo. 71,
 Paris, 1830) first incises the entire palmar groove, then proceeds to the
 dorsal incision and finishes with the disarticulation.  This process is as
 good as any other, no doubt; but in an amputation  of this kind  the sur-
 geon ought to hold himself in reserve to regulate his conduct by the con-
 dition of the parts rather than by what he learns in books.
  C.  There are eight arteries divided by this operation.   As they are
 bent  at an angle upon  themselves, in raising the tissues to close the
 wound, it is not generally necessary to apply the ligature.   The palmar
 flap, usually the only one, and always the longest, has no need of sutures
 to unite it to the  dorsal.  Strips of adhesive plaster suffice to keep it
 firmly attached to the head of  the metacarpal  bones.   Over these we
 apply a perforated linen, spread with cerate.  The  whole is then cover-
 ed with a thin layer of  lint, then a soft compress, and some long ones
 which embrace the stump from before backwards,  or obliquely, and in
 the  same direction as the adhesive straps.   After having properly pad-
 ded the palm of the hand, nothing more remains than to support all these
 pieces by means of a bandage, the turns of which, brought more or less
 into proximity with each other and  drawn tolerably tight, should be ex-
 tended above the wrist and passed once or twice between the root of the
 thumb, the remainder of  the hand and the free extremity of the stump.
  D.  The  same or nearly the same kind of bandage  also will  answer
after the extirpation of a single  finger.  Nevertheless we proceed some-
what  differently, according as we have preserved flaps or confined our-
selves to simple oblique incisions.   In the first case, in fact, there is re-
quired a narrow strip of  adhesive  plaster to fasten the two portions of
preserved tegument upon the head of the metacarpal bone ; while in the
other case it is sufficient to pass one crosswise and to approximate the
roots of the two collateral fingers, as much as possible by drawing gently
upon the bandage as it passes round the borders of the hand.  It is the
same  when we have adopted the oval method.
  E.  There is no need  of  remarking  that  when we wish to amputate
two or three adjoining fingers only instead of four, the operation should
be  conducted  upon the  same principles, that is, in such manner  as to
have but one flap for the whole  wound  instead of disarticulating  them
by as many separate operations.

                        § IV.—Accidents.

  However easy or trivial the disarticulation of the fingers may seem,
 it is nevertheless frequently followed by very serious accidents.   A man
 and a woman,  in the year 1825  and 1826, died  from this cause in the
 hospital of Perfectionnement; and a patient upon  whom I  operated at
 La  Pitie, in 1831, perished in the same way.   Among those  upon whom
 I have operated at La Charite,  two have  died, and it would be no  diffi-
 cult matter to find similar examples elsewhere.  It is  sufficient to re-
 mark that the operation  should not be decided  upon but with  caution
 and where absolutely required.  Its dangers arise from the  extreme fa- 
AMPUTATION OF THE UPPER EXTREMITIES.
147
 cility and fearful rapidity with which the inflammation, through the me-
 dium of the tendinous grooves, (coulisses,) sheaths, and synovial mem-
 branes and the exceedingly loose lamellar  tissue upon the dorsal and
 palmar surfaces both of the phalanges and hand, is propagated in the di-
 rection of the wrist, attacking at the same time the soft parts, the articu-
 lations and the surface of the bones, which in this manner soon become
 the seat of a suppuration which nothing can arrest.
   To dilate  the  fibrous sheath "of each finger amputated, as is recom-
 mended by Garengeot, (Opirat. de Chir., t.  III., p. 432,) J.  L. Petit,
 (Malad. Chir., t. III., p. 208,) and Bertrandi, and as  has been again
 recently  advised  by M. Barthelemy, (Journ. Heb.  Univ.,  t. XII., p.
 429,) would in no manner prevent the  development of those formidable
 phlegmasias, which besides are totally disconnected  with every kind of
 strangulation.   M. Champion has on two occasions subdued the inflam-
 matory accidents  which supervene  after amputation of the  fingers, by
 means  of caustic potash applied to the palm of the hand ;  but when cat-
 aplasms or the vigorous application of leeches do not arrest their pro-
 gress in the  beginning, there is nothing which can prove  really effica-
 cious but numerous  and deep incisions.  The remedy is painful, un-
 doubtedly, but it is a question of life and death ; and every one who has
 had an opportunity of witnessing their  sometimes almost miraculous ef-
 fects will not hesitate an instant in resorting to them.

            Article II.—Amputation of the Metacarpus.

   Like the fingers, the bones of the metacarpus  may be amputated in
 their continuity or at their articulations, and separately or all together ;
 they may also be exsected or even extirpated.

                      § I.—In their Continuity.

   Though the case may be rare in which we may have occasion to am-
 putate the first and last bone of the metacarpus in their continuity, it is
 not so with those which support the fore, middle, and ring finger.
   A. Anatomy.—The bones of the metacarpus, enlarged at their two
 extremities, incurvated in front, convex and wider on their dorsal sur-
 face, which is covered only by the flattened tendons of the  extensor
 muscles of the fingers, and by cellular  tissue, veins and skin, and sepa-
 rated by spaces of less width near the wrist than elsewhere, constitute
 in their ensemble a sort of grating, protuberant behind, and the concavity
 of which is occupied by the inter-ossei muscles, the tendons of the flex-
 ors, the lumbricales muscles, the two arterial palmar arches of the hand
 and their branches, the distribution of the median nerve, the muscles of
the thenar and hypo-thenar eminences, and the  palmar aponeurosis and
common integuments.   Though scarcely moveable at their posterior ar-
ticulations, they may however be approximated  so as to incline towards
each other in front at  their digital  extremities ; from  whence it follows
that after having sawed obliquely through their middle  portion, we are
enabled to efface in a great degree  the chasm which results from it, and
that the deformity produced by this kind  of amputation is much less than
from the removal of one of the  fingers.  As their phalangeal extremity 
148            NEW ELEMENTS OF OPERATIVE SURGERY.
 is in a state of epiphysis to the age of six or ten years, we may in chil-
 dren, and if the disease requires it, amputate one or all the fingers, by
 means of the bistoury.   At a later period the saw becomes indispensa-
 ble.
   B.  Operative Process.—The chisel, gouge and mallet, have, as in am-
 putation of the fingers, been employed though more rarely for the remov-
 al of the metacarpal bones.
   I.  Partial  Amputation.—In the hand, we  must sacrifice nothing un-
 less compelled to do so.  (Progres de la Chirurgie Militaire, p.  127,)
 has often seen, and many times himself performed an amputation of a por-
 tion of the hand with success.  " We have often," says M. Larrey, ( Clin.
 Chir., t.  III., p.  609,)  " not had it in our power to save anything but
 the thumb alone, or the thumb and little finger, or the two or three last
 fingers of one hand, but they constitute hooks  that are extremely use-
 ful to the patient."  In a case where the hand  was crushed, M. Cham-
 pion obliquely divided the four first bones of the metacarpus, after hav-
 ing  disarticulated the thumb, and  preserved  the little finger.  " This
 little  finger,"  says  the author, " performs  important  services  as a
 hook.
  a. The Ancient  Process.—The parts  being  arranged,  and  held  as
 for amputation of a  single finger, the operator traverses, at some lines
 beyond the disease, the whole thickness of the hand from its dorsum to
 its palmar surface, then directs the  point  of the bistoury, held in the
 third position, upon the bone itself perpendicularly ;  inclines it a little
 to one side while  drawing  upon  the  skin;  then  straightens  it  to
 graze  the surface of the  bone ; approximates it  to the median line
 when its point reaches to the outside, and terminates  by cutting towards
 himself with the entire edge of the instrument as far as to the middle
 of the  corresponding inter-digital commissure.   After this first incision,
 one precisely  similar is made upon the opposite side, but in such  man-
 ner that the two form  but one only  behind ; that  is to say,  that the
 thumb and  forefinger hold the  tissues apart  to the  left, while the bis-
 toury,  carried  back  to the commencement of the wound, glides from the
 other  side to  fall also into the same division in front.  We then divide
 what  remains  of the soft  parts about the bone, by passing around its
 entire circumference with the point of the instrument.  A thin piece of
light wood, sheet-lead, or pasteboard, or a thick compress is then insert-
 ed deep in the wound, to prevent the saw which must divide the bones,
from  before backwards  by a long  bevelled section from wounding the
flesh.   This bevel in consequence of the kind of motion peculiar to the
carpo-metacarpal  articulation, must  be placed upon the ulnar side for
the two last fingers, and on the radial side, on  the contrary, for the two
first.
  When the bistoury has  not been  carried too far outwardly,  the col-
 lateral arteries are not usually wounded except at the root of the finger;
 in the contrary case, we run the risk of  wounding their common trunk
 to the right and left, which, nevertheless, does not generally prevent us
from dispensing with the ligature or torsion.
  In  dressing, it suffices to keep the lips of the  wound gently approxi-
mated by means of some strips of adhesive plaster applied transverse-
ly, and three  or four turns of bandage.   In trying to obtain a perfect 
AMPUTATION OF THE UPPER  EXTREMITIES.           149
coaptation, we  make  traction upon the posterior articulations, but this
is  calculated to  give rise  to the train of formidable evils pointed out
above.  This operation, which is not appreciably more difficult than
the disarticulation of a finger, makes a bleeding surface or wound three
or four times larger,  and necessitates the division of  soft parts that are
more delicate and far more numerous; so that in this respect, at least,
it is certainly much more serious, nor should we have recourse to it un-
less after ascertaining that the other will not suffice.
  b. New  Process.—I  have  long substituted the following for the an-
cient process.  An  assistant separates the fingers apart, and holds the
hand.   Embracing the diseased finger with my left hand, I make an in-
cision  drawn  obliquely  from the  posterior to the anterior articulation
of the metacarpus,so  as to go around the entire root of the finger.   Set-
ting out from  the point where this terminates, another incision on the
other side proceeds to join the former at a very acute angle on the back
of the hand, as in the ovalar  method.   I afterwards isolate the bone
on  its sides and  palmar surface, to  beyond  the  diseased  portion.  I
had at first used  the rowel-saw  to divide from the dorsum to the palm
of the hand, but  M.  Liston's pliers enables  us to perform the section
with far greater facility.  Using this  instrument, all the soft parts in
the palm  of the  hand are  protected  from injury, and the  operation is
at  once easy  and rapid.  None of the five patients upon whom I have
used these pliers have had  any accidents follow, and everything shows
that the bone thus divided heals as well  as after the use of the saw.
   This process, should it be generally  adopted, will  rarely make it ne-
cessary to disarticulate the bones of the hand.  By this process, the
operation  performed  by M. Simonin, (Dicade Chir., 1838, p. 52,) 10
remove the second bone of. the metacarpus, would have been made very
easy and  very simple.  It is, after  all, only an improvement  of the
ovalar method, and  especially of the process long since employed un-
der  similar circumstances  by M.  Langenbeck, (Rust's Handbuch der
Chir., 1.1., p. 641.)
  II. Amputation in  mass,—a. Louis {Mem de VAcad. Roy. de Chir.,
t. II., p, 272) made the  section of  the greater part of the bones of the
metacarpus, in such manner as to leave only  their posterior portion, in
the case of a young girl, who was  quite  satisfied  in  having this mere
vestige of the hand preserved.  It would be-better  still should their
anterior extremity (leur tete) alone be  diseased, to  divide them all in
this manner transversely, rather than to disarticulate them.   The opera-
tion could not  present any  great  difficulties.  A semi-lunar incision,
with the convexity anteriorly,  would lay bare their  dorsal surface ; a
narrow knife, passed between  the bones  and  the soft parts, from  one
border of the hand to the other, would form a palmar flap of from twelve
to eighteen lines in length ;  a bistoury would then divest each bone of
the tissues that surround it,  in order to render the  section with the saw
more neat and easy.
  b. A Single Palmar  Flap.—In such  cases, M. Van Onsenort makes
in the palm of the  hand,  placed  in supination, an  incision  near the
fingers, with its convexity anterior, and comprising the entire thickness
of the  soft parts.  From each extremity of this incision, he makes
another which  is oblique, and which  are directed  respectively to the 
150
NEW ELEMENTS OF  OPERATIVE SURGERY.
 radial and ulnar borders of the wrist.  The upper extremity of these
 are  united by a transverse incision, which  divides through the whole
 of the tissues on the  dorsum of the  metacarpus.  We  then, by means
 of a narrow bistoury, isolate  the bones from  their muscles and perios-
 teum ;  hold back the divided parts, by means of a retractor  bandage
 with five tails, and then saw through the bones.
  c.  A process  much more  simple, and one  to  which, considering all
 the circumstances, I give the  preference, consists, after the dorsal flap
 is formed, in denuding each bone upon its sides, and then dividing them
 successively with Liston's pliers, before making the palmar flap.

                     § II.—In the  Contiguity.

  A.  Partial Amputation.—All the bones  of the metacarpus  may be
 separately disarticulated and  amputated, together with the finger which
 corresponds to them.   This may be  done  with the whole together, or
 with the four last only, and  by a single  stroke.   But  it is almost ex-
 clusively on the first and fifth that disarticulation is performed, since it
 is more easy to amputate the  others in the continuity.
  I.  Metacarpal Bone of the  Tliumb.—From the mobility of this bone,
 and its shortness, we rarely think of dividing it by  the saw when  dis-
 eased, but prefer disarticulating it.  Nevertheless, if its anterior  extrem-
ity was alone affected, I see  no reason why  we  should not divide it
immediately posterior to this.   There can  be no  particular danger in
this operation, which, moreover, would not be  difficult, and might be
performed either by the flap or circular method, and would  differ from
amputation of the fingers at the joint in  this  particular only, that it
would  require the intervention of a cut of  the saw, or a stroke of the
cutting pliers, to finish it.
  a.  Anatomy.—The  metacarpal bone of  the thumb  which, upon its
dorsum and outside, is scarcely covered except by the  skin, and which
is concealed in front by  the whole thickness of the thenar eminence,
 presents, near the carpus, relations  which  it is important should be
noted.   The articulation of this bone with the trapezium being situated
 obliquely in  relation to a line which would extend to the  root of the
 little finger, and presenting, in some sort, a mixed character  between
 the  hinge and enarthrosis, and surrounded  with a very loose  capsule,
 may be reached upon all the  points of its circumference, but principally
 as its  two  posterior  or  dorsal  thirds.  The  tendons  of the extensor
 ossis metacarpi pollicis, and of the abductor pollicis manus, occupy and
 support its cutaneous region ; while the radial artery passes around its
 ulnar side in going to the palm of the hand  to  form  the deep-seated
 palmar arch.   As to the tendons of  the extensor secundi internodii
 pollicis, and of the flexor  longus pollicis manus, their position  in front
 and behind is too well known to require any particular notice here.  We
 determine the position of the articulation by gliding the forefinger from
 before backwards, either upon the  dorsum or on its sides, as it is im-
 mediately behind the first osseous tubercle we encounter.
  b.  Operative Process.—We may  disarticulate the  first metacarpal
 bone by a great variety of methods,  and with ease in whatever  way we
 do it, provided we possess any address or skill. 
AMPUTATION OF THE UPPER EXTREMITIES.           151
  I. Ancient Process.—If the surgeon is not ambidexter, the hand of
the patient should be held in pronation for the  left side, and supination
for the right; in the contrary case, it is placed in pronation for both
sides.   While the  assistant holds the wrist with one hand, and the
root of the four last fingers with the other, the operator -seizes  hold of
the thumb, which  he carries into  abduction ; then  directs  upon the
middle of the commissure the cutting  edge of the bistoury, held in the
first position, with its point  upward; divides  with its  entire  edge the
whole  thickness of the soft parts, grazing from before backwards the
ulnar border of  the bone as  high up as to the  carpus ; prolongs from
four to six lines towards the wrist the  incision of the  teguments upon
the dorsal and palmar surfaces ;  opens into the joint by inclining the
bistoury outwardly ; divides all the  fibrous parts with the point rather
than with the body of the instrument, in order that he  may avoid  wound-
ing the  skin ; reverses  the  thumb  at the same  time  upon its  radial
border, luxates  it,  and after  having divided the  articulation, cuts the
flap from behind forward, grazing  the  outside of the bone until he
reaches to within some lines  in front of the metacarpo-phalangeal ar-
ticulation.  To preserve to the flap, especially at  its  base, the required
width  and thickness, it is advisable, while  cutting through the inter-
osseous space, to incline the  handle of the instrument a little towards
the hypo-thenar eminence, and to direct its cutting  edge towards the
pisiform bone, or the ulnar border of the carpal extremity of the radius.
In prolonging the  wound of the skin to some lines  beyond the carpo-
metacarpal articulation, we  obtain a means of disjointing  the bones
with  ease, without notching or hacking the  margins of the flap which
is to cover the wound.
   If we have wounded the radial artery itself, we apply the ligature to
it.  The exact coaptation of the surfaces renders this resource unneces-
sary, when there have been no other arteries divided but the branches
on the thenar eminence.  After having applied the adhesive plasters, it
is well to place a mass of lint or a graduated compress upon  the outer
surface of the flap the base of which especially must be strongly pressed
against the second  metacarpal bone.
   2. Another Process.—An assistant holds the thumb ;  the  surgeon
with the three first fingers  cf his left hand seizes hold of as much of
the soft parts and draws them as far outwardly as possible ; plunges  in
the bistoury by  puncture from the dorsal  surface of the  hand to the
palmar surface of the thenar eminence, grazing the  radial  side  of the
articulation; cuts  out a flap  as in  the  preceding process, reverses  it
backwards, and causes it to be held  up by an assistant; he then himself
takes hold of the thumb; causes the lips of the wound to be held apart;
divides the joint from without inwards, luxates the bone and brings the
bistoury back to terminate the operation at the point  were it should have
commenced in the  other process.   As the final result is precisely the
same in the two processes, and as it is always less easy to  disarticulate
by this mode, which as it appears is still followed by M. Walther, (Rust's
Handb. de Chir.,t. I., p. 642,) we should give the preference to the first.
   c. Process of the Author.—In  the  place  of making the flap  by cut-
ting from within outwards, we may proceed in the  opposite direction,
that is, commence  with the  section of the integuments, and  reverse  it 
152            NEW ELEMENTS OF OPERATIVE  SURGERY.
afterwards by dissecting it from its  apex to its base;  this would  be
a more certain means  of giving it  as much regularity  as possible, and
the proper dimensions  desirable, only that it would require a little more
time.  In actual practice we obtain in this manner a  result infinitely
preferable to the processes  above described.
  4. New  PMcess.—I have frequently, in amputating the thumb, adopt-
ed the following mode.  A dorsal incision carried from the styloid pro-
cess of the radius to the middle of the commissure between the two first
fingers, [*.  e., between the two first metacapal  bones.  T.] and com-
prising the  teguments, the tendon  of the  extensor secundi  internodii
pollicis, with a part of the  first inter-osseous muscle, lays bare at first
the articulation.   While an assistant holds open the lips of the  wound,
the surgeon  divides the  ulnar side of the capsule, luxates  the bone,
and passing the bistoury underneath, separates it from the thenar emi-
nence by cutting the soft parts from behind  forwards and from  within
outwards.  The  palm of the hand being respected by this mode  enables
us to give to the flap the form and extent we may  require, and without
any special obstacles to overcome.
  5. Ovalar Method.—Lassus, Beclard, and M.  Richerand, have long
since described the  oval method for  the amputation under consideration.
The operation is commenced as I have pointed out.  The incision passes
round the anterior surface of the root of the thumb, [i. e., the palmar,]
to ascend upon the  outside  to its dorsal  surface,"and unite this  second
incision to the extremity of the first.   In the second  stage the point of
the bistoury is directed upon the articulation which is divided from its
dorsal  to its palmar surface;  after which  nothing remains to be done
but to detach the bone  from the soft parts which are adherent to it, by
gliding the instrument in  front of it  from behind forwards.   By this
means  we obtain an oval wound  which is elongated to a great  extent,
and the lips of which may be united with the greatest degree of facility,
so as to leave between them nothing but a linear cicatrix.  It is the best
and most simple of  all the  processes known, but not quite so easy as the
preceding,  which moreover accomplishes the same results.
  II.  The fifth Metacarpal Bone.—The bone which supports the little
finger is disarticulated and removed by the same processes as those
described for the thumb.   Its articulation with the unciform bone pre-
sents this remarkable  peculiarity ;  that it inclines  obliquely in  the di-
rection of a line which would strike in front of the articulation of the
trapezium with the  first metacarpal bone, and  that it is united to the
matacarpal  bone which supports the ring finger  by an articulation
which is nearly flat  and by  two or three_ ligamentous bandelettes.  This
articulation is recognized upon the outside by  passing the point of the
fore-finger  along the dorsal surfaces of  the last metacarpal bone, since
before  reaching the line of  the pisiform bone we meet with a slight pro-
tuberance,  then a small depression  which is exactly upon the interline
of the articulation.
  a. When we follow the ancient process we need  have no fear  of the
bistoury catching as it  does in amputating the thumb between the bones
of the carpus.  We must  therefore  carry it  unreservedly as far as to
the unciform bone by grazing the radial surface of the fifth metacarpal,
and directing the edge  of the instrument towards the median line of the 
AMPUTATION OF THE UPPER  EXTREMITIES.           153
wrist,  so as to preserve  almost  entire  the  hypo-thenar  eminence.
When  the inter-metacarpal ligament is divided, the point of  the bis-
toury,  which is then to be inclined  towards the ulna, readily enters into
the articulation.  In proportion as the other fibrous  tissues are divided,
the finger is to be reversed upon its ulnar  border, that the  instrument
may escape from the articulation, to form the base of the flap cutting out
the latter from behind forward,  and  prolonging  it beyond  the meta-
carpo-phalangeal articulation, while the little finger in  the  meanwhile
is brought nearly into its natural position.
  b.  The  second process in which we commence  in forming a flap by
plunging through the soft parts from one of the sides of the hypo-thenar
eminence to the other, before having separated the fifth from  the fourth
metacarpal bone, is in  this part of more easy and advantageous appli-
cation  than upon the other border of the  hand.  The soft parts which
naturally make a very  considerable prominence on the outer part of the
bone -which we are about to  remove, enable us by this means to cut
out a thick flap of sufficient width  ; but the disarticulation is also more
difficult than by the preceding mode.
  'c. The process  vjhich 1 sometimes employ for  the  metacarpal bone
of the  thumb is not applicable with the same advantage to  that of the
little finger, where the ovalar method is evidently preferable.   The in-
cision, commencing in front of the styloid process  of the ulna, is car-
ried obliquely forward to the  root  of the  little finger, passing round
its palmar surface from its ulnar  to its radial  border.   We  stop at the
commissure in order to re-apply the bistoury at this point in  order to
prolong  the  incision backwards to unite it at an acute angle with the
beginning of the first incision.
  We  might, moreover, begin just as well by falling on the commissure
between  the two  last  fingers, and  terminating with the  inner  incision.
As  to  the disarticulation, it  presents nothing peculiar, and does not
require any other notice.
  III.  The Middle  Metacarpal Bones.—Without being  impracticable,
the disarticulation  of these three bones  is, nevertheless, it  must be
conceded, much more  difficult than that of the two first; also  ampu-
tation  in  their continuity is generally preferred to their disarticulation.
If, however, we should desire to  have recourse tp  the last, it may be
performed either by the flap or ovalar method.
  A. The  Flap Method.—1. Metacarpal Bone  of the  Fore-finger.—
The bistoury directed from before  backwards, and  from the commissure
towards  the carpus, soon  reaches  the  ligament  which unites the meta-
carpal  bone of the  fore-finger to that of the middle finger.   We then
raise the handle to divide the  dorsal  ligament, and then depress it to
cut the palmar ; the finger is inclined towards the thumb, the articula-
tion  entered, then separated by the point  of the instrument, and the
operation finally  terminated by forming  upon the  radial side of the
bone a flap which is prolonged until it reaches beyond the metacarpo-
phalangeal articulation.
  2. Metacarpal  Bone of the Middle  Finger.—The bistoury is applied
between the two middle fingers.  Before  proceeding to the disarticula-
tion, the  wound must be prolonged in front  and  behind upon the wrist
to the  extent of half  an  inch, slightly approximating to the  median
  Vol. II.                   20 
154
NEW ELEMENTS OF  OPERATIVE SURGERY.
 line.   This articulation  is somewhat  oblique in the direction from the
 ulnar to the  radius and  from behind, for  which reason the  operation
 would be rendered much  more difficult if we commenced upon the other
 side.   When the dorsal  and palmar  ligaments are divided, and when
 the bone which we are about to remove is separated from  the metacar-
 pal of the ring-finger, we act upon its anterior extremity as if for the
 purpose of luxating it backwards, and then endeavor, while an assistant
 draws the lips of the wound towards the thumb, to disarticulate, its
 carpal extremity, upon which, moreover, is inserted the tendon of one
 of the radial extensors of the  carpus.   This  being accomplished, the
 bistoury is glided with its entire  cutting edge along the outer surface
 of the bone to the commissure of  the fore and middle finger.
  3. For the fourth metacarpal bone,  (i. e., the metacarpal  bone of the
 ring-finger,) we must direct the bistoury upon the same space; prolong
 the incision in the same manner  posteriorly, with this  difference, how-
 ever, that it must be inclined towards the ulna ; we then  separate  the
 two contiguous  osseous articulating surfaces, and divide the ligaments
 as in the preceding  mode, calling to mind that the articulation of the
 metacarpal bone of the ring-finger with the os magnum and the os unci-
 forme is oblique from without inwards and from before  backwards, and
 that it is also continuous  with that of the fifth metacarpal.   In travers-
ing the whole  palm of the  hand by two parallel incisions  which  are
united posteriorly  by means of oblique A incisions, M.  Rust (Rust's
 Handbuch der Chir., t. I., p. 653) may perhaps render the operation
more easy, but it produces a larger wound, and one which is manifestly
more difficult to heal.
  B. The  Ovalar Method.—M. Langenbeck (Rust's Handb. der Chir.,
t. I., p. 654)  was the first  who  successfully extirpated one of these
bones by the ovalar method.  The operator divides the integuments on
 their dorsal surfaces, by commencing at half an inch beyond the carpal
articulation ;  he prolongs his incision to one of the digital commissures,
brings it back upon the opposite  side by passing around upon the pal-
mar surface of  the root of the finger; then unites its two extremities
by cutting from before backwards, or from behind  forwards, after the
 same rules on the outer side of the bone which he is about to disarticu-
late.  While  an assistant separates as far  apart as possible the two
 lips of the wound, the surgeon, with the point of the bistoury, and
 without using any force divides in succession the ligaments of the artic-
 ulation ; and  with his  other hand makes an effort to luxate  the bone.
 When he has  finally effected this last result, the bistoury is glided flat-
 wise and horizontally, in  order to divide from the carpus to the root of
 the finger all  the soft parts which still adhere to its anterior surface.
  M.  Simonin, (Dicade Chir.,  1831, p. 51,)  in  disarticulating the
 second bone of the metacarpus, in a patient of his who  got  well, com-
 bined the ovalar  with the ancient process.  The oval  incision being
 made, this surgeon  slit up the palm of  the hand, and found more facility
 by this mode  in disarticulating the bone, removing with it the  finger at
 the same time.
   B. Simultaneous Amputation.  When the whole hand is affected in
 such manner  that the carpo-metacarpal articulation remains unimplicat-
 ed is it necessary to remove the  wrist at the same  time with it ?   To 
AMPUTATION OF THE  UPPER EXTREMITIES.
155
 believe in dogmatic treatises on surgery, there should  not be the least
 doubt upon this  subject, or, to speak  more correctly, none  of them
 have paid any attention to this question; at the present time, however,
 this is no longer the practice.
   In confining ourselves to the  disarticulation of the metacarpal bones,
 we preserve a greater  length to the  fore-arm, and a moveable  portion
 of limb, and  obtain incontestible advantages for the application of an
 artificial  limb.   M. Larrey (Clin.  Chir.,t. III., p.  609) affirms  that
 military surgeons have long employed this operation.  M. Yvan (Arch.
 Gin. de  Mid., t. XIV., p. 293) also  says that  many of the  military
 patients of the  Hotel of the  Invalids have  undergone this  operation,
 and have  done well after it.  On the other hand, I find in a  thesis sup-
 ported in 1803, detailed observations upon this subject.  In many sol-
 diers of the army of the Rhine, says the author, amputation was  per-
 formed at the carpo-metacarpal  articulation with the view of saving at
 least the  thumb.   J. B. J. A. Blandin,  (These, 1803,)  who describes
 this operation, and censures it, says this kind of disarticulation is very
 difficult;  that in one case purulent collections rendered it necessary at
 a later  period to amputate the arm, and in another the fore-arm, and
 that both died.
   Paroisse (Opuscules de Chir., 1806, p. 218) also in a patient of his,
 was enabled, by  confining himself to  the  extirpation of the three last
 bones of the  metacarpus, to  preserve both the thumb  and fore-finger.
 M. Delatouche, (Thise, Strasbourg, 1814, p. 45—46,) who, in remov-
 ing the fourth and fifth bone of the hand, was equally fortunate, says,
 that in fourteen or fifteen cases of this description, he has been enabled
 by this mode, to save a number of  fingers.  M.  Mornay (These, Stras-
 bourg, 1816)  maintains the advantage  of  saving the thumb at least.
 Troccon,  who thought himself  the author  of this operation, repeated
 it  a great  many times upon the  dead body, and  presented a  careful de-
 scription of it to the Institute, which obtained a somewhat favorable re-
 port  from  Percy and  Pelletan.  At a later period,  M.   Maingault,
 (Nouv. Mith. pour Amputer  la  Main,  &c.,)  in 1822, endeavored
 anew to  draw attention to it, without mistrusting, as it would seem,
 that any  person had spoken of it  before  him.   Since the  treatise of
 Troccon, M. Gensoul (Arch. Gin. de Mid., t. XIV., p. 293) has per-
 formed it  with entire success at the Hotel Dieu, of Lyons,  preserving
 only the thumb.   Before him M.  Guthrie had amputated the two  last
 fingers and their corresponding  metacarpal bone.  M.  Walther (Ibid.,
 t. XXIV., p. 135) has also performed this  operation for the second and
 third finger in one case, and for the third and fourth in another, ( Graefe
 und  Walther, Journal, Vol. XII., 1829.)   Finally, Troccon  advanced
 the idea that it would be practicable to remove at the same time one or
 more  bones of the first range of the  oarpus, and M.  Benaben  (Revue
 Midicale, 1825, t. I., p. 377) undertook to demonstrate the correctness
of  this opinion by successfully  performing amputation  upon the sca-
phoid, the trapezium, and the trapezoid bones, and upon the metacarpal
bones of the thumb and fore-finger.   Two English (surgeons)also have
claimed priority on these different points: the one, M. Sully,  avers that
in  1807, in a patient who is still  living, he  removed the last bones of
the metacarpus, and also the unciform bone, the pisiform, and the pyra- 
156            NEW ELEMENTS  OF OPERATIVE SURGERY.
 midal.  The  other, M.. Radiore, avers, that in an infant of nine years
 of age, in whom he removed the three middle metacarpal bones and the
 osmagnum, he preserved only the thumb and little finger.
   As  often as we can preserve the thumb or any of  the fingers, there
 is no doubt that we ought to adopt the process of these practitioners,
 and to follow the advice of Troccon and M. Maingault.  As a general
 rule, the  carpo-metacarpal  disarticulation  should be preferred to ampu-
 tation of  the  wrist.  But it is an  operation  which  exacts practice and
 an intimate knowledge of anatomy; so that if the surgeon does not feel
 sufficiently confident of himself to perform it without fear, he  ought
 not to undertake it.
   I.  Anatomy.—We have already spoken of the arrangement of the
 first and fifth  bone  of the metacarpus, with the trapezium, and unciform
 bones.  The metacarpal bone of the fore-finger, which is  but loosely
 attached on its outer border to that of the  thumb, but more  firmly unit-
 ed on its inside with the  third metacarpal bone, presents posteriorly on
 its outer side, a tubercle which is prolonged  some lines towards the
 wrist, and gives attachment to the tendon of the extensor-carpi-radialis-
 longior, (premier radial.)   [For all the muscles, see  Table at the be-
 gining of  Vol. I., this American Edition.  T.]   Its posterior articulat-
 ing surface is  articulated on its outer portion with the trapezium, and on
 its two inner thirds with  the anterior articulating surface of the trape-
 zoid bone, which is found incased there, as it  were, in a sort of trian-
 gular cavity.
  The third bone of the  metacarpus also presents a tubercle which pro-
jects beyond the interline of the os magnum and the  trapezoid  bone,
upon which tubercle is inserted the tendon of the extensor-carpi-radialis-
brevior, (second radial  externe.)   Its  posterior articulating surface,
oblique from without inward, rests in almost its whole  extent upon the
corresponding surface of the os magnum ; while the  articulating surface
of the  fourth  metarcarpal  bone, oblique internally  and posteriorly, is
united  with the radial half of the anterior articulating surface of the
os unciforme, and then with a similar articulating surface which is pre-
sented by  the os magnum anteriorly and on its  inner side.
  All these bones,  on their dorsal surface, are kept in contact by liga-
ments in form  of  longitudinal and transverse narrow bands,  (bandelet-
tes,) and on their palmar surface by ligaments much more irregular in
form, and   also by  fibrous  bundles which fill up the spaces which the
points  of the posterior extremities of these bones leave between them
in front.   Their synovial sheath is continuous, moreover, with that of
the carpus, and is  extended consequently  between  the  two ranges of
bones of this  part; so that  inflammation of the  osseous surfaces  as a
consequence of the amputation  we have been treating of,  must, as a
matter of  course, be of a very formidable character.
  In reviewing all these  articulations upon their dorsal surface, we see
that that of the first metacarpal, oblique  anteriorly and internally, ter-
minates at one or two lines in front of that of the second, the fnterline
of which  latter goes at first almost directly backward, becomes nearly
transverse before  leaving the trapezium, then turns round into a semilu-
nar direction,  with  its convexity backwards on reaching the trapezoid
bone, and  afterwards passes again obliquely backwards before abandon- 
AMPUTATION OF  THE UPPER  EXTREMITIES.
157
ing this bone and uniting itself with the third metacarpal.   The articu-
lation of the third metacarpal bone commences at half a line nearer the
wrist than the extremity of that of the  second, and  inclines obliquely
inwards  and  forwards, as  if  to  rest upon the posterior fourth of the
fifth metacarpal:  it terminates, moreover, at two or  three  lines nearer
the fingers than  the  commencement of the articulation of the fourth,
which last at first follows  such a direction, that if prolonged, it would
become blended (irait  se  perdre sur)  with the pisiform  bone; after-
wards it becomes almost transverse on arriving at the os unciforme, and
continuous, but in some sort without any line of demarcation, with that
of the last metacarpal, which  is also very slightly oblique posteriorly.
  The manner of identifying  externally the first and fifth  of  these ar-
ticulations having been  pointed out above, it is, as I  conceive, unneces-
sary, to recur to it here.
  II.  Operative  Process.—A. Method  Adopted by  the Author.—An
assistant supports the fore-arm,  while he  makes pressure  at  the same
time upon the radial and ulnar arteries.   The hand of  the patient, turned
in pronation, is embraced by the  operator,  who confines himself to hold-
ing the four last fingers, when he wishes  to preserve the thumb ;  with
a straight  bistoury, or a small knife, we  make a semicircular incision,
with its convexity forward, about half an  inch in front of the articular
line we have just described.   The assistant draws the skin back towards
the fore-arm.  With a second cut of the  bistoury,  the  surgeon divides
all the extensor tendons, and proceeds immediately to disarticulate, com-
mencing on the radial side if  he  operates with the left hand, and on the
ulnar side, on the contrary, if he operates on the right.  The point of
his bistoury should merely be  drawn over the whole extent of the dorsal
surface of the articular interline, for  there is  no  need of penetrating
the joint in order to divide  the ligaments.   If we  begin by  the thumb,
its  cutting edge  will be first  directed from  behind forwards  and from
without inwards ; then almost  directly backwards; afterwards trans-
versely,  obliquely  forward,  obliquely  backward,  then forward  again
through  the whole extent of the  articulation of the os magnum, with
the third  metacarpal bone, very obliquely backward upon arriving at
the fourth, almost transversely to separate this last, and in such manner
as to follow the same direction for the separation of the fifth metacarpal
from the os unciforme.  During  this manipulation, a certain degree of
force is exerted upon the  anterior  extremity of the  hand,  as if for the
purpose of luxating it.
   All the  articulations  being now  laid open, the point of  the bistoury
is used to complete the section of the fibrous  parts which may  still hold
them together.  When these are all completely  separated, the knife is
glided gradually towards  the  palm of the hand, and being turned flat-
wise, cuts out a semilunar flap  of an inch or an inch  and a half in length,
grazing,  as it proceeds, the  palmar surface of the  metacarpal  bones
which are to be removed.   The terminating  branches of the radial and
ulnar arteries have necessarily been divided.  Those of the first are
found upon  the dorsal  surface of the wrist,  and near its radial border •
the second must be sought  on  the inner side of the pisiform bone.  Im
mediate reunion, which is in some sort indispensably necessary, requires 
158
NEW ELEMENTS OF OPERATIVE SURGERY.
here the same precautions as  after the simultaneous amputation of the
four last fingers.
  b. Process ofM. Maingault.—-The process which I have just described
after having often made trial of it on the dead body, and which is found-
ed  upon the principles laid down by Troccon, is  not the same as that
of M. Maingault.  This last-mentioned author proposes that the surgeon
should commence by forming the palmar flap, with a small knife inserted
between the bones and the Wt parts, so  as to pass a little in front of
the projections of the unciform and trapezium bones, leaving untouched
everything  which appertains  to  the thumb.   He  afterwards makes  a
semi-lunar  incision upon  the dorsal surface of the metacarpus, at the
distance of an  inch from  the  articulation ; then  returns in front, and
while an assistant draws the flap backwards, he directs the  point of the
bistoury upon  the base of the first, [flap,] until he  exposes the inter-
articular line.  After which he proceeds to the disarticulation from before
backwards, commencing with the metacarpal  bone of the  little finger,
or by that  of the  fore-finger, according  as the  operation  is upon the
right or left hand.
  c. The trial which I have made of this process has convinced me that
it is not in reality very difficult.  From not being practised in it, however,
or from  its inherent defects, it has appeared to me that the other was
much more  convenient.   The  definitive result, however, it is seen,  must
be the same in both cases.
  d. If the two last metacarpal bones,  or the two first, only were to be
removed, the operative process would have to undergo some modifica-
tions.  It would be necessary, in the first case for example, to commence
by a transverse incision a little in front  of the  articulations, then to
make another parallel to the axis of the metacarpal bones, upon the
dorsum of that which supports the little  finger, in order to cut upon that
part a dorsal flap, which is to cover the whole ulnar side of the wound
after the operation.  This being done and the disarticulation completed,
we would terminate the  operation  by forming only a small flap,  of one
or two inches in length, which we should be obliged to separate down to
its base in  the palm  of the hand, in order to be  enabled to raise it in
front upon the transverse branch of the wound.  We should proceed in
the same manner nearly for the  removal of the thumb and fore-finger,
or for the  fore and  middle fingers.  Proceeding in this  manner, M.
Gairal, (Journ. Hebd., 1835, t. III., p.  64,) in the case of a man who
had a musket burst in  his  hand, was enabled to  preserve the two last
fingers.  Another patient, operated upon at Nancy (Gairal, Journ. Hebd.,
1835, t. III.) by the same process, lost only the three middle metacarpal
bones, while he preserved the thumb and little finger.
   Should it be  required to remove at the  same time  some of the bones
of  the  carpus, there is no rule  that  could be laid down in advance ;
these nice  operations  must in general be left to the anatomical  skill of
 the surgeon.  M. Van Onsenort, in amputating the inner half of the
 metacarpus, with unciform, pisiform,  and  pyramidal bones, cut out  a
 single  flap only upon the ulnar  border of the hand.  The  patient got
 well, and  preserved the use of his thumb and fore-finger, with the mid-
 dle finger  in a slightly ankylosed  state. 
AMPUTATION OF THE UPPER EXTREMITIES.           159
                     Article III.—The Wrist.

 _ In our times, says  Percy, it is only at Tunis, or among other barba-
rians, that they cut off the wrist by means of a large hatchet, driven by
a weight falling from above  between two grooved uprights, or a heavy
chisel, which is struck upon with a leaden hammer.   Nor is there any
one who any longer believes it necessary to amputate the fore-arm, when,
in order to remove the totality of the disease, nothing more i-s required
than to disarticulate  the hand.  Among the  moderns, however, there
are many surgeons who regard  this last operation as exceedingly dan-
gerous.  The facts related by  Slotanus, (F.  de Hilden, in Bonet, p.
504,)  Bartholin,  (Hist. Anat., cent. 5, hist. 63,) Paignon,  (Mem. de
VAcad. Royale de  Chir., t. V., p. 504, 1819,)  Leblanc, (Pricis des
Opirat., t. L, p.  317,)  Andouillet, (Acad,  de  Chir., t. V., p. 505,)
Hoin,  (lb., p. 506,)  Sabatier,  (lb., p. 504,)  Brasdor, (lb., p. 492,)
Lassus, (Mid.  Opirat., p. 541,) M. Gouraud, (Princip. Opirat., p.
79,) and other surgeons, who affirm that it is almost always successful,
have not dispelled the fears which it formerly  inspired, and which
Schmucker (Rougemont, Bibl. Ch. du Nord, 1.1., p. 56) still entertains.

                          § I.—Anatomy.

  The radio-carpal articulation, surrounded with numerous tendons and
synovial grooves and membranes, offers, moreover, this remarkable pe-
culiarity : that it is terminated at the  extremities of its largest diameter,
by the processes of the radius and ulna, which gives it a semilunar form,
concave transversely, slightly  concave also  from before  backwarks,
where  is lodged a  kind  of head  formed by the scaphoid, semilunar and
trapezium bones, which are kept in place by the internal, external, pos-
terior, and anterior ligaments.   As the first range of the bones of  the
carpus diminishes  (s'amincit) at its extremities, especially on the ulnar
side, a line  drawn transversely between the apices of the styloid pro-
cesses, would naturally strike between this range and the second.  The
pisiform, the point of the scaphoid, the crest of the trapezium, and that
of the unciform  bone, rise sufficiently above the line of the palmar sur-
face of the  radius and ulna, to require also that they should not be over-
looked at the moment of operating.  The skin on the anterior  surface
of the wrist  presents almost  constantly three wrinkles, which  may be
of some service in regulating the direction of the instruments.   One of
them, and  which is the most constant, is found immediately above  the
thenar and hypo-thenar eminences, and corresponds to the line of divi-
sion of the two  ranges  of the bones  of the carpus ; the  second, which
is noticed at  four to six lines behind  this, is over the line of the radio-
carpal articulation, and  the  third  s^ll higher up, corresponds  usually
with the epiphysal line of the bones of the fore-arm.   When these folds
are not very  obvious, it is ordinarily sufficient to flex the hand mode-
rately to make them distinct. 
160
NEW ELEMENTS OF OPERATIVE SURGERY.
                     §  II.— Operative  Process.

   The  amputation of the  wrist is performed only by the  circular and
 the flap method.  Owing to the arrangement of the articular  surfaces,
 and the slight degree of thickness in the soft parts, the oval method is
 not applicable to this operation.
   A. The Circular Method.—The surgeons of the last  century having
 contented themselves with remarking that the amputation of  the wrist
 was performed like that of the fore-arm and leg, without entering into
 any  details upon the subject, it is to be  inferred that they employed the
 circular method, described, moreover, with sufficient  clearness by J. L.
 Petit, the only one pointed out by Lassus and Sabatier, and the one, we
 must confess, which still presents the most  advantages and  facilities.
 The assistant who holds the  fore-arm, draws the integuments forcibly
 backwards.   The surgeon  seizes the hand of the patient, and  places it
 in a state of flexion, while he makes  his incision upon the dorsal surface
 towards the radius on the contrary, when he  incises inwardly,  and upon
 the ulna  when he reaches the  outside,  and in extension at the moment
 the instrument is passing underneath.   In this manner he makes a uni-
 formly circular incision, at a large finger's width in front of the process-
 es of. the fore-arm, and confines himself at first to the section of the
 skin which it is«easy to  push  back afterwards to near the joint.  A se-
 cond cut divides all the tendons upon a line  with the  retracted integu-
 ments.  We then enter the articulation upon  either one or the other side,
 taking the corresponding styloid process for our guide, and making the
 bistoury describe a curved line, with the convexity directed posteriorly.
  Though the radial  and ulnar arteries are  readily found, and may be
 either tied or twisted, they are often left in the wound without  this  pre-
 caution,  and without any  hemorrhage  resulting from  it.   As to  the
inter-osseous, it  is too  small to require the least attention.  If  the
 operation  has been well performed,  there will be found a sufficiency of
integuments to enable us to bring them  forward without any difficulty,
and to cover  the  articulating surfaces completely.  It is in these cases
that  Garengeot  and Louis (Leblanc, Op.  cit., t. I., p. 319) advise  the
 division of the  tendinous sheaths to the extent  of one or two inches,
in order to prevent the formation of purulent collections.  The inclined
position of the  stump at least seems, in these  cases, to be imperiously
demanded.
  B.  The Flap  Method.—I.  Ancient Process.—The army surgeons ap-
pear to have for a long time employed, and M. Gouraud in 1815 has de-
 scribed, a process which consists in making, on the dorsal surface of the
 wrist, a semilunar incision, with its convexity towards the fingers,  and
 whose two extremities seem to be continuous  with the styloid processes
 of the radius and ulna.   An assistant then immediately draws back the
 cutaneous envelope, and the operator divides the bridles which unite it
 to the subjacent  tissues.  ^ A second incision,  made upon the line of the
 articulation, serves to divide all the  extensor tendons and the posterior
 radio-carpal  ligament.  We then divide the  lateral ligament  and the
 tendons of the radial muscles, [sec  vol. I., Table of  the Muscles.  T.]
 and of the extensor-carpi-ulnaris, if they have not already been divid- 
AMPUTATION OF  THE UPPER EXTREMITIES.
161
ed at first.  Nothing more  remains than to separate the joint with a
nanw knife, which is glided in front of the carpus, so as to terminate
by cutting out a palmar flap of about an inch in length.  Some surgeons
recommend  giving this  flap a length of two  inches from  its roo£ and
consequently to obtain a portion of it from the thenar and hypo-thenar
eminences.   Should we have been enabled to preserve a sufficiency of
skin in the beginning, this precaution would be more injurious than ser-
viceable.  To cut it with facility, and give it all the regularity possible,
the cutting edge of  the instrument must be inclined in good season to-
wards  the integuments, in order  not to strike  against the osseous pro-
jections of the carpus, and that we may remove the pisiform bone at the
same time with the  hand.   Should  the  flexor  tendons, which  form in
that part a bundle of considerable size, make any resistance, we ought
not to  hesitate to direct  the instrument under them, in order to divide
them transversely.  The approximation and reunion of  the lips of the
wound will be thereby rendered more easy.
  This process, which is as prompt as it is simple, has the  advantage,
should the soft parts  posteriorly be degenerated, of enabling us to pre-
serve a sufficiency of them in front to cover the whole wound ; but it has
the disadvantage of endangering denudation of the boney angles and their
protrusion between  the lips of the wound ; for the thickest  and widest
part of the  cutaneous flaps is situated precisely upon the concave and
least sailent portion of the articulation.
  II.  To cut the 2 flaps before opening into the articulation, as has  been
done by M. Walther, (Rust's Handb., t. I., p. 609,) would perhaps give
more  regularity to the wound, but  would  not in any way change  the
character of  the process.   M. Rust, (Ibid., p.  610,) who, by means of
two lateral and two transverse incisions, gives a square or  trapezoidal
form to the dorsal flap, which he then raises up to divide the articulation,
and to  finish as in the ordinary process, has, it  appears to me, rendered
the operation thereby unnecessarily complicated.
  III.  Process of M. Lisfranc.—The operator, provided  with a narrow
knife, transfixes the  tissues on a line with the styloid processes,  from
the radius to the ulna or from the ulna to the radius, according  as he is
operating on  the right or left limb ;  passes in  this manner between the
soft parts and the anterior surface of the carpus ; then brings the instru-
ment in front, and cuts  out, as in the preceding  case, a semi-elliptical
flap of about two inches in length.  This flap being raised up, or turned
back, enables the surgeon to make, immediately after, upon the dorsal
surface of the wrist, a semicircular incision nearly similar to that of the
process which I have just described, and at the same time to divide the
extensor tendons nearly on aline with the articulation ; then  to disartic-
ulate by passing under  the point of one of the styloid  processes ; thus
terminating the operation as in the circular method.
  IV.  In describing the process  which  M. Blandin, (Jadelot, Jour.
Hebd., t. III., p. 460,) on one occasion, adopted with success, the editors
of Sabatier have, as it were  unconsciously, added to it a slight modifica-
tion.  After  having formed the  palmar flap, in place of  carrying  the
knife behind the wrist to divide the integuments there, they proposeto
divide the joint immediately from before  backwards, and to finish with
the  division  of the  tissues  which cover  the   dorsum  of the  carpus.
   Vol.  II.                    21 
162
NEW ELEMENTS OF OPERATIVE SURGERY.
 Whether we adopt one mode or the other, this process presents nearly
 the same advantages and the ?amc  inconveniences ;  that is to say, it is
 infinitely less convenient than the flap method  usually  followed, and,
 moreover, differs from it by such  slight  modifications as not to require
 any further notice.
   V. The method of Rossi (Elim. de Mid. Opir. t. II., p. 233)  which
 proposes to  make two flaps, one to the right and  the other to the left, in
 the place of forming them in front and behind, also has no claims to our
 notice.
   VI. At the wrist as elsewhere the surgeon is often guided by the con-
 dition of the diseased  parts, much more than by the rules established
 upon  the dead body.  A man who had the  metacarpus and fingers con-
 tused by a cotton dresser exhibited  upon the palm of his hand a large
 flap of sound tissues.  After having abraded and regularized this flap,
 M. Champion, who has never had any occasion to regret having preferred
 extirpation of the wrist to amputating  the fore-arm above it, raised it
 up to its place and effected the cure of his patient.   In an army farrier,
 in whom a cancerous affection extended posteriorly to a line with  the
 articulation, I was obliged to take  the  flaps from  the  outside and in
 front.  The  patient recovered.
   VII.  The borders of  the wound should be approximated from before
 backwards.   A  roller  bandage brought down from the  elbow to  the
 wrist, and long compresses for each  side of the stump, protect  the syn-
 ovial membranes from inflammation and purulent collections.   A slightly
 depending position best suits the wound.  If any inflammatory engorge-
ment should take place in the stump we  must hasten to remove the ban-
dages, and to substitute emollient topical applications, and antiphlogistic
to the agglutinating means.

                    Article IV.—The Fore-arm.

   The law that we should amputate as far from the trunk as possible,
 and save as much  and  take away as little  of the parts as we can, and
 which is applicable  to all amputations of the  upper  extremity, is more
 especially so to that of the  fore-arm.   J.  L.  Petit, (Malad.  Chir., t.
 III., p. 207,) Garengeot, (Opirat.  de  Chir., t.  HI., p. 444, 2e t'dit.,)
 Bertrandi, (Opirat. de  Chir., p. 471,) and more recently M.  Larrey,
 (Clin. Chir., t. III., p. 603,) influenced  by false appearances or erro-
 neously reported facts,  have, notwithstanding, taken  opposite  ground.
 According to them, the lower third of the fore-arm is not sufficiently pro-
 vided with soft parts, and has too many fibrous  tissues to enable us to
 cover the bones  conveniently  after amputation,  or to secure  us against
 the thousand dangers from operations in this region.  Its upper half,
 on the contrary, provided with numerons muscles, and having but few
 tendons, presents the conditions the most favorable for the success of
 such operations,  and ought consequently to  be selected by preference at
 the expense of sacrificing some inches of tissues that might if necessary
 have  been saved.  To this reasoning we may reply, that even the thinnest
 part of the fore-arm, and which is the most completely destitute of mus-
 cular fibres, will always enable us to preserve a sufficiency  of skin to
 unite immediately and close the wound;  that in point of fact it is always 
AMPUTATION OF THE UPPER EXTREMITIES.
163
the integuments which form the cicatrices, and  that  these integuments
are at the same time so much the more  preferable and more supple and
solid, where  there is the least  quantity of muscle and tendon.  It is a
point, moreover, which experience seems to have now definitively settled,
for I meet with no one who desires to make it a subject of controversy.

                 § I.—Amputation in the Continuity.

   The fore-arm, besides its 20 muscles, and  their tendons, the radial,
ulnar and inter-osseal  arteries, their corresponding nerves, and the me-
dian nerve, and the aponeurosis, and the superficial veins which are dis-
tributed over its whole extent, presents  also for consideration, 1, Its two
bones moveable  upon one another, and  separated by a space  which
narrows as their extremities approximate, and which by means of a sort
of [intervening] membranous  diaphragm form the floor for the anterior
and  posterior inter-osseous cavities and fossae ; 2, A series of decussat-
ing  fibres and  of abundant lamellar tissue between the  different fleshy
layers, whose intimate connections allow of but very little retraction, at
the same time  that the ensemble of these parts is as favorable as pos-
sible to the development of phlegmonous inflammations and purulent col-
lections.
   A. Circular  Method.—All  the processes of the circular method, as
that of Celsus, the one by Wiseman and Pigray, those of Petit, Le Dran,
Louis, Alanson or Desault, are those that have  been  most usually em-
ployed in amputation  of  the fore-arm.   The  most generally followed,
however, at the present time, and the one which I think the best, is per-
formed in the following manner :—
   I. Process adopted by the Author.—An assistant placed upon the out-
side of the shoulder of the patient, who is supported upon the  side of  his
bed, or seated upon a chair if he is not too weak, compresses the brachial
artery against  the humerus below the axilla,  (See this volume, supra.)
A second assistant, or the same one if we  cannot procure another, seizes
hold of the fore-arm turned in pronation, and  holds himself prepared to
draw back the  skin towards the elbow.  The limb which is to be ampu-
tated should  at the same time be enveloped in linen and  supported by a
third assistant.
   a. First Stage.—The operator, seated upon the inside, seizes with his
left hand  the fore-arm  above the point where the skin is to be divided,
if he is on the left side, and under it on the contrary,  unless he is ambi-
dexter, where he is to amputate the right fore-arm, and then  makes a
circular incision upon the integuments  down to  the aponeurosis, and at
the distance of  two or three fingers' breadth below the place where he
intends to  make the section of the bones.  Should  any cellulo-fibrous
bridles interfere with the retraction  of the teguments he rapidly divides
them, and immediately bringing back the  knife upon the outer and pos-
terior surface of the radius, he makes a circular  incision as at first, cuts
through the whole thickness of the flesh as near as possible to the skin,
first  upon the dorsal region, then upon the palmar, and lastly upon  the
radial.  In order that the soft parts may not shrink or retract, instead
of submitting to the action of the knife, it rs necessary to effect their di-
vision by a saw-like movement  of the instrument,  which should not quit 
164
NEW ELEMENTS OF  OPERATIVE SURGERY.
the surface of the radius before resting fully against the ulna, keeping
the edge close to the surface of the latter bone as the incision is brought
round upon the palmar surface, if we do not wish any part to escape or
recede posteriorly.  I have no need of adding that the same  precaution
is equally necessary for the remainder of the circumference of the limb.
   b.  Second Stage.—The divided muscles retract to a greater or less
extent.   The knife is now directed behind upon the dorsal surface of the
ulna, and while the surgeon draws the  instrument towards himself, its
point as it proceeds falls upon the posterior inter-osseous  fossa which it
traverses to its depth, and  divides, as it returns and comes round upon
the  posterior  surface of the radius, every  thing which it meets  in its
progress.   It is now replaced underneath to complete in front  what it had
just  effected behind, after which nothing more remains undivided around
the bones.
   c. Third Stage.—The middle tail of the compress, slit into  three tails,
is then immediately passed, by means of a forceps, through the inter-os-
seous space from  the palmar to the dorsal surface.   The soft parts being
thus protected and drawn back, the surgeon proceeds to the section of
the bones,  commencing with the radius; he  continues  the  section  in
such manner as to act at the same time upon  the radius  and ulna, but
so as to finish upon this last bone.
   d. Fourth Stage.—After the amputation of the limb, and the retractor
compress is removed, the assistant charged with drawing back the soft
parts, immediately relaxes them.  We then attend to the arteries, search-
ing for them successively in the depth of the  tissues.   The anterior inter-
osseal which is accompanied  by a nervous filament, which it is well to
avoid, is usually found upon  the middle of the palmar  surface  of the
ligament of the same name.   The radial situated more  externally and
superficially, is seen  between the supinator radii longus, the flexor carpi
radialis and the  flexor longus pollicis  manus ; it is besides so remote
from the nerve  that its ligature does not in this respect exact  any special
precaution.   In order  to find the ulnar artery with its  accompanying
nerve on its inside, we must look for it on the inner side of the arm and
between  the flexor carpi ulnaris, the  flexor digitorum sublimis, and the
flexor  digitorum  profundis.   As to the  posterior  inter-osseal artery,
which is distributed  through the fleshy mass of the extensor muscles,
there is no need of troubling ourselves  about it, unless amputation is to
be performed at the upper half of the fore-arm.
   e. Fifth Stage.—The lips  of the  wound are to be brought together
from before backwards, and it is in this  direction that the adhesive strips
are to  be applied.  We thus obtain a transverse linear wound, whose
angles  embrace the bones, and have hanging out from them the ends of
the  corresponding ligatures on either side,  while the end of  the middle
ligature is to be brought up directly in front.
   II. Process of Alanson.—If the skin should  be lardaceous, (larda-
ce'e) or have contracted morbid adhesions with the subjacent tissues, it
would be better, after  having made the circular incision through it,  to
dissect  it up and turn it back upon its outer surface so as to  form a ruff
in the manner of Alanson and Brunninghausen.
   III. Anonymous Process.—Should any difficulty be apprehended about
dividing the muscles and tendons which are found at the bottom of the 
AMPUTATION OF THE UPPER EXTREMITIES.           165
 inter-osseous fossae, we may, after the integuments are incised and raised
 up, glide the knife flatwise between the bones and the soft parts, and im-
 mediately  after turn up  its cutting edge outwardly, so as to cut trans-
 versely from within outwards all the soft parts on a line with the raised-
 up  skin, and do this in succession upon both sides of the limb.  It was
 M.  Hervez de Chegoin, (Mem. de VAcad. Roy. de Chir., t. II. p. 273,)
 I believe, who in  the year  1819  first published the suggestion of this
 modification, which M. Cloquet says he has often employed with success,
 (Diet,  de Mid., t. II., p. 153,) and which, from inadvertence no doubt,
 the editors of  Sabatier had appropriated to themselves.
   IV. All the muscles being divided, it is possible  that we may desire
 to detach them still more, in order to be enabled to saw the bones higher
 up.  In  this case we detach with the point of the knife or bistoury the
 two borders of the inter-osseous  membrane to the extent of some lines.
 Here, as in all  other points of the limb, we ought to preserve  so much
 the greater extent of integuments, as the operation \s performed higher
 up, or to speak more correctly, in proportion as the volume of the part
 is more considerable.  Nor must we forget that owing to the deep-seated
 muscles being inserted  upon the  bones nearly throughout their whole
 extent, they retract but very little  towards the elbow, and that  it  is there-
 fore principally on the skin that we must rely for uniting the wound and
 covering the stump.
   B.  The Flap Method.—Circular amputation of the fore-arm general-
 ly succeeds very  well, and allows the cure to be accomplished in the
 space of from three to four weeks.  Nevertheless it has been proposed
 to substitute the flap method for it.  In our own times it has still  been
 employed by M.  Graefe,  in the manner recommended by Verduin, and
 Lowdham, and as Ruysch  says he  has seen it performed, that is, by cut-
 ting a flap on the palmar surface of the limb and finishing the rest of the
 operation in the same manner as in the circular method. Vermale, Ledran,
 (Opirat., p. 565, 569,) Klein, Hennen and M.  Guthrie, prefer, on the
 contrary, making  two flaps, one in front, the other behind.  Under this
 point  of view  it would be difficult to withhold the preference from the
 process  of Vermale, which is eulogized also by M. Langenbeck  (Rust's
 Handb. der  Chir., t. I., p. 693,)  and Rossi, (Opir. cit., t. II., p 233,)
 over that  of Verduin.   I have performed it  and also caused it to be
 repeated upon the dead body by a great number of  pupils.   I have per-
 formed it on the living subject twice, and I am satisfied that it is gene-
 rally less advantageous than the circular method, though the operation
 is easier and more quickly done.   It is true that it is not then with the
 skin only but  also  with much of the fleshy fibres that we cover the ex-
 tremities  of  the bones.  The two flaps are sufficiently thick, and sup-
 plied with a sufficient abundance  of cellular tissue to adapt themselves
 accurately together, and to  furnish with security  all that could be re-
 quired for immediate union.  To be enabled then to unite by first inten-
 tion, each should have a length of about two inches.   If the disease ex-
 tends more on one side than on another, we need not make but one flap,
 or we may give them an unequal length.  So that one does not perceive
 at first why  this mode of operating may not be applied  as low down as
the circular  method.  Unfortunately upon examining it  more attentive-
ly, it is perceived that most of these advantages  are  illusory.  All the 
166
NEW ELEMENTS OF  OPERATIVE SURGERY.
 muscles  cut  with a sloping edge necessarily augment the traumatic sur-
 face.   Being included within the thickness of each flap, they serve only
 to increase the danger  of the inflammations which may be developed.
 The bones also are not the less exposed to protrude at the angles of the
 wound ;  and  the most simple reflection makes it apparent, that, by a cir-
 cular  incision, an inch of integuments  will more accurately close up a
 wound of two inches  width from before backwards, than flaps one-half
 longer, because of the void which these latter constantly tend to leave at
 each side of  their base.  The following, however, is the operative pro-
 cess :—
   I.  Operative Process.—The limb being turned in pronation, and pro-
 perly  held, the operator  cuts his  palmar flap, by passing his knife from
 one side of the fore-arm to  the  other, between the bones  and the soft
 parts,  which latter he  divides obliquely from  above downwards.  To
 form the dorsal flap, he draws the lips of the wound backwards, replaces
 the point of the instrument in the upper part of the  first division,  causes
 it to glide posteriorly, and finishes with the same precautions as before.
 Directing the. assistant to turn back immediately  all  the soft  parts, he
 passes  round  the radius  and ulna as in the circular method, cuts what
 may remain of the soft parts, inserts the retractor and afterwards  effects
 the section of the bones as in the usual mode.
   II. Remarks.—By cutting  the  palmar flap first, we are enabled to
 give greater thickness to the dorsal, and the palmar surface  of  the fore-
 arm being turned downward, the blood  which escapes at first, in no
 wise interferes  with the  remainder  of the operation.  Moreover this
 precaution is far from being  indispensable.  The important point is to
 obtain  two  flaps of nearly equal dimensions, and  not to take off too
 much of their  angles.  It is certainly remarkable  that a military  sur-
 geon who, no doubt, in the movement of armies is prevented from keep-
 ing pace with  the progress of  science, has conceived the idea of apply-
 ing the ovalar method to amputation of the fore-arm, and of making the
 point of the oval fall upon the ulna!  The limb  might  be left in supina-
 tion instead of placing it from the beginning in pronation ; but then the
 sawing  of the  bones  would produce more  concussion upon the  joints
 and would not be as easy.
   The  radius and ulna are recommended to be sawed at the same  time
 so as to finish  however on the last, because the  ulna, from bein«-  more
firmly  connected with the humerus, supports the action of  the instru-
ment better than the radius could  do.   In  directing the  operator to
place  himself  on the inside between the limb and the trunk, I have not
pretended to  lay down an invariable rule.  Bertrandi  (Opir. cit., p.
473) remarks, that when the patient is in  bed, if we did not place our-
selves upon the outside, we should be little at our ease, at least for the
right limb.  The English  and German  surgeons, and  among  them M.
Guthrie, are in an error in saying  that the flap  operation is only appli-
cable to the  upper part of the fore-arm.  It is applicable to its entire
extent.   Ledran (Opir. cit., p. 563,) had already remarked that a pa-
tient operated  upon  by him in this manner, recovered in twenty  days
while by the circular method he did not obtain cicatrization  under two
or three months ; which, however, is in no respect remarkable, because
at  that time they were not yet  successful after  circular amputation in
obtaining union by the first intention. 
AMPUTATION OF THE UPPER EXTREMITIES.            167
   III. Reunion and the dressing are performed here in the same way
as at the wrist, and  the  consequences of the operation exact the same
precautions in both cases.  M.  Davidson  performed this  amputation
successfully for an  elephantiasis  of  the hand ; but M. Mussey, (Gaz.
Mid.  de  Paris, 1838, p. 394,) was obliged to  amputate also the arm
and afterwards the  shoulder;  M. Baud (These No. 142, Paris, 1831)
has  performed it, though there was a fracture of the arm ; in a patient
of M. Blanche (Puchot, These No. 207, Paris,  1835) no ligature was
required;  and Hoeff (Gazette Salut., 1787, No. 7)  also performed  it
without tying the arteries.

                § II.—Amputation in  the  Contiguity.

   Some  surgeons of the last century, on the strength of a passage in
Pare, (liv. XII., ch.  37,) who says he ventured to disarticulate the fore-
arm that had become gangrenous in a soldier with a fracture, have sup-
posed that by systematizing this operation, practice  might derive some
advantages from it, that among others of saving  three or four more
inches to the  limb than  in cases  where  amputation was performed on
the arm itself; other facts confirm this remark.   In a nun, says Cattier,
(Biblioth.  de  Planque, t. V., p. 11, in 4to.,) who would not permit her-
self to be amputated upon the  living part, the  fore-arm ultimately de-
tached itself  at the  elbow, and the patient  recovered.   A girl, (Acad.
des  Sc. Hist., p. 41, art. 10, 1703,)  in  whom  the  two  fore-arms had
separated at the elbow, took them herself to the Academy of Sciences!
But many  of  the moderns  have objected that this  advantage is of too
trivial importance to be purchased at the risk  of numerous difficulties
and dangers of every kind which  must  necessarily  accompany a disar-
ticulation of this nature.  If it be possible  to cut from the soft parts a
flap sufficiently long to cover  the whole extremity of the articulating
surface of the humerus, it must be equally practicable  to do so in cir-
cular amputation immediately below  the joint.  In the contrary case it
is remarked, that we ought not to decide upon leaving so large a carti-
laginous  surface  exposed, and that amputation of the humerus would
therefore become indispensable.
   These  arguments  are less  conclusive  than they at first sight appear.
Because  the soft parts may be in a  condition to be  saved, it does not
follow that the bones are sufficiently sound to allow of the action of the
saw, or to  preserve the least portion of them.   Necrosis, caries, com-
minuted  fractures, &c, may  extend up to the  articulation, and without
the surrounding parts having  entirely  lost their  primitive character.
The diseased bones also being once  removed, who does not know that
the soft parts ultimately often  become restored to their  natural state ?
Moreover, the operation in itself less  dangerous than amputation of the
arm, is far from being as difficult as has been imagined.   M. Rodgers,
(Velpeau's Anat., American translation, etc., annot., Vol. II., p. 520,)
of New-York, and M. Chiari, (Bulletin de Firussac, t. XII., p. 275,)
have performed it successfully, and Dupuytren has also had every rea-
son to be satisfied with it.  For myself, I consider it advisable, where-
ever the bones are  diseased to the  extent of an inch or two  from the
joint. 
168
NEW ELEMENTS OF  OPERATIVE SURGERY.
  [Dr. James Mann, of Connecticut, performed this operation in 1821.
The patient  had received a gunshot wound, which carried away nearly
the whole of his right  fore-arm.   For seven days there  was a profuse
discharge of synovial  fluid, but this  at  length  subsided, and  in  four
weeks, a cure was effected (.V.  Y.  Med. Repository. Vol. VII. 1821.)
Dr. J. Kearny Rodgers operated at the  New-York Hospital in 1827.
The discharge from a musket had badly shattered the radius  and ulna,
and as there was  not enough of the  integument, to cover the ends of
the bones, he amputated at the elbow joint.   In two days the stump had
completely united, except in the course of the ligatures.  In about three
weeks, these came away, and the  stump was perfectly sound.   ( Op. Cit.
Vol.  VII. or N Y.  Journ. of Med. and  Collat. Sciences, Jan. 1853.)
In the Gaz. des Hop. 1839, is a notice of a successful case by Blandin.
M. Roux is opposed to this operation,  but Mr. Liston in his Lectures on
Surgery, Lond. Lancet, 1845, remarks that he has  performed  it more
than once, and that " there is no objection to it."  G. C.  B.]
  B.  The Flap Method.—Owing to circumstances, or from  necessity,
Pare  either  has not,  or but very obscurely, described, his  method, sup-
posing, without doubt, that any person could divine or imitate him.
  I.   Process of Brasdor.—After  various  trials,  Brasdor  (Mem. de
VAcad, de Chir., t. V.) determined upon  the following rules :  A semi-
lunar incision, with its convexity downwards, and comprising the poste-
rior  half  of  the circumference of the limb, is first made at some lines
below  the apex of the olecranon, in  order to enable us to  divide the
lateral ligaments, and the tendon of the triceps, and to lay open largely
the articulation of  the radius.   The knife then passed flatwise from one
side  to the other, between  the  anterior  surface of the bones and  the
soft  parts, forms a large flap  whose base corresponds to the joint, and
its apex  to a point three or four inches  below.  Finally, we terminate
by disarticulating the ulna from the coronoid process to the olecranon,
and by the division of the triceps muscle, if that has not  already been
done in the beginning.
  II. Process of Vacquier.—In the third Thesis in quarto, supported at
the Faculty of Paris  at the commencement of the present century, Vac-
quier proposes the following  modification  to the process of Brasdor :
he commences by cutting with a double-edged knife the anterior flap from
below  upwards, as high up as to a line  with the articulation ;  then di-
vides the ligaments  which unite the  radius and ulna to  the humerus ;
luxates the fore-arm, and  terminates by  deatching  the  olecranon from
the large tendon which is  inserted upon it, and from the integuments,
so as to leave a flap of some lines in length behind.
  III. Process of Sabatier.—Sabatier ascribes to Dupuytren the pro-
cess  by which it is considered more  advisable to saw through the olecra-
non and leave it, rather than to remove it, and to form a flap of the cha-
racter of  that of La  Faye for amputation of the shoulder, or of that of
Verduin in  amputation of the leg, rather than literally imitate the pro-
cess of Vacquier.
   IV. Process of Dupuytren.—According  to MM. Sanson and Begin,
Dupuytren performed amputation at the elbow-joint seven or eight times
successfully, by cutting a flap  after the manner of Verduin, that is  to
say, by plunging a double-edged knife in front of the  articulation, from 
               AMPUTATION  OF THE UPPER EXTREMITIES.            169

one  tuberosity of the humerus to the  other, between the bones which
he grazes and the soft parts  which are  raised up with the left hand, in
order to divide them from above downwards.   The disarticulation being
effected, Dupuytren completes the operation by sawing through the  ole-
cranon, or removing it.
  The  difference between these  various  processes is much less than
Vacquier supposes.  The final result of all of them is nearly the same,
except that that of the  member of the ancient  academy, being a little
more tedious and difficult, ought to be laid aside.
  V,  Process of the  Author.—I see no  advantage in  preserving the
olecranon, as Sabatier advises, and as  Dupuytren  has frequently done.
The triceps does not require it for the  movement of the humerus,  and
it is evident that its preservation can in no way favor the success of
the operation.  For the saw  to reach its anterior surface, it is necessary
that the articular surfaces  should be completely disjointed.   No obsta-
cle can then interpose to prevent our detaching it from the integuments
which cover it behind.  But  supposing that  there  positively exists a
wish to preserve it, the  following  modification has  appeared to me to
present some  advantages.   The limb is held  moderately flexed, and in
supination.   With a knife with one cutting edge only, we make an in-
cision transversely on the upper part of  the fore-arm, a little below the
tuberosities of the humerus,  in order to form a flap after  the manner of
Dupuytren.  The  assistant  takes hold of this flap  and  raises it up.
The operator then  divides transversely, as in the  circular method, an
inch below the  condyles, the  teguments which  remain behind; causes
the skin to be  raised up, returns in front, divides  the  external  lateral
ligament, and disarticulates the radius.  Finally, after having  carefully
divided all the soft  parts which surround it, he saws  through the ulna,
immediately below the anterior border of  the coronoid process, as near
as possible to the joint, and in a direction  continuous with the humero-
radial  interline,  [i. e., the line of the inter-articulating surfaces of the
humerus and  bones of the fore-arm.  T.]   We thus avoid all the diffi-
culties attending the disarticulation of the humerus, and the operation
is as  speedy as by  any  other mode ; there is no need of making  any
traction or exertion upon the bones, and the wound, which has consider-
ably less width, must be less  disposed  to suppurate, and more  easy to
unite by first intention.
  VI.  Another modification,  applicable to all  the flap  processes,  and
which I should much prefer,  would consist in cutting and dissecting the
parts from the skin to the  bones, instead of plunging the knife at first
between the flesh and bones, as is the objectionable practice infamphithea-
tres.
  B.  Circular Method.—I have satisfied myself that circular amputa-
tion, in these cases, would  offer decided advantages.  An inch of inte-
guments,  preserved below the elbow, would be sufficient to cover  the
trochlea of the humerus, while, by  the flap method, there would.be re-
quired three or  four in front.  All the muscles being  sacrificed,  the
wound would in reality be less in extent, less disposed to an abundant
suppuration, and  cause less  intense  reaction upon the system.  After
having divided the skin circularly, I dissect it, and turn it back as high
up as on a level with the joint, after which I  divide the  anterior mus-
  Vol.  II.                   22 
170
NEW ELEMENTS OF  OPERATIVE SURGERY.
 des, then the lateral ligaments in order to disarticulate from  before
 backwards, and terminate with the division of the triceps  behind.   The
 brachial artery alone  requires  tying or twisting, and  the  reflected fold
 of skin may be  brought down without  the least difficulty  in front, so as
 to close up the wound.

               Article V.—Amputation of the  Arm.

   Amputation  of the arm, required most  generally for some disease of
■the humero-cubital articulation, is usually performed  below the middle
 part of the limb.  As other affections, however, such  as lesions of the
 humerus itself, may also exact  this operation, we  are sometimes  com-
 pelled to amputate much nearer the shoulder.

                           § I.—Anatomy.

   The humerus, constituting  the only bone in the arm, cylindrical in its
middle portion, twisted slightly upon itself, and near the elbow flattened
in such manner that its  borders are felt  naked under the skin, is also
surrounded  with numerous muscles.  The deltoid,  coraco-brachialis,
long head of the triceps  and the biceps, which are all attached to the
scapula, together with the pectoralis  major, and  the latissimus dorsi,
[see Table of Muscles, Vol.  I.,] form a distinct system, whose retrac-
tile powers we  must make allowance for when we are about to amputate
above the deltoidal tuberosity.   As these muscles are all inserted below
the head of the  humerus, M. Larrey came to the conclusion that, in
amputating  upon a line with the surgical  neck, the fragment of bone
preserved would  be of no  use, but, in fact, hurtful, from being  kept in
a state of permanent extension by the supra-spinatus and infra-spinatus
muscles.  Below the deltoid-muscle, the biceps which extends from the
shoulder to the fore-arm without any adhesions, is the only one after its
division which  can retract  to any  considerable degree ; the others, the
brachialis interims, and  the three divisions of the  triceps, having their
fibres implanted upon the humerus itself,  cannot retract but very little
from the point where the knife has divided them.

                     § II.— Operative Process.

  ■If, like Petit, after having divided and  raised up the skin, we should
confine ourselves to dividing all the muscles  upon the lower half of the
arm at the point upon which the saw is to  be directed, the biceps would
rarely fail by its subsequent retraction to  produce a denudation of the
bone.
  A. Circular Method.—The integuments  are too moveable upon  the
aponeurosis to require the trouble of dissecting them and turning them
back upon  their external  surface, as Alanson proposes.   Among  the
processes then  to be selected, there remains that of Celsus  or Louis,
modified by Dupuytren, and  that of Desault.
  I. The Lower Half.—The patient being seated, and the artery com-
pressed, as in amputating the fore-arm, an  assistant  seizes the limb and
raises it from the trunk at  almost a right angle.  The rule recommends 
AMPUTATION OF THE UPPER EXTREMITIES.          171
that the surgeon  should place himself upon the outside ;  but when we
operate^ on  the left arm there is some advantage in placing ourselves
on  the inside.  With the left hand we draw back the skin in proportion
as  the  instrument proceeds.   The division of the integuments is made
as near the  elbow as possible.   In incising the muscles circularly on a
line with  the  retracted skin it is important  to cut through the whole
thickness  of the biceps.  We  may, in fact, after the manner of M. S.
Cooper, divide, at first, this muscle only, in order to make the division
of those of the deep-seated layer only, at a few  lines from the point
where we  are to saw the bone.   When the humerus is laid bare, it could
not be  otherwise  than  advantageous to separate the fleshy fibres from '
it  parallel to  its  length, as was  recommended by  Bell, and as is still
practised  by M. Graefe.  M. Hello (These No. 258, Paris, 1829)  also
maintains  that  the deep-seated  fibres thus preserved  are the only ones
which can be brought down in front.  I will add to this, that it is then
necessary  to  dissect the skin, as recommended by Alanson; and after-
wards to divide all the tissues  perpendicularly and with a single stroke
of the knife.   In whatever  manner we operate, we must take care that
we do not wound the radial nerve.   The last muscular layer should be
divided at about  three inches  above the line of the division of the in-
teguments.   The retractor compress, and the section of the bone require
no particular directions.
   The brachial artery is found between the biceps and the inner portion
of  the triceps,  close to the median nerve, and between its  two accom-
panying veins.   The situation of the other two or three branches which
require some attention, will be indicated by their bleeding.   The practice
of  closing the  wound from one side  to the other, though  there  would,
in fact, be a  little less void  to be overcome in closing from before back-
wards, arises from the preference that exists of having a cicatrix directed
from before backwards, rather  than transversely.
   II. The  Upper Third.—The  biceps  above the  deltoid  depression,
being at this point nearer to its origin, cannot  retract as  far;  but  the
volume of muscular  tissues being much greater, it is as indispensable
as it is lower down to  save a considerable portion of integuments,  and
to favor their  retraction as much as possible before making the  section
of the  bone.   De la Faye  (Mim. de VAcad. Royale de Chir., t. II., p.
241) had  already  proposed, and Leblanc (Pricis d' Opir., t. I., p. 328)
combated the  process advocated  by M. Larrey, (Clin. Chir., t. III., p.
560,) to wit:  that it is better to disarticulate the  humerus than to  am-
putate it above the  muscles, which  connect it with the chest.  The ad-
vice of  Leblanc, Percy, (Rapport a VInstitid sur la Des articulation du
Bras,)  and Richerand, however, has prevailed.  Experience has proved
that after the  cure, the deltoid muscle, the pectoralis major, the latis-
simus dorsi,  the teres major, and coraco-brachialis, are not without their
action upon  this  small extremity of bone as  De la Faye called it,  and
that they may  execute  various movements upon the stump. The small
portion of the arm which remains, augments at least the protuberance of
the shoulder,  prevents  the slipping of the suspenders, preserves  the
hollow  of the  axilla, and  most usually allows of holding against  the
chest certain foreign bodies, as for example, a cane, and port-folio.   " It
is a constant source of satisfaction  to me,"  says M. Champion,  " when 
172
NEW ELEMENTS OF OPERATIVE SURGERY.
I reflect upon  the  usefulness which a stump like this has proved itself
susceptible of,  in three  patients in whom I had saved it."  Besides, it
is not necessary then to open into  the articulation, nor consequently to
fill up the large cul-de-sac which exists  between  the  acromion and the
scapular tendon of the triceps muscle.
   B.  Flap Method.—The arm is the limb which appears to be the least
favorable to the flap method ; so much the more so as its rounded  form
and the position and small volume of its  bone are wonderfully adapted
to the success of the circular method.   Klein and M.  Langenbeck, not-
withstanding, have endeavored  to  bring the other into vogue.   I have
myself had recourse to it on two occasions on living man, and have  often
performed it, or caused it to be performed, upon  the  dead  body.   At
the first glance, we might suppose that a great advantage  could  be ob-
tained  from it, for union by the first intention.   By the flap method, it
is not the skin only, as in the circular, but the muscles themselves, which
cover the extremity of the bone  and shut up the wound ; in this we have
nothing  to fear from the retraction  of the muscular fibres or the isola-
tion of  the  cutaneous  envelope ; three  incisions  by the  knife, one for
each flap, and  another for the denudation of the bone, and one division
by the  saw, complete the whole operation.   Well!  with all these ad-
vantages, the rapidity and facility of the  manipulations  are all that are
real.  The muscular mass to which so much value is attached, is, after
all, calculated only to favor phlegmonous inflammation of the stump,
with a constant tendency to slip from one side to the other, and, should
auppuration  ensue to ever  so  slight an extent,  to protrude  the  bone
through  one of the angles of the  wound.   Nowhere,  in  fact, are the
inconveniences of the flap method so conspicuous.   Nevertheless, Saba-
tier himself advises it when we are obliged to amputate near the shoulder.
  I. Process of Klein.—A narrow knife, plunged through the arm, from
the radial to the ulnar  side, and grazing the bone, cuts out a first semi-
lunar flap of about  two inches  in length ;  after having formed another
in the same manner upon the opposite side, both are raised up ;  we then
divide at their base the small quantity  of muscle still adherent to the
bone, which last is sawed with  the usual  precautions.  It is almost a
matter of indifference also whether we begin with one flap or the other.
  II. Process of M. Langenbeck.—The assistant raises up  the integu-
ments with force; the operator, seated on the inside, supports the lower
part of  the limb with his left hand  for the right arm, and vice  versa for
the left  arm ; provided with a good knife in the other hand, he cuts with
a movement from below  upwards,  and from the skin to the bone, an in-
ner lap, which should have, as  in the preceding  case, a length of from
two to three inches ; then, in passing the knife and his wrist underneath,
to bring them  back in front of the arm, he is enabled thereby to form an
outer flap similar to the first.   I have  seen  young German physicians
practise this process in our  theatres, and execute it  with the  greatest
 celerity; but such exhibitions of power and address can possess no im-
 portance except in the eyes of  those surgeons, who, like  the pupils of
 MM. Langenbeck and Graefe,  go  for those only who, in amputations,
 operate with the greatest rapidity,  and count even the seconds.
    III.  Process of Sabatier.—Sabatier recommends the flap method only
 in cases where the operation is performed so high up that it is impossi- 
AMPUTATION OF THE  UPPER EXTREMITIES.
173
ble to employ the tourniquet.  His  process which had already been  de-
scribed by Leblanc, (Opir. cit., t. I.,p. 327,) consists in forming, by
means  of a transverse incision and two longitudinal incisions, a flap, of
the shape of a trapezium, at the expense of the antero-external portion
of the  deltoid muscle, then in raising this flap up, and by a circular in-
cision, dividing the remainder of the soft parts before proceeding to the
section of the bone.  It is to be understood, moreover, in this  case, as
in all others, when the amputation is to be performed  near the shoulder,
that the compression of the artery should be made above the clavicle, or
upon the second rib, as I shall point out farther on.
   [Artificial Arm.—In cases  where a fragment of the humerus is  pre-
served, M. Van  Peterssen, a Dutch  sculptor, according to the report of
M. Majendie, made to the Academy of Sciences of Paris, Feb. 17,1845,
( Gaz. Mid., Feb. 22,1845, p. 125-126,) has contrived an ingenious piece
of mechanism, which,  both in  its form and  articulations,  representing
the wrist, hand,  and fingers, is  made to execute by means of springs and
the leathers, by  which it is fixed to  the stump and chest, a great number
of the functions of a living, healthy  arm, so as to become  exceedingly
useful  in seizing bodies  with the hand, lifting a tumbler, food, <fcc., to the
mouth, in fact, performing a great number of the movements of flexion,
extension, &c.  The whole weight is but 500 grammes, and  the  cost
about  500 francs or less.  The examination made by the commission of
the Academy (of which M. Velpeau was one) of persons who  had had
this apparatus substituted for one or both arms, proved highly  satisfac-
tory, and their report expresses unqualified commendation of the inven-
tion, in which favorable conclusions  the Academy also entiely concur-
red.   T.]

       Article VI.—Amputation of the Arm at the shoulder
                               Joint.

   It is an error to suppose that disarticulation of  the arm had  not  been
ventured upon until the beginning of the last century.   Laroque, (Journ.
de Mid., 1686, Juin, p. 3,) in the year 1686, relates a case of this oper-
ation.  The limb had  become  gangrenous.   " The surgeon took a small
 saw to amputate the humerus ; but having perceived that the bone shook
near its articulation vnth the shoulder, he made a jerk upon it, when the
bone readily escaped from its  socket, (boit,) after  which the  boy was
 soon restored to his former health."  Though the idea must have often   „
presented itself to the minds of surgeons, as to La Gareine, (Bibliot. de   c
Planque^X. V., p. 9, in  quarto,) the fear of opening into so large a joint,  /
and the ignorance of the means how to suspend the course of the blood  ^
in the limb  during the operation,  together with the proximity  of the
 trunk, had deterred the boldest practitioners from undertaking it.  Le
 ">ran (Garengeot, 2e edit., tome  III., p. 454 ; le edit., tome II., p. 382,
 L720) is the first who has described,it.  His father had had recourse to
 it about the year 1715, (Obs. de Chir., t. I., p.  315,) for a necrosis of
 the humerus, accompanied with copious suppuration, and completely cur-
 ed his patient.   Since  then, it has  been pretended that Morand, the fa-
 ther,  (Opuscules de Chir., p.  212, 2e partie,) or Duverney, (Mihleew,
 Elements of Surgery, &c, 1746,)  had performed it before Le Dran, but 
174
NEW ELEMENTS OF OPERATIVE SURGERY.
of this no satisfactory proof has been given.  At the present time, the
advantages of this amputation are no longer disupted by any one.  It
has been so often performed that it is useless to discuss its practicability.
   [Mr. Guthrie informs us  in his Lectures on some of the more Impor-
tant Points in Surgery p. 6, that previous" to the return of the medical
officers of the army, in 1814, teachers  of surgery in London, taught that
amputation  at  the shoulder joint  was a  most formidable operation on
account of the impossibility of arresting  the flow of blood.   This fear
however, did not deter American surgeons from performing it in 1781,
1782, as was done by Dr. John Warren of Boston, and Dr. Bailey of New-
York.   Previous to  1814, also, Dr. Bowen  of Providence, had at the
same time with the arm removed the acromial end of  the scapula.  For
the details, we refer the  reader to the  Bost. Med. 8r Surg. Journal, Vol.
XX., 1839, p. 210 ; and New England Journ. of Med. 3f Surg. Vol. III.
1814, p. 314.   G. C. B.]

                          § I.—Anatomy.

  The  articulation  of the  shoulder being surmounted by two processes
which extend  beyond its line in front, and greatly augment its vertical
diameter, presents an arrangement much more  favorable for immediate
reunion  in a transverse direction, than from above downwards.   In its
union  with the  body of the bone the  head of the humerus forms an ex-
tremely  open angle, and the fibrous capsule is inserted a little upon the
inside.   In the  amputation it is necessary that the edge of the instru-
ment should describe a circular line exactly corresponding (semblable)
to the  plane of the hand, if we desire  to  separate the fibrous tissues
from it  with facility.   Finally, the glenoid  cavity, surrounded with a
tendinous  border, having greater  height  than  width, seems to be still
further prolonged upon its upper part by means of  the vault formed by
the two processes just mentioned.
  In proceeding from above downwards, wc find about this joint,besides
the common integuments and a very thin  aponeurotic layer, the deltoid
muscle, a  loose cellular tissue,, the tendons of the supra-spinatus, infra-
spinatus, sub-scapularis and teres minor muscles, together with the
fibrous capsule and the tendon of the long division of the biceps ; on the
inside the coraco-brachialis and the other portion of the biceps ; lower
down the scapular portion of the triceps;  then the  brachial plexus
and axillary vessels, and under the skin  the pectoralis major, the  latis-
simus dorsi, and the teres major muscles.   Many of these parts may be
readily recognized upon the outer surface.  Thus the apex of the  acro-
mion is easily distinguished above  the stump  of the shoulder, and on
the inside  appears  to be continuous with the  clavicle.  The coracoid
process a little nearer to the thorax, and more  prominent  than the last
mentioned bone, may also be very easily distinguished  by the touch.  In
that part is found also a triangular space which may be made of prac-
 tical value.  Bounded  on  the  outside and below  by the  head of the
 humerus, above by the  clavicle and acromion, and  on the thoracic sido
 bv the coracoid process, this space conducts directly into  the articula-
 tion.  The posterior border of the axilla, raised up and  turned out-
 wardly upon the side of the scapula, also  enables us to  reach below the 
AMPUTATION OF  THE UPPER  EXTREMITIES.           175
acromion  and to  traverse the upper and outer part  of the  articula-
tion.   In  some persons  the acromion is much more  prominent than  in
others.   Sometimes also its anterior border is greatly depressed, so that
its humeral side presents a very deep cavity.   In  infancy  it remains a
long time cartilaginous.   In  two subjects, considerably advanced, that
is to say, adults, I  was enabled by a very slight effort, to separate it as
an epiphysis of the spine of the scapula.   These different anomalies being
of a nature to render  disarticulation of the arm either more easy or
more embarrassing, should, as well  as the other anatomical  details
wliich  I have just  given, be always present in the mind of the operator.

                     § II.— Operative Process.

  The  amputation of the arm at the joint, is one of those that offer the
greatest variety in the number of  the operative processes.   Every sur-
geon, who has performed it, has deemed it his duty to propose one.  The
circular flap and ovalar methods, and all the  different modifications that
these general  processes admit of, have been used for this amputation.
  A. The Circular Method.-—The idea of applying the circular method
to the disarticulation of the arm, does not belong, as M. P. F. Blandin
(Diet,  de Mid.  et  de  Chir. Prat., t. II., p. 258) supposes, to the au-
thor of the article on  Amputation in the Encyclopedia.  De la Roche,
(Encyclop. Mithod.  Chirurg., t. I., p. 109,) who prepared this article,
adopts the flap, and not the circular method ;  but Garengeot (Opir. cit.,
p. 460, t. III., 2e edit.;  t. II., p.  378, le  edit.) says positively that,
in his time,several persons gave it the preference.   Bertrandi (Opir de
Chir., p.  454) also speaks of and censures it.  Alanson described it in
1774, and proposes  that the  muscles should be divided obliquely, as in
amputation of the thigh.  It is a great error, therefore, for M.  Graefe
to have supposed that he was  the inventor of it, and that other moderns
should  have claimed this honor; but each one of these  authors has pre-
sented it under a particular point of view.
  I. Ancient  Process,  or  that of  Garengeot.  Tne passage in Garen-
geot which refers to the simple  circular method, points out, but does
not describe, this method.  The artery being compressed by an indirect
ligature, [see  vol. I.,]  and the soft parts raised up by an assistant, an
incision is made successively through the integuments and muscles down
to the bone, commencing at three fingers' breadth  below the acromion;
a last cut of the knife detaches the head of the humerus from the glenoid
cavity, and completes the operation.
  II. Bertrandi is evidently  more clear.  A large convex bistoury di-
vides through the body  of the deltoid upon its dorsal surface, at some
distance from the  acromion, arrives at the biceps muscle, opens the  cap-
sule, passes behind the head  of the humerus after we have luxated it,
and  terminates  the division of the soft parts with that of the posterior
half of the limb;  " so  that when the arm is separated, there remains a
circular incision through the soft parts,  around and in front of the gle-
noid cavity."
  III.  M. Cornuau  (These No. 71, Paris,  1830) has proposed a pro-
cess founded on the  same principle as the preceding.   The skin being
divided at four fingers' breadth from the acromion,  and drawn back by 
176
NEW ELEMENTS OF  OPERATIVE SURGERY.
an  assistant, the operator proceeds to the section of the muscles, which
he  accomplishes with  a single stroke of the knife, carried transversely
from  the  coraco-brachialis muscle down to the tendon of the teres ma-
jor, causes them to be raised up, opens into the joint, which he traverses
from  above downwards, grazes the neck of the humerus, and terminates
by  a second transverse incision, which unites the two extremities of the
first, includes the vessels, and make a circular wound.
  IV. Process of Alanson and  M. Graefe.—Alanson's method has
nothing in it peculiar.  But M. Graefe, in order to form,  at the  expense
of the muscles, a hollow cone with it3 base downwards, uses the broad
noint  of a buckler-shaped knife.
  V.  Process of M.  Sanson.—Adopting the pure circular method,  M.
Sanson (Elem.  de Pathol, etc., t. III., p. 498, 2e edit.)  divides at the
yame stroke both the skin and  muscles, at an inch  below the acromion
and before  disarticulatng the humerus.
  VI. Process  of the Author.—I have  repeated all  the modifications
of the circular  method  upon the dead  body, and have ascertained that
there  is  no  other method more rapid, or forms a more regular  wound,
or one more easy to unite by the first intention.   The process which has
seemed  to  me to combine  the most  advantages, consists  in dissecting
and raising up the skin to the extent of two fingers' breadth, and with-
out interfering  with  the vessels ;  then to divide the muscles as near as
possible to  the joint,  which is to be immediately laid open ; terminating
the operation with the division of  the triceps, and of the  bundle of ves-
sels whose  trunk has  been previously secured by an assistant.
  B.  The Flap Method.—The  different  processes  included under  the
flap method, may be divided into two classes.   By one, we make a trans-
verse  wound ;  while  the others, on the contrary, produce a solution of
continuity whose greatest diameter is the vertical.
  I. Transverse Method.—Each one  of these  two  classes forms, to
some extent, a particular method, whose respective  advantages  and dis-
advantages  should be  carefully considered.  The first was  for a long
time the only one employed, and to this belong the processes of Le Dran,
Garengeot, De la Eaye, and Dupuytren.
  a.  Process of Le  Dran, (Opirat., p. 571.)—The patient being seat-
ed upon a chair, an assistant seizes the arm and holds it at a short dis-
tance  from the trunk; with a narrow knife, the surgeon  then  makes a
transverse  incision through the deltoid, the  two portions of the biceps
a little in front of the acromion, the  tendons which are attached to  the
head  of the humerus, and the fibrous capsule:  while  an  assistant  gives
a swinging movement to the arm, and  luxates its head from below  up-
wards, the surgeon, holding his knife constantly in a transverse direction,
passes the instrument  behind and cuts out a flap, of from  three to four
inches in length, at the expense of the muscles of the posterior part of
the limb, in which  flap are comprised the plexus of nerves, the vessels,
 the borders of  the axilla, and various muscles.
   b.  Process of Garengeot.— Garengeot's  mode  of operating (t. III.,
 p. 457) differs in three particulars  from that of Le Dran.  In order to
 compress the artery, he advises, instead of a straight  needle, to use  one
 that  is  curved, which is to be inserted  from  before backwards  through
 the muscles, and to  graze the neck of the humerus.   With the  view of 
AMPUTATION OF THE UPPER EXTREMITIES.      .    177
forming an  upper flap  at the expense  of the  deltoid, he  recommends
the first incision to be  made at three fingers' breadth in  front of the
acromion.  Finally, in terminating like Le Dran, with a flap in the axilla,
he gives it less length  and cuts it in a square  shape, in  order to adapt
it better to the deltoid flap.
  c. Process of De la Faye.—La Faye (Mim. de VAcad, de  Chir.,
t. II.)  does not apply any previous ligature.  Differing from Garengeot,
and coinciding with Le  Dran, he recommends but one flap only ; but, in-
stead of placing it below, he takes it from  above, and gives it the form
of a trapezium.   A transverse  incision is first  made, at  about four fin-
gers' breadth  from the  apex of the acromion ;  two other incisions, one
of which is begun upon the inside and the other upon the outside of this
process, are continued in a line with the muscular  fibres  to the extremi-
ties of the first.  The flap being  dissected and raised up,  enables us to
enter the joint, luxate the humerus, lay  bare the soft parts of the axilla,
and to apply a ligature  upon the artery before  detaching  the arm from
the trunk immediately  underneath.   In place of a trapezium flap, Por-
tal,  (Pricis de  Chir., t.  II., p. 791,)  imitating  Dahl,  (Amputat. ex
Articul., etc., 1760,) prefers one which is V-shaped.
   d.  Process  of Dupuytren.—In  a thesis  supported  in  1803, Grosbois
recommends the following modification of the process of La Faye :  With
one hand he seizes the whole thickness of the soft parts  which  are to
form the upper flap;  with the other he plunges through  these tissues at
the  base  of the  deltoid, with a small knife  held  horizontally, and the
cutting edge of which  is to be directed forwards  ; the  flap is then cut
out from behind forwards and from within outwards, taking care to give
it the  suitable  length.  Grosbois speaks of this modification as one that
belongs to him, and.which he had long  reflected upon.   It is probable,
however, that he derived the idea of it from the lectures of Dupuytren,
for it is under  the name of this professor that it is generally known.
   c.  Process of  M. V. Onsenort, (Graefe and Walther, Journal, t. X,,
p. 469.)—In  place of forming the  deltoidal flap by cutting from the
soft parts to the  skin, it may be done in the  opposite direction ;  that is
to say, from the  integuments to the articulation and from the apex to
the base, giving it also a semilunar form.  This mode, too, which  does
not differ materially  from that of  Garengeot, is also, by  some pupils of
medicine, ascribed to Dupuytren.  I have  seen MM. Dubled and Guer-
sent (the younger) perform it upon the dead body with  great rapidity;
and M. V. Onsenort, who uses a knife curved on its flat side, endeavored,
in 1825, to point out it great advantages.  Cline, who commences by
compressing the artery upon the first rib, and who makes a flap capable
of covering the wound  with a narrow  knife at the expense of the del-
toid, then  divides the articulation, and  with a single stroke the  muscles
which  connect the arm to the shoulder  and the trunk.   This process,
which the surgeon of London was in the habit of employing a long time
since, and  which  is adopted also by  Chiari, (Renzi, trad. Ital. de ee
Livre, p.  306,) is described by M. Smith, in the work by Dorsey, (Ele-
ments of  Surgery, vol. II., p. 222,) in  an exceedingly obscure manner;
it has, however,  a good  deal  of resemblance to  the  preceding, and  I
 ought to add  that, in making trial of it by the mode indicated, I found
 that I could perform the operation with almost inconceivable rapidity.
   Vol. II.                      23 
178
NEW ELEMENTS OF  OPERATIVE SURGERY.
   /. Process of Grosbois, attributed to MM. Lisfranc and Champesme.
 —Grosbois (These No. 190, Paris, 1803) had  already  remarked  that
 another advantage could be obtained from his proposed modification of
 the process of La Faye, by proceeding in  such manner as to open at the
 same stroke into the upper part of the articular capsule.  MM. Lisfranc
 and Champesme have constructed  from this suggestion the basis  of a
 new process,  (Coster,  Manuel de  Mid.  Opir., 3e edit., p. 95.)   The
 arm being slightly approximated to the trunk is  carried upwards and
 outwards.   The  operator being placed in front  of the shoulder applies
 the point of his knife to the coraco-acromial  triangle, one of its edges
 being  in a  direction  upwards and  forwards, the other  backwards and
 downwards ; he then plunges it through the soft parts and the articula-
 tion from  within outwards, from  before backwards, and  from above
 downwards, so that it may come  out an inch behind  the acromion ; he
 then with one hand seizes the deltoid and raises it up ;  divides it from
 behind forwards and  slightly from below upwards ; passes round the
 upper  part of the head of the humerus, giving gradually to the blade
 of  the instrument a  direction  almost  horizontal; separates the  arm
 from the trunk as soon as he has proceeded in his incision to the extent
 of  about an inch, and finishes the flap as in the process of Grosbois and
 Dupuytren.
  g. Bell (Cours de  Chirurg., traduit par  Bosquillon, t.  VI.)  com-
 mences with a circular  incision at four inches below  the joint;  he then
 makes a longitudinal one upon  each side  in  order to form  two flaps in
 the manner of Ravaton; dissects and raises up  these flaps,  and finishes
 by  disarticulatiug.
  h.  The process of Laroche  (Encyclop. Mithod., Part. Chir., t. I.,
 p. 109) differs from the  preceding in this, that  the circular and lateral
 incisions being made, the author raises up  the anterior flap, and proceeds
 to the  division of the joint before completing the posterior  flap.
  i. Appreciation.—Of  all  these  modes the  most rapid and simple is
 that of Cline, or of M. Onsenort; but it  is difficult then to give to the
 upper  flap all the extent  desirable.  That of  Grosbois which comes
next, would be yet more rapid if in performing it, surgeons who are
 unpractised did  not run the risk  of striking the  point of their knife
against the head of  the humerus or  the  acromion.   It  endangers,
moreover, the formation of a flap much too thin at its base.  It is evident,
however, if we should be satisfied with an upper  flap, that the process
 of Grosbois or of Dupuytren would be preferable to the three incisions
 of La  Faye.
  II.   The Vertical Method.—To the second class of the flap method
 belong all those  processes whose object is to place the  flap in front or
 behind, or full as well to make one on each side.
  a. Process of  Sharp.—The first process which  appears to belong to
 this series is  that of Sharp,  (Opirat. de Chirurg., p. 389.)   Thi3
 author first divides the skin, the deltoid and the pectoralis major, from
 the apex of the acromion to the hollow of the  axilla, so  as to lay bare
 the vessels and to be  enabled to tie them ; he then passes through  the
 articulation from within outwards, and  terminates by dividing  the  soft
 parts on the opposite side, so as to preserve as much of the integuments
 as  possible. 
AMPUTATION OF THE  UPPER EXTREMITIES.
179
  b. TJie Process of Bromfield is too complicated and too long to be
described at present, though it belongs to the vertical method.
  c. Process of Poyet.—Poyet (De Mithod. Amput.,  etc., 31 Aout,
1759) in a thesis upon  the  disarticulation of the arm, proposes to make
a longitudinal incision from the apex of the acromion to nearly as far as
the deltoidal  depression upon the  humerus ; then to separate the lips
of the wound, in order to divide the articular capsule and the tendons
which  surround it, and to luxate  the  head of the bone, terminating by
passing the knife between this last and the muscles which are divided
with a single stroke from  above downwards.  Dorsey  (Op.  cit.,Yo\.
II., p. 333)  of Philadelphia, was successful  with a process  nearly the
same as that of Garengeot.
  d. The Process  which Laroche describes in the Encyclopedia, instead
of belonging  to the  circular method, is  no other than that of Bell or
Ravaton, modified so that one of  its  flaps is  uoon  the inside and the
other upon the outside.
  e. Process  of Desault.—The limb held between extension and flexion
is brought slightly forward ;  the surgeon embraces with  one  hand the
tissues of the shoulder, and with a narrow knife divides them from above
downwards and from before backwards, while grazing the head of the
humerus; he forms a first  and inner flap from  three to four inches in
length, which includes the anterior  border of the axilla and the vessels
and nerves, and which the assistant raises immediately up in order that
the operator may divide the joint from before backwards or from within
outwards, and terminate  by forming  a postero-external  flap similar to
the first.
   e. (bis) Hasselberg (Nouv. Procidi pour desarticufer VHum., 1788)
in describing the process of Desault, says that the artery  is  compressed
between the  scaleni muscles, and the arm raised to a right angle, and
that the knife ought at the very first to divide the articulation, and that
this first flap has  the form of a triangle.   Allan (Journal  Giniral de
Medecine, t. VIII.) on the contrary represents that Desault formed his
upper flap with the deltoid alone.  Nevertheless it is certain that Giraud,
(Ibid., p. 414,) a  pupil of  Desault, r#3ommends cutting a  lower or axil-
lary flap at first, then to divide the joint  from below upwards, and to
terminate with the upper flap.
  /.  Process  of M.  Larrey.—In  operating  after the manner of De-
sault, the artery is  divided  at the  first  stroke of the instrument, and
this might lead to  serious  accidents if, from any cause whatever, it
should  afterwards become  impracticable to terminate   the  operation
promptly.  M. Larrey has therefore  considered  that it would be better
to commence with the posterior flap, open the joint on its  external side,
and terminate with the inner flap.
  g.  Another Process of M.  Larrey.   M. Larrey, (Clin. Chir.,  t.
III.,  p. 563,) who has so  often performed  this  operation in the  army
campaigns,  describes  another process whose advantages  he greatly
extols.   In the same way as is done by Poyet, he first divides the whole
thickness of the stump of the shoulder in the direction of the fibres of
the  deltoid, and to the extent of four inches.   He then  separates the
two lips of the wound, at the upper  extremity of which lie re-inserts
the  knife and plunges it from above  downwards, so that it may  come 
180
NEW ELEMENTS OF  OPERATIVE SURGERY.
out in front  of the  posterior border of  the  axilla, and thus form  the
outer flap.  Returning to form in the same  manner the anterior  flap,
and leaving between them  all the soft parts which  separate  the two
borders of axilla, in order to avoid  the artery and plexus of nerves, he
then divides the deep-seated tendons and the  capsule.  After  having
divided the joint, he passes the knife behind the head and surgical neck
of the  humerus in order to  terminate with  the section of the pedicle
which unites the two flaps below, obtaining by this means a wound which
is nearly oval.
  h. Process  of Dupuytren.—In  the  place  of forming the posterior
flap by puncture, Dupuytren  cuts it from without inwards, that is, from
the  apex to the base, and in other respects proceeds in the same manner
as M. Larrey.
  i.  Process of M. Delpech.—If we omit to  form an outer flap, or give
this flap but very little  length, and strike almost  directly upon  the pos-
terior face of  the articulation in order to open into and divide it, ter-
minating by cutting a large inner flap, we have the process of Delpech.
  j. 31. Hello ( These  No. 258, Paris, 1829) after having cut an outer
and upper flap like Dupuytren, proposes that we should afterwards pass
the  knife between the shoulder and the chest, to terminate the operation
according to the rules  of the  circular  method.   This process adopted,
he says, by Fouilloy, and which Laisne (Jour.  Gin. de Mid., t. VIII.,
p. 401) compelled  by  the state of the tissues, had  also  already  em-
ployed, is particularly serviceable  where the  humerus is shattered, and
where the displaced boney fragments  render the formation of  any flap
whatever by puncture more difficult than usual.  Two sailors thus ope-
rated upon in England  about the beginning of the present century, were
cured on the twentieth day.
  k.  Process  of M.  Lisfranc.—M. Lisfranc, in order to avoid  the
objections made to the process of Grosbois, and at  the  same  time to
retain its advantages, causes the arm to be held a short distance  from
the trunk, places  himself outside of it, applying the point of a long
knife in front  of the posterior boiler of the axilla as if to raise up this
border, divides the  whole  thickness of the muscles and the  articulation
itself from below  upwards  and from  behind forwards, and brings the
instrument out between the anterior border of  the  acromion  and the
coracoid process, raises  the arm a little  and inclines it slightly back-
wards, passes  around the upper and posterior  half of  the  head of the
humerus with the  blade of  the  instrument, cutting  in  this manner his
posterior flap, and then returning  to the joint and finishing like Dupuy-
tren or Delpech.
   C.  The Ovalar  Method.—Correctly interpreted, the origin of the
 ovalar  method might  readily be discovered  in the processes of Poyet,
 Sharp, Bromfield (Observ.  Sr Cases,  etc.,  1773) or M. Larrey.   It  is
 nevertheless   true,  that it belongs  neither to Beclard, to whom it is at-
 tributed in France, nor to M. Guthrie  who was the  first  to describe  it
 in England.   I find it very  accurately  described in many  theses of the
 school of Strasbourg, and especially in that of A.  Blandin supported
 in 1803, and  still more clearly in  that of Chasley, who had already em-
 ployed the term  ovalar to designate the  form  of  the wound.   The  sev-
 eral processes which it presents scarcely differ from each other. 
AMPUTATION OF THE UPPER EXTREMITIES.
181
  I. Process  of M.  Guthrie.—In the process of M. Guthrie,, the  two
incisions which should describe a kind of V, and which are made to set
out from the apex of the acromion, to descend obliquely, the one in front
the other behind, down to the lower extremity  of  the corresponding
border of the  axilla, comprise at first no more than the common integu-
ments.   The muscles are afterwards  divided in the same direction and
a little higher up, that is to say, on a line with the retracted skin.
  II. Process of Biclard  or Dupuytren.—On the contrary,  when we
wish to imitate Beclard or  Dupuytren, we go immediately down to the
bone ;  but in both cases each side of the wound should be slightly  con-
vex in front and sufficiently superficial in its termination to avoid  run-
ning any risk of wounding the vessels.  The apex of the flap is detached
and reversed downwards by a third stroke of the knife before proceed-
ing to  open into the articulation ; in fact the base of the V remains
untouched to the end of the Operation, and is not detached until  after
having  disarticulated the bone  and grazed the posterior surface of its
upper fourth.
   III.  Process  of M. Scoutetten.—M. Scoutetten  after having,  like
Sharp, brought the inner incision from above downwards, as  far as the
outward border of the  axilla, while passing around on the axillary side
of the arm, resumes it on the outside to prolong it from below upwards,
with the precaution, carefully kept in mind, to divide only the skin un-
der the root of the limb, and not to touch the vessels.
   IV. Process  adopted by the  Author.—a.—First Stage.—When the
muscular fibres are divided very near their origin, their retraction must
be  inconsiderable; it is therefore  advantageous, when the patient has
the  shoulder  abundantly supplied with muscular tissues, to follow M.
Guthrie, and divide the skin and  cause  it to retract  before proceeding
farther.   In an opposite state of things this precaution is unnecessary ;
the integuments and the  muscles may  then be divided with the same
stroke of the  knife.
   b.  Second  Stage.—The  delicate  point in the  oval method, is the
opening into the  capsule.   If the  bistoury  goes too  deeply the fibrous
pouch  recedes, becomes folded  on itself like a piece of wet linen, and
is rather masked than cut.   If  it should strike  within the anatomical
neck of  the humerus, the ligamentous adhesions will be but imperfectly
destroyed, and the difficulties will appear still greater.   To obviate this
embarrassment, we should, after the lips of the wound  are separated by
the assistant and drawn back towards the shoulder, seize the arm with
one hand, make the head of the bone project, turn it upon its axis  from
without  inwards, introduce  flatwise  a very  finely  sharpened bistoury
between it and the tissues,  place this bistoury afterwards at a right an-
gle upon the capsule, on a line  with  or a little beyond the anatomical
neck of the bone, and divide them upon its full edge, and perpendicular-
ly all the tendons, commencing with the  terres minor and finishing with
the sub-scapularis,  and while taking  care to let nothing escape, use the
head of  the humerus as a  point d'appui to make it roll  upon its axis
from within outwards, in  proportion as the instrument proceeds  from
behind  forwards, or from  without inwards.  By this means  we  open
freely  into  the  articulation, and can luxate the  arm with ease ; which
enables us to make tension upon the parts of the capsule remaining, and 
182
NEW ELEMENTS OF OPERATIVE SURGERY.
which we at length completely detach by directing the bistoury forwards,
backwards and then inwards, as if for the purpose of grazing the bone.
   c.  In the third stage the assistant, placed outside the shoulder, glides
his thumb upon the artery in front of the glenoid cavity, compresses this
vessel in the species of pedicle which unites the  lower extremity of the
two first incisions, while with a. small knife or the same bistoury he has
been using from the beginning, the surgeon makes the section of the base
of the primitive V, and  completes the separation of the limb from the
trunk.
   V.  When we wish the two incisions to set out from the acromion, we
should make use alternately of the right and the left hand ; but should
we not be ambidexter, it is very easy to make the second incision from
below upwards, so as to unite it with the first.   A'good bistoury, rather
convex than straight, answers for every stage of the operation.   Some
persons, however, prefer a small amputating knife ; and there are others
who commence with the first and finish with the  second of these instru-
ments.

            § III.— Comparison of the different Methods.

  In all the processes which have passed under consideration, to what-
ever method they may belong, the temporary suspension of the course
of the blood must be attended to.   The indirect  ligature  of Ledran and
Garengeot is not to be trusted, and besides forms of itself an operation
sufficiently grave.  Ledran had already remarked (Opir., p. 571) that
it  could be dispensed with.   If,  like La  Faye, Paroisse, (Opusc de
Chir., p. 208,) and some others, we  apply a thread around the artery
before completing the lower flap, we  rarely fail to include  in its parts
that ought to  have  been avoided.   We cannot  imitate  Sharp  and
Bromfield without increasing the sufferings of the patient and protract-
ing the duration of the operation.   Compression, on the first rib, as re-
commended by Camper, whether by the thumb or  with  a hand-pelote,
or should we resort to the tourniquet of Dahl, applied  upon the second
rib in front of the clavicle, a kind of compression which  Paul of Egina
(Portal, Anat.  Mid., t. II., p. 232) had already pointed out to  arrest
the  blood," they exact  conditions  which do  not always  exist,  and
would, if badly executed, expose the patient to the risk of perishing
by hemorrhage under the hands of the operator.   But we have it  in
our power, by doing as most of the moderns do, to prevent this accident
by a plan far more secure and simple.   For this purpose it is sufficient,
as we have seen, to leave  uncompleted the section of the flap which in-
cludes the vessels, until after having  divided the articulation.  The pre-
vious and  direct ligature  upon  the  subclavian artery  which was still
made use of in 1821 by M. A. H.  Stevens, (S.  Cooper,  American Edi-
tion of his Elements of Surgery, 1822,) would not become necessary
 except in the event of extensive derangement of the parts.
    In fact while the knife is  passing  from above downwards upon tne
 posterior surface of the disarticulated humerus, the assistant placed be-
 hind, embraces the base of this flap  in order to compress it between his
 thumb  which rests upon the bundle of vessels, and the other fingers
 which act as a point  d'appui  upon the skin of  the axilla.  In place of 
AMPUTATION OF THE UPPER EXTREMITIES.
183
 using one hand only, there would be no  objection to our employing two,
 if the thickness and width of the soft parts preserved seem to render it
 requisite.   By this mode of compression  which is available for any one,
 it is evident that we may complete the operation without any apprehen-
 sions, and that the ligature upon the vessels afterwards requires no spe-
 cial directions.  Without knowing  who  first  gave this  rule, Poyet, in
 his Thesis, supported in 1759, states that he  followed  it.   Bertrandi
 (Opirat. de Chir., p. 456) also distinctly mentions it, but without de-
 signating its  author.   Others attribute it to Ledran (lb., p.  571)  him-
 self, who in fact describes it in 1742, but in an imperfect manner. How-
 ever this may be, it is hardly  over twenty years, and  since the recom-
 mendations of Deschamps, (Allan, Jour, de Sidillot, t. VIII.,) M.  Lar-
 rey (Clin. Chir., t. Ill,) and M. Richerand, that it has become general-
 ly adopted.  The other arteries which it is also sometimes  advisable to
 tie, are the acromial, the external thoracic and circumflex arteries, and the
 common scapula.  We do not generally attend to them until after having
 secured the trunk of the axillary artery.  If they should  bleed too  free-
 ly, or any  circumstance compel us to  protract  the  operation, each one
 of them may be tied as the knife divides them.   As to omitting the liga-
 ture and depending upon the elbow of the lower flap to stop the hemor-
 rhage, all the surgeons of the present day, say with  Decourcelles, (Ma-
 nuel des Operat., p. 391,) that we cannot trust ourselves to this.
   Out of so  many processes, there  is no one which merits an exclusive
 preference, nor any one which may not effect the object we have in view.
 That of Le  Dran  is  the best where the soft parts of the hollow of the
 axilla have alone preserved their normal condition.   When, on the  con-
 trary, none of these tissues are healthy except at the stump of the shoul-
 der, we are then compelled to have recourse to that of La Faye, as mod-
 ified.  If the  disease  should have extended farther upon  each side than
 from above downwards, the process of Garengeot or Cline would be ap-
 plicable.  The circular  method would become necessary where the  skin
 had  undergone  degeneration around  the  whole limb, and as high up
 nearly as the articulation, and might be replaced by the ovalar method,
 if it should appear possible  to save a little more of the tissues behind
 than in front.   If the alteration has  proceeded  farther up on the outside
 than upon the inside, the process of Delpech would have its value.   It
 would  be the same with that of Sharp and Desault, or better still,  with
 that of Laisne or M.  Hello in the contrary case, provided the artery in
 the beginning has been avoided by the instrument, and, as has been said
 above, protected  afterwards during  the remainder of the  operation.
Finally, when the tissues are not more diseased on one side than on the
 other, but are  more so  in front or behind, it is advantageous to place the
flaps vertically, and to give to  each  of them  nearly the same length.
We may then choose between the processes of M. Larrey, Beclard and
M.  Lisfranc.  The mobility or immobility of the limb,  the position in
which it is found fixed by the disease, and the relations of the head of
the humerus with the glenoid cavity,  and the processes of  the scapula,
often  also  make  one  process  preferable to another.  But it is at the
bedside  that the skilful surgeon may or can appreciate these several in-
 dications.  In a patient in whom the whole of the arm was occupied by
 a  cancerous affection, I  was  obliged  to employ the ovalar process re
 versed.   The  patient, nevertheless, got well. 
184
NEW ELEMENTS OF OPERATIVE SURGERY.
   Now, supposing that  there is nothing in the state of the parts which
compels  us to adopt one process in preference to another, which is the
method that offers the most advantages ?  In the transverse method, there
exists between  the acromion and the lower border of the glenoid cavi-
ty  an exvacation too deep and wide to  enable us in approximating the
base  of the flaps, to fill it up completely, for the purpose of promoting
easy union by  the first intention.   We should then unquestionably adopt
such  processes as procure a vertical cicatrix.  The rapidity of that to
which M. Lisfranc gives the preference, leaves nothing to desire.  The
process of Desault, reversed as  it  is  by the modification of M. Larrey
and Dupuytren, does  not require a much greater length  of  time.  The
ovalar process, however, as it procures a wound infinitely more regular,
though it exacts more address and more accurate anatomical  knowledge,
is, in  my  opinion, still preferable.  By practice  it ultimately becomes
easy,  and  I have seen M. Chaumet, of  Bordeaux, finish  it in thirty se-
conds upon the dead body.   I am not aware  of any other  than the circu-
lar method by  the process of M. Cornuau, or that of my own, which are
preferable  to it, or can be substituted for it  with advantage.   xUl these
variations  in the operation, however, are of such trivial importance in
practice, that it would be puerile to  dwell upon them at the present day.
The process of M. Manec and M. Lessere (These No. 57, Paris, 1831,)
who recommended removing at the same  time with the arm, one the
acromion,  the  other the  acromion-glenoid cavity and extremity of the
clavicle, cannot be applicable unless  the bones of the shoulder be actual-
ly diseased.
  I have already remarked that the  disarticulation of the shoulder is an
extreme measure, and  that  we ought to reject the advice of those who,
like La Faye, recommend  that it  should be  performed  even in cases
where it might be dispensed  with by applying the saw below the head of
the humerus.  It does  not  follow,  nevertheless, formidable  as it was
first thought  to  be, that  it is much more dangerous than amputation in
the continuity.  " We have so  often performed, and seen  performed
successfully, extirpation of the arm," says M. Gouraud, " that we doubt
if it is scarcely more dangerous than amputations between the articula-
tions, and  it is  questionable, in fact, if in wounds from fire-arms it is not
preferable to it." M. Bancel, in his Thesis, cites sixty successful cases.
M. .Larrey avers that he has found it succeed in ninety cases out of
a hundred.  Sabatier speaks  in admiration of the success this surgeon
had in fourteen cases out of seventeen; and Percy allows  that out of
seventy persons thus amputated, we  lose only a sixth part.   Immediate
union is specially applicable to  it,  and for the subsequent  treatment,
the same precautions pointed out under amputations and operations in
general are specially required, whether in  relation to the dressings or
the regimen, or to prevent visceral  inflammations, moderate  the general
reaction, and protect ourselves against the consequences which too often
result from capital operations.
   [Dr. Stephen  Smith, whose statistics of  surgical operations are now
 so extensively known, published a very valuable paper in  the New York
 Journal of Medicine, &c, January,  1853, in which he furnishes us with
 the following summary of the comparative results of amputations at the
 shoulder-joint, of the arm, and the thigh, performed  in  different Euro- 
AMPUTATION OF THE  UPPER EXTREMITIES.
185
pean and  American  Hospitals.—Of 71  cases  of amputation at the
shoulder-joint, 34 died.   Of 275 amputations of the arm, 103 died.  Of
598 cases of the thigh, 279 died.
   Mr. Guthrie's tables show an astonishing difference in the rate of
mortality between  the primary and secondary amputations at the shoul-
der joint.  Thus, of 19 cases of secondary amputations, 15 died, whilst
in the primary amputations, in 19 cases, but one died!
   Of 40 cases in private practice, of American Surgeons, 13 were fatal,
and one doubtful.  In  7 cases,  anaesthetics were used, and only one of
these was fatal.   G. C. B.]

           Article VIII.—Amputation of the Shoulder.

                         § I.—Indications.

   After amputation of the arm at the joint, it would seem that  we could
advance no farther upon the root of  the limb for the purpose of its re-
moval.  Nevertheless, if the disease should have invaded a part of the
shoulder as well as the arm ; if the clavicle, acromion, coracoid process,
and even the head of the scapula, should have all become  implicated  in
the  disorganization, what should the surgeon do ?   Should he  remain a
passive spectator of the  progress of a fatal disease ?   The Samuel Wood
mentioned by Cheselden, and the three other patients whose history is
given by Carmichael, Dorsey and Mussey,  (Gaz.  Mid. de Paris, 1838,
p. 394,) had the shoulder entirely torn off, and nevertheless got well!
M.  Larrey, (Carteron, Bulletin  de  la Fac de Mid., t. IV.,  p. 218,)
in his campaigns, has frequently been obliged to remove with the arm a
large portion of the scapula or clavicle, and more than on one occasion
has success rewarded his courage.   After having disarticulated the arm,
M. Clot believed it to be necessary to remove also the neck of the scapu-
la, and his patient recovered, (Lancette Frangaise, t. IV., p.  84.)   In
1808, moreover, M.  Cuming, (Bull  de  Firuswc, t.  XXII., p. 91,)  at
the Hospital of Antigoa, [Antigua ?]  removed the whole of the shoulder,
with the arm, in a patient  who recovered perfectly.   Since  then, M.
Brice,  in the  year  1827, was equally fortunate  with M. Clot, in remov-
ing a portion of the clavicle and scapula at the same time with the arm,
in a Greek soldier  with  a gun-shot wound.   Amputation of the shoulder
may also become necessary in order to save the arm.   Janson has given
an  example  of this  kind.   I find a second case  in the thesis of M.
Piedagnel (These  No. 250, Paris, 1827) which belongs to Beauchene.
A third belongs to  M. Lucke,  (Bull, de  Fir., t. XXII., p. 89,)  who
performed the  operation  in 1828,  as  will be  mentioned elsewhere.
Bonfils and  M. Gensoul (Journal des  Hopitaux de Lyon, p. 97—100)
have each  removed  the shoulder for a cancerous  tumor, once, and M.
Syme (Edinb. Med. and Surg. Journ., October, 1836) had a case which
recovered after he had removed the acromion, glenoid cavity, and corres-
ponding portion of the clavicle, as M. Hunt (American Med. Recorder,
vol. I., 1818) had already  done in a  patient forty-six  years of  age,
who had already  undergone amputation of the hand, and afterwards
disarticulation of the arm for the same disease.  M. Mussey also ( Gaz.
Mid. de Paris, 1838, p. 394) was obliged in one  case to extirpate the
   Vol. II.                     24 
186
NEW ELEMENTS OF OPERATIVE SURGERY.
 entire  shoulder, and  the  patient recovered.  (See  Exsection of the
 Shoulder, farther on.)
   This amputation is sometimes  required in  cases of necrosis, caries,
 and comminuted fracture, with more or less extensive disorganization of
 the soft parts, because simple disarticulation of the arm would not allow
 of our  removing the whole disease.  At other times, it is required for
 some degeneration, or  for a tumor composed  of  abnormal tissues, and
 which includes apart of the arm, and extends beyond the joint.   Again,
 the tumor and morbid degeneration may involve only the scapula and the
 tissues that surround it;  in such cases we may preserve the arm.

                     § II.— Operative  Process.

   A.  First Case.—We lay bare  the  diseased bones until we  come to
 the sound parts ; the flaps, formed and managed as in amputation of the
joint, are  also cut out in this or that manner, according to the  state of
 the tissues, and then reversed  and  held by assistants ;  if it should ap-
 pear  impossible to avoid the artery, we then make pressure upon it on
 the first rib, should  it not seem  more advisable to apply the ligature to
 it at the outset.  If it should become necessary to remove the three projec-
 tions which terminate the scapula in front, the saw should be applied behind
 the root of the coracoid process, or on  the outer side of the spine of the
 scapula, in order to remove the whole at a single  cut.  When only one
 of them is diseased, either the acromion, the glenoid cavity or the cora-
 coid  process, it is better to saw from  without inwards,  or from behind
forwards; whilst the outer extremity of the  clavicle requires that we
should saw  from before backwards, or from above  downwards.  It is
unnecessary to remark, that in order to accomplish these  different kinds
of sections in a proper  manner, we should make use of a saw similar to
that  generally used for the section of small bones, or the chain saw of
Jeffray.  Upon the  supposition that there  are only  some splinters or
fragments of bone which may  easily be removed  from above the joint,
we must confine ourselves to extracting these, and to the processes for
 disarticulation of the arm.
   B.  Second Case.—As the  form, size, and precise  seat of the tumor
in these cases can  have no fixed relations, it is,  for  the  same  reason,
 difficult to trace out the rules  for such an operation.  It is, by falling
 back  on his intimate knowledge of  the parts, and the resources of his
 own  mind, that the surgeon  will be enabled to determine the precepts
 which should then  guide him.  In the year 1825, there were received
 at the Hospital  of Perfectionnement, at the same time, two men, having
 enormous  colloid tumors upon  the shoulder.  One died  without being
 operated upon, and the examination, after  death, showed that the two
 upper thirds of the humerus, and the greater part  of the tissues  that en-
 velope it, together with the anterior half of the bones of the shoulder,  '
 were replaced by a lobulated, whitish  mass, as friable  as the  texture
 of an apple or a green pear.  M. Roux, with a desire to save the other,
 operated upon him Dec. 6, in  presence of M. Marjolin, and a great num-
 ber of students.  The tumor which had existed  four years, occupied
 the right  arm, was double the size of the head of an adult, and of an
 ovate form with the point descending nearly down to the elbow, and its 
AMPUTATION OF THE  UPPER EXTREMITIES.           187
base prolonged as high up as to the root of the acromion.   The patient
was 54 years of age, strong, of good constitution, and in full vigor, and
there was no indication that any of the viscera were affected.
  The first flap was circumscribed by a semilunar incision, with its con-
vexity in front, and extending from the middle of the spine of the scapu-
la to below the anterior border of the  axilla ; two  branches of  the
acromial artery being opened, they bled freely, and I compressed them
with the fingers.  A second flap, corresponding in its base to the infra-
spinous  fossa, and of the same form as the preceding, was then cut upon
the outside and behind ; a branch of the common scapular artery of
considerable size being divided,  it was immediately  stopped by the  fin-
ger.   It was deemed proper to exsect the  acromion in order to continue
the dissection of the diseased mass with greater facility; threads were
applied  upon various small  arteries, and the incisions continued down
to the clavicle and glenoid  cavity.  These  two portions of bone were
immediately removed  by the saw.  After  a protracted  search, the axil-
lary artery was at last found.  The tumor now was held only by a loose
pedicle, which included the  vessels, and  which I seized with  my two
hands in order to enable  M. Roux to complete the removal of the limb
without danger.  Finally, the operator returning in search  of the re-
mains of the tumor, removed also  with his saw the coracoid  process,
and the anterior fourth of the scapula.
  Although the patient did not lose more  than twelve  ounces of blood,
he became pale and seemed greatly prostrated.  - During the day he re-
mained  very comfortable, but the night passed  without sleep.   On the
7th, in  the morning, the pulse  continued small, the chest constricted,
and a cold sweat was remarked upon his  face, which retained its pale-
ness ; but there  was no actual suffering.  This state of exhaustion grad
ually increasing, death supervened on the 9th, at 7 in the morning, with-
out being preceded by delirium or any commotion.
  The necropsy exhibited nothing which could explain this result, which
was  as  fatal as it was rapid.   The tumor  weighed twelve pounds ; a
plaster cast of it was carefully taken, which should be found in the  mu-
seum of the Faculty, where  I deposited it.
  This kind of tumor, moreover, is very common.  It gives to the limb a
shoulder-of-mutton form.  Pelletan has noticed it,  and  Hey has  given a
plate of one.  The tumor in the  patient of M. Gensoul, and  also of that
of M. Syme, was similar to this.  I have seen three other cases, and I could
easily enumerate here twenty examples of the same kind.  In the haunch
I have seen two cases of it:  one, a Polish officer, who went to Bordeaux,
and  died  there ; and the other, a young man who died at La Charite ;
in this last the tumor weighed over thirty pounds. A patient, in whom
I removed the arm, with the acromion also, had this tumor.   Belonging,
as they  do, to the class of encephaloidal tumors, the tissue which com-
poses them is reproduced with frightful rapidity.
  C.  Third Case.—So also  where the  scapula alone and its dependen-
cies  are affected, a definite  rule  for proceeding is wanting; for some
times the  tumor  is wholly on the outside of this  bone, sometimes on  the
inside, while in other cases it projects from both its two surfaces, com-
prising to a greater or less degree its whole substance.  On the other
hand, it is evident that the disease, in place of a morbid, external growth, 
188
NEW ELEMENTS OF  OPERATIVE SURGERY.
consist of an extensive  degeneration of the bones.  (See Exsection of
the Shoulder, infra.)

 [Disarticulation  of the Scapula and  Arm together.—Avulsion.

   The possible Disarticulation of the  Scapula,—if such a phrase is
allowable,—becomes a matter worthy of consideration from the  new
facts, of late years, upon the subject of limbs torn from the body.
   The subject of Avulsion of the Limbs, at the articulations,  gene-
rally caused by persons getting  entangled, or suddenly drawn intp  por-
tions of machinery, in manufactories, going with  great rapidity, is one
that has, within a few years, attracted considerable attention, while the
recoveries from such frightful lacerations have led to some curious  and,
as it seems to us, important pathological  results  for surgery.  One of
the most recent and terrific cases on record, which recovered, is related
by A. King, M. D.,of Glasgow,  (Cormack's Lond. Sr Edinburg Month-
ly Journal of Med. Science,  Feb. 1845, p. 96,  &c.)  The patient, a
stout boy, 33t.  15, had his whole left arm, with the scapula  entire,  torn
off, by his hand being  caught in the wheels of  a grain-mill,  Oct. 10,
1843, leaving  a jagged,  irregular, and  ghastly  wound, commencing an
inch from the  sternal extremity of the left clavicle, and coursing along
the under  third of the  neck,  thence downwards, forwards, and back-
wards, terminating at the fourth false rib anteriorly and laterally, and
three inches on the  right side  of the upper portion of the dorsal division
of the vertebral column posteriorly.   The loss of integument was chiefly
behind and below the situation of  the left clavicle.   The muscles on the
front and side of the chest, with  the exception of a very few fibres, were
removed, exposing the intercostals;  they  had  been dragged  from  their
thoracic attachments, leaving the skin loose and puckered, as if too ample
for the subjacent textures.  No fragment of the scapula could be discov-
ered in its  situation.  The clavicle was drawn downwards and forwards,
but maintained its connection with the sternum.  The axillary artery pro-
jected  from beneath the displaced clavicle, to the extent of  two inches
and a half, and pulsated strongly to within an inch of its orifice, but  gave
exit to no blood.   On a minute examination of the torn orifices, the ex-
ternal coat of the vessel  uras found to be divided into three irregular pieces
which encircled each other and  hold in their embrace a small c.oagulum
of blood.  There was no venous hemorrhage, and no large venous trunk
discovered.  The nerves were torn at irregular distances, varying  from
three to five inches  from  the  surface  of  the wound ;  their extremities
were greatly attenuated, and the slightest  irritation upon them gave rise
to the most acute suffering.  The artery was secured by a ligature, being
deemed, as it  certainly was, the most prudent course, for it would hardly
have been otherwise than an act of unwarrantable temerity  to   have
looked for its cicatrization after  the torsion which had been effected or
 forced upon it, by the violence  of the accident.   About two inches of
 the projecting portion of the clavicle was  sawn off, and the integuments
 were  drawn  together by  adhesive  plaster, which  was made  to cover
 without any stretching,  the vessels, nerves, and indeed  the whole wound-
 ed  surface with the exception of a small, irregular  portion near the
 spine about three  inches in circumference.   The patient did not  even 
AMPUTATION of the upper extremities.
189
swoon, but was found standing by the wheels, which had been promptly
stopped ;  and not until his tattered  clothes, adhering with his torn-off
shoulder and arm to the machinery, were being removed, did ho evince
even pain, and then complained  but little.  Not two cups of blood, in
all, were  found on the floor, and on the arrival of the surgeon, half an
hour  after the accident, not a drop of blood oozed  from the frightful
wound!   Nor was there any hemorrhage afterwards.  The reaction was
trifling, and appeared to be only what was required by nature to restore
tone to the system  from so violent a concussion.   The pulse continued
for several weeks steadily at, or a little over, 130 in a minute, and soft
and of moderate strength—the tongue  clean, skin cool, and  appetite
good, and patient lively.  The continued celerity of the  pulse, in fact,
might, as  we think, be readily accounted for by  so great a destruction
and sudden ablation of parts, without hemorrhage, which thus accumu-
lated or concentrated just in the same  proportion to this loss of substance
the nutritive powers left in the circulation, and therefore the quantity of
blood in the whole system ;  requiring consequently its more  rapid  pas-
sage through the  heart and lungs.  On the tenth day several  portions
of the integuments which had been brought over the face of the nerves,
and some  of the ragged margins of the wound had separated  by slough-
ing ; but  healthy granulations were springing up on ail sides.   The
plexus of  nerves, which had become exposed to the extent of three inches,
lay together  in a mass, and were  partly  sphacelous; but when touch-
ed by the dressings, or otherwise, the boy manifested a degree of terror,
says the surgeon, I have seldom  seen equalled, and declared he would
sooner  perish than allow any  interference.  The ligature  lay in contact
with the nervous  mass, and in consequence of the extreme sensibility of
the part, was allowed to drop off with the sphacelated nerves, about the
middle of the sixth  week, after the  boy  had been  walking  about for
some  days in perfect health.  A dissection of  the  torn off limb  and
scapula exhibited a fracture  midway on the humerus,—the integuments
on the outside of the head of the humerus entire, but on  the inner and
anterior surface of the bone, completely removed, and the  nerves and
blood-vessels  exposed,—the nerves torn and  separated into  small bun-
dles like pieces of cord, some h\ inches long, and the shortest one  inch
from the shoulder joint,—the artery (the brachial) torn directly across,
about  two inches on the distal side  of the shoulder-joint, and looking
as if severed by a cutting instrument,—the  internal and  middle  coats,
on being laid open, presenting the appearance of  being slightly retract-
ed and  puckered,—the  acromion and carocoid  processes of the scapula
entire, but the other portions  of the bone (scapula) so mutilated and
crushed to minute fragments, with the  surrounding muscles, that they
could not  be distinguished from each other.
  Dr. King draws  attention to the  leading feature of the  absence of
hemorrhage, and  the trifling shock  on  the system  produced by so im-
mense and lacerated a wound, unaccompanied, it may be said, even with
syncope, and at no time stupor or fever, strictly so called.  Such slight
morbific effects from such terrible violence, which have been frequently
noticed also in similar cases, lead to the supposition that, could disar-
ticulation, thus almost  instantaneously  accomplished by  a natural ap-
plication of mechanic force, rapid and as it were spontaneous, while the 
190
NEW ELEMENTS OF  OPERATIVE SURGERY.
 patient has^ scarcely time to be conscious of the operation,  be thus
 performed intentionally  and by  art, and limbs thus quickly wrung or
 twisted  off from their joints, there  would be  less to be  apprehended
 from consecutive symptoms, than  after  the  most dexterous application
 of surgical  instruments.   The  general arguments, also, advanced  of
 late years with  so much  earnestness by  Amussat  and  others, in favor
 of torsion of arteries (see vol. I. of this present  Amer. ed. of Velpeau ;
 also this vol. II.) in preference to ligatures, seem to acquire great weight
 from details like those of the above remarkable, not to say almost marvel-
 lous and incredible, case ; for  herein torsion was certainly exercised
 on a vast extent of surface and upon a gigantic scale as to the great
 trunks interested.   In truth, the first ideas  of torsion  as  a surgical
 expedient unquestionably came from the almost total absence of hemor-
 rhage in  such wounds, and which  dissection, as is seen  in this case,
proved to have been effected by  the  same  breaking  and  rolling up of
 the two inner  coats and  the  resistance and preserved integrity of  the
 outer elastic  coat, which  are  shown  to be the results  where arteries
 are submitted  to torsion by a surgical  instrument.   Dr. King finds  but
 a very few cases of avulsion on record.   Belchier, (Philosophical Tran-
 sactions, vol. XL, p. 313,) relating the case of the man who  had  the
 arm and shoulder-blade torn off by a mill, says he was not  sensible of
 any pain, but  only a tingling  about  the wound; and  actually did  not
 know his limb was torn off, till he saw it in the wheel! and soon recov-
 ering from  his pain, or rather fright at this loss, came  down a narrow
 ladder to the  first floor of the mill!   The boy described by Mr. Carter,
 (Medical Facts, vol. II., p. 18,) whose left leg and  thigh and part of
 the scrotum were torn off by a slitting-mill, was found by the surgeon
 lying on the floor under a blanket, seemingly free  from  pain, and only
 anxious because his parents would be in such trouble !  The same in  the
 boy  aged nine, whose leg M. Benomont (Hist,  de  VAcad, de  Chir., t.
 II., p. 79) states was  torn off  at the knee by the  wheel  of  a carriage,
 but whose only trouble was an anticipated reprimand from his parents.
 The girl  aged eleven  years, described by Dr. Clough,  (Memoirs of  the
 Medical  Society of London, vol. III., p. 519,)  had  strength  to walk
 across the court, from the  coach  to the hospital, shortly after' her  hu-
 merus had  been  torn  from the scapula in a mill.  Two other cases
 (Traite Complet des  Accouchem., par M. De la  Motte, Obs. CCCXLI. ;
 see also Dr. Cooper's case, New York Jour, of Medicine, vol.  I., p. 284)
 are too imperfectly given  to allow of more than merely this reference
 to them.   In one case only, that of a child as related by M. Carmichael,
 (Medical Commentaries, vol. V., p. 80,) the avulsion of the left arm
 by a mill, though the patient recovered a little and spoke, was soon  fol-
 lowed, but without any loss of blood, by cold extremities, low tremulous
 pulse, and convulsions over the whole right side of the body and face.
   In one case  only, also, of the above was  there profuse  hemorrhage :
 viz., in that of Belchier, (Loc. cit., p. 314 ; also Cheselden's Anatomy,
 p. 321.)
   Dr. Jones (Jones on Hemorrhage, p. 42, cap. XII.) has clearly shown,
 in his valuable experiments, that in these lacerations, which is seen also,
 savs  Dr. King, in the natural instinctive act of brute animals  in bruising
 the umbilical cord, nature providentially guards against the loss of blood. 
AMPUTATION OF  THE UPPER EXTREMITIES.
191
 The brittle, internal coats of the vessels give way, and their retracted
 debris  fill up the outer, firmer, elastic coat, and this plugging up of the
 vessel, (see Costelloys Encyclop., part V., art. Avulsion,) and also the now
 elongated  conical narrow orifice of the external coat, all resisting the
 force of the circulation,naturally favor the deposition of coagulum lymph,
 and consequently, cicatrization.  These are now the most approved views,
 and more recent observations  have shown  that the important part  in
 this process is rather  in  the mechanical breaking, rolling, and pushing
 up of the two inner coats, (as  in torsion,)  than in  the deposition of
 lymph,  as Dr.  Jones imagined.   [See  notes supra, under arteries, &c]
   In the case of Dr. King, he justly remarks, as we think, that the lacera-
 ted fragments of the nerves exposed should have been immediately re-
 moved  by the knife, which would have greatly diminished the present
 suffering, and danger of neuralgia afterwards.   So should lacerated and
 contused portions of cellular tissue  and fibre be removed by the knife  to
 avoid  sloughing and  suppuration; but in this case there were no such
 parts, as the whole mass appears to have been whipped off, smack and
 smooth, down to the ribs !
   It is  true, as  Dr. King says, that we see only the favorable side pro-
 bably of most such cases, to wit, the fortunate ones, while the fatal re-
 sults are hushed up.  But  it  must be confessed that  their phenomena,
 viewed  in any light, are pregnant with important reflections, and lead,  as
 in  this  case  of Dr. King especially, to the conclusion almost irresistible,
 that the entire scapula and its muscles in front and much of those behind,
 together with the arm and a section also of the  clavicle may be removed
 from the body and be followed notwithstanding by a perfect restoration of
 health.   It is difficult to conceive how such a terrible and extensive de-
 struction of soft parts, muscular tissues, vessels and nerves, and exposure
 of aponeurotic, cartilaginous and synovial  surfaces  and  sheaths could
 have so resulted, and  with scarcely any constitutional disturbance.   It
 would  seem  to give a less formidable aspect to lacerated wounds than
 that in  which they are  usually regarded; though there is no question
 scarcely in our mind that a smooth incision  or separation with the knife,
 could it have  been made in the proper directions and  at the proper
 places  of division, as  in  those which nature  herself  for example had
 selected in this violent disrupture, the result would have been attended
 with less danger of a fatal issue  and  better  prospects of  cure.  The
 natural  and  best line of division of  the  parts, however, for  the most
 perfect  torsion of the  vessels, is doubtless the  one here rudely adopted
 in such  accidents.   And the question  therefore comes back to this, how
 far nature in such violence is to be imitated by surgical art in attempt-
ing, in  cases that may offer, such scapular disarticulations as the fore-
going, and whether these are  not  to be considered valuable lessons in
pointing out  to us the path by no means yet wholly explored, where (as
in anaplastic operations) unachieved triumphs that we  can scarcely an-
ticipate   are  still in store for  surgery, so far as enormous destructions,
ablation and  restitution of parts are possible without loss of life.
  Some  consideration is undoubtedly to be  attached to the extreme and
almost instantaneous rapidity  with which  such ablations are effected.
This unquestionably has great and favorable influence  upon the results,
and it is to  be received in some sort  as an argument in favor of the 
192
NEW ELEMENTS OF OPERATIVE SURGERY.
 once highly lauded but now universallv reprobated achievement, which
 most surgeons  plumed themselves upon, of completing the most bloody
 operations within a limited number of seconds.
   We notice some  remarks on  the above important case of Dr. King,
 made at a meeting of the Medico-Chirurgical Society of Edinburgh, Jan.
 22, 1845, (Cormack's Jour.,ib.)  Dr.  Watson on that occasion justly
 doubted that the slight hemorrhage in such cases depended on the for-
 mation of a clot, as it required according to his experiments seven days
 to  form in a deligated artery.  It was well observed by Dr. Douglass
 Maclagan that the art of avulsion was in the highest degree favorable to
 the interruption of the course of the blood, as he had proved many years
 since by experiments on the dead human subject and in living animals,
 in association with Prof. Turner.  In dragging out arteries forcibly, un-
 til  they gave way, the same result was produced, viz., the cone-like pro-
 longation of the tube,  and  the shaping of it into the form of a pencil,
 pointed for vmting.  ' The prolonged outer coat formed the apex of the
 cone; the inner coat was retracted within and projecting into the canal.
 This strengthens greatly the now received opinion that the actual plug-
 ging up  of the artery by this species of membranous tamponing, has  in
 fact, as  seen in torsion, much  more to  do  with the arrestation of the
 blood than  has  the  formation  or deposit of  a clot of lymph.   The clot
 alone, however, may  be the tampon, as  it would appear by the late in-
 teresting experiments of M. Amussat, (see  our note on these, supra,)
 which plugs up the cut extremities of an  artery, causing thereby a  spon-
taneous  cessation of  the hemorrhage.   It is also a matter for reflection
how far  avulsion is to be copied in using torsion on arteries.   It would
seem reasonable to suppose that torsion,  so far as it respects the contin-
ued  twisting or revolving  of the artery round upon its long axis, by
means of the forceps used, is  too much insisted upon, and might injure
and rupture in various places the important outer tunic ;  and consequent-
ly that the first step in the process, viz., that of endeavoring to break up
the  two inner coats  and to  push them towards the cardial side, is the
point to  be most attended  to;  or that this last in fact is less important
than the simple act of elongating the artery by the forceps in the left
hand, inasmuch as it would  appear that this elongation itself, with  little
or no torsion, suffices to rupture the inner coats and to bring the  outer
 elastic tunic like a hood or cap well over  them as the inner ones retract.
 This it  might naturally be supposed it would do from the elastic exter-
 nal tunic  submitting  so readily to this traction, while the middle tunic,
 by  the natural contractile action of its fibres and the brittleness of the
 inner coat, seem more  disposed  to recede  or retract within the outer
 coat. In the living body, however, this elongating traction must neces-
 sarily be  exercised with  caution, inasmuch a3  a rupture of the  trunk
 high up  within  the tissues  might be attended with serious consequen-
 ces.
   Actual Amputation of Scapula, &c.—In  proof of the practicability
 of  removing the scapula, as  we  have said  in our remarks on the ex-
 traordinary  case of  Dr. King above, the entire  scapula, together with
 the external extremity of the clavicle, have been subsequently amputated
 with complete success  by Professor Rigaud of Strasbourg (Seance of
 the Acad, of Sciences of Paris, July 15, 1844.— Gaz. Mid. de Paris, 
AMPUTATION OF THE LOWER EXTREMITIES.
193
Tom. XII., 1844, p. 469)  in  an old soldier aged  51, for an  osseous
tumor which formed on the anterior angle of the left  scapula ; but it was
only the scapula itself with its clavicular attachment which were removed,
and not until at the expiration of eight  months  after the Professor had
previously  taken off the  arm of the same side at the scapulo-humeral
articulation.for a tumor on its upper portion.   M. Rigaud sent casts of
the parts to the Academy at Paris.   T.]
                           CHAPTER II.

                        THE LOWER EXTREMITY.

   Amputations in general are more difficult and  serious in the lower
than  in  the  upper extremities.   They are performed  also on the foot,
leg, and thigh, and in the continuity as well as contisruitv.

                Article I.—Amputation of  each Toe.

   The case is not the same with the toes as with the fingers.  The uses
of the latter render their preservation important, and their length al-
lows  of  their partial amputation.  The toes on the  contrary, serving
only for  standing  upon, and  having but little extent, may be entirely
removed without essentially impairing the functions of the foot.  Nor
do we scarcely ever amputate  for one or two  phalanges of the toes,
or in the  continuity of the metatarsal phalanx.  Of these the first  toe
alone might  form an exception to the rule, upon the supposition that its
last phalanx was affected in such manner  as to allow of our  saving a
sufficiency of the soft parts to form a suitable flap.
   A.   The Great  Toe.—The first  toe  seems to be an  exception to the
general rule, under another point of view.   From the time of Le Dran
(Opirat., p.  569—Observ.,  t. II., p.  369)  to the present day, most
surgeons have  preferred  dividing the metatarsal bone behind its head,
rather than restrict themselves to separating the great toe from it.  In
disarticulating this toe, we create, it is asserted,  a disgusting deformity ;
the anterior extremity of the bone forms a considerable projection, which
is difficult  to cover, is liable  to painful  friction  against the  shoes, and
must in fact only interfere with instead of assisting in the functions of
the foot.   It  is  certain that  the deformity is less observable after the
amputation of the first  metatarsal bone than after the removal of the
toe only ; but it is also undeniable that  the  power of standing is much
more difficult and  less secure in the first case than in the second; that
this boney prominence which we desire to get rid of, is of the greatest
utility, that it hinders the foot  from turning inwards and  gives a firmer
basis to the support of the  frame.   Under this  point of view then, am-
putation of the great toe alone ought to have the preference.
   I have disarticulated the  first  toe  both  by  the flap and the ovalar
method.   If the disease  occupies  the phalangeal  articulation only, I
   Vol. II.                  25 
194
NEW ELEMENTS  OF OPERATIVE SURGERY.
make a circular incision behind it, and divide the first  phalanx in it3
continuity, either with the cutting forceps or Liston's nippers.
   In making flaps upon the sides in disarticulating  this toe, it is neces-
sary to give them a considerable degree of length, and it seldom happens
that we  are not  interfered  with  underneath by the  sessamoid bones.
The ovalar method taking all things  into view, is the preferable one ;
but in performing it the surgeon should take care not to go too far be-
hind on the plantar surface of the foot.  The sessamoid bones, prolonged
as they are under the head of the metatarsal bone, would give him con-
siderable annoyance, if he did not take the precaution to  immediately
bring back the bistoury in front under the border of the phalanx.
   B. The Little  Toes.—If it should  happen that one of  these toes was
affected  only  at its extremity, there would be two reasons to justify
amputation as far from the  metatarsus as possible ; 1, the obligation to
remove nothing which gives  support to the body;  2, the advantage of
avoiding  the  sheath of the flexor tendons.  In a boy, aged nine years,
I removed in this manner the last phalanx for  an exostosis accompanied
with fungous ulceration of the ungual  surface of the third  toe.  In an-
other case I removed  that of the second toe, and in a third, that of the
first.   The  operation  presented no difficulty in any of them, and in the
first the  wound healed perfectly by first intention.  No other scarcely
but the flap method from the dorsum to the plantar surface can be ap-
plicable in  such cases.  The  pulp  of the toe furnishes a cushion which
can be readily raised up and which closes the wound exceedingly well.
   C.  As the processes to be followed, moreover, are  precisely similar
to those which have been described for the removal of the fingers, there
can be no  necessity of recapitulating  them here.   I will remark only
that the natural cavity which  corresponds to the  dorsal surface of  the
metatarso-phalangeal articulations,  and the prominence which the plan-
tar surface forms in front  and underneath, render amputation of each
toe in its  totality somewhat more difficult than that of the fingers, and
that the ovalar method  possesses  still greater advantages for the ap-
pendages  of the foot than for those  of the hand.
  D.  The disarticulation of either of the three  middle toes, scarcely
produces the slighest  alteration in the form of the foot.  A young girl
and a young man, in whom I had removed one of these  toes, in conse-.
quence of a caries, earnestly desired  me to do the same on the other
side, in order, they said, that they might have the two feet equally nar-
row !   We shall see farther on what course in this respect is to be adopt-
ed for the first and fifth toe ;

    Article II.—Amputation of several of the Toes at once.

  Amputation of two, three, or of all  the five  toes could  also be per-
formed in the  same way  as for the fingers.  It would be neither more
complicated nor more  difficult, and would  present the  same chances
of success.  There arc so few wounds so serious as to implicate all the
toes, without affecting at the same time a greater or less  extent of the
metatarsus,  that the proposition made  about twenty years since to am-
putate several of  them at once appeared to be  new, (Gautheret, These
1820.)  Examples, however,  had been related of such amputations' 
              amputation of the lower extremities.            195

and especially in cases  of frost-bite.   [See a note on this subject, Vol.
I., Introduction.  T.]  A boy, aged sixteen years, was operated upon in
this manner by Garengeot, ( Opirat., t. III., p. 416.)  Also in the case of
another boy a similar operation was performed at the hospital of Padua,
(Biblioth. de Planque, t. II., p. 389, in quarto.)  In one patient  Bloch
(Biblioth.  Chir. du Nord, 116) performed this operation on  both feet.
In another case Delatouche (These,  Strasbourg, p.  5, obs.  12,  1814)
says they were  amputated completely by a bullet, and that no consecu-
tive  accident took place.  M. Baud and M. Scoutetten (Arch.  Gin. de
Mid., t. XIII., p. 67) have also both performed this operation with  suc-
cess.   I have amputated, says M.  Champion, all the toes in two soldiers,
who were  frost-bitten, always keeping in view to preserve to the foot,
even if it  were but a single phalanx, the  greatest degree of support
possible  for the body.  I saw at La  Pitie, a patient operated upon in
this  manner by  Lachapelle, more than  forty years since.  I have  met
with two other similar cases  during the wars of the Empire.   A  recent
case also has been  published by M. Chaumet, (Journ. Hebd., t. III., p.
83.)

           Article III.—Amputation of the  Metatarsus.

  The bones of  the metatarsus are amputated like  those of the meta-
carpus, and by as many  different processes, either in the continuity or
contiguity, or separately or all together, of which many  examples have
been given by Hey,  C. Bell,  Langenbeck, Ferrand, Desault, Laumonier,
MM. Moreau, Daniel Aubry, &c.  They may also be removed by ex-
traction or evulsion, while at the  same time  preserving the correspond-
ing toe.

    § I.—Amputation of the Bones of the Metatarsus separately.

  A.  Amputation of the tnree middle metatarsal bones is  performed
quite frequently, and always  after the same rules as for the amputation
of the corresponding metacarpal  bones.  Some surgeons maintain even
that it should have  the preference over simple  disarticulation  of the
toes.   M. Thomas, for example, with whose opinion M. Petrequin  (Gaz.
Mid.,  1837, p.  367) seems  partially  to  coincide, maintained  in 1814
that it is less difficult and less dangerous  than  this last, and that the
deformity which results from it is also less  striking.   This is evidently
an error.
  I. To remove any one of the middle bones of the metatarsus  by the
ancient method, it is necessary to divide by two successive incisions the
whole  thickness of the sole  of the foot, to disturb  some of the  tarso-
metatarsal articulations, and  to produce a very  extensive wound ; while
the amputation  of a toe, performed as it is in an instant, makes  only a
very trifling wound and  one which is easier healed.  Thus  in the foot
as in the hand, and for the same reasons, we must not attack  the  bones
of the metatarsus only so far  as it may be found impracticable to remove
the whole of the disease by disarticulating the toes.
  II. Process of the Author.—When this operation  becomes necessary
it is easily performed  by the following process  which I have already 
196
NEW ELEMENTS OF  OPERATIVE SURGERY.
described under amputation of the bones of the metacarpus.   I encom-
pass the root of the toe  with an oval incision,  whose extremity is pro-
longed  backwards upon the dorsum of the foot to beyond the limits of
the  disease.  Afterwards detaching the soft parts upon each side and
then  underneath, I have  soon  isolated the bone, which I exsect with
Liston's pliers, without dividing  the sole of the  foot, and which thus
exhibits no trace of any cicatrix after the cure.
   The three  patients  upon whom I operated in this manner rapidly re-
covered, and scarcely any traces of the mutilation  were perceptible !
   B.  Amputation of the First Bone of the  Metatarsus.—Some practi-
tioners, and among them M. Gouraud, maintain that it is better to dis-
articulate the first bone of the metatarsus than to divide it with the saw.
Ledran  had already pointed out the disadvantages of this method while
endeavoring to give  popularity to the other, which has been  generally
adopted ever since M. Richerand recommended to saw the bone  slant-
ingly, or taperingly,) in place of making the section transversely as was
done in  the last century.   After disarticulation, the base of  the wound
represents a capital L, whose horizontal branch formed by the first cu-
neiform bone makes a disagreeable projection on the inner border  of  the
foot.  The operation is besides more difficult,  and the wound less easy
to unite by first intention.  Amputation in the continuity, when we take
care to make the saw act in a very  oblique  direction  from behind for-
wards, leaves  no  prominence on the inner  side of the bone.  It  does
not require  so  great a destruction of parts, nor that we should  attack
any articulation.   I am of opinion, therefore, that it ought to have  the
preference so long as the disease  does not oblige #s to carry the  instru-
ment up  to the tarsus.  I  have had every reason  to  be satisfied with
these rules.
  I. Ordinary Processes.—The different  processes pointed  out  for the
thumb and first bone of the metacarpus, are  applicable to  the meta-
tarsal bone of the  great  toe.  It was in these cases that Lebas (Bul-
letin de la Faculti, t. V., p. 417-190) and  Beclard at  first made  use
of the ovalar method, that Richerand employed  the  V incision,  and
where the  flap methods  have also  frequently been made trial of; but
none of these methods have satisfied me in practice.   These, then, are
the processes which I have followed  :—
   II. As it is  difficult to  draw  the soft parts sufficiently inwards from
the plantar surface of the foot, and  to plunge  in the bistoury form
above downwards, between the bone  and  the muscles; as it is  almost
impossible, moreover, in  proceeding  in this  manner, to give to the point
of the flap the regularity, width, and length desirable, I prefer making
my incision  from without inwards, and to trace out its  extent and form
by dividing the skin from  behind forwards, first on the dorsal surface,
then on the plantar surface nearly as  far as the  anterior  extremity of
the first phalanx of the  great toe, and afterwards to  raise up and dis-
 sect  this flap while reversing  it from its  apex  to its base.  Having
 incised the'  integuments of the  commissure in such  manner that the
 borders of the whole  wound  pass  outside  of  the head of the bone, we
 plunge the knife through  the first inter-osseous space, while an assistant
 also  draws  the integuments outwardly as  much as possible.  We then
 divide  the tissues  with the full edge of the  blade from behind forwards, 
AMPUTATION OF THE LOWER EXTREMITIES.            197
bringing the knife out by the commissure of the two first toes.   The
knife being then immediately  replaced behind, we divide above and un-
derneath, on the inner and  outer side, all the tissues which may be still
adherent to the bone.  A piece of wood or pasteboard, or even a sim-
ple compress folded several times and placed in the bottom of the wound,
protects the soft  parts  against the action of the saw.   The operator
seizes  with his left hand the toe and the articular extremity which he
intends to remove, causes the foot to be turned outwards, applies his
nail to the point where he  wishes to begin the section, and then, with
a small saw in his  right  hand, divides the bone"at  a very  acute  angle
from its inner to its outer surface and from behind forwards.
   One of the  dorsal  or inter-osseous arteries of the metatarsus, or one
or two  branches of the plantar arteries, occasionally, but  not  always,
require the application of the ligature ; the flap now brought upon the
wound, should  be adjusted to it accurately, and supported by strips of
adhesive plaster and a suitable bandage.
   III.  New Process.—When the plantar surface of the foot is not too
much degenerated, I  proceed  in  another  manner.   An incision, to be
carried along the inner border of  the bone from the line of its posterior
articulation as far as in front of the infra-phalangeal prominence, en-
ables us to detach, horizontally  from above  downwards, from  within
outwards, and  slightly from before backwards, the whole thickness of
the  sole of the  foot,  and to form  in this manner a  flap which remains
adherent  in the  whole extent of its outer border.   A second incision,
carried from  one extreme  to the other of the first, by crossing  very
obliquely the dorsal  surface of the  bone, and in such manner as to fall
upon the first inter-digital commissure, then  enables  us  to  terminate
the  operation as in the process described above.  We have thus a very
regular wound, and a thick, large flap, which does not implicate the
sole of  the foot, and  which moulds  itself exactly to the fibular side of
the wound.  It is a method whose  results  in practice  are of the  most
satisfactory character, and one which I recommend  to the  profession.
   C. Fifth Metatarsal Bone.—The last bone of  the metatarsus might,
like the others, be  amputated in its  continuity ; but  the  projection
which it forms behind, the uselessness of any portion of it that we  might-
preserve, the ease  with  which it  can  be disarticulated, and  the little
deformity that results from it, are the reasons why  we generally prefer
amputating  it in the  contiguity.  This  amputation  is  not to be  made
like the preceding; the ovalar method is better adapted to it.  If, how-
ever, we should not incline to make trial  of this, we  ought, with the
bistoury held vertically, to cut through the whole inter-osseal  space
from before backwards, from the commissure of the fourth and fifth
toes to the anterior face of the cuboidal bone ; then disarticulate the
bone, pass  from its dorsal to its  plantar surface, detach its  head, and
cut a flap of sufficient length at the  expense of the  soft parts  upon the
outer border of the foot, and which flap can be made to cover with ease
the whole extent of the solution of continuity.

         $  II.—Amputation of the Metatarsal Bones together.

   Though down to the time of Chopart  surgeons  were in the habit of 
198
NEW ELEMENTS OF OPERATIVE SURGERY.
 having recourse to  amputation  of the leg  for  diseases  even which did
 not complicate  the  whole of the foot, they not unfrequently, however,
 confined  themselves to  the  partial removal of this part, which, at the
 present time, it is the prescribed  rule to amputate as near the toes as
 possible.
   I. According to Fabricius of Hilden, amputation of  the  metatarsus
 could  not have been unknown  to  the  ancients, who  performed it with
 the  chisel and  mallet, and, without doubt, only in  its  continuity.   In
 recommending it, Sharp (Opir. de Chir.,p. 390) advises that we should
 use a small saw, and states that he has once seen it performed with suc-
 cess.  Hey  revived  it again at  the  end of the last century, and gives
 the case of  a young  woman, in  whom he  removed the  first four toes,
 with a  large portion of the corresponding metatarsal  bones ; but  he
 complains of the great length of time which the  wound  took to cicatrize.
 The  operation  is  easier upon  young  persons, because,  during infancy
 and in this part, the  bistoury may very often be substituted for the saw.
 M. Raoult, in 1803,  and M.  Thomas, in 1814, recommended this opera-
 tion  in  their theses, supporting it, as it appears to me, on  very good
 arguments.  In 1828, Murat and M.'J. Colquet  (Journ. Hebd., t. IV., p.
 43) found that this operation fully answered their expectations.  Since
 that  time, M. Pezerat  (Journ.  Compl. des Sc. Mid., t. XXXIII.) has
 performed it once, and with success; and M.  Mayor  (Journ. des Con-
naiss. Mid.  Chir., t. I., p. 138) who has  also given his sanction to  it,
has been equally well satisfied with it.  I cannot, in fact, understand
why the transverse section of the metatarsus, rather than its disarticu-
lation, should not have the preference whenever the  disease  admits of
this operation.
  I will also add that the first of these operations, if had recourse to in
proper time, would, as it appears to me, render the other  rarely necessa-
ry-
  II.  Operative Process.—a. A flap of the soft parts of greater or less
length, is first cut, at the expense of the sole of the foot, by  plunging a
 small knife into  this  part from one border to the  other.   We then di-
vide by a semi-circular  incision inclined slightly forward the skin and
tendons of the dorsal surface at some lines in front of the point where
we design to apply the saw.   These soft part (ies chairs) being drawn
back by an assistant, the surgeon, one after another, denudes the bones
 with his bistoury up to the base of the flap, in order to effect with greater
 ease  their simultaneous or successive section from one side to the other,
 or from the dorsum to the plantar surface of the foot.
  b.  The process of M.  Pezerat, which  consists in making three flaps,
 one dorsal, one  plantar, and the other on the inner border, ought not  to
 be adopted, unless the diseased condition of  the  parts renders it impossi-
 ble to employ the preceding process.
  c. In concurrence with M.  Champion (These, Resect,  des  Os,  etc.,
 1815) and M. Mayor, it should, in my opinion, be adhered to as a rule
 to divide  the bones  as far as possible from the leg.  A  dorsal and a
 plantar flap of equal  length, and even the circular  incision, or the mak-
 ing one of the flaps shorter or longer, or the cutting out of two or three
 or four flaps instead  of one,  should be preferred, if the state of the soft
 parts seem to require it.   Liston's pliers might also be advantageously 
AMPUTATION OF THE LOWER EXTREMITIES.
199
 substituted for the ordinary  saw,  and the  dressing would require  no
 special precautions.
   [Amputation of the Metatarsal Bones.—Mr. Smye (Cormack's Lond.
 and Edinb. Monthly Journ., Src, Feb. 1843, p. 94,) speaks of M. Lis-
 ten's " happy employment" of straight cutting pliers, in exsections of
 the metatarsal and other small bones, instead of variously  formed saws
 previously in use, as  if it were something new  in surgery.   We are of
 opinion that the germ of this instrument is far more ancient than might
 be supposed, and  an argument in  favor of this is, that  in early times
 when strength, and immediate and  obvious adaptation to the purposes in
 view, and not skill and adroitness, were most looked to, some such coarse,
 rude, but valuable article as, for example, the common cutting nippers
 of a blacksmith, to cut off, in an instant, protruded necrosed metatarsal
 and  metacarpal  bones, and those of the phalanges, would  rather have
 been resorted to than the tedious, painful processes of sawing.
   Certain it is, (see Vol. I., Prefatory matter,) a similar instrument to
 Mr.  Liston's was constantly employed by me in  the years  1831, '32, '33,
 at the Hospital of the Seamen's Retreat,  New-York, for one or all the
 metatarso-phalangeal extremities of the metatarsal bones,  in cases of ne-
 crosis, from having been frost-bitten, and  which  had been in some in-
 stances, maltreated by poulticing, &c.  The bones, as I have said, were
 thus unsparingly clipped off, until the bleeding, excised surface of their
 extremities presented a  fresh red and healthy  appearance, though now
 buried half an  inch or more in the  tissues, and until the healthy appear-
 ance of the soft parts also  indicated  that the seotions  were made at the
 proper  place.   The  soundness of this practice was made manifest by a
 fine, healthy stump, which was  thereby procured without  any trouble or
 danger  of incising or dissecting the tissues for flaps, the  necessity of
 which was superseded by excising the bones deep in the  tissues ;  these
 latter, of  course, in cases of frost-bite, as no constitutional  taint exists,
 being rarely degenerated as far back  as the bones.   T.]

        Article  IV.—Disarticulation of the Metatarsus.

   Upon the supposition that the state of the foot does not allow of mak-
 ing the  section of the bones of  the metatarsus, or that the surgeon does
 not wish to resort to this operation, it may be possible, by  means of their
 disarticulation, to save  the tarsus,  and the use of certain  important
 muscles.
                                 §1.

   From surgeons being generally uninformed upon this subject, the oper-
ation in the year 1816 was looked upon as a new one.  A great number
of practitioners had,  however, as we  shall  see, either recommended, or
described, or even performed  it!   " As this amputation," says Garen-
geot, ( Opir., t. III., p. 414,) who has forcibly pointed out its  advantages,
" has to be made upon  a considerable number of articulations which
are not  upon the same line with each other, it is one of a very embar-
rassing character.   To conduct the  bistoury between the  bones of the
metatarsus, &c, and to divide the ligaments which  connect them, and
to save as much skin as possible, are all the directions we  can give." 
200
NEW ELEMENTS OF  OPERATIVE SURGERY.
  ^ Leblanc, (Precis d' Opir., t.  I., p. 310,) still more laconic, restricts
 himself to this remark: " We may, in certain cases, amputate a portion
 of the foot, saw through the bones of the  metatarsus, or even separate
 them from their articulations, as has been stated by  many practition-
 ers."  The same remark was made by  Brasdor, (Mem.  de VAcad, de
 Chir.)  Vigaroux (CEuvres Chirurg., etc., p. 250) performed this ope-
 ration on the  left foot of one of his patients, in 1764, and Laroche (En-
 cyclopid.  Mith., part.  Chir., t. I., p. 107)  enforces  the necessity  of
 preserving in  the amputations as much of the foot as possible.  In Eng-
 land, it was  performed by Turner in 1787, (London  Medical Journ.,
 1787;  Gaz.  Salut.,  1789, No. 38.)  Percy says he performed  it, in
 1789, with great difficulty on  a  monk of Clairvaux ;  and M. Larrey
 (Clin. Chir.,  t.  III., p.  671 ;  Mini, de  Chir.  Milit.,) says he has been
 in the practice of performing it since the  year 1793.   We find it  de-
 scribed also in  the Thesi's  of M. C. Petit, in  1802.   " I have," says
 Rossi, (Mid.  Opir., t. II., p. 229,) " by means of the  cutting instru-
 ment, successfully extirpated the bones of the  metatarsus, in a carious
 state, and saved the tarsus. "  In  1814, it was performed successfully
 by M. Berchu.
  The following is the  process  given in 1803, by A. Blandin, who had
 employed it several times successfully : " I divide," says he, " the skin
 and tendons on the  dorsum of the foot, by carrying the cutting edge of
 the bistoury from before backwards, and making it glide  upon the body
 of the bones up  to the place of their  articulation, in such manner as to
 preserve a  small  flap, (dorsal;) I then  divide all  the  ligaments; and
 afterwards, with the point of the instrument  which I carry through the
joint to  below the  tarsus,  I complete the  division of  the bridles, and
 amputate the  entire part with a single transverse section, preserving,
 as on the dorsum, a small portion of  the tissues of the sole of the foot,
 in order to form a second flap."
  M. Plantade in his  Thesis, 1805, held  nearly the same  language.   A
 child of four years  of age, upon whom the operation was performed by
 Yatman, (Bibliot.  Mid., t.  LIX., p. 261,) got well in fifteen days.
 Nevertheless, M. Villerme  and M. Lisfranc, who  made  this  operation
 the subject of  a special investigation, presented to the Institute in 1815,
 supposed that they were to some  extent the authors of it.  We are at
 least  indebted to them for having  given  a careful description of the
 process to be adopted.

                          § II.—Anatomy.

  The three cuneiform bones united, present in front a kind of mortice
 slightly flaring  which is exactly filled up by the posterior extremity of
 the second metatarsal bone, and the  inner wall of which cavity has a
 length of about  four lines, with an inch in height, while its outer wall
 has hardly two lines in extent from before backwards.
   The articulation of the first metatarsal  bone, which is consequently
 found two  or three lines farther  forward than that of  the third, is less
 wedged than any of the others ;  its surfaces represent  a double oblique
 plane, from within outwards, in  the  direction of a line  which would
 strike' on the  middle of  the metatarsal bone of the little  toe,  and then 
AMPUTATION of  the lower exttemities.
201
from above  downwards, and from before  backwards.  That of the me-
tatarsal bone of the middle toe, in other respects situated transversely
like that of the  second, is found to be two lines in front of the bottom
of the mortice already  described above.  The  interline of the fifth is
oblique from  without inwards, as if to strike upon the  middle of  the
first metatarsal  bone ; while the fourth is almost horizontal on its outer
part,  and inclines in front like the preceding at the moment  when it is
about to become continuous with the third, being situated usually at one
or two lines behind the latter.
  As the second  metatarsal bone is enclosed  as it were between the
bones of the  tarsus, it is rare  that  the third cuneiform bone is not, in
its  turn, enclosed in  another  kind of mortice, of one or two  lines in
depth, formed by the third  metatarsal bone in front, together with the
second and  fourth upon its sides.  If the first did not exist, the second
should  equally be wanting.  In fact, if the  third  cuneiform  bone  was
upon  the same plane as the second, the articulation would be perfectly
regular from the outer  border of the foot to the first; but  this bone
often makes so considerable a projection, that it reaches  nearly to aline
with the first cuneo-metatarsal  articulation.   In such cases, the disartic-
ulation of the two mortices is attended in both with nearly the same
difficulty.  Other  anomalies also are  sometimes met with.  I have, for
example, seen the  antero-internal articulating surface of the cuboid bone
extend half a line,  or  even a line, beyond  the metatarsal articulating
surface of the third cuneiform.  In another subject, the  two last meta-
tarsal bones united, resembled a sloping ridge, the crest of which, placed
vertically, was sunken to a depth of three  lines  upon the front of the
cuboidal bone ;  and  this was  found to exist in both  feet of the same
subject.  On another occasion, I found the dorsal border of the extrem-
ity of the third metatarsal  bone inclined  obliquely backwards, to the
extent of a line and a half, upon the corresponding cuneiform bone.
M. Zeigler has seen the tubercle of the fifth metatarsal bone  prolonged
as far as the line of the articulation of the  os calcis.   I have often no-
ticed, also, in persons who are in the habit of wearing tight boots, that
a tubercle, resembling an exostosis, will very frequently  be formed upon-
the dorsum of the second  cuneo-metatarsal articulation.  Finally, se-
veral of these articulations may become anchylosed.
   The dorsal tarso-metatarsal  ligaments, the antero-posterior as well
as the transverse, being nothing more than simple bandelettes or ribbons,
do not require any special description.  On the plantar surface, however,
it is somewhat different.  There  these bones  terminate, almost  all of
them, in  a sort of  flattened edge or crest, which, by permitting them to
incline towards each other, forms the transverse concavity of the foot,
leaving between them small triangular spaces, which are filled by fibrous
bundles.  One of these fasciculi, viz. that which unites  the outer sur-
face of the anterior projection of the first cuneiform bone to the inner
surface of the second metatarsal, merits every  attention from the ope-
rator.  It is especially remarkable by its thickness in a vertical direc-
tion,  bounded by that of the articulation  itself; as to the others, there
is nothing of any special importance to remark concerning them.
  Viewed in its ensemble, the tarso-metatarsal articulation represents  a
line slightly convex forwards, and the extremities of which  correspond
  Vol. II.                     26 
202             NEW  ELEMENTS OF  OPERATIVE SURGERY.
nearly to the middle of the space which lies between the malleoli and
the roots of the toes.  Upon the outside, it is designated by the poste-
rior extremity of the tubercle  of the  last metatarsal bone, observable
under  the  skin.   On  the  inner side it is also very easy of recognition,
by  observing that the first cuneiform and the  first metatarsal bone, each
present a prominence under the  integuments near the plantar surface
of the foot, which gives  the articulation the appearance of being de-
pressed.   A  line, drawn  transversely from the outer extremity of the
articulation to the inner border of the tarsus,  falls a little in front of the
scaphoid bone, and  is distant about three-quarters of an inch  from the
tarso-metatarsal articulation on the inside.  It cannot, therefore, be a
matter of much difficulty, before proceeding to the operation, to identi-
fy both its  direction and position.   As it is to the lower or plantar tu-
bercle of the  posterior extremity of the  first metatarsal bone that the
tendon of the peroneus longus  muscle is attached, and that this tendon
usually contracts  some adhesions  as it passes under the third cuneiform
bone, the  mere  disarticulation of the metatarsal bones does  not neces-
sarily  destroy its action   It is the same with the peroneus brevis and
peroneus tertius  muscles, which are inserted in part, at least, upon the
dorsal surface of the cuboid bone, and also with the tibialis anticus and
tibialis posticus muscles, whose continuity, in like manner, is not destroy-
ed by the disarticulation of the first bone of the metatarsus.
  The disarticulation of the metatarsus is, without  doubt, one of the
most  difficult  operations  than we can encounter.   To perform it, most
authors who have described it recommend that we should employ at the
same time both the bistoury and the saw.

[Practical observations  on Amputations at the tarso-metatarsal
       articulations.—By Dr. Charles Edwards,  Cheltenham.

  Supposing the single or double flap formation at the option of the ope-
rator, in order, first, to get the line of cicatrix near the upper margin of
the stump, and secondly, to avoid the painful and unnecessary dissecting-
up  of an anterior flap, I think it best to make but one flap—a plantar
one.
  To reach the line of articulations, and have a precisely adapted flap,
ink the following lines :—First, a line near the roots of the toes, a, b, g,
close by their commissures.   Precisely parallel with this dotted guidance-
line draw another arched line, commencing at the projection of the fifth
metatarsal bone, or an eighth of an inch below it.   This parallelism will
prove  an  equal, if not superior guide  to the articulation between the
first metatarsal  and internal cuneiform than any conjectural measure-
ment  from the  projection of the  navicular, which itself, in certain dis-
eased  states, is  not easily felt.  This arched  line will be the  course for
the dorsal incision ; the  structures retracted, not reflected, will corres-
pond  to the joints.
  Unite  across the plantar surface the cornua of this irregular  arc by a
right line: it now only remains to mark its periphery, which will be de-
termined  by .inking, if thought necessary, another arched line on the
plantar surface, precisely  bounding the roots of the toes, I, m, n (as a,
b, g, on the dorsal surface). 
AMPUTATION OF  THE LOWER EXTREMITIES.          203
        a, b, g, commissure guidance line    I, m, n, periphery of plantar flap.
        C, D, E, line of dorsal incision.    c, g, base line of ditto.

  Having thus accurately  defined the measurements,  I would conclude
with a few observations on the plantar flap, the dorsal incision, and finally
the management of the second metatarsal bone.
  As to the plantar flap, commence with a strong scalpel at, or slightly
beyond, either  extremity of base-line, and deeply groove out the whole
circuit of the  flap from without, carrying your  incision round by the
plantar arched line  till it meet correspondingly the other extremity of
base-line.  Finish  this  flap, not with  a scalpel or bistoury, but with a
small, straight-edged amputating knife, one stroke of which will smooth-
ly  reach  the base by reason of its greater breadth.   Thus, in addition
to  a  more perfect outline of the flap than can be obtained from within
after  the disarticulation, by cutting from without no tendons are left pro-
jecting to be clipped.   Some authors say, " Keep close to the metatar-
sal  bones."   If, however, you  have, and leave too much muscle in this
plantar flap, you will incur difficulty  in  bending it up over the stump,
and much pressure and many sutures to keep it there: I speak to ope-
rators on the living body.
  Secondly, as to  the  dorsal  incision, see that  the assistant  who has
charge of the  arterial pressure presses perpendicularly to the surface,
and does not disturb the parallelism, while the dorsal incision is being
made, by unequal or, indeed, any tegumentary retraction.
  Finally, with respect  to  the  disarticulation, when  from  disease you
cannot save  the head of the first metatarsal  bone, or leave behind that
of the second with impunity, I have in an  instant disarticulated the lat-
ter, without previously removing any projection of  the first cuneiform,
by  the following  method:—The plantar flap being formed as directed,
and the  union of its  base extremity and the corner of dorsal incision
clearly made, disarticulate the  first metatarsal, then press the metatar-
sus, not downwards, but rather directly outwards  (this manipulation ad-
mits  of easier demonstration than description).   The  point of a scalpel
applied laterally, by a person knowing where to expect the articulation,
will most readily  penetrate it, and so the chief difficulty of the whole
operation  will  be  readily overcome by any  dexterous hand.—LanceU
April 30,1853, p. 405.  G. C.  B.] 
204            NEW ELEMENTS OF OPERATIVE SURGERY.
                   § III.—Partial Disarticulation.

  Instead of removing the whole metatarsus, it may be sometimes prac-
ticable  to  take away only a portion of it.  Briot (Progris de la Chir.
Milit., p.  187) states that a patient, in whom he removed the two last
bones of the metatarsus and the corresponding toes, was afterwards en-
abled to walk without difficulty.   The same was the case in the  patient
operated upon by Beclard, (Arch Gin de  Mid., t. V., p.  182.) M.
Bouchet (Montfalcon Etat Actuel de la  Chir., p. 44) states that  he has,
in the same manner, removed the third, fourth, and fifth metatarsal bones.
In  one  case of Beclard, (Arch. Gin. de  Mid., t. V., p. 186,) he took
away only the two first.   M. Ouvrard (Melanges de Mid. el de Chir.,
p. 221) succeeded also in removing the third and fourth, and in preserv-
ing the  fifth.  M. Macfarlane (Gaz. Med. de  Paris, 1836, p. 515) has
removed the second metatarsal bone only, together with its toe ; but in
such cases  disarticulation should be interdicted.
  The disarticulation of the  metatarsus endangers inflammation of all
the joints of  the foot, is tedious and difficult of execution, and possesses
no  advantage over the section of the bones a little in. front.  When the
metatarsal  bone is laid open upon its dorsal surface, by means of  a very
long ovalar  incision, it. should be divided by  the rowel saw, if the dis-
ease has extended very far, or, in the contrary case, by Liston's pliers.
Thus modified, the operation becomes rapid and simple.

                  § IV.—Disarticulation in mass.

  A.  Process of Hey.—In a young girl of eighteen years of age, ope-
rated upon  in 1799, by Hey, he  made a taansverse incision at the dis-
tance of about half an inch in front of the articulations ;  then made ano-
ther upon each side,  from the corresponding extremity of the first to the
root of the first and fifth toes.   In order afterwards to form a  flap, he
detached all the soft parts from the plantar  portion of the  foot, and turned
them back.   After having disarticulated the four last  metatarsal bones,
he  decided also upon removing the projection of the  first  cuneiform
bone, which he did by means of  the saw.  The patient  recovered per-
fectly.
  B.  This process is as good as any other, except that  the lateral inci-
sions and the precaution of forming the plantar flap, before disarticulat-
ing the bones, render the operation both  longer and more difficult. Hey,
in remarking that the four last  metatarsal bones are found nearly upon
a line, wishes to convey,  as I  understand him, that their respective pos-
terior articulating surfaces extend but very  little beyond each other,
and not as  they have made him say, that they form a  perfectly trans-
verse line.   As to the section of the first cuneiform  bone, it does not,
in my opinion, deserve the  censure which our surgeons have undertaken
to cast upon  it.  Beclard (Bull, de la Fac.  de Mid., t.  VI., p. 319 ;
Archiv. Gin., t. V.,  p. 194) and M. Scoutetten (Arch.  Gin. de Mid.,
t. XIII., p. 54) have performed this operation, and have had no reason
to be dissatisfied with it.
  C.  Process of Turner.—Turner, who recommends saving as much of 
AMPUTATION OF THE LOWER EXTREMITIES.
205
 the skin as possible, after having divided the soft parts, made the sec-
 tion of the bones upon their  dorsal  surface.  M. J. Cloquet (Diet,  de
 Mid., t. II., p. 171) also thinks it better after having formed an upper
 flap, that we should make a transverse section of the bones rather than
 stop to disarticulate them.  M. Blandin  attributes  this process to Be-
 clard, who has  not, that I am aware of, published it anywhere.  It is
 probable -that M. Blandin confounds  the  section of the first cuneiform
 bone, which in fact was  performed by Beclard, with the proposition  of
 M. Cloquet.  I do not know that  any other person than Murat, (Journ.
 Hebd., t. III., p. 44,) who once performed it successfully at the Bicetre,
 in 1828, has ever employed it; but I cannot perceive how it can be more
 dangerous than simple disarticulation ; a priori, in fact, we would  be
 led to believe that it would less frequently be followed by serious acci-
 dents.  The laceration, instead of the  incision of  the  ligamentous, or
 fibrous tissues, which appears formidable to  some persons cannot be as
 injurious as the tractions which we are compelled to make  upon  the ar-
 ticulations of  the tarsus, when we undertake to separate the metatarsus
 from it with the knife.   The  surfaces of the sawed bones are fully as
 favorable to the  immediate union of the wound as would be  the carti-
 laginous surfaces.
   The  recommendation of M. J. Cloquet, which appears to have been
 only  intended by him for those surgeons who had not had it in their
 power to make themselves sufficiently familiar with the tarso-metatarsal
 disarticulation, has been adopted by M. Mayor, who takes upon himself
 the responsibility of laying it down as a law, justifying in every particu-
 lar, by his own practice, what I have  said above, and what I had already
 stated in this work, in the edition of 1832.
   D.   Process of M. Lisfranc.—I do not give the  process of M. Vil-
 lerme, because that physician himself avows that that of M. Lisfranc is
 to be preferred.
   E.  I shall, however, now  give a description of the process  which I
 employ, after  my own trials with it, that all the responsibility of it may
 rest with the author.
   I.  First Stage.—We make use of a narrow strong knife for all the
 stages of  the operation.   A good bistoury, however, would answer until
 we have nothing farther to do than to make  the  palmar flap.  If the
 surgeon is ambidexter, he commences on the  outer  border of the foot,
 holding the knife in the  right  hand, for the right  limb, and in the left
 hand  for the  left limb ; otherwise, we begin  in the  last case  upon the
inner border of the metatarsus.  An assistant seizes hold of the lower
part of the leg, compresses the posterior tibial artery behind the internal
malleolus and  the anterior tibial upon the  instep, at the saife time that
he draws back the skin on this last-mentioned part.   The o{Jfcrator first
identifies  the  extremities of the articular line, and  with one hand em-
braces the  point of  the foot upon its dorsal surface, in order to act more
freely upon the entire  metatarsus.  With a knife in the  other  hand, he
makes a semilunar  incision, with its  convexity forward, and at six  to
ten lines in front of the articulations.  The  instrument is reapplied^
the first incision, in order to divide, on a line  with the retracted skin,
the extensor tendons and other soft  parts which may remain adherent
to the bones, and in such  manner that this second incision may corres- 
206            NEW ELEMENTS OF OPERATIVE SURGERY.
 pond with the line of the articulation.   In arriving at the border of the
 foot, it is important not to descend too low towards the plantar surface,
 for in terminating the operation we should not then be enabled to give
 all the breadth required for the base of the principal flap.
   II.  Second Stage.—If the articulation has not been laid open with
 the same cut which has divided the tendons, we enter it by carrying the
 point of the knife behind the tubercle of the fifth metatarsal bone, in
 the  direction of  a line which, extending obliquely forward, would fall
 first upon the head, then on the middle portion, and then on the posterior
 extremity of the  first metatarsal bone, making the  incision almost trans-
 versely in arriving at the articulation of the fourth metatarsal bone, and
 inclining it again in front at the  moment of entering the articulation of
 the third, which  latter is separated by immediately directing the instru-
 ment transversely.
   The  second bone of the  metatarsus prevents us usually  from going
 any farther in this direction.  We then withdraw  the knife, in order to
 apply it, with the  point directed upwards, to the  inner border of the
 foot, so as to divide  from within outwards, and from  behind forwards,
 the articulation of the first  metatarsal  bone.   The surgeon then imme-
 diately places it  in a perpendicular  position with its point downwards,
 and turns its edge backwards, upon arriving at the second metatarsal bone
 or upon  the inner side of the cunean mortice ; then plunges it towards
 the plantar surface of the foot, and as far  as the line of the apex of the
 articulating surfaces, then pressing against its handle as if  to give it a
 vibratory movement,  from behind forwards, and then from before back-
 wards, he divides the great  ligament,  which  is the key of the  articula-
 tion.   Withdrawing  it again, in  order  to come upon  the posterior ar-
 ticulating surface of the second metatarsal  bone, he  places  its  point
 horizontally transverse upon the superficial  surface of this bone.  As
 the joint is never  more than  three lines behind, it is easy to open into
 it by cutting successively at distances of half a line at  a time  from the
 articulation of the  middle metatarsal bone which  is already laid  bare,
until we shall have reached  that of  the second.   All  the articulating
surfaces  are now  laid open, and  the  point of the knife being inserted
between them, readily divides all the  remaining ligaments.
  III.  Third  Stage.—There now remains nothing more  to do than to
form the plantar flap  by grazing the plantar surface of  the bones [with
the edge of the knife, until it reaches]  nearly as far as the  metatarso-
phalangeal articulations.  This flap  should be an inch longer  on the
inner  than it is on the  outer side ; also it  should be made to terminate
in a bevelled, (shelving,) and not a  square-shaped edge, and  in order
that it maytadapt itself better to  the semicircular curvature of the dor-
sal borderof the  stump, it should be slightly rounded  upon its  digital
extremity, and not be made wholly transverse.  If  we prefer having its
inner fully as thick as its outer  border,  we must take care while cutting
the flap, to hold the handle of the instrument  in a much more  elevated
position than its  point; and in order that the phalangeal head of the
metatarsal  bone3, that of the first especially, may  not  arrest the blade
of the instrument, it is important  to give to its cutting edge, and that at
an earlv period, a strong inclination towards the skin.
  IV.  Dressing.—The arteries divided and requiring torsion or the lig- 
AMPUTATION OF THE LOWER EXTREMITIES.
207
 ature are the internal and external  plantar arteries, the dorsalis pedis,
 and some other secondary branches  of little importance.  The principal
 flap being raised up against the articular surface, ought to cover it ex-
 actly and  have its border adjusted  back  against  the little  flap which
 should have been preserved upon the dorsal surface.  If upon'this last-
 mentioned surface  the integuments should have been divided upon a line
 with the articulation, the bones of the tarsus would, not fail to become
 denuded immediately after.   It is easy then to conceive  that it would
 be a difficult thing to cover them conveniently with the lower flap.  As
 the tendons  retract less than the skin, should they have  been divided
 also at the first incision, their extremities might obtrude between the lips
 of the wound  and considerabely interfere with its union by first inten-
 tion.  It is better, therefore, to exsect them with  the scissors.  The
 strips of adhesive  plaster, in order  that they may more firmly sustain
 the coaptation of the parts, ought to be made  to reach from the postero-
 internal and lower surface of the heel as far as to the stump, then ax-
 tending longitudinally over the dorsal surface of  the foot, they  should
 be made to pass round the lower part of the leg  or at least  be carried
 to thf neighborhood of the malleoli.
   The  patient having been carried  to his bed, should be placed in such
 manner as that the leg and foot upon which the operation has just  been
 performed, may rest on  their outer  side, and  be in as perfect a state of
 relaxation as possible.  Here, as after all amputations of the extremi-
 ties and still more  so here than under any other circumstances, method-
 ical compression [by bandages] from the lower third of the  leg nearly
 as far as to the vicinity of the wound, would  be  one of the best means
 we could adopt to  prevent  the  development of synovial, venous, or any
 other form of inflammation.
   F. Process of M. Maingault.—Having in the year of 1829, conceived
 the idea of cutting out the plantar flap at first by plunging  the knife by
 puncture between  the soft parts and the bones, with the  view of  then
 disarticulating the tarsus, in the direction from the plantar surface to the
 dorsum of  the foot, I soon after made several trials of it upon the dead
 body, in the rooms of the School of Practice, and afterwards at the hos-
 pital of St. Antoine;  but having found it more difficult to disjoint upon
 this side than upon the dorsal surface, I had entirely renounced it with-
 out having made it  public, when M. Maingault, (Bulletin de Firussac, t.
 XIX., p. 60,) who  had devised  the  same  process, gave a eulogistic ac-
 count of it to the Academy.   His method in this case is exactly similar
 to the one he  has  proposed  for the disarticulation of the metacarpus.
Though practicable, it has appeared  to me, all things being considered,
less advantageous and more difficult than the preceding, and consequent-
ly of no utilty but under  circumstances where it would not be possible
to adopt the  latter.

           Article V.—Disarticulation of the Tarsus.

   When  the bones of the tarsus themselves are affected, the removal of
the metatarsus  alone  is manifestly  insufficient.   We then take away
 separately or at one operation the three cuneiform bones, and the cuboid
and scaphoid. 
208
new elements of operative surgery.
                    § I.—Partial Disarticulation.

   If the cuboid bone and the two metatarsal bones which it supports
should be alone diseased, we might after the manner of Hey remove only
the outer third of the foot.  Unless there should be an absolute neces-
sity, we should not amputate the whole of the tarsus.  We must confine
ourselves to the disarticulation or amputation of the bones that are affect-
ed.   The patient  mentioned by M.  Villerme, (Journ, de Mid. cont.,
1815, p.  32, ) and who died at the expiration of six  weeks, had had the
three cuneiform bones  and  the corresponding portion of the metatar-
sus, removed.  M. Ruyer, (Revue Mid., 1832, t.  IV., p. 187,) in remov-
ing the great toe and the metatarsal bone which supports it, and also
the two first cuneiform  bones, was enabled to save the four  last bones
of the metatarsus.   The cuboid bone and the two metatarsal bones which
are articulated to  it in  front, have, together with the  fourth  and  fifth
toes,  been removed with a no less  fortunate result, first by Beclard,
(Arch.  Gin.  de  Mid., t. V., p. 190,) then by M. McFarlane, (Gaz.
Mid., 1836, p. 516,) which operation has also  been  successfully per-
formed  in Holland by M. Kerst.  These operations, moreover, are in
their character extemporaneous, and if I may use the  term, magistral,
whose manipulating  processes cannot be laid down in advance.  It is
necessary that the surgeon should invent them in some  sort,  every  time
he is obliged to perform them.  The incisions of M. Kerst  have some
analogy to those which I recommend for amputation of the first metatar-
sal bone  ; if somewhat modified they would have answered equally well
in the process of M. Ruyer,  (See exsection  of the foot.)
   [Wliere one of the tarsal bones only is carious or degenerated, it may,
Mr. Syme thinks, ( Cormack's  Lond. Sr Edin. Monthly  Journ, &c. Feb-
ruary, 1843, p. 95,)  be taken away at the same time with its correspond-
ing diseased metatarsal bone.  Thus the first metatarsal with the inter-
nal cuneiform bone, and the os cuboides with the  two metatarsal bones
articulated to it, &c. T.]

                  § II.—Disarticulation in mass.

  Amputation between the os calcis and astragalus on the one part, and
the scaphoid and cuboid bones on the other, is like that of the metatar-
sus, an operation, the origin of which can be traced to the ancient writers,
and would have belonged entirely to France, had not Fabricius of Hil-
den clearly alluded to it, and several persons actually described or per-
formed it before the time of Chopart, and which operation since its dis-
covery has, in reality, only been brought to perfection by our own coun-
trymen.  It is therefore  somewhat strange that up to the present time
the honor of this operation should  have been given to  Chopart,  who
never spoke of it until in the year 1787.   Hecquet of Abbeville, how-
ever, in the  year 1746, showed to Winslow (Acad, des Sc Hist., p. 58,
1746, in 12mo.) a foot which had been separated in front of the astraga-
lus and os calcis.   Vigaroux, (CEuvres Chir., etc., p. 250,) however, in
the year 1764, declares  that he had amputated the foot at the tarsus for
a gangrene.  Lecat, (Mercure de France, Dec, 1752, 2e partie.   Ma- 
AMPUTATION OF THE LOWER EXTREMITIES.
209
jaut, Prix de VAcad, de Chir., t. III.,  p.  232.) moreover, had had re-
course to it and formally recommended it in 1752.  But A. Petit (Mid.
du Cceur, p. 365,) who had performed it twice before the year 1799, did
not make known his observations until after Chopart.
   A.  Anatomy.—The articulation  separated by Lecat, is infinitely less
complicated and less difficult to disunite than the preceding.   The four
osseous  surfaces which compose it, possessing some degree of mobility,
are far  from  being as closely wedged  together as those  of the tarso-
metatarsal articulation.   The rounded  head of the astragalus is main-
tained in the cavity of the scaphoid bone, by means only of loose fibro-
cellular  bands.   On its outside and on  its dorsal surface  the  same ar-
rangement exists for the os calcis and the  cuboid  bone.  The  strongest
and most  important ligament of this joint is that which passes  deep
down  from the os  calcis to the fibular  extremity of the  scaphoid, and
which may also be denominated the key of the articulation.  The articu-
lar line in this part is divided into two very distinct portions.   Its inner
or astragalean half represents a half-moon with a very regular anterior
convexity.  Its  outer  or calcanean half on the contrary  represents  an
oblique plane from within outwards and from behind forwards ;  so that
in blending with the other it forms a sinus of considerable depth, which
seems to be continuous with the dorsal cavity of the os calcis, and where
we may  be easily misled at the time of the operation, if we do not accu-
rately call to mind the disposition of the parts.
   Like  that of the metatarsus,  the articulation  of  the  bones  of the
tarsus with  each other, is exceedingly  concave  and unequal upon its
plantar surface, where the scaphoid and cuboid bowes form a projection
which must  not be forgotten when we  are  about to  separate the  soft
parts from them.  Its inner side is marked by a slight depression which
is bounded behind by the tuberosity of the os calcis, and in front by the
corresponding tubercle of the scaphoid, a tubercle which we  no longer
search for at the present day, in order to strike between the astragalus
and the  os naviculare.  On the outside,  the articulation of the tarsus is
found at eight or ten lines from the posterior extremity of the fifth me-
tatarsal  bone, near  the middle of the space which separates this tuber-
cle from the small  crest, on the outer surface of the os calcis, to which
is attached in front  the tendon of the peroneus  longus.  Upon the dor-
sum of the foot, the articulation under  consideration is indicated by the
slightly  depressed line which is felt by the finger in front of the head of
the astragalus.
   Anomalies may form exceptions to these rules.   The tubercle, of the
scaphoid is sometimes scarcely perceptible.   In other  cases the  tendon
of the tibialis  posticus becomes the seat of a sesamoid bone which in
great part effaces the articular depression.  M. Plichon (These No. 261,
Paris, 1828) has remarked, that the calceneo-scaphoidean ligament, or
that species of articular key mentioned  above, may be transformed into
an epiphysal cartilage, and become  completely osseous, even in quite
young persons.   He has several  times met with this peculiarity, and
while  sustaining his  thesis exhibited a specimen of it before the  Pro-
fessors of the Faculty.  We can  readily conceive the difficulties the
surgeon would encounter in such cases in terminating his operation.  It
was this without doubt which  had  produced the  species of  anchylosis
   Vol.  II.  .                  27 
210
NEW ELEMENTS OF OPERATIVE SURGERY.
 which M. A. Cooper  was compelled to break before finishing a partial
 amputation of the foot;  and the same as that  spoken of by M. Fisher,
 (Nouv. Bibl. Mid., 1829, t. II., p. 432,) and which  would have yielded
 only to the saw, if it had been necessary to amputate in this  caseduring
 life.  M.' Plichon  also remarks, and with  reason, that the  head of the
 astragalus extends much farther in certain cases than  in others  beyond
 the line of the  anterior surface of the os calcis, and that the calcaneo-
 cuboidal articulation is then less oblique in front.
   B.  Operative Process.—The manner of disarticulating the scaphoid
 and cuboid bones has necessarily  varied only  in its less important de-
 tails.  Chopart, who did not  have  the advantage  of the  anatomical
 knowledge which  we possess  to-day, spoke of it as  an operation  of
 considerable difficulty.   It is a fact  that in 1799  Pelletan  was nearly
 three-quarters of an hour in  performing the operation;  though he had
 before him the foot of an articulated skeleton ; but since M. Richerand
 and Bichat demonstrated that we may always feel under the  skin the
 projection of the inner  extremity of the scaphoid bone,  the difficulties
 which accompany  the operation have become so much lessened, that it
 is at the present time  one of the most easy  in surgery.
   I. Process of Chopart.—The limb and the surgeon  should be placed
 as in  the preceding disarticulation.   A transverse incision is first made
 at two inches in front of the malleoli.   Upon the  extremities of this
 incision  the  operator makes two  others of slight extent;  dissects up
 the trapezoidal or quadrilateral flap which  they form, and turns it back
 upon the leg ; opens the articulation from the inner to the outer border
 of the  foot;  divides the  calcaneo-scaphoidean   ligament  in  passing
 through  the joint; arrives upon the plantar  surface  of the  scaphoid
 and cuboid bones, and  finishes with the incision for the  lower flap,
 which he prolongs to near the extremities of the metatarsal  bones.
   [Chopart's operation,  notwithstanding it had been so  long in use on
the continent, was  never, as  Air. Syme  thinks, (Cormack's  Lond. and
 Ed. Month. J, 8rc, Feb., 1843, p. 95,) performed at Edinburgh  until
by him in 1829, (Quarterly Report  of the Edinburgh Surgical Hos-
 pital, Edinburgh Surgical and Medical Journal,  1842 ;) since which
he has practised it repeatedly  with  the  most satisfactory  results, and
 without any inconvenience from the danger apprehended that  the pre-
 dominant power of the tendo Achillis would cause a pes equinus of the
 stump.   Mr. Syme  found that the cut extremities of the tendons on the
 fore part of the joint  speedily acquired new attachments which enabled
them to counteract  this antagonism.   This  opinion we shall  see has not
 been verified by  the experience of other surgeons.   T.]
  II.  Process of  M.  Richerand.—M.  Walther  gives  a  little more,
 (Rust's Handb. der Chir., t. I., p.  674,)  and M. Graefe  (Ibid.) a little
 less length to the dorsal flap ; in other respects their description of the
 partial amputation of the foot is the same as that of Chopart.  The mo-
 dification proposed by Bichat  and M.  Richerand has been long since
 adopted in France,  that is to say, instead of circumscribing a dorsal flap
 by three incisions,  we  confine ourselves to one  incision which is semilu-
 nar with its  convexity forward, and  made at a few lines only in front
 of the articulation.  Klein and M.  Rust  (Ibid)  making this  flap still
 shorter than that of Chopart, propose to go at once into the articulation. 
AMPUTATION OF THE LOWER EXTREMITIES.
211
M.  Rust recommends that a long incision  should be made on each bor-
der of the foot to trace out beforehand the form of the plantar flap.
  III. Process of M. Maingault.—M.  Maingault recommends that we
should in the same  way as for the metatarsus and  metacarpus, proceed
from the plantar to the dorsal surface in disarticulating the bones of the
tarsus, and  considers that this new process should be adopted at least
in certain cases.  On that point I coincide with him entirely.
  IV. It appears to me superfluous to discuss the relative importance
of these various modifications of the general operative  process ; all of
them may  find  their  application in practice.   If there were no soft
parts that could be preserved except upon the dorsal surface, for exam-
ple, it is clear that  we must take  them from here, and that we should
on the contrary take them wholly from the plantar region, if the integu-
ments were degenerated upon the  dorsum of the  foot nearly up to the
leg.  If there were neither sound tissues enough above nor below, to ena-
ble  us to obtain a  flap to cover the wound, I cannot see why we might
not decide  upon cutting two of them of  equal extent.   But when the
sole of the foot is not too much disorganized, the course recommended
by Bichat is unquestionably the most rational and the  best.   A semi-
circular incision from one malleolus to the other, as advised by M. Bou-
gard,  (Annales  Cliniques  de  Montpellier, 2e serie,  t.  IV., p.  68,
1829,) would have  no other advantage than to give a little greater length
to the wound.
  V.  Process adopted by  the Author.—a.  First Stage.—Therefore,
while the assistant  who compresses the arteries draws back the integu-
ments, the surgeon with one hand embraces the  back of the  foot, and
with a small knife  in the other makes an incision  slightly convex at an
inch in front of the articular  line, and  carries the same  from the inner
to the outer  border of the foot for either limb, if he is ambidexter, or
from the outer to the  inner border  for the left foot, when he can use
only his right hand with  confidence.  After having caused the tissues
to be drawn back, he reapplies the instrument to the wound and divides
in the same  direction and near to the  retracted  skin, the tendons and
other tissues which still cover the osseous surfaces, and may almost al-
ways enter the articulation by this second incision.
  b.  Second Stage.—If not, after again  assuring himself of the posi-
tion occupied by the scaphoidal tubercle, the surgeon divides upon the
whole extent of the  dorsal  surface, and from  within outwards, the
fibrous bands which unite the  scaphoid bone to the astragalus without
endeavoring to penetrate  into the joint;  seeing  that the head of the
last-mentioned bone, (the astragalus,) encased and hidden in the cavity,
and as it were overlapped by  the  thin border of the other, (the scap-
hoid,) would form an obstacle to his doing so ; he therefore describes a
semi-lunar incision, being particularly on his  guard not to prolong the
outer branch of it too far backwards, but  taking care on the contrary in
order to disarticulate  the cuboidal bone, to incline the cutting edge of
his  knife, first transversely,  and then a little forward,  and as soon as
the articulating surfaces are separated wide enough apart to admit of
it, to make the section of the thick fibrous bundle which unites the os
calcis to the scaphoid, in order to reach the deep-seated surface of the
articulation. 
 212            NEW  ELEMENTS OF OPERATIVE SURGERY.

   c.  Third Stage.—The operator then directs the cutting edge of his
 instrument forwards ;  grazes the under surface of the tarsus, and cuts the
 plantar flap;  depressing the wrist, if it is the left tarsus, and elevating
 his wrist on the contrary if it is the right; [See first stage above. T.]
 in order that this  flap may not be  thinner on the inner than the outer
 side, and prolongs it a little more on the inner than on the outer border,
 because of the astragalus which rises much higher towards the leg than
 the os  calcis does.   As the vertical  extent of osseous  surfaces  ex-
 posed is greater than  after the metatarsal  disarticulation, the flap should
 be  prolonged forwards almost  as far as  for this last,  although it was
 commenced nearly two inches farther back.
   d.  M. Sedillot in order to give greater  exactness to this process, and
 following out what I have said of it above, forms his inner flap precise-
 ly in the direction of  the great diameter of the astragalo calcanian sur-
 faces.   We have thus a narrow  wound, giving a linear cicatrix, easy to
 unite  and to be kept  united, allowing a  free discharge to the pus, and
 requiring but little integuments to cover it.  Every person is aware how
 difficult it is to cut out a plantar flap of sufficient length in the disarti-
 culation of the metatarsus and  tarsus.  M. Sedillot (Communique par
 VAuteur)  has pointed out an expedient which removes the embarrass-
 ment.   All that is required  is, that while  grazing the plantar surface of
 the metatarsal bones,  the cutting edge of the instrument should be made
 to fall upon the  sesamoid bones of the  great toe.  The knife which is
 constantly  found to catch at this point,  must be made to pass  around it,
 when  by incising through the integuments at two to three lines in front
 of it we obtain a suitable flap.
   e.  Dressing.—To  tie the arteries in  proportion as they are divided,
 as Chopart advises, is a useless precaution.  The only arteries after
 the operation that demand  attention,  are the dorsalis pedis and the two
 plantars.  The  dorsal  integuments  are  now immediately  brought in
 front, and the plantar flap is raised up, and kept upon the cartilaginous
 surfaces by means of  long strips of adhesive plaster, and a roller  ban-
 dage methodically applied.
   C.  Consequences.—The  cure, after this operation, may  possibly be
 effected in fifteen or even ten days.   It is liable to all  the  accidents of
 other  amputatians.  Inflammation  and  suppuration in  the neighboring
 articulations, or of the tibia and os calcis, would be a very serious ac-
 cident.  This  inflammation  proved fatal in a  patient of M. Lallemand,
 (Ephimir. de Montpellier, Journal Analyt., 1829, p. 413,) by extending
 to the leg by means of the tendinous  grooves.  A young man also ope-
 rated  upon by M. Simonin, (Decade Chir., 1838, p. 1,)  was seized with
 delirium and  died.  But the reversion of  the  heel is the inconvenience
 which has  been most usually complained of.  This is a real  difficulty,
 and has been established by M. Larrey.   It occurred in a patient I saw
 in the Hospital of St. Louis in 1820,  which case is referred to also by
 M. Mirault, (Arch. Gin. de Mid., t. V., p. 195.)   A  second patient,
 also amputated at the hospital of Saint Louis, presented another example
 of it in  1836.   M. Fleury (Ephimir. Mid. de Montp., t. II.) has also
seen a case.  M. Blandin, therefore, ( Gaz. Mid. de Paris, 1838,) who
questions its reality, is mistaken.   Means  have even been proposed both 
AMPUTATION OF THE  LOWER EXTREMITIES.            213
to prevent and  remedy  it.  M. Berchu, for  example, supposes that it
might be prevented by keeping the leg flexed  after the operation.
  In adopting this opinion, M. Lallemand  recommends  the limb to be
placed upon its outer side.   M. Mirault  thinks we should do better by
applying a roller bandage to the whole of the leg; but  there are no
grounds to suppose that such expedients would  have the least efficacy.  In
the patients in whom I have noticed the reversion of the heel, it was
evidently owing  to the impossibility of uniting the wound by first inten-
tion, and because the  border of the plantar flap  had not been attached
to the dorsal border of the wound.  The best preventive means, therefore,
consists in doing everything in our power  to accomplish agglutination,
or at least partial union of the two lips of the wound.
  It has been, moreover, supposed that  the section of the tendo Achil-
lis  would overcome this retraction.   M. Champion  formally  proposed
this, in supporting his  thesis in January,  1815, and M. Villerme  be-
lieved that the idea  originated with him; but Antoine  Petit had done
better, (Disc, sur les Mai. Obs. a Lyon, p. 364 ;)  having had recourse
to this auxiliary operation in one of his two patients, he obtained com-
plete success.  With this  claim we may even say  that A. Petit is  the
inventor of tenotomy  in  France.   When, however, the flaps have been
well constructed and are well  supported, the retraction of the tendo
Achillis, after amputation  of the  tarsus, occurs  only as  an exception.
Neither  M. McFarlanenor Dupuytren have  seen it.  It occurred in none
of  the five cases that I operated upon,  and M. Blandin says he has met
with it but once out of the eleven of these  amputations that he has per-
formed.
   \_A reversion  of the os calcis  backward, following partial amputation
of the foot, was completely cured by M.  Hippolyte Larrey, by a division
of  the tendo-Achillis, (Seance de VAcad, de Mid., Nov. 9, 1841;  vid.
Archiv.  Gin. de Mid., 3e ser., Dec, 1841, p. 515.)  T.]

   Article VI.—Comparative  Value  of the  two modes of Partial
                   Disarticulation of the Foot.

   Since surgeons have  demonstrated that it is  quite as practicable  to
disarticulate  the  metatarsus as  it is the  whole anterior range of the
bones of the  tarsus,  it  has been  asked  which of these  two operations
should have the preference.  A question like  this ought not to have been
propounded.  These  operations are not calculated to replace each other,
and each has its  special applications.   When disarticulation of the
 metatarsus suffices, amputation after the  manner  of Chopart becomes
useless ;  in the  same way as  when  the  disarticulation  of the scaphoid
and cuboid bones  admits  of our removing  all  the disease, there is no
need of  amputating the leg.  Some persons, however, still seem to be
of the opinion that, even where the disease  does not extend beyond the
 metatarsus, it is better to amputate like Chopart.  To support this  pro-
 position, they argue upon the difficulties of the tarso-metatarsal disar-
 ticulation, the few advantages that can result from it, the severe pain it
 must produce, and the  greater  dangers that must ensue from it.  The
 synovial membrane, which lines the anterior cunean and  cuboidal articu-
 lating  surfaces, being   continuous with  that  of the cuneo-scaphoidal 
214            NEW elements of operative  surgery.

articulations, is, says M. Blandin, (Nouv. Biblioth.  Mid., 1828, t. I.,
p. 212,) the reason why inflammation, when once developed  here,  is
readily  propagated to all these anfractuous  surfaces, and  terminates
in their disorganization.
  To these  reasonings it may be answered : 1, That with exact anato-
mical knowledge, we may succeed in performing the operation in question
without any great  difficulty ; that a single  cut of the saw, moreover,
would speedily relieve the  embarrassment, if any should occur  from the
projection of the first cuneiform, or of the second metatarsal bone ;  2,
that the section of  the ligaments  and the separation of all  the  bones,
may be  made with such rapidity as to cause no  great severity of pain,
if we take the trouble of dividing instead of tearing the fibrous tissues;
3, that the inconveniences  which  are spoken of, are, up to  the present
time, based  upon little  else than  conjectures, and  that  this operation
has not  been performed  sufficiently often  to enable us to draw  an exact
parallel between it  and  that of Chopart; 4, as to the disposition of the
cartilaginous surfaces, it  is such in fact that the surface, not the synovial
membrane,  of the  second  cuneiform bone, is quite  often not  always,
where it unites with the  great cuneiform bone, continuous with that of
the anterior surface of the scaphoid ; but it is quite true that the synovial
head of the astragalus, and the anterior  surface of the os calcis which
is also sometimes  continuous  between these  two bones  as  far as the
cartilaginous pulley of the last, has less  extent than that of which we
have just  been speaking ?
   The new  operation gives a length to the foot which easily admits of
standing  and walking and the movements of flexion and extension.   It
causes but a trifling deformity, which may be easily concealed by giving
a slight modification to the shoes.  In the method of Lecat  it  has often
happened, as I  have said above, that the heel is turned back to such
extent as not to  allow  of the patient walking with a  simple buskin.
This inconvenience, it is  true, is quite rare ;  but it is possible,  however,
and in  itself is a sufficiently  serious thing.  It is not owing to the ex-
tensor tendons of the foot having  been divided.  It is known that these
tendons, after their section, scarcely retract, and that they contract firm
adhesions to the cicatrix ; but the  posterior branch  of the lever repre-
sented by the foot, being left in some sort by itself,  the tendo Achillis
thereby acquires a predominance  over it  which it was far- from having
before.
   If this operation presents at the present time numerous examples of
success, it has also alike had  its reverses ; and if the other has  some-
times caused death, it has also been performed  with  perfect success by
Percy,  Hey, Blandin, Berchu, Beclard, Janson, Miquel, Lisfranc, Kluy-
skens, Zinc, Scoutetten,  Guthrie, Bedor,  (Riv. Mid., 1823, t. III.,  p.
379,)  Jbbert,  (Journ. Hebd., 1828, t. II., p.  336,) and Ouvrard, (Mil.
de Med.  et de  Chir., t. L, p.  138.)   The safety and  interest of patients
therefore require that both these operations should be retained in prac-
tice, and neither of them substituted for the other.
   If the surface of the os calcis and of the astragalus should be altered,
 and the disease has  extended only to some lines in  depth, ought we in
 that case to renounce the  partial amputation of the foot ?   M.  Roux,
 in one  of his cases, having struck behind the joint which he wished to 
AMPUTATION OF THE LOWER EXTREMITIES.           215
open, immediately decided upon removing  with a saw  the  projecting
portion of the two first bones of the tarsus.   Serious accidents followed,
and  the  patient  ultimately died ; the tibio-tarsal  synovial  membrane
had unfortunately been opened during the operation.  I would not follow
the example of M. Roux where the articulation is healthy.   But if the
cartilaginous surface of the astragalus and os calcis were affected, it is
my opinion that this  modification  ought to be adopted, and that we
would thereby  avoid the necessity of sacrificing  the  patient's  leg; it
being  understood that we should take  every necessary precaution to
avoid the accident of  which I have spoken.   This advice, and which I
gave in 1832, has been  attended to.  M. Mayor (Journ. des Conn. Mid.-
Chir., t. I., p. 138)  followed it in four cases, and  it  does not  appear
that anything serious ensued.  We have  therefore in this another modi
fication of partial amputation of the foot.

           Article  VII.—Disarticulation of the Foot.

                      § 1.—The whole Foot.

  From  the rule laid down, in other respects so just, that  we  should
amputate the least quantity of parts possible, surgeons have  repeatedly
asked the question, whether if disarticulation of the foot would carry
out our intention, it  ought not  to be preferred to amputation of the leg ;
and  whether after this disarticulation it would not be possible  for the
patient to walk with a particular kind of shoe, or a sort of buskin which
would conceal  his deformity ?  It was once successfully performed by
Sedillier, and Brasdor (Mini,  de  VAcad.   Royale  de  Chir., t.  V.,
1819,) asserts that the cicatrix which was  completed in a short time,
never re-opened during the twelve  years  that the  patient survived.
Hippocrates, Fabricius of  Hilden, and Scultetus, appear  also«to  have
alluded to it but in  a very vague manner.   Since  then, other persons
have again proposed it, but without being enabled however to effect its
adoption.  Rossi (Med.  Oper., t. II., p.  229) also  states  that  he  had
performed it with ease.
  The projection made by the malleoli below the tibia, renders the cica-
trix, it is asserted, incapable of  sustaining the weight of the  body after
the cure.  The deficiency  also of soft parts in this place, and  the nu-
merous tendons that  surround the articulation, diminishing the prospect
of immediate reunion, gave room to apprehend accidents of the  most
serious nature.   But  are  not most of  these  difficulties  and  dangers
imaginary ?  What  is certain  is, as Brasdor had already  remarked,
that the  projecting  points  of the malleoli  soon become  smoothed, and
the whole extremity of the limb rounded, and that it is in our power to
preserve a sufficient  quantity of integument to cover a great portion of
the wound.  Theoretic objections,  and  one or even two facts,  are not
sufficient to decide a question of this kind definitely, and I am of opinion
that if favorable circumstances presented, it would be  allowable on this
subject to make additional  trials ; so much the more so, since, according
to M. Couprie, (These No.  110,  Paris, 1825,) there was  an old  soldier,
familiarly known for a long time, who had undergone in the campaign of
Russia the amputation in question, and. who walked by means of a bus- 
210            NEW ELEMENTS OF OPERATIVE SURGERY.
kin.  This buskin, designed by the  patient, was constructed upon the
same principle as that of M. Mille, of which  we  shall  speak  shortly.
M. Lenoir, (These citie, p. 30,) who dissected  the  limb in 1834, says
that the amputation in this man's foot had  not  been  regular, and that
one of the malleoli was wanting ; which adds a still  greater interest to
the result.
   A. The operation in itself moreover, would offer no difficulty.  Two
semilunar  incisions, one over the  instep, the other  above the heel, at
twelve to fifteen lines in front of and behind the articulation, and uniting
so as to form another semilunar incision on each side, at about an inch
below the malleoli, would constitute the first stage.   After having drawn
back the  skin, we should divide as near as possible to the articulation,
the extensor tendons of the toes and of the peronei muscles, that of the
tibialis anticus, and  those of the flexor muscles of the metatarsus, the
tendo Achillis, the external lateral ligaments, the internal lateral, and
the anterior and the  posterior.  The astragalus could then be separated
without any  effort from its fibulo-tibial socket, and  removed  with the
rest of the foot.  The hemostatic means having been  applied, I  should
prefer bringing the lips of the wound together from before backwards,
in order that its angles might enclose the points of the malleoli.  It is
to attain this object that I recommend  incising the integuments at some
distance  from the malleoli and articular indentations, and not close to
them as is advised by Brasdor and Sabatier.
   B.  If the flaps should be arranged as Rossi  recommends, one upon
the inside and the  other  upon the outside, the flaring of the malleoli
would render coaptation utterly  impossible, and it would be absurd at
the present day to endeavor to cut them out by passing a double ligature
through the  articulation, as  this author professes to have done with
success.

                 §  II.— With the Astragalus alone.

   M. de  Lignerolles  nas  communicated to me an improvement  which
will probably cause this operation to be received in practice.   By leav-
ing the astragalus, and amputating  only the os  calcis with the foot, we
should have, instead of the projections of the malleoli, a large and nearly
flat surface at the extremity of the stump, and  there is every  reason to
believe that a shoe or a buskin  properly made,  would find in  this part
a convenient point d'appui.  In such cases, we should cut the flaps upon
the sides, and  raise them upon the malleoli, before proceeding to the
disarticulation.
   [M. Simon, of St. Thomas'  Hospital, London, does not excise the
astragalus, in amputating at the ankle-joint.   He considers  the stump
thus  obtained preferable to that in Professor Syme's operation, as it is
broader, while  increased  mobility  and additional length are secured.
The results, as witnessed several years after the operation, in one instance,
were very satisfactory.   G. C.  B.]

                       Process of M. Syme.

   Mr. Syme  (Cormack's Lond. and Edinb. Month. Jour, of Med. Sc, 
AMPUTATION OF THE LOWER EXTREMITIES.
217
Feb., 1843, p. 93, &c.) in cases where Chopart's operation cannot be
performed on the  tarsus, gives a decided preference to amputating at,
in other  words  disarticulating, the ankle joint, and this  also on every
occasion where, according to old usages, the leg would have been taken
off below the knee.  To make a better  and rounder stump he usually
excises the malleoli with a cutting pliers.  The plantar flap is made by a
transverse  incision through the middle of the tissues of the foot, meeting
the  corresponding dorsal incision  directly  over and in a line with it,
except that the  latter has a convexity given to it forward.  The thick-
ness  of the tissues  about  the os calcis form a firm  support, and  the
whole contour of the stump is exceedingly well adapted to an artificial
apparatus  with hinges, straps, &c, to supply  the form and motions of
the foot.
   This operation becomes necessary also (loc.  cit.)  where caries affects
the  astragalus or os calcis, or as very frequently happens,  is seated in
the articular  surface between these  bones, for partial  amputation there
can  be of no avail.   Also  more  especially in those  cases of compound
dislocation of the astragalus and caries of this bone, with its adjoining
articulating surfaces, and for which hitherto amputation of the leg above
the ankle had been deemed necessary.
   It may be objected, continues  Mr. Syme, who has paid great  attention
to this subject, that when the joint itself is diseased, entire removal of
the  articulation  must be requisite.   But, says this surgeon, in what is
commonly  called  disease of the ankle, the joint between  the astragalus
and os calcis is affected much more  frequently than  that  between the
astragalus and bones of the leg; and even  where the  latter  condition
really exists, it would be easy to remove all of the bone that is essential
for  recovery, by sawing off a slice from the articulating extremities of
the  tibia and  fibula, as the caries penetrates to no great  depth in the
cancellated texture.  The advantages at the ankle over that at the knee
he considers to be, 1st, The  risk of life is smaller;  2d, A more  com-
fortable  stump will  be  afforded; 3d, The limb will be more seemly  and
useful for support and progressive motion.
   The risk of life is less because the  parts removed are not so extensive,
being but little more than by Chopart's  operation ;  there is less also to
fear from  hemorrhage  immediate or secondary, because the vessels are
less and merely branches of the posterior tibial artery and of the ante-
rior tibial near its termination ; and  the cavities of cylindrical bones
not  being  opened, there is no danger of exfoliation from the  dense os-
seous texture, and inflammation  in the medullary veins.  (See  a case of
medullary  suppuration in the tibia below.)
   The stump too is more  comfortable, because  it is  formed of parts
peculiarly  well calculated to protect the bone from injury, and not dis-
posed to contract like the muscular tissue ; the nerves also being small-
er here, their cut extremities will be less  apt to enlarge  and  become
the  seat of uneasy sensations, while  the  absence of exfoliation ensures
complete union of the integuments over the  bones.  And the  limb  will
be more useful and  seemly from full  play  being afforded to the move-
ments of the knee joint, without the embarrassment of an  imperfect
stump.
   Mr. Syme therefore strongly  advocates amputation at the ankle joint,
   Vol.  II.                  28 
218            NEW ELEMENTS  OF OPERATIVE SURGERY.
as an operation that can be advantageously introduced [revived or gen-
eralized he should have  said, as it will be seen by the  text supra and
infra, and the notes above, that it has been long known.   T.] into sur-
gery ; and regrets  having cut off many  limbs  that might have been
saved by it, (Loc cit., p. 95—96.)
  This surgeon, since the period at which the  above memoir was pub-
lished, has continued to practice this amputation with we believe unva-
rying success, and by a later  communication from that  surgeon to the
same journal, (Cormack, Aug., 1844, p.  647, &c.,)  we are informed
that he is more and more satisfied with the decided preference  which
ought to  be given to it, and is happy to find that this method is rapidly
gaining ground.   He does  not, he  says, pretend to claim to be the
author of it, as it had  been performed on the  continent  he assures us
by different surgeons, long before he  thought of it.  Mr. Syme, however,
is we believe fully entitled to the merit of having practised it more fre-
quently than any other person, and as a natural consequence of this, of
having made such improvements in the manipulating process, as to have
given greater assurance  of a successful result where his  mode has been
adopted.   He also intimates in the communication last referred to, that
kis greater familiarity with the operation  at present has  enabled  him to
rectify an error that he labored under at  the time he published his first
cases.
   The best instrument, he says, is a  large  bistoury or small amputating
knife with a blade about four  inches long.  The grasping of the ankle
by an assistant renders a tourniquet entirely unnecessary.   In his first
operations, he says, his flap was made unnecessarily long.   Both incisions
should, as before said, be continuous, and exactly opposite to each other,
and both of them convex  forwards, each convexity reaching to a line
drawn round the foot midway between the head of the fifth metatarsal
bone, and  the  malleolus externus ;  and they should meet a  little way
farther back, opposite the malleolar projections of the tibia and  fibula.
Care should, he remarks, be taken to avoid cutting the  posterior tibial
artery, before it divides into the plantar branches, as in two cases where
he did so  there was  partial  sloughing  of the flap.  These  branches
nourish  the flap, and  must be left intact.  If  the  ankle joint is sound
the  malleolar processes should be removed by cutting pliers ; but if the
articulating surfaces of  the tibia and fibula be diseased, a thin slice of
these  bones should be sawed off.  The edges of the wound should be
 stitched together and lightly dressed.
   [Professor Pirozoff, of St. Petersburgh, has so modified Mr.  Syme's
 amputation at the ankle-joint as to obtain a longer stump, and one the ex-
 tremity  of which is better adapted to bear pressure.  The cavity of the
 heel-flap being filled by  the posterior extremity of the os calcis which is
 preserved  in  this operation, the healing process is accelerated.  It ia
 also easier of execution than that  performed by Professor Syme.  Of
 course, this proceeding requires a perfectly healthy state of the os calcis.
 The peculiarity of this modification consists in preserving the posterior
 extremity of the os calcis as shown in the following diagram  which wa
 take from Professor Gunther's " Lehre von den Blutigen Operationen "
 &c. &c.   Leipzig, 1853, Taf. 18. Fig. V. 
AMPUTATION OF THE LOWER  EXTREMITIES.           219
            The letters, a and b represent the line of section of the bone.

   Mr. Teale, of Leeds  has, recommended  another modification of am-
putation at the  ankle-joint (Lond. Med. Times and Gazette, May, 1854,
p. 539.)  The  lines of incision in his method allow of the removal of
one or more of the tarsal bones, and if necessary, the foot at the ankle-
joint.   A transverse incision is made across the sole of the foot, com-
mencing about three-quarters of an inch in front of one malleolus, and
ending at a similar point in front of the other malleolus. A second incision
is then made in the median line, beginning  over the tendo Achilles', on a
level with the  ankle-joint, and joining the former at right angles in the
sole of the foot.   The two  lateral flaps thus marked  out being next
dissected upwards  close to the bones, the calcaneum and astragalus are
freely exposed.  If from the  extent of the disease, other bones of the
tarsus require  removal, they  may readily  be reached by extending the
median incision a little  forwards.   In removing the entire foot, the two
extremities of the transverse incision may be united by a curved incision
across the dorsum  of the foot.  Mr. Teale refers to an important fact
in reference to the attempt to  preserve any of the  tarsal bones in stru-
mous affections, viz. the articular surfaces may appear healthy  while
their cancellous structure is in an early stage of the disease.   G. C. B.]
   Until a recent  period, this  surgeon says, the  leg was generally am-
putated wherever the disease of the bone extended upwards beyond the
metatarsus.  In 1829 this surgeon ventured (Edinb. Medical and Sur-
gical Journal,  Oct., 1829) to  adopt Chopart's  process  in a case of this
description where amputation  of the leg had been  proposed.   His suc-
cess was complete in this and five other similar cases ;  since when the
operation he considers to have been firmly established in Edinburgh.
   But Chopart's  process cannot reach cases where the caries is between
the astragalus  and os calcis, or in the ankle joint itself.  In the former
situations the gouge cannot be depended upon, but in one case  M.  Syme
succeeded by making a breach through this part of the  foot, and insert-
ing a seton besmeared with escharotics as  red precipitate, &c.  But he
would rely only on the operation.  Formerly, too, the leg was amputated
in those complicated dislocations of the ankle joint where the astragalus
is displaced  from  falling with great force on the heel; afterwards the
practice was to  save the limb, but this is  a tedious and dangerous pro-
cess, as Mr. Syme thinks; for out of 13 such cases at the Royal Infirm-
ary, Edinburgh, only two recovered of those  not amputated; besides 
220
NEW ELEMENTS OF  OPERATIVE SURGERY.
 which the foot remains stiff, sensitive, and in fact an incumbrance.  For
 all which  reasons  he advocates amputation at the joint in such cases.
 (See Mr. Hancock on this subject below.)
   Mr. Syme, gives in addition to the six successful cases in which he
 had already performed this amputation, four others, which make ten in
 all.   He considers that there are, in reality, but very few occasions in
 which it can be necessary to amputate the leg itself above the ankle ;
 having done so himself, viz., below the knee, in only one instance since
 he adopted the operation at the ankle—this last method being in this
 one exception inapplicable, from the peculiar circumstances under which
 the patient was placed.
   In fact,  malignant  tumors of the tibia and  fibula require, says Mr.
 Syme, amputation of the thigh;  and compound  fractures of the  leg, so
 severe as  to  demand removal of  the limb, hardly admit of the opera-
 tion being performed below the  knee, on account of the soft parts so
 near the seat of the injury being unfit for the healing action.
   The advantages at the ankle (to recapitulate) are, in conclusion : 1st,
 That there is less mutilation ;  2d, Greater utility of the limb ; 3d, Much
 less  danger than in  amputation of the leg, because the shock must be
 much less, from the  small extent of soft  parts removed, being little more
 than  in  Chopart's partial section of the foot; because, also, the small-
 ness of the arteries  divided  presents  no risk of serious hemorrhage,
 while  the  cancellated texture of the bone exposed is not liable to ex-
 foliate, and  the  medullary canal remaining  entire, inflammation of its
 contents  and also of the veins is prevented.
   [Mr. Syme states that the advantages which he originally anticipated
from this operation have been fully realized, his  experience now amount-
ing to upwards of fifty cases.  In addition to its other advantages, such
as the formation of a more useful support for the body " than could be
obtained  from any  form of amputation of  the leg," he considers that
amputation at the  ankle joint is  almost entirely free from danger to
life.
   According to  Mr.  Guthrie, this operation has not answered, in  some
of the hospitals of London, the expectations entertained of it from its
success in  Edinburgh, the  flap  formed  from the* under parts, or  heel,
having frequently  sloughed (Commentaries in  Surgery, p. 102).   Mr.
 Syme, however, asserts that this is the fault  of  the operator, who is not
sufficiently  particular to make the flap of a  proper length, and  to pre-
serve the posterior tibial artery intact, until it has divided into its  plan-
tar branches.   Mr. Guthrie is disposed to think that it is an operation
more likely to be eminently successful in military surgery, as the  parts
are here sound  with  the  exception of the  injury  for which it is per-
formed.
   During the winter  of 1846-47, we saw the first case in which ampu-
tation  at the  ankle joint  was  performed in London, and  were much
pleased with  the appearance  of the stump, after it was healed.  The
 operation in this instance, was performed by Mr. Fergusson, and in the
last  edition of his  Practical Surgery,  (1842)  p. 491, he remarks that
he has now had considerable experience  in this proceeding, and does not
hesitate  in  giving it  his  strongest recommendations.   He  adds, " If
 length of limb and stump, and  a  perfect covering  to the ends of the 
AMPUTATION OF THE LOWER  EXTREMITIES.           221
bones, be advantages, certainly  this proceeding  affords them."  We
know of no instance in which this operation has been performed in this
country, but that  reported  by Dr. John Watson, in  the  N  Y. Med.
Times,  Nov. 1853.  G. C. B.]
  In  a  case related  by Mr. Lyon, of Glasgow, (London Medical Ga-
zette, May 31, 1844,  p.  302,) which commenced with  osteitis of the
tarsal and metatarsal bones, and  in seven months ended in caries, leav-
ing the  os calcis and astragalus still unaffected, he proposed Chopart's
operation, which  being declined, and these bones in another month be-
coming  also involved, he now  was induced, as the only resort, to recom-
mend the process  of supra-malleolar disarticulation, so strongly recom-
mended  and so successfully performed by Mr. Syme, of Edinburgh, ac-
cording to the useful modifications which the latter surgeon has given to
it.  This proposal was  agreed  to.  Mr.  Lyon was  not deterred from
proceeding, though the malleolar processes were soft—a  condition com-
mon in  strumous subjects.   He made an opening at the most dependent
part of the posterior flap, as a safety valve for any pus that might col-
lect, recommended by Mr.  Syme.  A finger's  breadth of the anterior
flap mortified on the fifth or sixth day and separated, when granulations
soon after agglutinated  the cellular surface of the flap  to the synovial
membrane.
  Mr. Lyon thinks he erred in applying cold lotions to the wound, as it
may diminish  too much  the  vitality of the flap, [the anterior flap, no
doubt.  T.] which being composed  only of skin and cellular membrane,
and but loosely connected  with the adherent parts,  (as in circular am-
putations,)  may, if treated thus,  be more disposed to  gangrene.   Card-
ed  cotton  and applications of warm water are preferable.  The same
tendency to gangrene exists in the posterior flap in this  method of Mr.
Syme, as it is large and thick, and the condensed cellular substance and
thick cutis  of which it is  composed is but poorly supplied with blood,
viz., only from the vessels  that pass through the skin and cellular sub-
stance of the posterior and inferior part of the leg;  hence the circula-
tion in these small vessels is weak,  and liable to interruption.
  To meet  these  objections,  Mr. Lyon properly recommends that the
margins of the two flaps  should be carefully placed in close and easy
contact, in order that primitive union may take place, and the  blood pass
from  the anterior into the posterior flap, and thus prevent gangrene ;
which is the more necessary, since immediate union  between the syno-
vial  membrane covering the cartilage and the  condensed cellular mem-
brane lining the flap  is not to be expected.   We should, therefore, be
careful  to employ sutures and plasters, and avoid pressure, compresses,
and  bandages.  Interrupted sutures and short strips of plaster to ap-
proximate the lips are eminently serviceable.
  M.  Stanski, in all cases, prefers  the supra-malleolar method to Cho-
part's operation.   He relates an interesting case, (Gaz. Mid. de Paris,
t. XII.,  1844, p. 528—529,) to illustrate this,  of a woman aged forty-
seven, who, from spraining the left  ankle, was attacked with inflamma-
tion in  the part,  which was  followed  by a large number of  fistulous
openings about the joint, discharging pus in such quantities as to bring
on symptoms of phthisis.  The foot was amputated on Chopart's princi-
ple, but  the  retraction  was so great backwards, that  the  cicatrix was 
222            NEW ELEMENTS OF OPERATIVE SURGERY.

drawn underneath, giving pain on walking, and  again became a running
sore.   M. Stanski now amputated the limb above the ankle, and affect-
ed a  perfect cure.   The reasons  why, in his  opinion,  this operation
should always  be substituted for  Chopart's, appear  quite  conclusive.
The examination of the amputated foot shows us, says M. Stanski, that
Chopart's amputation, far from presenting an advantage to the  patient,
is rather injurious ;  for, in this operation, the bones of the tarsus  being
disarticulated almost on the line with the anterior border of the articu-
lar pulley formed by the tibia and fibula, the  tendons of the  anterior
muscles of the leg, in supposing even that  they took their point of
attachment on the astragalus, act on an arm or lever  so short, as, com-
pared with that on which the  muscles of the posterior  region of the leg
exercise  their action, that  they cannot, in any  manner, counterbalance
the  power of these  last; and if they are  inserted  ever so little on the
skin, as occurred  in the  case in question, their action is lost as to  the
movements of the foot, while the tendons of the posterior  muscles, at-
taching themselves to the lower surface and  posterior extremity of the
os calcis, preserve all their action.   It  results from this, that the  fibres
of these  muscles, in  retracting, draw up the heel forcibly backwards,
and favor, by that, the  retraction of  the  ligaments  and  aponeurotic
fibres  which are found behind the tibio-tarsal  articulation, and finally
draw  the cicatrix of the stump downwards—an inconvenience  which
prevents  the patient  from resting on his foot, and which cannot  be es-
sentially  remedied by  any  mechanical  shoe, nor by the  section of the
tendo  Achillis, as was  proved also in this case.   The greatest  obstacle
to putting the  foot  down, however, was  the strong retraction of the
posterior  fibres of the  external lateral ligament, which  thus kept the
foot in permanent extension.   Therefore,  to bring the foot  down to its
place, it would have been necessary not only to make  the section of the
tendons of all the muscles of the posterior  region of the leg, but also,
and perhaps  principally, of the posterior fibres of the external lateral
ligament, in order to replace  the astragalus back into the articular pul-
ley of  the  tibia and fibula, from  which it had  become  evulsed, and to
keep it there in spite of its powerful tendency  to escape from its posi-
tion.
  [M. Lucien Boyer exhibited very  recently, to the Academy of  Medi-
cine of Paris, May 20, 1845, (see  Gaz. Mid., Mai 24,  1845,  p. 332,)
a striking  illustration of the  advantages  of  the  new apparatus of  M.
Martin, so much extolled by M. Velpeau,  (see supra,) which is adapted
to the leg in amputation at or above the malleoli.   The case exhibited
was a young boy, aged ten or twelve, upon  whom M. Boyer had per-
formed this operation, and who, with the aid of M. Martin's apparatus,
could  walk, run,  leap, and make every kind of evolution, almost with
as much facility as if he  had  had a natural limb.  T.]

             Article  VIII.—Amputation of  the Leg.

   Though amputation of the leg is now less frequently performed than
 formerly, it is often  rendered indispensable,  from diseases of the tibio-
 tarsal articulation, complicated fractures, wounds from  fire-arms, gan-
 grene, &c. 
AMPUTATION OF THE  LOWER EXTREMITIES.
223
                      § I.—In the  Continuity.

  The rule which advises that we should amputate as far from the trunk
as possible, has been but rarely applied to the leg.  The point selected
for the division of the bones, even in cases  where the disease has not
extended above the lower articulation, is at two or three fingers' breadth
from  the  tuberosity of the  tibia.   The  tendinous  expansion  of the
sartorius, gracilis, and semi-tendinosus  muscles, is by this  means  pre-
served.  The  stump not only possesses flexion  and extension, but is
of sufficient length to enable the knee to rest firmly and without any
inconvenience upon  an artificial leg.  It is  easy, also, to obtain  a suffi-
ciency of soft parts to cover the wound.  We may, nevertheless, when
the disease does not extend above the tibio-tarsal  articulation, amputate
the leg either in its lower or upper third.
   A.   Amputation at the Lower Tliird.—As we approach the malleoli,
we ultimately  meet with nothing but integuments.  The cicatrix is
formed with difficulty, continues in a state of tension, and is easily rup-
tured.  After  the cure, the  stump being too projecting behind, is con-
stantly exposed to strike against external  objects,  and thus becomes
more  annoying than useful;  to such a degree, in fact, that many persons
operated upon in this manner, have themselves requested a second am-
putation, of which cases Sabatier gives examples,  and which had already
been  previously  noticed by  Pare, (CEuvr.  Compl., liv. XII., ch. 29, p.
358.)  Higher up, the saw traverses the tibia in its spongy and thickest
portion.   The  fibrous  expansion, known  under  the  name  of the pes
anserinus, [see a  note on this, Vol. I.,] might be wounded, which would
impair the action of certain muscles of the thigh upon the stump.   Such,
at least, are the arguments which for a long time past  have been adduced
in support  of  the precept  which  has just  been  given.  Nevertheless,
V. Solingen (Man. des Opir. de Chir., p. 240) has  vigorously opposed
this doctrine.  According to him, we should amputate the leg like the
fore-arm, as low down as possible.   By employing a  shoe, supported by
two thin and polished blades of  steel, which are fixed upon the sides of
the leg by means of cogs properly adjusted, patients walk almost with
as much facility as with their natural foot.   Many foreign  surgeons at
that epoch concurred  with  him in opinion,  nor did  Dionis (Dimonstr.
des Opir.  &c, p. 742, 9e  dem.) differ widely  from him.  However,
there was no  longer any discussion upon this process, when Ravaton,
(Journal  de  Vandermonde,  t. V.,) White,  (Cases in Surgery, 1770,)
and  Bromfield, (Obs. and Cases, Src, 1773,) about  the middle of the
last  century,  imagined that they had discovered it.  Like  Solingen,
these authors extolled the employment of machines,  those among others
of Wilson, (Rossi, Mid. Opir., t. VI., p. 219,)  designed to  admit of
flexion and extension of the leg, and of walking, in fact, in the  same
way, as with the  natural limb.   Ravaton's buskin, secured by means of
leather straps, left a slight  void under the point corresponding to the
 cicatrix, in order to avoid compression upon it.  But Sabatier  objects,
 with reason, to this  mode, because the weight of  the body must  thereby
 force the integuments upon the extremity  of the stump to  mount up-
 wards, and thus  continually make tractions upon the cicatrix until it is 
224            NEW ELEMENTS OF OPERATIVE  SURGERY.
torn.   M. Larrey expresses the same opinion of it.  Vacca, (Salemi,
Mid. sur VAmput., etc., 1829,)  Brunninghausen, (Soulera, These, t.
XIX., 2e partie, Strasbourg, 1814,) and  M.  Soulera, (Soulera, These,
Strasb., 1814,) have, notwithstanding, ventured in our days to revive
this  practice.   Rossi, also, (Mid. Opirat., t. II., p. 205—219,) in  his
book, on two  different occasions, does not  hesitate to recommend it.
Lucas  and Alanson, (Man. de VAmput., trad, par Lassus.) in imitation
of White and  Bromfield, also  amputated the leg  in its lower third,
which  amputation  is likewise  recommended by  Platner,  Delaroche,
(Encyclop.  Mith.,  part.  Chir., t.  I., p. 99,) and  by Benjamin and
Charles Bell, (Systemof Operative Surgery, 1807,) and was performed
by Wright in three  cases.
  I.  It must be confessed that amputation of the leg in its lower portion,
is, from the small quantity of soft parts found- there, a much less serious
operation than in the place of election.  The teguments that may be
preserved, suffice for reunion, even by the first intention.
  We  cannot assert  that it is impossible to construct machines  of a
sufficient degree of perfection to simulate the portion  of the limb des-
troyed, and to allow of walking, in such manner as to render the deformity
almost imperceptible.  Solingen, White,  Ravaton, Bell, Bromfield, and
many  other German  surgeons,  relate facts  which prove  the contrary.
Because some  patients have  done badly under  this operation, it by no
means follows  that it is to be rejected  for  all the  others.  Success in
such cases must depend upon many circumstances, which, in my opinion,
have not been  sufficiently weighed.   The cicatrix may be more or less
firm, or it may be  placed at  the centre or at the circumference of the
stump.   Though it may  be true that buskins have not yet received all
the perfection desirable, it does not follow that human art may not attain
this point.   The two patients thus operated upon who have fallen under
my observation, are enabled to walk by means of so imperfect a buskin,
that it is difficult  for me to conceive of the absolute  necessity of making
use  of the knee  as a point  d'appui  for  an artificial limb.   I come to
the conclusion, therefore, that in  persons who are not obliged to make
long and fatiguing marches,  and who  attach much importance to  the
natural form of the leg, or to the appearances of a natural conformation,
amputation  by the  method of Solingen, might occasionally be adopted.
There would be an  advantage, as I conceive, in such cases, to divide the
integuments in such manner that  the cicatrix might be thrown behind,
and  not upon the central part of the  stump.
   Since the year 1831, the epoch at which  I held this  language, ampu-
tation at the lower third of the leg has been reintroduced in practice.
M. Keate, (Lenior, These de Cone, 1835,  p. 24,)  of London, has  de-
clared himself  an advocate for  it on  certain occasions ; M. Riberi, who
treats of it at great length in his work on  amputations, states  that he
has  performed it five times with  success.    Public attention has been
again  awakened upon this subject, by more ingenious  and perfect  ma-
chines, first by M.  Mille, (Journ. Hebd., 1835, t. II., p. 161,) and then
by M. Martin,  (Bulletin  de VAcad. Royale de Mid., t. I. et II., 1837,)
than the buskins that were first in  use.  M. Goyrand, (Journ. Hebd.,
1835, t. II., p. 261,) at Aix, has performed  it four times, and been well
satisfied of it.  I was the first that had recourse to it at Paris, (Dufresse, 
AMPUTATION OF THE LOWER EXTREMITIES.
225
 Journ. Hebd., 1835, t. IV., p. 129,) viz., in June, 1835, in a patient
 who had had his foot crushed, and who recovered.  M. Roux, (Garavel,
 These  No. 331,  Paris, 1837,)  M.  Blandin,  (Ibid.,) and  M.  Serre,
 (Comple-Rendu  de  la  Clin,  de Montpellier,  1837,) also  soon after
 employed it.   These new facts, moreover, are  in accordance  with  the
 judgment I have given above.   (exhibited at the Hospital of La  Char-
 ite, a young girl operated  upon by M. Blandin, and who, by means of
 M. Martin's buskin, walked with great freedom,  ascended and descended
 the stairs without trouble, and could leap upon  a chair, so as, in fact, to
 completely mask  her mutilation in the eyes of the spectators.  Never-
 theless, this apparatus is still  too complicated, is too much in need of
 the supervision of a skilful mechanist, and is too  dear to be attainable
 by most persons.  Where this is to be  used, I should recommend ampu-
 tations at the lower third of the leg, in those only who live in cities, or
 are in easy circumstances.  Working people,  and those  who have to
 perform severe labors, and  who, the greater part of the day, have to be
 on their  feet, or  walking, are more at their ease, and more secure with
 the old drum-stick under the knee, than with the buskins of MM. Mille
 and Martin.
   [The views of our author are more fully expressed in his Report to the
 Academy of Medicine, October 12, 1841, on a memoir addressed  to the
_ Academy by MM. Arnal &  Martin, entitled : De VAmputation sus-mal-
 liolaire  de la Jambe, comparie d V Amputation  au lieu dJElection, (See
 Journ. des Conn. Med-Chir., de Paris, Novembre, 1841, No. 5, p. 215-
 216.)
   The following, says M.  Velpeau, are  the propositions which these
 physicians establish in favor of supra-malleolar  amputation :—
   1. It may be performed  with  more promptitude and facility than the
 ordinary operation ;
   2. It causes less pain ;
   3. It is less  frequently  accompanied  with  gangrene of  the flap, so
 common in the ordinary method ;
   4. It exposes to less risk of seondary hemorrhages ;
   5. The traumatic fever which it causes is milder and less violent;
   6. The cicatrization is more rapid ;
   7. In consequence of the rapid cure of the wound made by the ampu-
 tation, it is less liable to be attacked with hospital gangrene ;
   8. The accident of conicity of the stump follows it less frequently ;
   9. The patients are less frequently attacked with purulent absorption  ;
   10. In  conclusion, the  patient, after the cure, is less exposed to the
 accidents of general plethora, and  can make   a more free  use  of his
 limb.
   MM.  Arnal and  Martin had  obtained  from the practice of twenty-
 five surgeons a collection of ninety-seven cases of supra-malleolar  am-
 putation, of every diversity of condition,  as respects sex, age, disease
 and country.   Out of these ninety-seven cases, there were eighty-seven
 of complete cure, that is,  the proportion of the  cures to the deaths is as
 nine to one; while Dupuytren admits, that in amputation at the place
 of election, one dies out of every four  cases.
   Considering all the above propositions separately, M. Velpeau comes
 to the following conclusions :
    Vol.  II.                    29 
226
NEW ELEMENTS OF OPERATIVE SURGERY.
   1. Supra-malleolar amputation is manifestly less dangerous than that
which is practised at the place of election.
   2. It is practicable to adapt to the  limbs  which have undergone this
operation,  prothetic (i. e., substitute) means  which allow  of walking
and of concealing the deformity.
   3. The artificial limb which  possesses the most  advantages is that
which has been devised  and constructed by M. Martin.
   4. By means of this  artificial leg a patient is  enabled to walk, sit
down, get up, ascend  and descend a stairs, in a word to execute all the
movements required in the occupations of social life.
   5. In those who have  it not in  their power to procure such a substitute,
the question still arises, whether supra-malleolar amputation ought to
be preferred to the other.
   6. It would  be a discovery  of the highest interest to find a cheap
substitute which would  fulfil all the  conditions required to allow of the
movements of the limb.
   M.  Gimelle  stated that  after the  return of the French  army  from
Russia, about thirty to forty patients who  had been amputated  above
the ankle, were received into  the Invalides, and that out of this number
such was the inconvenience of the stump, that twenty-one or  twenty-two
submitted to the amputation at the place of election.  As a further ar-
gument in favor of the  latter operation, M. Gimelle remarked that M.
Pasquier at the Invalides  had  not  lost a single case out of  thirty-four '
amputations at  the place of election.
   M.  Larrey at the  same sitting of the Academy  maintained that in
those operations he cured eight  or nine out of ten ;  and had, before M.
Pasquier, obtained nineteen successful results by this mode of operation;
that when  on  the  contrary we amputate  near the malleoli, we cannot
look for  reunion by the first  intention ; for it is necessary  before  the
wound can close that the osseous extremities should become smoothed
away and rounded off, which necessarily requires a very long time.
   M.  Velpeau replied: It is well ascertained at the present time that
in amputation   at the place of election, the proportion of deaths is as
one to  four or five ; while in supra-malleolar amputation it is about one
in ten.  This then is one great advantage ; for it is something, according
to my ideas, to lose one-half less of our patients.   I can state that the
five persons on whom I have  performed this operation, have recovered
the use of their limb to such extent, that it is scarcely possible to imagine
that they had undergone an operation.  A lady upon whom I performed
it lately  met me in the street, says M. Velpeau, and I could scarcely
recognize her,  for  nothing  in   her  step differed  from  that of other
persons.  She has been  enabled  this winter to attend  balls and to dance.
I don't pretend to say, continued the Professor, that she has made any
extraordinary pas, (entrechats,) but she has certainly engaged in many
country  dances.   The  thanks of the Academy were  returned to  the
authors of the memoir, and it was sent to the committee of publications  :
the Academy, so for  at least, expressing their  concurrence with MM.
Arnal, Martin,  and Velpeau.   T.]
   II.  Operative Process.—Many processes have  been employed in am-
putation of the leg at its lower third.
   a. Various  Processes.—M. Salemi  recommends that  we  should cut 
AMPUTATION OF THE LOWER EXTREMITIES.
227
the flap behind, and of sufficient size to cover  the wound.  M. Robert,
(Berard, Diet, de Mid., 2e edit. t. XVII., p. 260,) by this mode, cured
his patient  in  thirty days.   After having divided  the  skin  circularly,
M. Blandin, (Garavel,  These No. 331, Paris,  1837,) made  a longitu-
dinal incision in front and  behind, in  order to have a flap on each side.
Others, as M. Lenoir for example, have proposed, after having divided
the integuments by the circular  method, to raise  them up in front like a
ruff, to the  extent of an inch, and to confine ourselves  to the division
of their connections in  proportion as they are drawn back.  The facts
are not yet  sufficiently numerous to enable us to appreciate the relative
value of these different  processes.  That of M. Blandin originates from
the  process of M. Larrey,  and  that of M. Lenoir  from the  process of
Sabatier for amputation of  the  leg at the place of election, and neither
have any greater or less value above the malleoli  than below the knee.
   b. Process of the Author.—An  assistant  compresses  the  artery at
the pubis, or applies the  tourniquet at the lower  third of the thigh.   A
second  assistant supports the  foot, while  a third  seizes the leg, and
prepares to  raise up the integuments.
   The surgeon, placed indifferently either upon  the outside or the  in-
side, circularly  divides  the  skin as near as possible to the base of the
malleoli, and raises it in the manner of a ruff, to the extent  of an inch
and a half in front, and an inch  only  behind.   He then proceeds to the
section of the tendo Achillis, and then to that of the anterior and lateral
tendons, at  the base of  the cutaneous fold.   The inter-osseal knife  is
generally not required, since at  this point the two bones  are separated
only a few  lines apart.   It is with the point of the bistoury, therefore,
that we complete the division of the soft parts.  If the split compress
[the retractor] is used, it should have but two tails, and should be  made
to embrace  the limb obliquely from without  inwards.   The section  of
the bones has nothing peculiar, except that it is almost useless to remove
the upper angle or inner border  of the tibia, as is sometimes done at the
upper third.
   The only  arteries that  require the ligature or torsion, are the anterior
and posterior tibial and the fibular.  The integuments being now brought
down,  are united together from  before backwards and from without in-
wards.  In  bed the stump is kept extended or moderately flexed upon a
large cushion.   The consequences are nearly the same as in the upper
third of the limb, except that the reaction here is less, and the cure gen-
erally more  prompt.
   B. Amputation of the  Upper  Third.—Some persons have placed the
point of election (vid. supra) either  higher  up or  lower down than I
have given  it above.  Hey, for  example, fixes it at the middle of the
limb.  M. Garigue, (These, Strasbourg, 1836,) on the contrary, propo-
ses, as De la Motte (Traiti de Chir'., t. II., p.  334, Obs.  313, edit. Sa-
batier) and  Bromfield had advised before him, that we should amputate
much nearer the articulation, and even above the tuberosity of the tibia.
M. Larrey (Clin. Chir., t.  III., p. 557) strongly advocates this  plan,
which M. Guthrie ( On Gunshot Wounds, 1815) also formally approves
of, and which Percy and Malvini, it is said, (Mim. de VAcad.  Royale de
Med., t. II., p. 12) were the first to recommend.
   I. The point where these  surgeons amputate, however, should be con- 
oog
NEW ELEMENTS OF OPERATIVE SURGERY.
 sidered rather one of necessity than of election.   Viewed in this light,
 I agree with them in opinion.  If it were not advisable to amputate at
 the knee, I should always prefer  amputation of the leg, if it were only
 at an inch below the articulation, rather than amputation of the thigh.
 I am even of opinion that it would be better, as a general rule, to make
 the section of the bones immediately below the tuberosity of the tibia,
 than at the place where it is usually preferred.  The section of the ten-
 dons of the sartorius, the gracillis, semi-tendinosus, and ligamentum pa-
 tellar would not prevent these organs, in the end, from retaining their
 action on the upper extremity of  the leg.   In  this part there is no long-
 er any inter-osseal space.   The popliteal  artery is the  only  one which
 has to be tied ; or, at least, there are no others but the  fibular and pos-
 terior tibial which may properly require this assistance.  The head of
 the fibula may be removed.  The amputation of the leg then resembles
 that of the limbs where there is  but a single  bone.  Tho spongy state
 of the tibia, far from being an inconvenience, presents, on the contrary,
 the advantage of rendering the development of the cellular granulations
 more easy and  more prompt.  It must, however, be  admitted that in-
 teguments only are found in the  anterior  half of the circumference of
 the leg at this place, while, farther down, the  muscular  tissues come to
 their assistance ;  but, as it is the  integuments definitively which always
 shut up the wound, I cannot see what great  evil can result  from it.   In
 conclusion, did not the spongy substance  of the tibia,  in contact with
 the pus, expose to phlebitis and to the resorption of morbific matters;
and did we not, in operating above the head of the fibula, run  the  risk
of opening into the synovial  membrane of the knee joint, which mem-
brane is sometimes prolonged as far down  as that point, of which M. A.
Berard has communicated to me  two examples, of which I myself have
now seen a number of instances,  and which M.  Lenoir  (These de Con-
cours, etc., 1835, p.  7) has noticed  in  twenty-four subjects, I would,
without hesitation, adopt the method of MM. Garigue and Larrey.
  In order, when the disease is very near the  knee, to preserve  the  in-
ferior attachment of  the  ligamentum  patellae, and to leave intact the
mucous bursa which is found  behind it, M. Larrey proposes moreover
that we should direct the saw more or less obliquely from below upwards,
and from before backwards.   We may in  this manner  remove  all the
fibula and leave a small portion of the tibia which will prove equally
useful as a point d'appui to the artificial leg; but in such cases the better
practice appears to be to amputate at the joint.
  II.  Anatomy.—After the details above  there can be  no necessity of
giving a long description of the leg.  The tibia being thicker than  the
fibula,  and situated on a much more  elevated plane is  the  reason why
the greater thickness of the leg is in the direction from within outwards
and from before backwards, instead of being transverse.   Its inner side
being entirely unprovided with muscles, cannot after amputation, whether
by the circular or flap method, be covered except by the integuments.
Its sharp edge which forms a sort of crest in front, usually gives to  its
section in this part a  very acute point, which may  perforate  the skin, if
it is not attended to.   In the lower part of the calf the conical form  of
the limb  gives to the integuments when cut circularly  too  narrow  an
opening to be easily raised up, wjiile above, this opening represents rath- 
AMPUTATION OF THE LOWER EXTREMITIES.
229
er the mouth of a funnel.   The tibialis anticus muscle, the extensors of
the toes and the peroneus tertius, which fill up the outer inter-osseal fossa,
and adhere  almost  to  the whole extent of this cavity,  are  incapable
when divided of retracting beyond a few lines.  It is the  same with the
peroneus longus and brevis muscles, and with the  deep muscular layer,
or the tibialis (posticus) and flexors of the  toes which fill up the poste-
rior inter-osseous fossa  ; while the gastrocnemii  and even the soleus,
should we  amputate very low down, might  retract considerably.   The
anterior tibial artery bending at a right angle at  the moment it arrives
upon the front part of the inter-osseous ligament,  soon also associates
itself with the nerve of  the same name.   The  posterior tibial and pe-
roneal arteries which separate  sometimes lower  down and sometimes
higher up from the peroneo-tibial are  almost always met with,—the first
behind the external border of the tibia upon the posterior  surface of the
flexor longus digitorum  pedis and tibialis posticus muscles, the second
behind the fibula, in  the midst of the fibres of the  flexor longus  pollicis
pedis.  M. Lenoir, (These citie, p. 8,) who maintains that the nourish-
ing artery enters into its  groove at two inches and a half, and into its
canal, which itself is generally an inch  long, at two inches and a  half
or three inches and a quarter below the  tuberosity of the tibia, proves
by  that fact, in corroborating the assertion of Decourcelles, (Manuel
des  Opirat., etc., p.  387,) that  this artery is divided in  the thickness
of the bone, even when we amputate  at the place  of election, and out-
side of  the tibia when we amputate a  little higher  up ;  and also  that we
are certain to avoid it by  following the  rule of M. Larrey.   Moreover
the nerve is almost constantly found situated upon  the fibular side of the
tibial artery.
  III.—The Operation.—The leg may be amputated  either by the cir-
cular or flap method.
  a.  Circular Method.—I.  Process of the Author.—The patient, being
placed upon a bed or operating table, is to be supported there in a pro-
per manner.
  First Stage.—To  guard against hemorrhage,  compression  is to be
made on the femoral artery, on the body  of the pubis, or against the
inner side of the femur  on a line with the little trochanter, or finally by
means of a tourniquet or garrot.  The garrot or tourniquet is to be pre-
ferred when there are not a sufficient number of assistants, or when wo
cannot  rely entirely upon them.  These instruments are applied upon
the thigh with so much the greater advantage, inasmuch as they cannot
in any manner interfere  with the surgeon while he  is amputating the leg,
and that they serve also to diminish the pain and benumb the limb.
  The operator ordinarily places himself on the inside;  this is a gene-
ral  rule which has been  long established.   The  reason  given for  it is,
that it is more easy in this manner to  complete the section of the fibula
before we  have got through the tibia, than if we were placed on the out-
side.  Ledran, however, has  remarked that the surgeon  may dispense
with this rule without danger, and even  perhaps with some advantage.
Graefe and M.  S. Cooper, on the other hand, maintain  that it is full as
advantageous to be placed always on  the outside, or that it is  at least
not necessary to be on the inside for amputation of the right leg.  If, in
fact, when on the inside and operating on the  left  leg, the correspond- 
230            NEW ELEMENTS OF OPERATIVE  SURGERY.

ing hand being towards the upper  part of the limb, is enabled to raise
up the integuments in  proportion as the right  hand  divides them;  this
cannot be done upon the right leg if we follow the rule laid down. Con-
sequently the precept which it would be proper to substitute for the an-
cient one, and which  I have myself conformed to for a long time past,
in this :—The operator is to place himself in  such manner that  the left
hand may always grasp  the leg on the  side  towards the knee, unloss
however he should be ambidexter ;  in  fact in this last case there would
no longer be any more necessity for his placing himself between the two
limbs than upon the outside of either.  It  would, moreover, be  puerile
for  the surgeon to place himself outside, for the division of the soft parts,
and  then within when the bones only remain to  be divided,  as some
English and  German  surgeons have recommended.   Still more out of
character would it be to leave the sound leg between the operator and
the  one to be amputated, in order never to  place himself between these
parts.   The foot being wrapped in a fold of linen, is with the entire
diseased portion of the leg confided to the last assistant.
  Second Stage.—The operator, provided with an amputating  knife,
cuts circularly through the whole thickness of the skin, commencing at
the  crest and finishing at the inner  border of the tibia; he  then, by
means of a second cut, unites the two extremities of this incision on the
inner face of the bone, unless  by a movement  of rotation of the hand
upon the handle of the instrument, and which I have already  described,
he  should prefer  passing round, without stopping, the  whole circum-
ference of the limb.   Drawing back with his left hand the integuments
thus divided, he detatches their cellular bridles, and raises them an inch
or an inch and a half, or with the thumb and forefinger he seizes them
by the upper lip of the wound, near the fibula.   Then  he dissects them
with free strokes by means of the  point of a knife or a bistoury, and
promptly reverses them from below upwards, in order to form a sort of
border or ruff.
  Third Stage.—Having brought back  the knife to the base of this cuta-
neous ruff or circle and to the same point on the tibia, the operator in-
cises from before  backwards,  and from within outwards,  so as to divide
the aponeurosis and all the  muscular fibres which  rise above the level
of the anterior inter-osseous fossa.   Depressing the wrist, he divides in
the same manner  the  peronei muscles, and then in gradually bringing
the knife inwards, those of the calf or posterior surface of the leg, and
again  brings the  instrument in  front and  detaches  the  aponeurosis on
each side ; then immediately applies its heel on the outer surface of the
fibula  and  proceeds to cut from  the  handle to  the point.   When the
point arrives upon the inner side of this last bone, we cut through the
inter-osseous space, in order to divide all the deep-seated fibres, and
while withdrawing the instrument to divide also on the outer surface of
the tibia.  Replacing the  knife below  the limb and upon the same point
of the fibula, the  operator now again brings it back upon the posterior
surface of this bone;  again traverses the  inter-osseous space, and comes
out  from it in the same manner as in front; divides all  the  remaining
muscles behind the.tibia, and finds that he has described  in this manner
a perfect figure of 8, as has been said in  speaking of amputation of the
fore-arm.  It is advisable, as in this last-mentioned member, to make a 
AMPUTATION OF THE LOWER EXTREMITIES.
231
second cut with the bistoury on each border of the inter-osseous mem-
brane.  We then pass from behind forward and between the bones, the
middle tail of the compress split into three tails; the different parts of
which properly unrolled and then united are  confided to the assistant
who is charged with holding back the muscular tissues.               "
   Fourth Stage.—The  surgeon fixes the nail of his thumb at the spot
where the  tibia has been denuded, and applies the saw to this  point,
making at  first only small cuts.  He then  elevates his wrist so as to
complete the section of  the fibula  first, finishing  with  that of the bone
upon which he commenced ;  since the fibula if  alone would  not present
sufficient resistance to the  action of the saw, and would also have  its
upper articulation exposed to a severe  concussion.  This last reason I
think is far from conclusive, but the first is sufficient to justify the pre-
cept.  As  soon as the section of the  fibula is completed, the assistant,
who  holds the lower  part of the leg  and the  operator who embraces
with  his left hand the upper  part, should  take care to compress this
bone  with  such firmness that it can no longer be shaken by the  move-
ment of the instrument.  M.  Roux advises to saw it higher up than the
tibia ; for which reason he inclines the saw obliquely upwards and out-
wards.   By this  mode of procedure M. Roux thinks he places  himself
more securely on his  guard  against  the subsequent protrusion  of the
fibula.  This is a matter of little importance, and the section of the two
bones on the same line is full as good.  Much  less can I understand
why some in imitation of certain practitioners should recommend their
section separately.  In fact,  to render  the section of the  fibula more
easy, if the surgeon were  placed  on the out instead of the inside, all
that would be necessary would be, after-tracing out a groove of proper
depth on the principal  bone,  (tibia,) to have the aids turn  the leg into
pronation and to  make a slight depression of the wrist.
   V. Fifth Stage.  The anterior angle of the tibia, upon which  the
skin is supported, and against  which it is pressed by the weight  of the
muscles of the calf, which tend to  drag it backwards after the dressing,
sometimes  causes perforation of the tegumentary coverings. Surgeons
have  early thought of the  means  by which  such a difficulty  might be
prevented,  and which is  ordinarily  avoided when amputation is perform-
ed very high  up on the limb.   I have  seen MM. Richerand and Cloquet,
at the Hospital of St. Louis, obviate  it when it threatened, by applying
a piece of pasteboard in the form of a splint  to the posterior surface of
the stump.   A much surer method consists in removing with a cut  of the
saw the corner of the angle or the osseous border itself.   It is not known
to whom belongs the first suggestion of this improvement,  unless it be
to Assalini, who I believe first  speaks of it in his Manuel of Surgery.
Military surgeons have been for a long time in the habit of practising
it.  It was pointed out in the beginning  of this century  by an  army
surgeon, whose name  has escaped  me.  M. Marjolin also, and Beclard,
in teaching it in their lectures, have caused its  adoption among French
surgeons.  MM.  Guthrie, S.  Cooper, and  other English practitioners,
have also long since made mention of it, without however appearing to
accord to it any very great importance.  In place of the anterior angle
it is the inner border, it is said, that M. Sanson saws off, but there  can
be no fixed rule in this matter.  Whether it is  the border or the  angle, 
232            NEW ELEMENTS  OF OPERATIVE  SURGERY.
what to do is to remove the salient  point, and that constitutes the whole
affair.  I have often adopted and often omitted it, and have noticed that
it was only really  necessary in thin  persons with flabby  integuments,
and  when  we  amputate rather  low  down.   Perhaps in such  cases it
might be advisable to follow the plan of M. V. Onsenort, who before
rounding off the cut surface of the  tibia  dissects a flap from the perios-
teum, with wliich he covers the end of the bone.
  2.  Process  of Sabatier.  The process  of M. Sabatier only differs
from the preceding in this, that this author prefers incising in the first
place the integuments  upon the anterior  half of the limb, and  that we
should draw them  back before  continuing the circular incision a little
higher up behind.   His reason is, that on the calf the skin retracts with
the muscles, while in front of the tibia and of the anterior aponeurosis
it will go up no higher  than it is raised up by force.   This is a modifi-
cation which, without having any thing objectionable about it, has never-
theless  generally   been neglected.  Decourcelles  (Man. des Oper.,
etc., p. 385, 1756)  obtained  the same result by keeping the limb flexed
while he incised the integuments in front.
  3  Process of Physick.—M.  Ch.  Bell considers himself the  inventor
of a process which Dorsey (Elem. of Surg., t. II., p. 317) ascribes to
Physick, but wliich rather belongs to Decourcelles,  (Opirat.,  p. 385,)
and  which  is as follows : first the skin is divided, then the muscles of
the calf are cut very obliquely from below upwards, completing  the
circular section much nearer the knee on the anterior  half  of the leg,
and terminating the operation as in the ordinary mode.
  4. Process  of B. Bell—M. Baudens (These No.  51, Paris, 1829)
after  having circularly divided the soft  parts, proposes that we should
detach all the  muscles to the  extent of an inch or two, with the  point
of the knife held in a direction parallel to the axis of the bones.  This
advice which  was  given by Bell, and which  has been adopted by M.
Champion in amputations of the arm  or thigh, and for all  amputations
in general,  may have  its advantages, and is in  concurrence with the
precept lately revived with much earnestness by M.  Hello, ( These No.
258, Paris, 1829.)
  5. Dressing.—In operating at the place of election, we  have in suc-
cession to seize the  anterior tibial artery, associated with its nerve, and
which must  be separated from it in  front  of the inter-osseous ligament,
between the tibialis anticus muscle and the extensors of the toes ; then
the posterior tibial  artery,  the  peroneal  and some branches of the su-
rales, and sometimes also the nourishing  artery of the tibia.
  Very frequently the first of these vessels retracts far into the tissues,
the reason  of which, according to M. Ribes, (Mini de la Soc.  Mid.
d'Emul., Arch.  Gin. de Mid., 2e ser., t. III., p. 199,) is found in the
double curve which the artery is obliged to make, in order to get in front
of the inter-osseous ligament.  M. Gensoul ( These No. 109, Paris, 1824)
on the contrary thinks that this [apparent]  retraction is owing to the
fact that the muscular fibres which surround the artery, being too adhe-
rent to mount upwards, make the vessel appear to retract much more than
it in  reality does, much more even than  those of the posterior  part of
the limb which the muscles draw up still  higher.  The difficulty of find-
ing this artery, according to M.  Sedillot, (Gaz. Mid. de Paris, 1833, 
              AMPUTATION OF  THE LOWER EXTREMITIES.            233

p. 363,) is owing to the knife  mashing  and bruising it in dividing the
muscles of the inter-osseous space.  Without absolutely rejecting the
first and third of these  explanations, I would more willingly adopt the
second.  When  the section of the bones  is made immediately below the
tuberosity of the tibia,  one trunk alone replaces the posterior tibial and
the peroneal, but then we meet also with the nourishing  artery  which
here possesses considerable volume.  Higher up still  the anterior tibial
itself may not have  yet separated  from the popliteal, [i.  e., strictly
speaking, from the peroneo-tibial trunk of the  popliteal, which trunk
and the anterior tibial form the two great divisions, i. e., the bifurcation
of the popliteal itself.   T.J which last artery alone [i. c, the popliteal]
in that case requires a ligature, together  with the inferior articular and
the surales.
   Practitioners  differ also as to the direction  uihich  should be given to
the union of the wound.  In France it  is almost always obliquely from
within outwards and from before backwards, as is recommended by M.
Richerand.  Many operators in England, among others M. Hutchinson,
still unite the wound as  formerly, directly from before backwards, hop-
ing by this means to avoid the stagnation of the fluids and the pressure
of the point of the tibia against the skin.   To give in fact greater secu-
rity to this method, M.  Larrey advises to slit the skin in front and be-
hind, to the extent of half an inch.   There are others again who unite
transversely after the  recommendation  of M. Guthrie ;  but there can
be no question that if we have  adopted the precaution of removing the
angle of the bone as has been pointed  out, that the method of M. Rich-
erand is the best; and that  this alone enables us to bring the tissues in
a line with the smallest diameter of the  limb, and that it presents in no
way any obstacle to the discharge of the  pus.
   If the  amputation  has been made very low down, the leg should be
supported upon a cushion, and kept slightly flexed and inclined upon its
outer side ; otherwise we place the stump upon small pillows which raise
the ham much higher, and prevent the wound from pressing against the
mattress.
   II.  The  Flap Method.—It was to  the leg particularly that  Lowd-
ham, Verduin, Sabourin, &c, were desirous of applying  their method.
It was upon this part of the limbs also that Garengeot, De la  Faye and
Le Dran  made  their first trials.   But Louis, Lassus  and Sabatier,  hav-
ing undertaken to establish the circular method, and  the  flap operation
seeming  to  be more painful  and difficult, it was almost entirely re-
nounced.   It is now,  however, near  thirty years since it was again re-
vived among us by  M.  Roux  and  Dupuytren.   Hey in  England, and
Klein and M. Benedict in Germany, who eulogize it much, succeeded in
causing its adoption  by some of their countrymen.   Heliodorus (Pey-
rilhe, Hist, de la Mid., in 4to,  p. 392—393) also, who first divided the
soft parts in front, then sawed the  bones and finished with the  section
of the muscular masses behind, did he  not follow the flap method, he
who so  accurately applied to supernumerary fingers the so called me-
thod of Ravaton ?  What appears, however, to have chiefly deterred the
moderns from it is  the size of the tibia, whose inner face, taken in
whatever way we choose, can never be covered by  any thing but the
skin.   The necessity, also, of taking the greater portion if not the whole
    Vol.  II.                    30 
234            NEW ELEMENTS OF OPERATIVE SURGERY.

of the flaps from behind, was another motive for its exclusion.   As, how-
ever, there may be  cases whesre it becomes  indispensably necessary, I
believe it my duty here to  point out the  principal  processes  by which
this operation may be performed.
  a. Process of Verduin.—A. two-edged knife, plunged into the leg at
a point a little below where we intend to apply the saw, first cuts out at
the expense of the calf, a semi-lunar flap of about four inches in length ;
the instrument  being then  brought  in front is immediately  afterwards
made to divide the integuments and  muscles as in the circular  method,
at the base of the flap which has been raised  up; the inter-osseous fossae
are then cleared out and the bones sawed as in the usual way.
  Loder and  M. Graefe (Rust's Handbuch der Chir., t.  I., p.  569) have
modified  this process in this, that in  order to leave.a less quantity of
muscle they draw the skin back forcibly  while making the incisions, and
also preserve a small flap in front.
  b. Process of Hey.—In order to be more sure of the length of the
flap, Hey advises to mark out the middle of the  upper  part of the tibia
by a circular  line, then to trace out  a second an  inch  lower down, and
then a third at four inches  below the  first;  afterwards he makes  two
others, one on each side, parallel to  the axis  of the limb, and which are
drawn from the union of the two anterior thirds with the posterior third
of the superior circular line down to the lowermost circular line.   The
first  indicates the  point where the bones are to be  sawed; the  second
that at which  the integuments are to be divided in front, and the third the
place where the knife must  be arrested ;  while the two lateral lines give
the form  and extent of the flap ; which in other respects Hey cuts out
in the same way  as Verduin and  Lowdham.   No one I should judge
among us would be tempted to follow this scaffolding of  geometric  lines
and rules.
  c  Process of Ravaton.—The  circular incision made at four inches
from the  place where the amputation  is to be performed, allows of
another being placed on the inner side and near the inner border of the
tibia, then a third on the outer border of the leg, and both of which are
to fall upon  the  first at a right angle.   The two square or trapezoidal
flaps, one anterior the other posterior,  which result from these incisions,
are then to  be dissected  from  below upwards and raised up ; nothing
more  remains to do than to clear out  the inter-osseous space, introduce
the split compress and saw  the bones.
  d. Process of Vermale.—In order to  form  the first flap, Le Dran
(Opirat  de  Chir.^ p. 55) who states that he has performed the method
of Ravaton and Vermale  successfully, carries the knife from the inner
to the outer side  of the  leg, and  thus  begins by forming the anterior
flap; nothing then is easier than to draw back a little the fleshy tissues
behind and cut out a posterior flap.
   e. Process of Dupuytren.—Instead of commencing with the anterior
flap, Dupuytren first  plunges  his instrument between the posterior sur-
face of the bones and the soft parts, taking care to leave more tissues
behind the fibular than Le Dran did.
  /. Process of M. Roux.—As it  is next to impossible to preserve as
much of tfie tissues in front as behind, M. Roux has proposed to make
an incision on the inner face of the tibia about 2  inches in length, which 
AMPUTATION OF THE  LOWER EXTREMITIES.
235
Commences upon the inner border and runs obliquely from behind for-
wards, and from above downwards, and terminates on the anterior bor-
der of the bone.  This incision, when the posterior flap is formed, readi-
ly allows  of our  bringing the edges of the wound up to a level with the
crest of the tibia, and of making a flap in front which possesses greater
regularity and thickness.
   III. Ovalar  Method.—By slightly modifying the circular method for
the leg, we may easily transform it into the ovalar.  For this purpose it
is sufficient to  divide the skin in such manner that one of the extremi-
ties of the antero-posterior diameter of the incision, shall be manifestly
placed nearer  the  thigh than the other.   Thus M. Baudens (Clin, des
Plaies d'Armes-d-feu, p. 50,) who  extols this method, places the apex
(sommet) of his oval behind towards the ham ; while M. Sedillot (Gaz.
Mid. de  Paris, 1833, p. 363) recommends  that it should  be in front
towards the knee.
   IV. Appreciation.—All the flap processes in fact are reducible to that
of Lowdham and that of Vermale, the one allowing of but a single flap,
the other furnishing  two.   When the skin  is degenerated  much higher
up in front than behind, and that we are obliged  to amputate very near
the  knee, the first  is the process that becomes necessary.  I have seen
M. J. Cloquet  employ it successfully  at  the Hospital of Perfectionne-
ment, upon a patient, who but for that  would have evidently lost the
thigh. Under all other circumstances, the method with two flaps appears
to me more suitable,  though it be a little more difficult.  When there is
only  one flap we are obliged to make a right angle with it near its base
in  order  to apply it  against the bones.   Immediate and complete union
is next to impossible ; and sufficiently acute pains rarely fail to come on.
The  accidents  wliich may result from the method in question, justify to
a certain  extent the fears of surgeons of the present day, and their re-
pugnance to  undertake it.  By means of two flaps on the contrary we
can easily close the wound; the parts being neither  angulated  nor
drawn upon, are found in the conditions the most favorable possible for
immediate reunion.
   In making trial on the  dead body with the process of Vermale, and
which I have once at the Hospital of Saint-Antoine employed on living
man, I omit the small preliminary incision of M. Roux ; but I take care
to  embrace with the left hand the two sides of the leg, and to draw as
much of the integuments as I possibly can towards the front.  The point
of the knife is then directed upon the inner face of  the tibia; brought
up to a line  with  the crest of this bone, while pushing the skin before
it; passed along in  front of  the inter-osseous ligament; a little raised
up in order to pass in front of the fibula, and again inclined backwards,
while the  operator draws  the  tissues  towards him,  at the moment the
knife is  cutting  through  the outer border of the limb.  The flap being
thus  out,  we  return  to form a  similar one behind, while the rest of
the operation being based upon the process of Dupuytren, presents nothing
peculiar.
   In whatever  manner we proceed, it is necessary that the inner angle
of the wound should not be quite as high up as the other,  if we do not
wish to  run the risk of denudation of the bone and necrosis.  As a
general  rule, the circular  method merits  the preference over the flap 
236
NEW ELEMENTS  OF OPERATIVE SURGERY*.
process, but this last presents advantages which we may profit by, when
either at the lower or upper third, the soft parts on the periphery of tho
leg have  degenerated much higher on one side than the other.  By en-
abling us to preserve what is sound, it puts it in our power also to avoid
removing so large a portion of the bones.  The same may be said of the
ovalar  method.   As to immediate reunion, which some of these proces-
ses are  said to effect  with more certainty than others, it will be neces-
sary in the first place to establish the fact that this has ever actually been
accomplished, which  has not been done up to the present time.   On this
subject  I fear more  importance has been attached to the process itself
than to the facts in the case.  In no case do I find that the wound defin-
itively  closes  without  any suppuration.  M.  Serre,  (Gaz. Mid.,  p.
825,) who in France  zealously advocates primitive reunion, and who, to
ensure it  with  more certainty, uses the suture  after amputations, never,
however, cures  his patients under fifteen  days.  Now I  have obtained
results no less satisfactory, by the  method I have  pointed out for treat-
ing amputations in general.
   \Flap Operation  in Amputations.—Mr.  Fergusson  (Pract. Surg.)
invariably recommends the flap operation of Lowdham, (claimed as one
of British  origin.)   So also do Messrs. Liston, Lizars, and others  edu-
cated in the Edinburgh School,  Sir George Ballingall, equally favora-
ble to it, does not concede all the advantages claimed for it, nor coincide
in the censures  cast upon the circular incisions.  In the Edinburgh  hos-
pital alone, over 400 amputations by the flap method were performed he
thinks, in the space of twelve years.
  Rapidity  of execution,  and  a far better and more fleshy and less cu-
taneous  cushion to the stump, are  two  of  the great advantages of the
flap  method.  But  the latter result may be  obtained in the  circular, by
giving a slope to the incisions from the divided  edges of the bone to the
surface.
  In thick  muscular  parts  as  at the deltoid and calf, the flap mode is
objected to as  giving too large a cushion;  but whether by  the circular
or flap,  this redundance disappears and the end of the bone is ultimate-
ly left in both cases with a similar covering,  i. e., condensed cellular tis-
sue, which forms the best stump.   Non-union,  suppuration, exfoliation,
protrusion  of bone, tumors  on  the ends of  the nerve, (fee,  are as com-
mon after the flap, as after the circular operation.
   Sir George Ballingall,  after  his extensive experience, confesses  that
it is difficult to  relinquish the flap operation after having once been in
the habit of performing it, because it presents facilities so much greater
than other processes.   T.j

                   § II.—Amputation at the Knee.

   A. The  disarticulation of the leg, though  obscurely  alluded to by
Hippocrates (De Articul., t. II., p.  381, edit.  Vanderlinden) and  Guy
de Chauliac, (Trad, de Joubert, p. 464,) and more clearly specified by
Fabricius  de Hilden, (Observat.  Chirurg.,  p.  504,) did  not, however,
seriously attract attention until the last century.   Notwithstanding the
efforts of J. L. Petit, (Malad. Chirurg., t. III., p. 20,) Hoin and Bras-
dor, who endeavored to bring it again into repute, it was  recommended 
AMPUTATION OF THE  LOWER EXTREMITIES.           237
by no one, and M. Blandin was  almost the  only  person who  had the
courage to reproduce  the  arguments of Brasdor in favor of it; it  was,
in fact, an operation  which at the first glance  seemed destined to be
proscribed from  modern  surgery, until I myself, in  1829, made the
attempt to re-produce it into practice.
  De la Rocque (Planque, Biblioth., t. V., p. 12, in 4to.) informs us of
the case of a young girl seventeen years of age,  who was amputated at
the knee, and recovered perfectly.  In one of the cases mentioned by
J. L. Petit, the amputation of the knee appears to  have been had re-
course to only because the instruments to perform it in the continuity
were wanting.  The other was a young man who had both bones of the
leg in a state of exostosis and caries  throughout  their  whole extent.
There is every reason to believe that these two operations, of which J.
L.  Petit was a witness only, resulted in a perfect  cure.  A slater, who
nineteen days before had fallen from a  height of  thirty-two feet, was re-
ceived into the hospital of Dijon on the 26th of July, 1764.   His leg
was in a state of  gangrene as high up as the knee.   Hoin (Mini,  de
V Acad. Roy ale de Chir., t. V., p. 508,1819) disarticulated the leg, and
though there were not soft parts sufficient to allow of immediate  reunion,
the man ultimately got well.  In the month of July, 1771, he was still
living, could use his wooden leg  with  freedom, and  ascended the  scaf-
foldings and upon  roofs as he had done before the  accident.  Gignoux,
(Ibid., p.  512,) of Valence, speaks of  a young girl whose leg had  been
separated from the thigh by gangrene, and whose health for the  last four
years had been completely restored.   Sabatier (Mid.  Opir., t. IV., p.
548., 1824) mentions having  seen a boy in whom a ball had carried
away the  leg without  wounding the patella, but without being followed
by  any unpleasant consequences.   Dr.  Smith, (Journal des Progres, t.
I., p. 240,) in  the  year 1824, disarticulated the leg in a young lady, who,
ever since, has been enabled to walk by means of  a wooden  substitute.
A scrofulous patient was amputated in the same manner, in the year 1824,
at the hospital of Saint Louis, by M. Richerand.   A variety of accidents,
such as purulent abscesses and collections, it  is true, at first alarmed the
surgeon, but the wound, nevertheless, ultimately  cicatrized.   M. Dezei-
meris, in 1829, met, in the streets of Paris, with a  male adult who  had
been amputated at the knee.   This person could walk with ease, but by
means of  a cuish and without  using his  stump as a point d'appui on the
artificial leg.   M.  Bourgeois has told me that he noticed a case  in every
respect similar, at  Etampes. Rossi considers this operation as very sim-
ple, and says he has performed it twice with success; but  the patient
who was operated  upon by M.  Blandin, at the hospital Beaujon, died on
the  tenth day after the operation,  in consequence of phlebitis.
  B. Appreciation.—Thus have we 14 authentic  cases of amputation at
the  knee joint, and of these, 13 cures  ; which, it  cannot be denied, is
for  the first, a  most encouraging result.  Amputation in  the continuity
has certainly never furnished more  satisfactory proportions.  To those
who would object that the  amputation in the patients of Gignoux and Sa-
batier was performed as much by nature as by the surgeon ; that gangrene
had done  part of the  work in the cases mentioned by  Hoin ; that that
of M. Blandin ultimately died  ; that all were young subjects, and could
not use their stump for a long time; we may reply:—1, that if the wound 
238
NEW ELEMENTS OF  OPERATIVE SURGERY?
properly closed after the spontaneous fall of the limb, or after gangrene
had already commenced the  division  of the tissues, there is no reason
why it should be otherwise when the operation  has  been performed by
art; 2, that the accidents to one of the patients came near falling a
victim,  do  not belong to disarticulation  more than  to pure and simple
amputation of the leg, and that his death, which occurred eight months
after, was  the result of his primary  affection ; 3,  that we cannot  see
why adults should have less chances of success from  this amputation
than young persons ;  4,  that the length of the cure  must be imputed to
peculiar circumstances,  and  not  to  the  character of the operation ; 5,
finally,  that M.  Smith had no complaint to  make  in respect to any of
these inconveniences.  But let us continue the exposition of facts.
   In the month of January, 1830,1  received into the Hospital of Saint-
Antoine, an orphan boy, aged 19, who was addressed to me by M. Kap-
eler.   The operation was fixed  for the 14th of the same month.  As
there was not a sufficient quantity of soft parts remaining behind, I pro-
posed to obtain a flap in front, of a certain length.   The wound reunited
but imperfectly.   No accident  happened, and  though there still  re-
mained exposed a transverse surface an inch in width from before  back-
wards,  which the flaps  would not cover, the cicatrix, nevertheless, was
completed at the expiration of two months.  This patient, whom I have
often  since seen, enjoys  the most perfect health.  The stump bears and
transmits the weight  of  the body to his wooden  limb with the same fa-
cility as if  he  had undergone only  amputation  in the continuity of  the
leg.
   A man, 29 years of age, of good constitution, and  born in the colonies,
was sent to me at the Hospital of Saint-Antoine on the  24th of May  fol-
lowing, by  M. Thierry, who had  been sent for to him for a comminuted
fracture of the left leg.   Gangrene  soon made  its appearance, followed
shortly after by an ichorous suppuration, which becoming more and more
copious, with pains excessively acute at the time of dressings, and even in
their interval, and an  almost continued  febrile movement, with diarrhoea,
&c, soon made me,  on  the other hand,  entirely despair of  saving  the
limb.   I decided upon amputation at the knee, and  performed it on the
4th of  June.  The febrile  reaction made it necessary  to bleed on  the
first and second day. No accident  afterwards occurred up to the fifth;
but on the  sixth and seventh, a superficial erysipelas made its appear-
ance, and reproduced the fever.  In spite of this intercurrent phlegma-
sia, and of two small purulent patches, which formed at a later  period
at the angles of the condyles, and finally, of  the consequences produced
by deviations in regimen, causing, in fact, a real attack of indigestion,
the cure was completed by the sixtieth day.
   In  the month of July, 1830,1 had to examine, at  the Bureau of Hos-
pitals, a young man aged nineteen years, who had been  amputated  seven
years before, and who came to ask for a new wooden leg. He told me
that the operation had been performed upon  him at  the Hopital des Ea-
fants.  The cicatrix was behind, and  though the inner condyle, from being
an inch longer than the  other, could alone rest upon the artificial limb, he
has, nevertheless, always been enabled to walk as well as if he had un-
dergone amputation  below the joint.
   Since that period, the disarticulation of the  leg  has been performed 
               AMPUTATION  OF THE LOWER EXTREMITIES.           239

once  with success, by M. Nivert of Azai-le-Rideau, on an adult man,
who had his limb  shattered by the discharge of a musket, M. Baudens,
.(Bulletin de VAcadimie  Royale de Midecine, t. I.,) has published an
additional case ; M. Chaumet has informed me of another successful one
by M. Pichozel;  and an American surgeon  has related to me that he
has performed it twice with a fortunate result.  Some other practition-
ers have not  had  the  same  good fortune.  A patient operated upon by
M.  Jobert,  (Plaies d? Armes-d-feu,  p. 293,) died  in  consequence of
suppuration in the thigh.   M. Laugier, who performed it twice, lost
both  his  patients, and I have seen  myself four fatal  terminations.  It
is true that  in all of them the amputation  was performed under the
most  unfavorable  circumstances.  I am  informed by M. Blandin, that
the state of  his patient scarcely allowed of the slightest hope,  even
before the operation.   It was  the same  with  two patients on  whom I
performed this  operation at La Pitie,  in 1831.N  The one old man, with
gangrena senilis, died on the  twenty-eighth day in consequence of the
mortification having reappeared in the stump.   The other, an extremely
fat woman, with an enormous encephaloid cancer of the leg, which pre-
vented  me from  preserving the  integuments, except on the inner side,
was attacked with an  extensive suppuration throughout the body of the
thigh, and with a  large  ulceration  upon  the  sacrum ; she died on the
sixty-second day, without there ever having appeared, however, anything
of a bad  character in the wound itself.  One of M. Laugier's patients
had at the same time a comminuted fracture of the thigh ; and one of
those upon whom I have performed the operation at La Charite, a woman
seventy-six years  of  age, died, exhausted in consequence of the long
continuance of her sufferings.  I should add, however, that my fourth
patient, who was a man of 47 years of ago, was strong and in favorable
conditions.  I fear, therefore, that I may have  exaggerated the  safety
of this operation when I attempted to  revive it in 1830, (Archiv.  Gin.
de  Mid., t.  XXIV.,  p. 44.)   It remains  proved, however, that the
objections which have been made against it have no solid foundation:
1, By exposing, it is  said,  large and cartilaginous surfaces,  we incur
the risk of formidable accidents.  But this cartilaginous plate  which
invests the condyles, is a protecting covering, entirely destitute of sensi-
bility, and which will  remain for weeks entirely denuded, without the
slightest inconvenience resulting from it.   As  the pretended synovial
membrane, which Bichat has provided it with, does not exist, it is ut-
terly  impossible for this surface to become inflamed ;  2,*It produces an
enormous wound, which it is next  to impossible to cover  by  the sur-
rounding  soft parts.   This is a mistake.   This wound, so vast in ap-
pearance, is  reduced, on a close  examination, to a  division of the
integuments, and some fibrous layers and  muscles.  Provided the skin
can be preserved to the extent of two  or three inches, it is always quite
sufficient  to  procure  immediate  reunion.  3, This  wound is  made on
tissues which are not capable of becoming inflamed to the degree required,
or which  do  not allow of a prompt and solid  cicatrix, as  in the fleshy
part of the limbs.   Persons  are deceived on this point as well as on tho
other.  Nothing is better than  the  cutaneous teguments ; this  alone is
perfectly  adequate  to the formation of a good cicatrix.  Let the whole
synovial  surface of the  condyles be  covered  with it, and it  will ag- 
240
NEW ELEMENTS  OF OPERATIVE SURGERY.
glutinate as well as upon the cut surface of a bone or large-sized muscles.
4. This operation being more painful and more  difficult, is not followed
by as rapid a cure as an ordinary amputation.  This objection is not
more solid than  the  preceding ones ;  as the facts above indicated suffi-
ciently  establish.  5. Another  objection, and one which has been most
insisted upon, is, that it leaves  the patients  after the cure  in the same
state as those  who have had the  thigh  amputated, that is to say, that
they are compelled to walk with a cuish instead of a wooden leg.   I
confess  that this,  for a  long time, was an objection in my  mind.  But
this  is one, in fact, which it is not necessary to discuss at present, as the
cases I have related are before  us to determine its just value.
  What then should be  the reasons that ought to induce us  to proscribe
it ?  After amputation of the thigh, however  low down we may perform
it, the point d'appui, for the artificial  substitute, can only be made upon
the ischium.  The motions of the haunch are almost completely abolished,
and  progression is made in the same way as  if the coxo-femoral articu-
lation was anchyiosed.   After  disarticulation  of the leg, however, the
point d'appui is found  at the  extremity of the  femur.  The thigh pre-
serves all  its movements, and the  patient is in the  same condition as if
he had a simple  anchylosis  of  the knee.  If  it be true that, in respect
to the functions of the limb, it is infinitely better to perform amputation
of the leg in the  continuity than  to perform it upon the thigh, the ad-
vantages of disarticulation at the knee should equally be deemed to be
placed beyond all dispute, because the  weight of the body is transmitted
to the artificial limb in the  same way after  this last  operation as after
the  first.   The  wound in the  one  belongs almost entirely to the skin,
and  involves no bone and no aponeurosis  ; the surface to cover is convex,
regular, destitute  of every  kind of roughness, and has nothing to fear
from muscular retraction.   In the other, on the contrary,  the solution
of continuity comprehends  a  vast enveloping aponeurosis and  all  its
concentric laminas, muscles without number and of considerable volume,
a bone which is denuded  with  the greatest facility  and whose section
produces  a concussion  which  is far from being always without danger,
and, finally, the entire cellular tissue which  unites all these various parts.
In the knee, one artery  alone of any  considerable  size is divided ; tor-
sion  or compression-controls this almost with as much  certainty and ease
as the ligature.  At the thigh,  besides the principal  artery, we  have a
multitude  of secondary branches, which all  require to be tied with care.
  If the amputation of the leg in the  contiguity is dangerous, it is be-
cause of the  large and deep  synovial cul-de-sac  which is prolonged
upon the  sides of the condyles, and   upon the  anterior  surface of the
femur.  Purulent inflammation, if once established in this cavity, becomes
almost as formidable as in a great articulation.   Soon reacting upon
the body of the thigh, it creates there a swelling, an erysipelatous blush,
and  a cakiness, which  are not long in extending outwardly to  the hip—
ending  in suppuration  and abscesses, which pervade the whole extent
of the muscular tissues.  It was  from these causes  that three  of my
patients perished, as well as those of MM. Blandin, Jobert, and Laugier.
The boy operated upon by M. Richerand  experienced similar accidents ;
and  ivhen they  make their appearance, there  is real cause for serious
apprehensions.   If this  cause of dangers could  be abstracted, my first 
AMPUTATION OF  THE LOWER EXTREMITIES.
241
opinion on amputation at the knee would remain correct.   The disar-
ticulation  of the leg, therefore, without being a serious  operation  for
the reasons put  forth by the surgeons of the present time as by those
of the last century, is, however, on  the  other hand, sufficiently so not
to be undertaken when it is possible to amputate lower down.
   [In the New-York Journal of Medicine &c. for November, 1852, Dr.
Stephen Smith gives us the  following general summary of the operation
of amputation  at the knee-joint.   Of 86  cases, 37  died.   Among the
British surgeons who have most  frequently  performed this operation,
may  be mentioned Mr. Syme and Mr. Fergusson.   The latter thus ex-
presses his opinion  of the operation, in the  last (3d) Lond. edition  of
his Practical  Surgery, p. 502 :
   " There are many instances  of incurable  disease of the knee-joint
where the serious  mischief is limited to little more than the articular
surfaces;  in such cases, however great the surrounding swelling may
be, as also in all examples where the whole of the leg must be sacrificed,
whether for injury or. disease, Mr. Syme proposes to substitute this opera-
tion for the proceedings hitherto performed higher up; and in several
cases of the kind which  he has  published, and many occurring in my
own practice, the results  have  been so satisfactory  that I am disposed
to consider the operation well worth the attention of the profession."
   He has  given a wood-cut of a stump made by this  method, in 1845,
which he thinks is equal to any he ever made in the thigh.   This opera-
tion  has  been performed several  times in this city, during a compara-
tively recent period, by Drs. Parker, Watson and others, but the former
named gentleman does not speak of it in very favorable terms.   G. C. B.]
   C.  Operative  Process.—The patella, which J. L. Petit recommends
should be  removed, should always be preserved ;  the muscles  raise it
up, and soon  fix it above the condyles, where it can  neither interfere
with  the cicatrization, nor with the uses of the stump after the cure is
completed.
  I.  Process  of Hoin.—The process of Hoin, carefully described by
Brasdor and the only one mentioned by French authors, and which con-
sists in penetrating  the joint below  the patella from  before  backwards,
in order to termimate by cutting a large flap at the expense of the calf,
has more than  one inconvenience.   The anterior lip of the wound, drawn
upon  by the action  of the muscles  and the natural retractility of the
tissues, often afterwards  ascends above the cartilaginous surfaces.  Its
angles, now flaring  open and pushed back by the lateral  projection of
the condyles, soon leave a portion of the  bone denuded, in spite of  all
we can do.   The flap, always thinner at its  root than at its point, is
badly adapted to the  parts which it is intended to cover.  The state of
the tissues, also, sometimes renders it difficult to give it sufficient length
to bring it with ease to the  border  of the  retracted patella.  Finally,
it is rare in fact that the cicatrix is sufficiently high up to leave no room
to apprehend some degree of pressure upon it in walking or standing.
  II.  Process  of Leveille.—If we  confine  ourselves, after the manner
of Leveille, (Nouv. Doctrine Chir.,) to cutting a flap at the  expense of
the soft parts  anteriorly, we can rarely give extent enough to it for the
cicatrix to become sufficiently remote from the point  d'appui of the con-
  Vol. II.                  31 
242
NEW ELEMENTS OF OPERATIVE SURGERY.
 dyles.   Moreover, this mode of operating has not been  noticed in any
 work, except perhaps that of Monteggia, who barely alludes to it.
   III.   Process of 31. Blandin.—Nor  can I perceive what we should
 gain by commencing, instead  of finishing, with  the  posterior flap ; nor
 what good would  result  from making a precautionary counter-opening
 in the hollow of the ham for the passage of the ligatures and pus, as is
 proposed by M. Blandin.
   IV. Process of M.  Smith.—By cutting two flaps, as suggested by
 M. Smith, or rather  by Beclard, as I am informed by M. Hid mas, who
 assisted at the operation upon the child  mentioned farther Inek, we are
 not  under the  necessity of borrowing  so  much tissue  from  the  calf.
 Compelled to adopt this  process with  my first  patient,  I acquired the
 conviction that it presents at least as many advantages as  those of Petit,
 Hoin, and Brasdor.  Whether, however, there be one flap or two, noth-
 ing can prevent their shrinking and retracting as they thicken, and  con-
 sequently their  leaving a greater  or less  considerable  portion  of the
 condyles entirely denuded ; from  whence it results that the cicatrix in
 this part can  never be completed, except by a tissue of new formation.
  V. Process of Rossi.—The method of Rossi, (Mid. Opir.,  t. II., p.
 227,) which  consists in cutting one flap upon  the inside and the other
 upon the outside, instead of in front and behind, though  still  more ob-
jectionable, is not, however, to be wholly rejected when the skin  is
 much less altered upon the sides than any where else.
  VI.  Ovalar Process.—M. Baudens, (Bull, de VAcad.  Roy. de Mid.,
 t. I., p. 325,) by dividing  the skin in  front an  iuch  lower down  than
 behind, obtains a wound of an oval form, whose apex  terminates in the
 ham.   M. Sedillot, who arranges his  oval  in  an inverse manner, is
 obliged to prolong its point towards the patella.  In one case I was my-
 self  obliged to place the oval transversely ; but these  processes, though
 useful  where the integuments are  degenerated  higher up in one  direc-
 tion  than in another,  are,  as a general method, less  suitable than the
 following.
  VII.  New  Process.—a. In  the process which I have adopted, the'
 skin is divided circularly, at three or four fingers' breadth below the
 patella, and without involving the  muscles.  In dissecting it, to raise it
 up, or to reverse it outwardly, we must take care to preserve the ccllulo-
 adipose layer, which lines its inner  surface, and also not to strip  it  of
 its sanguineous  capillaries.  An  assistant is immediately to seize  hold
 of it, and draw it back to the knee, until the ligamentous  patella  having
 been divided, the  instrument can  strike upon the inter-articular line ;
 the surgeon then divides the lateral ligaments, widens the osseous sur-
 faces by making slight  flexions with  the leg, detaches the semilunar
 cartilages, completes the section of the crucial ligaments, traverses the
 joint, and terminates by dividing,  with a single  stroke of the knife, the
 vessels, nerves, and muscles of the ham perpendicularly to their track,
 and on a level with the raised-up integuments.
   b. Dressing.—After having tied or twisted the popliteal artery, and
 the less important branches which may require it, the operator  draws
 towards him all the skin that has been dissected, cleans it, and if his
 intention is to effect immediate re-union, approximates the lips in such
 manner that the angles  of the  wound may be placed  transversely. 
AMPUTATION OF THE LOWER EXTREMITIES.
243
Upon the supposition that primitive union cannot be attempted, a per-
forated  linen  should be applied  upon the whole of the wound, which
should then be filled with small balls of lint, (see Vol. I.,) and these
are to be covered with soft plumasseaux, (of lint,) and the whole sup-
ported by an ordinary containing bandage.
  c. By this  method the integuments  represent a species of purse, or
ruff, which envelop and  cover the condyles as well upon the sides as in
front and behind.  As its mouth has a diameter somewhat less that its
bottom, it is in the condition of a tight sleeve which one should attempt
to slide up from the wrist towards the elbow, that is  to say, that it has
very little tendency to slip up towards the  thigh.  The muscles being
divided square off at their root, where they are. very thin, can give place
only to a very  small  bleeding surface, while they leave the  skin  free,
and can no further aggravate the traumatic inflammation, or give appre-
hension of too abundant a suppuration, as in the other processes.  Fi-
nally, the ligatures, if these are used, are applied with facility, assembled
together at a point nearly approximated to the  vessels  they  embrace,
and in such manner as to irritate but  to a very trifling extent the inte-
rior of the wound.
  VIII. I do not wish to be understood, however, from these remarks,
that all the other processes are henceforward to be discarded as useless.
If the skin should be found to be too much altered in front and without,
being so much so behind, we must  rely on the method of Petit.  The
process of M. Smith, would to some extent, become a matter of neces-
sity, if the degeneration  proceeding higher up on the  sides towards the
condyles than  on the anterior and posterior surfaces, had already traced
out the  limits  of the flap to be formed.   But in otVier cases, so often as
circumstances  admit of a choice, the circular method offers indisputable
advantages, and deserves to have a general preference.

                 [Amputation at  the Knee-Joint.

  M. L. Blaquiere (Jour, des  Connaiss., &c, Paris, Aout, 1844, p. 60,
&c.) states, that while in Mexico, in 1833, he amputated at the Hospital
of Saint Juan de Rio de Oaxaca, the right leg at the femoro-tibial artic-
ulation, in an  Indian, aged  about 25, of the village of Tlacolula, in
whom  the  whole leg, to within a few inches of the  knee, had  become
sphacelated from hot bricks, used during  the  cold  stage of,  Asiatic
cholera, then prevailing in that capital.  M. Blaquiere did not wait for
the limitation  of the  gangrene,  as the  patient was in good  condition,
and without fever.  He adopted  the process of our author, M. Velpeau,
and  had every  reason to be satisfied with it;  for although the ruff of
integuments intended as a flap to the condyles, also sloughed away, and
the cartilaginous incrustation of the articulating surface of the condyles
exfoliated, the  surgeon, in another  visit to  Mexico, in  1843, found, on
a visit from the patient, that the wound had perfectly healed, with a very
small cicatrix, and that the limb had been made  very serviceable by an
apparatus which the  patient  had  contrived.  M. Blaquiere is strongly
in favor of disarticulations, wherever they can be performed, in preference
to amputations in the continuity.  He considers the accidents in the
latter, from the masses of muscular and  aponeurotic  tissues and large 
244
NEW elements  OF OPERATIVE surgery.
 trunks that have to be divided, and which give in the thigh particularly
 so enormous a wound to the stump, as infinitely more dangerous.  This
 disarticulation, has been practised in two instances with entire success
 by M. Murville, Surgeon  in Chief of the Military Hospital of Lille,
 (Gaz. Mid. de Paris, November 31, 1845.)  In one, an infant aged 20
 months, whose leg was crushed by the wheel of a carriage on the  middle
 portion of the limb, sphacelus  supervened and extended to about a fin-
 ger's  breadth from the  inner  tuberosity  of the tibia.  The  gangrene
 becoming limited, the leg was  amputated in June, 1845, at the knee by
 a circular incision, preserving  as much of the skin as possible in front,
 and of the  tissues  of the muscles posteriorly, the latter in order to fill
 up more perfectly  the  inter-condyloid notch.  Union  was  effected by
 first intention by means of four sutures and some adhesive  straps ;  and
 in order to  prevent more effectually the admission of air into  the supra-
 patellar  synovial cul-de-sac, the  lodgment of pus there, and infiltration
 of liquids into the cellular tissue of the popliteal space, two  graduated
 compresses  were applied, the one in front and the other  behind the ex-
 tremity of  the  stump.   On the tenth  day all the  ligatures, including
 that on the  popliteal  artery, had  come away, and  the wound was per-
 fectly  cicatrized.   Forty days after the  operation a wooden leg was
 adapted to the stump, which latter was as excellent a one as could  be
 desired.   The amputated limb  became perfectly developed, and the pa-
 tient, at the  time the case was drawn up, (by M. Ollagnier)  could  use
 it with astonishing  facility.
   In the other case, a man aged 48, the  tibio-tarsal  articulation was
 crushed by a block  of wood, and from neglect to attend to the patient
 violent inflammation had ensued, involving the whole leg in gangrene;
 after  reducing which by suitable  means, and especially by four deep
incisions in a direction with the axis of the limb, each from 5 to 9 inches
long, and'two of which  were in the anterior and two in the posterior
tissues, besides dividing the aponeuroses  transversely  to their  fibres,
the gangrene was in this manner by the sanguineous depletion and  the
elimination of the purulent collections, finally localized and limited.
  The mortification having extended  as  in the  other case to within a
finger's breadth of  the anterior spine of the tibia, it was concluded to
amputate at the joint, and not to  defer it  any longer for fear of puru-
lent  absorption.  The operation was performed 16 days after the acci-
dent by the  flap method,—one  incision which was circular and in front
and  two fingers' breadth below the patella, being  extended  from  the
lateral internal to the lateral external part of the knee, while the other
incision was made posteriorly so as to procure a thick flap in the tissues
in that direction.  Ten  ligatures were used, including that on the pop-
liteal artery; the wound was united by six sutures and adhesive straps,
with graduated compresses as in the other case, one above the patella,
the other on  the inter-condyloid  space.  The operation was accomplished
in 30 seconds.  Sixty-two days after the  operation an excellent  linear
cicatrix was formed, situated transverse to and at the apex of the stump,
which  latter it divided into two parts, one anterior and rather small, in
which was comprised the patella strongly retracted and slightly movable
at its  inferior portion; the other posterior in which was included the
most projecting point of the condyles.  On this latter portion fell the 
AMPUTATION OF THE LOWER EXTREMITIES.
245
pressure  of the wooden leg, which  he continued to use up to the last
date (Oct. 10, 1845) with as much ease as if he had been operated upon
at the place of election.
  Mr. Syme strongly urges amputation at the knee-joint, in other words,
disarticulation of the  leg at its tibio-crural  extremity, or amputation
immediately on the  condyles of the femur, close above the line of the
articulating surfaces, in every case where  it can possibly be done in lieu
of the prevailing modes of sawing through the shaft of the thigh bone,
at its middle  portions.   The next best place of division above, when it
cannot be done at the knee or condyles, he considers to be the  trochan-
ters.   All this practice he claims to himself the merit, in some measure,
of having first endeavored to generalize and render popular, (Cormack's
Lond. 8f  Edinb. Monthly Journal  of Medical Science, May, 1845,  p.
338, et seq.,)  as he had previously  enforced (lb.) a similar practice  in
regard to the  preference to be given to disarticulation of the ankle-joint,
if it is possible to avoid  section of  the  bones  of the  leg.  Mr. Syme
says the stern evidence of hospital  statistics still shows the average of
deaths not less than  50 to 70 per cent, in  amputations of the thigh, i. c,
in the  continuity, together with the frequent annoyance in many of the
survivors, of a protrusion of bone, accompanied sometimes with those
tubular or conical exfoliations, as they  may  be called, which  he  has
seen  extending into the interior of the  femur for  several inches, and
which have to be extracted from the  stump.   Diseases of the knee-joint,
as caries, and compound fractures  of the  leg and  thigh, and tumors
growing from the bones of the leg and thigh, are the cases which most
frequently demand, especially  the former, the process recommended by
Mr. Syme.  Diseases of the knee-joint,  however  great the  scrofulous
degeneration  and suppuration, may  be effectually  cured, the Professor
of Edinburgh  says, by  sawing  through the condyles a few lines above
the articulating  surfaces, as is proved by his  successes in these opera-
tions, and in his excisions of the elbow-joint, (See supra, in Vol. I. of
this  Amer. edit, of Velpeau,) and amputations at the  ankle.   For the
same  reasons, in  compound fractures of the leg, where the muscles or
integuments of the  thigh  would admit of amputation at its  middle or
lower  third, we ought to give the preference to the section at the con-
dyles.   So also, similar injuries of the thigh obviously  require amputa-
tion at the trochanters.   These modes, he believes, would be eminently
successful, and we are  encouraged so to think, he  says, from  the fact
that  out of twelve cases of amputation at the ankle-joint, in his own
practice, and  as many  more  in that  of other  practitioners, who have
been induced to adopt it, this operation (at the  ankle-joint) has not in a
single  instance, been followed by either the death of the patient, or ex-
foliation of the bone—even in cases where he would have declined am-
putating the leg as altogether desperate.
  A modification  of amputation at the knee-joint immediately above the
condyles,  so warmly insisted upon  by Mr. Syme, has been proposed
and found to answer excellently well by Mr. Fergusson, at King's Col-
lege  Hospital, London.  In a case aged 24, where  the left knee-joint
had been  for a length of time enlarged, with abscess and  more or less
pain on moving the joint, Mr. Fergusson  made a transverse incision in
front above the apex of the patella, then  plunged his knife transversely 
246
NEW  ELEMENTS  OF OPERATIVE SURGERY.
 in front of the ham-strings, cutting out a long thick flap from the calf,
 which, after dividing the femur close above the condyles and patella
 was  brought up into neat coaptation in front, healing nearly all by first
 intention, and forming a capital  stump.  The  surgeon  of London was
 led to this modification after having made up his mind to give Mr. Syme's
 favorite place for amputateing the femur below, a fair trial.  It certain-
 ly strikes  us as one that will prove useful in such cases.  Difficulties
 were found, however, in securing the popliteal artery from the morbid
 alteration and condensed hard character of the tissues around it.  Mr.
 Fergusson  considers Mr. Syme's arguments, (which we  have  stated in
 the text,) in favor of this amputation as evidently well founded, to wit,
 the less danger of inflammation and necrosis in the spongy condyles, than
 in the solid shaft, and also avoidance of the danger of dividing through
 the joint itself.  It  is become an axiom also, as Mr.  Fergusson says,
 to exsect  no more than necessary, as is seen (See our notes) in scoop-
 ing and trephining  out the carious part only of joints, small bones, shafts
 of long bones, i.  e., what is degenerated, and no  other portions in other
 words, pro  hac vice, and no  mode, (See London  Lancet, July, 1845, p.
 79.)  T.]
   [The following note to Dr.  Simpson's Statistics in Surgery, published
in the Edinburgh Mmthly Journal, Nov, 1847, p. 322, is worthy of re-
cord in this place
  " In  the  first observations which Mr. Syme published on amputation,
 (Ed. Med.  and  Surg.  Journal, Vol. XXL, p. 31,) he  strongly  main-
tained  that  ' the circular mode of  amputation is  in every point of view
bad ;' and, writing in 1842, he still held that ' amputation of the thigh
ought always to be performed by making flaps.'  (Principles of Surgery,
p. 156).  In 1845, Mr. Syme believing, from statistical evidence,  ' that
there is something  radically wrong in the  principle' of amputation of
the thigh, both by the flap and circular methods, proposed in their stead
amputation of the knee ; and thus dividing the thigh bone through its
condyles, instead  of through its shaft.—(See Month. Journ. May, 1845,
p. 337).  In the same Journal for November, 1846, (p.  225) he does
' not persist in advocating amputation at the knee,' but  avows himself
now satisfied that the old circular method of amputation may  be ' em-
ployed  at the lower  third of  the thigh  safely and advantageously,' and
should  be preferred to the flap operation at a  higher part of the limb,
when the circumstances afford room for choice."  G.  C.  B.]

            Article VIII.—Amputation  of the  Thigh.

                      § I.—In the Continuity.

   A.  In the thigh, quite  differently from what we do in the leg, we al-
 ways  amputate as  low down as  possible.   The more length the stump
 has the easier it is to  apply  artificial limbs.   The operation in  itself
 one of the most  dangerous, is so much the  more so the nearer we go to
 the trunk.   M. Langenbeck has recommended never to perform it at less
 than six fingers' breadth above the knee, alleging that lower down the
 artery  is  found  imprisoned, as it were, in the sheath  furnished to it by
 the adductor muscles, and from  which it would  be difficult to draw it 
AMPUTATION OF THE LOWER EXTREMITIES.           247
out in order to apply the ligature.   But whether the femoral artery be cut
above or below the fibrous canal it traverses, or in the canal itself, there
cannot in any case be any very great difficulty in seizing it, and  no use
certainly in dividing its sheath afterwards.  As it is rare, on the other
hand, that the disease allows of our  making the  incision of the integu-
ments at less than two or  three  inches  above the patella, the result is
that the  section of the femur is almost always made  at more than five
inches above  the  articulation, and that the  precept of M. Lagenbeck
therefore is superfluous.   [By the note above it will be perceived,  that
so far from approximation to the trunk being deemed by some practition-
ers the  measure of danger for the  femur,  Mr. Syme of Edinburgh  will
scarcely any  longer  hear of  an  amputation on this bone  except  at one
extreme or the other, to wit, at the trochanters or the condyles, and ne-
ver in the shaft.   T.]
   B. Anatomy.—As in the  arm, we find in the thigh  two layers of
muscles ;  one superficial, composed of the  rectus femoris, the sartorius,
the gracilis, the semi-tendinosus, and semi-membranosus, and the  long
portion  of the biceps flexor curis ;  the other layer deep seated and com-
prising  the three  portions of the triceps and  the adductors.  The first
reaching from the  pelvis to the leg, and each  having in some sort a dis-
tinct cellular sheath  which enables them to glide over each other  easily,
necessarily possess a very great degree of retractility, and to a greater
extent  the lower down we  make  their division ; the intimate union of
the others on the contrary to the bone prevents their  having more  than
a very limited power of retraction ;  from  whence it is that it is  the su-
perficial layer of muscles only, which after amputation sometimes leave
by theft retraction the femur uncovered, and thus gives rise to its pro-
trusion.   Near the pelvis we have, moreover, the psoas muscles and the
iliacus  internus, the glutaeus maximus, the pectineus ; then very  high
up the  glutaeus medius and  glutaeus minimus, the  obturators, the ge-
melli, the pyriformis, and the quadratus femoris, which by the distance
from their point of origin, would tend much more to enlarge the  wound
than to  denude the bone, if the amputation should be performed between
the little trochanter  and the hip [joint.]
   The femur being a little curved forwards at its  middle part, is covered
in front by a thinner tissue of soft parts and  by  muscles much less re-
tractile than it is behind.  From whence it happens, that in amputations
of the thigh the  cicatrix almost  constantly  inclines a little  more or a
little less backwards and inwards, and  that the  extremity  of the  bone
scarcely ever corresponds with the  centre of the  stump.  The crest
which the bone presents on  its posterior part, constituting the termina-
tion of a cylinder  of sufficient regularity, easily splinters under  the ac-
tion of the saw, and  is a point, therefore, that  we should  be  on our
gaurd against during the operation.
   The femoral artery is the only  inportant trunk  we meet inferiorly.
Being hidden behind the sartorius it is always easy to find.   The great
anastomotic, however, is not to be forgotten.  As it is sometimes envel-
oped in the fibres of the third adductor, whose  direction it takes, it is
in certain cases very difficult to isolate.   The  profunda and the perforat-
ing arteries, and nearer still to the pelvis, the superficial muscular artery
and the circumflex arteries,  must be added to the femoral; the first on 
248
NEW ELEMENTS OF OPERATIVE  SURGERY.
 the front of the adductor muscles or in their substance ;  the second, under
 the rectus femoris;  the two others on the inside and outside a little above
 the small trochanter.
   The femoral vein is so closely connected with the artery that the pres-
 sure upon  the  latter  prevents the blood  ascending in the former, and
 thus frequently  becomes the cause of hemorrhage.   The great sciatic
 nerve, free at the posterior part of the thigh in front of the  superficial
 muscles, and destitute in itself of the least  retractility, is found some-
 times pendulous at the bottom of the wound, beyond the level of which
 it may project for more than an inch, making the dressings exceedingly
 painful.  The best thing then to be done would be, as advised by Descot,
 (Affect.  Locales des  Nerfs, 1825,)  to divide  it immediately.  Another
 nervous branch which also requires some attention is that which accom-
 panies the crural artery.  Its small size  prevents it from being readily
 distinguished.  Taking  care, however, to recollect  that  it is always  on
 the inner and anterior side of the artery or vein, there will not be much
 difficulty in finding  it  and pushing it aside.  Inasmuch as it is quite
 possible that  much of the pain of which persons amputated complain,
 in assigning it to the limb  they have lost, may be caused by the ligature
 embracing certain nerves,  it is necessary to avoid these cords with care
 while tying the arteries.
  B.  Operative Process.—I.  Circular Method.—All that has been said
of circular  amputation in  general, specially applies to the thigh.  Of
all the amputations in the  continuity, this being the one that is  the most
serious and dangerous, is that  which has  particularly interested  the
attention of  Fabricius  of  Hilden, Wiseman, Pigray, J. L. Petit,  Le
Dran, Louis, Pouteau, Valentin, Alanson,  Hey, Desault, &c, iff their
treatises on removal of the limbs.
  a. First Stage.—The patient being placed  at the foot, or on the edge
of the  bed, or on a table,  and his thigh  left  free up to  its root, is sup-
ported by four or five  assistants, one for the head and arms, another for
 the pelvis, a third for the  sound limb, a fourth for the limb on the dis-
 eased side,  and a fifth to raise up the tissues.
  The tourniquet, or the garrot which some still use at the present day,
 and all kinds of bandages that were formerly in use above the point
 where the  tissues are to  be divided, in order to prevent hemorrhage,
 would prevent or, at least, interfere  too much  with the retraction of the
 muscles,  and should  be dispensed  with.  The  practice of Louis and
 Bordenave, (Mini, de V Acad. Roy.  de Chir.,  t. V., p. 59—60, in 4to,)
 adopted by almost all the moderns, and which consists in making pressure
 upon the artery on the body of the  pubis, as it relieves us from this  in-
 convenience, deserves the preference which is generally accorded to it.
 Noel, (Riponse aux  Quest, proposies par la Com. de  Sante", p. 24,)
 whom  the  commission of  health  asked which it was,  the garrot or the
 tourniquet,  that was  employed  in  the  army, replied:—" There  is  no
 Ion o'er any more talk in our army of the tourniquet and  garrot, than  of
 a Jubilee to the Jacobins of Paris. "   A pelote, pressed by an assistant
 against the femoral artery at its egress from the lower belly, for ampu-
 tations of  the lower extremities, or applied with force  under  the arm-
 pit for those of the upper  extremities, is advantageously substituted  for
 those two pernicious instruments which have been the subject of as fierce 
AMPUTATION OF THE LOWER EXTREMITIES.
249
disputes, he says, as the  treaty of grace.  The surgeon, unless under
peculiar circumstances, would not be excusable in following the ancient
method except there should be a deficiency of intelligent  assistants.
The inguinal  bandage, devised by Pipelet  (see  Atlas  de  VEncyclop.
Mith.,) at the suggestion of Louis, is  also useless.   Siegen,  observing
that the tourniquet was displaced  in a patient that Boon (Richter, Bib-
lioth  Chir., t. X., p. 462)  amputated,  placed his fingers in the groin,
and arrested  the  hemorrhage, so that Boon, who  otherwise  preferred
the tourniquet to benumb the limb, already advises, at this  epoch, to
make  pressure in  the groin with  the fingers upon a bandage rolled in
the form of a pelote.   In every case the tourniquet was to be placed as
high as possible.   In order that the root of the limb may always be em-
braced with the left hand, it is the practice in England for the  surgeon
to place himself always upon  the right side of his patient, so that in
amputation of the left thigh, the sound limb is interposed between the
operator and  the  limb  to  be removed.   There is  no occasion for  my
criticising a rule  like this, as every person  among  us will give it  the
name it merits.  In France,  the surgeon places himself on  the outside
for both limbs, which puts him under  the necessity,  for the left limb
only, of consigning to the assistant the entire  duty of  raising up  the
integuments and muscular tissues.
   b.  Second  Stage.—The first stroke of  the knife, which ought to
comprise, as far as  possible, the whole thickness  of the  integuments,
is made, in the first place, above the knee at  four or five fingers' breadth
from  the point  where  the  section  of the  bone  is to be  performed.
Whether we reach or not the aponeurosis and subjacent muscular fibres,
is a matter  of no  consequence ; the important point is, that the  skin
shall  have  been completely  divided.   In order to favor its retraction,
while  the  left hand of the  operator or that of an assistant draws it
back, it is  important to recollect, that in front of the  borders of the
ham,  it adheres  more  closely to the  aponeurosis than anywhere  else,
and that, in this place, it is usually attached  to the bottom of the supra-
condyloid grooves.
   c  Third Stage.—The knife being  reapplied on a line with the re-
tracted integuments, divides the  muscles, if not down to the  bone, at
least  through the superficial -layer.  After having drawn back this first
layer, the surgeon applies the instrument upon the base of the cone
which is formed  by it; divides, with  a third stroke of the  knife, the
remaining fleshy fibres; lays  bare the femur; applies the split compress,
crosses its two tails in front; divides the few tissues  which may be  still
adherent to the osseous portion which he is  about to remove, and saws
immediately  through the bone at  five  full  fingers' breadth above  the
first incision.   M. Van Onsenort, who places himself on the outside of
the patient,  divides, with  the first incision,  the  skin  and all the  soft
parts  on the inner and posterior  side of the thigh down to the bone.
While the divided muscles are contracting, he completes the section on
the outer and anterior side, and terminates the operation by taking care
to cut on a line with the extremities of  the contracted muscles.  I have
followed this process without having any reason either to complain of
or to  applaud it.
   Above the  middle part of the thigh, the  muscles retract much less ;
   Vol. II.                    32 
250
NEW ELEMENTS OF OPERATIVE  SURGERY.
 but as the volume of the limb is more considerable, we must here also
 commence at four inches below where the section of the bone is to be
 made.  Nearer  still to the hip, perhaps there would be some advantage
 in  making use  of M.  Graefe's buckler knife, in order to form a funnel
 out of the soft parts, or we might divide them as Alanson or Dupuytren
 does  by inclining the  blade of the instrument upwards.  In fact, their
 section perpendicularly makes almost a square-shaped wound, whoso
 borders it is sometimes very difficult to bring into  contact.   Also, it is
 an  inconvenience which may easily be avoided by taking the  precaution
 to dissect the skin to the extent of two inches, and  of reversing it back
 upon  its outer surface, in place of confining ourselves to  the division of
 the cellulous bridles which unite it to the aponeurosis, as in the process
 of Desault.  I have seen M. J. Cloquet unable to effect immediate reun-
 ion, in consequence of  having neglected this  precaution at the Hospital
 of Perfcctionnement, in the case of a young man in whom he had  been
 compelled to amputate  the thigh at a short distance from the great tro-
 chanter ; and the same thing  has happened to me from not having been
 enabled to observe this rule in a similar case.
  d. Fourth Stage.—The arteries that are to be tied or  twisted are the
femoral, the  great anastomotic, and  some branches of the articular ar-
teries, or of the last perforating artery below.  Their number increases
the  higher up we go;  so that above we have, moreover, the profunda,
the  superficial muscular arteries, and some branches of the circumflex
arteries, and of the  obturator and ischiatic.   With the veiw of facilitat-
ing the discharges, the French surgeons give such direction to  the wound,
that one of its angles looks forwards, while the other is  turned directly
backwards.  Some  practitioners of  Great  Britain  censure  this mode,
because, say they, the posterior angle of the  wound must necessarily  in
this manner, press upon the cushion or mattress.  Hennen, among others,
recommends that the tissues should be approximated from before back-
wards, and a transverse direction be given to the wound.  But, without
being  absolutely  essential, the French method is  evidently the best.  In
respect  to the position of the stump after the dressing, I have only  to
refer to what  I have said on this subject farther back.   I will only re-
 mark  that it is  difficult to give to its wound  an  inclined position.   For
 it would be necessary  for that purpose when the patient is in bed,  to
 make  a degree  of  extension  which  might be injurious, and which the
 natural action of the psoas and iliac muscles would render very fatiguing,
 if not  impossible.  Instead of a thick cushion, therefore, I place under
 the end of the stump only a simple folded aleze, (folded linen, see Vol.
 I.,) with the expectation, also, that the inferior angle of  the wound will
 occupy a more favorable position.
  If the torsion of the  arteries, which I have sometimes adopted, or the
 suture which  I have made trial of but in one case, would procure a re-
 union without  suppuration, they ought to be resorted to; but this result
 has not yet been proved up to the present time.   A child has been cured,
 it is said, in eight days.  In a patient of M.  Serre, ( Gaz.  Mid. de Paris,
 1836  p.'826,) nothing remained on  the tenth day but a few points in a
 state'of suppuration.  All this, however, does not furnish conclusive evi-
 dence.  The  cure  of one of  my patients, treated by simple approxima-
 tion  was effected on the twenty-second day;  others were almost entire- 
AMPUTATION OF THE  LOWER EXTREMITIES.           251
ly restored on the sixth, eighth or tenth day ; notwithstanding which, the
greatest  number were not  entirely well until  at  the  expiratipn of a
month or two!
  II. Fiap  Method.—Inasmuch  as circular amputation, by the modern
processes, when properly performed, generally admits of the lips of the
wound being brought together with facility, and of immediate reunion,
it has not  been thought necessary to make as varied trials of the flap
method above as below the knee.   Notwithstanding the  advantages that
Ravaton, Vermale, Le Dran and  Desault say they have  derived from it,
and  the  successes that  Paroisse had from it on the field of battle, and
although the  seven cases that Klein speaks of were almost entirely re-
stored in the  space  of ten days, and that M. V. Mott and many other
surgeons, German as  well  as  English, have also made trial of it with
advantage  in  these latter times,  it is, notwithstanding,  but very seldom
employed.   An objection made to it is, that it is more painful and tedi-
ous, which,  however, is far  from  being demonstrated;  also, that it re-
quires a greater  extent of sound  parts, which assertion, as it appears
to me, has  some  little more  foundation;  and that it  exposes to more
serious general accidents which,perhaps, so far as this last point is con-
cerned, may also  be  somewhat true.   I tried it but  once;  the bone
escaped from the upper angle of the wound, and the patient died.  Some
surgeons, as M. Guthrie for example, who, moreover, prefer  the circu-
lar  method, nevertheless have recourse to the flap  process where it be-
comes necessary to  amputate  the thigh at its upper third ; it offers, in
such cases, unquestionable  facilities for the approximation of the lips
of the wound.
   [Mr.  Guthrie in such cases gives the preference to the flap operation
as  modified by Mr.  Luke  of the London Hospital.  The patient being
so  placed  that the  thigh  projects beyond the table, the surgeon stands
with his  left hand towards the body, or on the outside, when amputating
the right, and on the inside, when amputating the left thigh.  The knife
to be used ought to be narrow, pointed, and longer by two or three inches,
than the diameter of the thigh at the place of amputation.  The point
of the knife should be  entered  mid-distance between  the anterior and
posterior surfaces of  the thigh, which may be effected with accuracy if
the  eye  is  brought  to a level with the thigh, when the middle point is
easily determined.  The posterior flap is to be formed first, by carry-
ing the knife transversely through the thigh, so that its  point shall come
out  on the  opposite side, exactly midway between the anterior and pos-
terior surfaces.  In traversing the thigh, the knife should pass behind
the  bone, and  will be more or less remote from it in different individu-
als,  according  to  the  greater or less development of the posterior mus-
cles, when  by  cutting obliquely downwards, to the extent of from four
to six inches,  according to the  thickness of the thigh, a posterior flap
is formed.  The  anterior  flap is effected, not by making a flap, but by
commencing an incision through the  integuments and muscles on the
opposite  side of the  thigh  to the surgeon, and at a little distance ante-
rior to the  extremity of the posterior flap.  This incision is made from
without  inwards, through the integuments, so as  to form an even curve,
and without angular irregularity, over the thigh,  to near the base of the
posterior flap  on the side on which the surgeon stands.  The  length of 
252
NEW ELEMENTS OF OPERATIVE  SURGERY.
   this  flap is determined by that of the posterior.  It will therefore vary
   Irom four to six inches, as before stated ;  and for its completion, will
   require  a second or perhaps a  third application of the knife.  In the
   two  flaps thus made, the division of almost  all the  soft structures is in-
   cluded, a  few only, immediately ^surrounding the bone remaining uncut.
   Those are to be divided  by a circular sweep of the  knife, at  the part
   where it is  intended to saw the bone ; and in this  way it is sufficiently
   denuded for the application of the saw.  The flaps  being held back, the
   bone is to be sawn through in the usual way.  If  the ischiatic nerve lies
   upon the surface of the posterior flap, it should be removed.   The whole
   surfaces  as well as the edges of the flaps, must be kept in accurate con-
   tact  by  means  of compresses, adhesive plaster, and sutures.  In the
   great majority of amputations thus treated, it is claimed that primary
   union has been secured, non-union of the flaps being the exception,—
   union, the rule.
     Mr. Luke's amputation  of the leg differs from that of  the thigh  in
   some particulars.  There  is a  greater variety in the proportion which
   the soft  parts  in the posterior  flap, bear to those  in the anterior: and
   the distance  from the  bones at which the limb is transfixed in the first
   step of the operation is  subject to such variety, that in the large calf
   the mid-point for the  introduction of the  knife lies at some distance
  from  the  posterior aspect of the bones ; in the small calf it is close to
  it.  The  course of the knife through the limb is oblique, instead of trans-
  verse, for the purpose of accommodating the line of incision to the plane
  of the two bones.  The  anterior flap has proportionately more integu-
  ments and is  thinner than in  the operation on the thigh, yet its base and
  length are rendered  equal to  the base and length  of the posterior flap,
   and may be adjusted evenly with it when the  stump is dressed (Guthrie 's
   Commentaries in Surgery, pp. 83, 97).
     Mr. Skey  states in his  Operative  Surgery, Lond.  Ed.  p.  323, that
   Messrs. Lawrence and Stanley, have almost abandoned the flap operation,
  as  did the late Mr. Bransby Cooper.  He himself  gives the preference
  to  the circular.   There can be no  doubt that it may be performed with
  the greatest   rapidity,  and  Mr. Skey remarks  that  he  has  by this
  method  amputated the  thigh "within half  a  minute."   In December,
  1853, we  removed a thigh, by  the  flap amputation, in  twenty seconds,
  and we have  heard  that it has been done in fifteen  seconds !  Mr. Fer-
  gusson and Mr.  Erichsen  give a decided preference to the flap amputa-
  tion particularly in the middle and upper third of the thigh.  G. C. B.]
     a.  Process of  Vermale.—Nothing  at  the  present time would induce
   any one  to employ  the 3  incisions of Ravaton, to  obtain the flaps that
'  we' may require.   It is infinitely more simple to plunge the knife at first
   through  the thickness of the limb, as has  been  recommended by Ver-
   male.  The patient and  the assistants being arranged as has been already
   described, the operator places himself outside for the right limb, and in-
   side for  the  left, which position, however,  could in a case of necessity
   be reversed;  he then  grasps the muscles  with his left hand and  draws
   them more or less from  the bone, plunges in  a long knife, so that it may
   fall upon the anterior surface of the femur at some lines  below the point
   where he wishes to make the section; he now slightly inclines the point
   of his instrument so  that it may graze the outer side  of  the bone ; and 
AMPUTATION OF THE LOWER EXTREMITIES.
253
immediately after directs it in such manner that it may come out from be-
hind  at the point diametrically opposite to that at which it entered ; he
then cuts from above downwards, and from within outwards, in order to
form  his outer flap, to which he gives a length of from three to four fin-
gers breadth, and which an assistant immediately raises up.  The knife
being brought back to the anterior angle of the wound, pushes aside the
tissues on the side of the axis of the body, glides upon the inner surface
of the femur, reaches behind  the bone, and in order not to cut the soft
parts posteriorly a second time, the surgeon  crowds them  back and
separates  them towards the inside ;  he  in this manner cuts out a second
flap of the same form and of the same length as the first.
  If we should adopt the ideas of Hennen, and wished to give a trans-
verse direction to the wound, the flap method would  in no way interfere
with it; in that  case all that would be  necessary would be to place one
of these flaps behind and  the other in front, instead of making them on
the inside  and outside of the limb.   I  should prefer commencing with
the outer flap, for the reason that from there being less of soft parts there,
it is important to draw them to that  part as much as possible, in  order
that there may not be too  great a difference in the thickness of the two
halves of the wound, and  especially because  we  could in  this  manner
dispense, if necessary, with compressing the artery at the inguinal space,
since it is not divided until at the  moment when we are terminating the
flap.
   b. Process of M. Langenbeck.—In  place of cutting out the flaps by
puncture from the deep-seated parts to the skin, M. Langenbeck divides
the tissues from the  integuments to the  bone.  He places himself on
the inside for the right limb, and  on the outside for the left limb, unless
he  makes  use of his  left hand;  he then causes the skin to be drawn
fa'^ibly back by an  assistant;  seizes  himself the knee with  one  hand,
aLd with a knife of medium length cuts with a single stroke all the soft
parts which cover the inner side of  the femur, from  below upwards and
from  the superficial parts to the  deep-seated, in such manner in fine
that his  instrument arrives upon the bone only, at three inches above
the point where  he has  begun his incisions upon the integuments.  An
assistant raises  up this flap.  The operator now directs his  fore-arm
behind, then outside, and  then  in  front of the thigh, and  cuts upon the
outside a flap similar to  the first,*taking care that the extremities of
the half moon that it forms shall coincide  with the angles at the base of
the inner flap.
  c.  In both these processes it will be necessary, after having raised up
the two flaps, to  apply the instrument near their root, in order to detach
any remaining soft parts  that may be still adherent to the bone, and to
be enabled to apply the saw a little higher up on the bone than where
the point of the  instrument first struck.
  It is evident also that we could get along very well with a single flap,
either on  the inside or outside, in front  or behind, if the state of the
parts were such as not to allow of our cutting a second one in the op-
posite direction  ; and  that all  the details of the  flap  amputation in
general are precisely applicable to that of the thigh in particular. M.
Bancel, (These,  Strasbourg, 1806,) who  says  he has followed in  every
point the  process of Vermale, declares that he  has performed it sue- 
254           NEW ELEMENTS OF OPERATIVE SURGERY.

cessfully more than  sixty times.   M. Hello, (Th-se citic,) who. after
the example of M. Fouilloy  and that of M. Plantade, (Th]se, Montpel-
lier, 1805,)  had recommended it  before them, restricts himself to a
single flap cut at the expense of the soft parts anteriorly, and maintains
with reason that his process has the advantage over all others of making
the most effectual resistance to the sally of the  bone, inasmuch as the
fleshy masses are drawn by their own  weight upon the whole extent of
the wound.   I doubt, however, if the circular method properly porformed
is not still  preferable to all  those  modifications  which ought not to be
retained, as it appears to me, but for  cases  that  are exceptions.  If I
employed it, I should cut out a larger anterior flap and a smaller posterior
one, instead of obtaining  them on the side, and  would thus deprive the
bone of the power of protruding through one of the angles of the wound.
If the disease should render  it necessary to make the  section of the
bone on a line with  or very near  the trochanters, as in the patient of
Knox, (Edinb. Med. Sc Phys. Jour., Vol. XVIII.,) or that of M. Develey,
(These  de Paris,) and as I have myself twice done, the  flap method
might have its advantages ; but then it is a matter of less importance
whether the flaps should be made in one way rather than another, as it
is the condition of the soft parts which would be the surgeon's guide.
   C.  At the thigh the stump requires subsequent cares, which surgeons
perhaps  do not sufficiently attend to.  In many cases nothing more is
done than to place a cotton cap upon it; others cover it with compresses
or flannel.   M. Thomas, (de Revigny,) in order to keep the flesh under
the end of  the  bone, has contrived a sort of blowse of linen, which an-
swers its purpose  sufficiently well.  He moreover arranges at the bot-
tom of the cuish, under the  cushion which is  to  support to a greater
or less extent the stump, a sort of wadded spring, which he much extols,
and has very often applied to the drumstick of numbers of persons for
a long period back amputated by him at different places.
   This  spring  which had  already  been used to raise up  the  heel in
shortenihg  of the leg, and of which M. Champion has transmitted me a
pattern, would  answer equally well for the supplemental bootikins [or
buskins] for the foot.
   [Modification of the  Circular  Operation in Amputation  in the Con-
tinuity of the Thigh.—M. Le Sauvage, of Caen, (Sitting  of the Aca-
demy of Medicine, Paris, March  22, 1842; Journ. des  Conn., &c, of
Paris, Mai, 1842, p. 215-216,) has proposed a modification  of the circu-
lar operation in amputation of the thigh, which  appears to us to be very
judicious, and one  that it is truly surprising has not suggested itself
before.   It consists in the  mode of making the section of the bone.
After having drawn the soft parts  as far back as  can be done by the
split compress, in  order to  denude the bone  as much as possible, he
directs his  saw in  such manner as to give an ovalar surface to the end
of the bone, looking obliquely  forwards.  By this means, we avoid the
irritation of the sharp angles of the straight transverse section, and the
void they necessarily make ; and the special advantages we obtain are
the better adaptation and more ready adhesion (without suppuration) of
the middle of the triceps muscle  and the other soft tissues to this large
smoother surface of the end of the femur ; whereby  there is less danger
afterwards of protrusion of this extremity from the stump, and of rupture
of the cicatrix.  T.] 
AMPUTATION OF THE LOWER EXTREMITIES.           255
                     § II.—In the  Contiguity.

  A.  History.—Morand (Opuscules de  Chir., t. L, p. 176) appears to
have been the first who entertained the idea of amputating the thigh at
the joint, and conceived  the possibility and success of this  formidable
operation.  Two young surgeons, Wholher and Puthod, (Morand, Opusc,
&c, p.  176,) who had been his pupils, made a formal proposal of this
kind to the Academy of Surgery, on the  3d of March, 1739, and obtain-
ed, on the 26th July, 1740, a favorable report from Le Dran and Guerin
the younger.  Ravaton (Chir. d?Arm., p. 323-26) would have perform-
ed it in 1743, if his brother surgeons, called  in consultation with him,
had not been opposed to it.   On the 7th of March, 1748, Theroulde sus-
tained a thesis of Labourette on this  subject,  and which  theme Morand
succeeded in getting submitted to the  Concours  for  the  year 1756, and
again, in 1759, the Academy not having on the first occasion found any
memoir worthy of the prize  they had proposed.   They received thirty-
four memoirs, and gave the  prize to that of  Barbet.  Goursault, Mou-
blet, (Journal de  Vandermonde, t. II., p. 240, etc.,) Lefebrve, Puy, and
Lecomte, also, each published a treatise on disarticulation of the thigh.
Almost  all  of them agreed that it was  practicable—some  from  trials
made on the dead body, others from experiments on dogs ; while Barbet
 (Acad.  Roy. de   Chir., t.  IV., p. 1) reasoned  thus, from analogy and
from the fact that a  child of fourteen years, attacked  with gangrene
from ergoted rye, and who  had been amputated in this  manner by La-
 croix  of Orleans, in  presence of Leblanc, first on the  right and four
 days after on the left thigh, appeared to be  on  the point of recovering,
 and did not die until fifteen days after the first  operation.
   Perault of Saint-Maure, in Touraine felt obliged to imitate Lacroix,in
1774, upon  a patient named Gois, who had the  thigh crushed between a
wall and the tongue of a carriage, and afterwards destroyed nearly as
high  up as  the hip by the  progress  of gangrene.   This patient,  whose
history is given by Sabatier, (Mid. Opirat.,  t.  IV., p. 542,) recovered,
and was for a long time a cook at an inn at  Sainte-Maure, where I saw
his son in 1815.   Kerr, according to M.  S. Cooper, (Diet, de Chir., etc.
 p.  85,)  performed the  same operation  nearly  about the same time, on
 a young girl aged fourteen  years.  Perhaps the case ascribed to R. H.
 Toll, by Sprengel, (Histoire de la Mid., t. VII., p. 331.) is the same as
 that of Kerr.  M. Delaunay (Bull, de la Fac. de Mid., t. VI., p. 197)
 states that  he saw the case  of a man at Moscow, whose thigh was dis-
 articulated  by  gangrene, and who got well.
   Pott and Callisen having severely censured this operation, and Bilguer,
Tissot, &c, in vain defended it, there was scarcely longer  any  mention
made  of it  in  England and Germany, at the beginning of the present
 century.  It was  in the French  armies, however, that  it was put suffi-
 ciently to the test. A. Blandin gives three  examples  of it.  He per-
 formed  the operation on the first  of   these  cases, in  the month of
 Fructidor,  an  III., and effected a perfect cure.  The  second was also
 saved, and  the third did not die until on the fifty-eighth day.  M. Per-
 ret, another military  surgeon, had the  good fortune,  about the same
 time,  also  to  succeed  in a case.    So also Mulder, in 1798,  on the 
                NEW ELEMENTS OF OPERATIVE  SURGERY.

  £0Sl°f i™F1,S*Ined Wiertz> aged eighteen  years ;  while Rossi says
  tie saw (Uin. Chir., t. III., p. 616) a case that recovered after sponta-
  neous disarticulation.   At the year 1803, M.  Larrey had  already sev-
  eral times disarticulated the thigh, and his memoirs relate  two well-as-
  certained successes: one on a Russian at Witepsk, and the other on a
  £rench soldier at Mojaisk.  According to M.  Gouraud, Dr. Millengcn
  had two similar successes, and  had published  them at London.   M.
  Baffos (Bull, de laFac. de Mid., t. III., p.  71-112) was  the first who
  performed extirpation of  the thigh at Paris, which was in 1812, at the
  Hopital des Enfans, on a child aged seven  years, who recovered from
  the operation, though  the cotyloid cavity was diseased, but died from
  the progress of the scrofulous affection at the expiration of three months.
  A soldier wounded  at Merida and  operated upon by M. Brownrigg, in
  1812, recovered so perfectly that he returned to reside in England, where
  many persons have since seen him, (The  Cyclopedia of Practical Surg.,
  p. 182.) M. Guthrie succeeded in the  same operation Upon a French
  prisoner, whom M. Larrey exhibited in 1815, (Bull, de la Fac de Mid.,
 t. V., p. 510,) and is now at the Invalides.  Another successful case in
 France was  that of  Delpech, (Arch. Gin. de  Mid., t. XVII., p. 301 ;)
 a third and afterwards a fourth, in England, viz., by  M. A. Cooper in
 the year 1824, and  by M.  Orthon in 1826.  M. Mott, (Philad.  Journ.
 Med. & Phys.  Sc, vol, XIV., p. 101,) in 1827, published a fifth case,
 and M.  Wedemeyer (Bull, de Ferussac, t.  II., p. 165) a sixth.  The
 patient of M. Syme  (Ibid., t. IV., p. 143) was cured by the thirty-fourth
 day.   The one that M. Brice operated upon  in 1825, and who came near
 perishing from hemorrhage, was seen by, this surgeon, some  months after,
 at Poros,in perfect health^ as" was also that of M. Hysern, seen  by him;
 ;three  years after, at Barcelona./, M. Mayor's case  (The Cyclop, of
  PfactrSurg.,  etc.,  p. 182) also recovered.  A soldier, who had been
/ operated upon in Africa, had been a long time cured  when he was ex-
 hibited, by M. Baudens, (Bull, de VAcad., etc.,  t. L, p.  324,) to  the
jAgademy of  Medicine.
   il^Appreciation.—At the present day this operation which, less than
  fifteen years ago, M.  Richerand  scarcely  admitted to be practicable,
  counts more than twenty perfectly authentic cases of success.  But how
  often has death also been the result!  MM.  Thomson, Kerr, A. Blandin,
  A. Cooper, Brooke,  Cole,  Walther, (Journ. de  Chir.,t. VI. p. 1,)  Larrey,
  Guthrie, Emery, Dupuytren, Blicke,  Krimer, (Bulletin de Firussac, t.
  XVIII.,p. 80,) Brodie, (Ci/clop. of Pract. Surg., etc., p. 182,) Gen-
  soul,  (Lane  Frang.,  t. II, p.  220,) Clot,  (lb.,  t. IV., p. 96,) Roux,
  (Arch. Gen. de Mid., t. XV., p. 467,) &c, have each had the misfortune
  to see at least one of the patients on whom they had performed this oper-
  ation, perish.   The second case operated  upon by Delpech,  (Ibid., t.
  XVII., p. 301,) died at the expiration of two months ; and that of M.
  Carmichael, (Cyclop, of Pract. Surg., p.  182,)  died  on the fifth  day.
  One  of those of M. Pelikan (Graefe and Walther, Journ.,  etc.,t. XIII.,
formed the operation twice, and  both  patients died, one on the third
and the other on the fourteenth day.   M. Sedillot, ( Gaz. Mid de Paris,

<  v- ■  • > 
AMPUTATION OF THE  LOWER  EXTREMITIES.           257
1833, p. 923,) M. Blandin, (Journ.  Hebd. Univ., 1835, t. IX., p. 369,)
M. Gerdy, (Bull de Thir., t. VIII., p. 318,) and Vidal, which last I as-
sisted, have not been more fortunate, and it would be too easy to multi-
ply at  the  present  day similar  examples.  The two patients operated
upon by  Kerst both died, and Dupuytren has told me that he had had
the same misfortune in three of his cases.   M. Larrey, however, seems
to give it the preference even in cases  where it would be practicable to
make the  section of the bone between the articulation  and the little
trochanter.
  I am fully of his opinion in this matter.   The cases that have occurred
in my own practice, and the two amputations of this description that I
have  had an  opportunity of examining, have satisfied me conclusively
that he is right.   My patients were in such a state of exhaustion when
they  desired  to be operated  upon, and the disease had made such
progress towards the pelvis, that I can scarcely  comprehend how they
were  enabled to support such lesions  even for a few hours.  Those of
Barbet, Keer, Baffos and Delpech, died in consequence of the progress
of their primitive affection, and not from the effects of  the operation.
In the other cases the disease  was  of so serious a character that a pure
and simple amputation of the thigh, had it been allowable, would probably
have had the same result.
   [In 98, cases of  amputation at the hip-joint collected by  Dr. Stephen
Smith, (New York  Journal of Medicine, September, 1852,) 56 died.   M.
Sedillot  states in the second edition of his Traiti de Medecine  Opera-
toire, torn. prem.  2d part, p. 457,)  that he has had a second  successful
case, and he  also refers to another in the practice  of Morel.   Within
two years  past, three fatal cases  have occurred in  the  hands of Drs.
Webber  and Van Buren of this city,  and of Mr. Charles Guthrie, of
London.   We  have, therefore, 103 casSs and  59 deaths.  Mr. Guthrie
remarks in his Commentaries on Surgery, p. 77, that Professor Langen-
beck, when lately in London, informed him  that he had  performed this
operation several times during the Holstein war, and he believed more
than once successfully.
  In the report of a successful case of amputation on the hip-joint, (Ed.
Med. Surg. Journ. vol. XXI, p. 27,) Prof. Syme  remarks : " I firmly
believe that if the operation be done  properly, and  above  all, quickly,
its success will be  general, if not  uniform."  On the 5th  of  January,
1853,  Mr. Mackenzie, performed this  operation  " in less  than  ten  se-
conds,"  and though scarcely a teacupful of blood was lost, at the time,
yet secondary hemorrhage supervened some eight days afterwards, which
proved fatal.
   Mr. M. attributes the greater success at tfre present day, to the improv-
ed  modes of operating, the use of  anaesthetics <fec, by which the effect
of the shock is modified.   (Dub. Med. Press, p.  182, March 22,1854.)
                                                        G.  C. B.]
   Therefore  a comminuted fracture, a necrosis, caries,  osteo-sarcoma,
spina  ventosa, or any incurable degeneration  whatever, of the  femur,
extended above its  shaft, or gangrene, or any other disease in fact which
has progressed nearly as high up as the  haunch, and which is of such
Berious character as to  demand amputation, will  claim  disarticulation
provided the cotyloid cavity and the bones of the pelvis are not affected.
    Vol. II.                    33 
 258            NEW ELEMENTS OF  OPERATIVE SURGERY.

 Wounds from  fire-arms, with lesion of the bones in the upper  third of
 the thigh, are the circumstances under which it is most decidedly indi-
 cated.  As it then becomes  important  that  the  instrument should be
 carried to some distance above the disease, I cannot see why we should
 hesitate to make trial of it.  The reasoning and the facts already known
 on this subject, induce us  to believe that, other things being equal, it is
 not  more dangerous  than amputation at the most  elevated fifth of the
 femur.  Its execution is more easy and infinitely  more prompt; nor is
 the wound  much  larger.   We divide the same muscles  and  the  same
 vessels, and there is no  need of so much  tissue to effect coaptation.
 Let it be performed under circumstances less desperate, and I am con-
 vinced it will give a reasonable proportion of cures, (See Exsection of
 the Head of the  Femur,  infra.)   [It is thus  seen that Professor Vel-
 peau fully coincides in opinion with Baron Larrey against the proposition
 of Mr. Syme, who would  always  amputate  rather  at the  trochanters
 than disarticulate the femur.  See note on Mr. Syme's views below.   T.]
   C.  Anatomy.—The head of the femur constituting more than a hemi-
 sphere, is so enveloped in its fibrous capsule that it will continue  there
 as if  strangulated in it, unless its section has  been made near the  coty-
 loid border.  It is this,  doubtless, which induced M. Weber (Arch.
 Gin. de Mid., 2e serie, t. XII., p. 238) to think  that it is kept  in its
 place by atmospheric pressure.  The circumference of its transverse
 plane (plan) on which rests the axis of the femoral neck,  obliquely out-
 wards, downwards and* slightly backwards, being  about to be exposed
 to the action of the instrument  at the moment  of the  operation, the
 surgeon must not lose  sight of it.   The arrangement of the internal
 ligament is such that when stretched by the head of the femur upon our
 reversing the limb outwards, it will almost present itself spontaneously
 to the cutting edge of the bistoury.   It is true that when  we commence
 on the outer side  of the  joint, it is found relaxed in proportion as we
 incline  the  thigh inwards ; but as it in no manner interferes  with the
 luxation of  the bone, we way divide it with great ease upon  the inner
 side of the cotyloid cavity
   The coxo-femoral  articulation, covered  outwardly by the psoas and
 iliac  muscles, and  slightly by the  rectus femoris, and on  the  inside by
 the pectineus  muscle and  the vessels  and nerves, is more  superficial in
 front  than in any other place, and corresponds  here to  the union of the
 middle  and outer third of Poupart's  ligament.  Behind it is separated
 from the integuments by a  space of  considerable size, which is filled up
 by the  third adductor, quadratus  femoris, semi-tendinosus, semi-mem-
 branosus,  biceps,  obturators,  gemelli, and  pyriform muscles,  together
 with  loose or adipose cellufar  tissue, the great sciatic nerve and some
 vessels.  A triangular notch filled up by the glutei muscles and fascia
 lata, bounded by the great trochanter below and by the external  iliac
 fossa  above, separates its outer side from the skin, while the great tro-
 chanter itself is almost naked under the integuments.   Upon  its inner
 side is observed a kind of gorge formed by a concavity upon the femoral
neck, which descends to below the little trochanter, and which is filled
up by the principal mass of the adductor muscles and the gracilis, the
 terminations of the psoas   and  iliac muscles, and of the  pectineus, all
which obliges us to look for the capsule upon a plane much more nearly 
AMPUTATION OF THE LOWER EXTREMITIES.            259
approximated to the symphisis  pubis, and one much higher up than the
axis of the limb would seem to indicate.
  A point not to be  neglected  in a case of embarrassment  would be
the lines  drawn from  the antero-superior spinous process of  the ilium,
from the great trochanter or crest of the pubis, to measure the distance
which  separates  those different  points  from the  articulation ; but the
above directions will usually answer for the surgeon grounded in anato-
mical relations.  The  great and  little trochanter, even the head of the
femur  continuing in a state  of cartilage up to the  age of ten or fifteen
years,  could, if necessary, be divided in young persons by the  knife if it
should  prove difficult  to get round  them at the time of the  operation.
The anomalies which may be presented by the cotyloid cavity, the tube-
rosity of the ischium, the neck of the  femur, and the projections which
are around its base,  have scarcely any other relation than to the length,
prominence or direction of these  different  objects; consequently  they
very rarely present  any real difficulties at the moment when the instru-
ment is in the act of disarticulating the thigh.
  D.  Operative Process.—I.  Circular Method.—a. English Process.
Abernethy appears to have  been  the first who conceived that  the ampu-
tation of the thigh at the joint could be performed by the circular meth-
od.  This surgeon first causes pressure to  be made upon the artery on
the body of the pubis,  then incises the skin, and afterwards the muscles
at some inches below  the  articulations ; then separates the muscular
tissues  from the great  and  little trochanter, divides the capsule, luxates
the bone, cuts through the inter-articular  ligament, removes the limb,
ties the different arteries, and finishes by bringing together the lips of
the wound from before backwards, and keeping them in contact by strips
of adhesive plaster.
  M. Colles is not the  only person who  has employed the method of
Abernethy on living man.   M. Krimer has also followed it.   Dr. Weitch,
who also  prefers it, before looking for the  articulation, lays bare the
femur downwards, to the extent  of two or three inches  below the  inci-
sion of  the  soft parts, in  order to make use of it afterwards  as a lever
to disengage the bone from its socket;  a precaution, however,  altogether
useless, for it is always practicable, after dividing the capsule, to move
the limb in this or that direction, with all the force that may be required.
  b. Process of M.  Graefe.—Circular amputation is also eulogized by
M.  Graefe, who uses it, in fact, for  almost  all disarticulations.  As at
the shoulder, so at the  thigh, he makes use of his  large  knife to divide
the tissues, entering  with it from  below upwards, and moving it in  such
manner from the skin to the head of the bone, as to dig out as regular a
hollow  cone as possible.  Having noticed  that the head of the femur
was sometimes difficult to enucleate, M. Graefe advises that  the coty-
loid border should be divided upon the notch of the same name ; but if
the  operator takes care to divide the  fibrous capsule accurately upon
the  largest circle of  the articular head,  as I have  pointed  out, he will
have nothing to fear  from this inconvenience, which, according to M. S.
Cooper, presented such difficulty to a celebrated practitioner of London,
that he  was for half  an hour at work in disarticulating the bone.
  II. Flap Method.—The flap method has been almost always preferred
for  this amputation.  A multitude of different processes, moreover, have 
260
NEW ELEMENTS OF OPERATIVE SURGERY.
 been devised for this purpose.  I will  not  notice  those  of  Ravaton,
 Mouolet and  I etit-Radel, because they are too complicated or too diffi-
 cult.  Jiarbet, Perault, and M.  Baffos, having only been called upon to
 nnish, so to speak, what  nature had begun,'have consequently had  no
 particular method of proceeding to be described.
   a- Process  of Lalouette.—We  find  described in a thesis under the
 presidency of Lalouette,  who was a relative of Le  Dran, one of the
 best  processes that can be employed.  This  consists, says Louis, who
 describes this mode of proceeding, and which  was adopted also by Gou-
 raud, Puy and Lecompte, in commencing with an incision  ncany semi-
 circular upon the outer part of the thigh, so as to  disarticulate the femur
 before all other  things, and  then in finishing with  the section on the
 inside in such manner as to leave a flap of four to five fingers'  breadth.
  The following is the manner in which it is described by Theroulde,
 (These de  Halter, t. V., p. 265,  ou Trad. Fran^., t. IV., p.  45 :)—A
 tourniquet compresses the artery ; the patient is  placed upon the sound
 side ; the operator makes a semicircular  incision, which  begins above
 the great trochanter, terminates at the tuberosity of the  ischium, and
penetrates down to the joint.   He then, while an assistant brings the
limb inwards, open3 the capsule with a second stroke of the knife, lux-
ates the  femur, divides the  remains of the capsule, grazes the neck of
the bone, and  terminates by cutting a flap on the iuside of greater or
less extent, according to the greater or less degree of embonpoint of the
patient.   M.  Lenoir, (Jour.  Hebd.  Univ., t. V., p.  205,) who  extols
this method, effects compression upon the artery by means of  the  hand
of an assistant, who, as soon as the articulation is divided, presses against
the vessel with his thumb in the thickness of the tissues.
  b.  Process of M.  Plantade.—Many persons  have thought  that  it
would be more  advantageous to place the flap  wholly in front rather
than on the inside of the  thigh.   M. Plantade, who was one of the first
to broach this idea, viz., in 1805, proposes that we should cut  out the
flap by  means of three  incisions in the  same way as for  the scapulo-
humeral  flap of La Faye, that we should divide  the articulation on its
 antero-internal surface, and terminate by making a very small flap behind.
  c  Process of  M. Manec—In April, 1831, M. Manec showed me on
 the dead body, the manner in which he had modified the process of  M.
 Plantade.  The  knife being directed to the middle of the space which
 separates the  spine of the ilium from  the  great trochanter, is carried
 from above downwards, and from without inwards, between the muscular
 tissues and  the  antero-internal surface  of the  femoral neck, so  as to
 come out in front of the ischium, and immediately form a large flap,
 whose free semilunar border looks downwards  and  outwards.  An as-
 sistant immediately grasps this  flap, and raises it up, taking care at the
 same time to compress the artery, unless we  should  prefer to  apply the
 ligature to it before proceeding farther.  In terminating,  M. Manec  di-
 vfdes the outer and posterior soft parts, by the semicircular incision of
  Moublet and before disarticulating, or he first  divides the joint, and does
  not divide the soft parts till the last.  This last method, which M. Mal-
  gaigne  attributes to Beclard, and which M. Robert has systematized, is
  one°of  the best.  M. Lenoir, who adopts the first  stage of this  modifi-
  cation  proposes, and with good reasons, as it appears to me, that after 
AMPUTATION OF THE  LOWER  EXTREMITIES.           261
the formation of the flap, we should always terminate the section of the
soft parts, as if we were performing the circular amputation, and before
we proceed to the disarticulation.
  d.  Process of M. Ash mead.—M.  Ashmead, a surgeon of Philadel-
phia,  also communicated to me in April, 1831, a process founded  upon
the same idea as the preceding.  Like M. Manec, he gives the semilunar
form to his flap, and like M. Plantade, he cuts it from the  skin to the
deep-seated parts.   After having made the incision into the integuments
on the region indicated, he raises them up a little, in order  to lay bare
the artery  and tie it.  Indifferent as to the  hemorrhage, he proceeds to
the section of the muscles, reaches the capsule, disarticulates the femur,
and finishes like M. Plantade or M. Manec.
   e.  Process of Delpech.—A  process, which gives a result  almost the
same, in every respect, as  that of Lalouette, is that of Delpech.   This
professor first ties the fermoral at its emergence from the crural  arch ;
then cuts an inner flap by plunging a narrow one-edged knife from before
backwards, between the gorge of the femur and the soft parts, directing
it downwards towards the skin, and with greater or less rapidity.   This
flap being formed, is grasped and raised up by an assistant.  The ope-
rator then gives a semilunar shape to its base, comes down upon the
inside of the articulation and divides the  fibrous capsule and  inter-
articular ligament; he then causes the thigh to be placed in its natural
position, makes a semicircular  incision below the external iliac region,
unites in this manner the anterior and posterior extremities  of the base
of the flap, and makes a little  nearer the great trochanter  the section
of the three glutei  muscles, the obturator internus, the pyriformis, the
gemelli, and the outer side of the  capsule.   Nothing remains but the
arteries and the dressing.  Delpech  maintains, that with a single flap
immediate union is more easy and certain.   A gentle pressure, says he,
easily induces the  fleshy  tissues to mould  themselves to the  cotyloid
cavity, which  prevents inflammation, suppuration,  exfoliation  of the
cartilages, and fistulas.   Moreover, as his flap  presents a very  long,
oblique cut, he prefers  that  upon the  outside the section of the integu-
ments should be somewhat more elevated than that of the  other parts,
in order that there may not be too much skin, and that the coaptation,
which he also favors by means of the suture, may be more perfect.
   /.  Process of M.  Larrey.—Le Febure, who wrote to Louis about the
year 1760, to inform him of the result of his  researches, had already
proposed to tie the femoral  artery in the fold of the groin  before com-
mencing the operation.  M. Larrey has made a precept of this precau-
tion, which, he says, allows the surgeon to proceed with greater security,
and saves an infinite deal of risk to the patient.   The artery being tied,
and the operator placed on the outside of the limb, directs the point of
a long  knife to a spot  about two or three fingers' breadth below, and
within  the antero-superior  spinous process of the  ilium, so as to fall
 directly upon  the anterior surface of the bone ; he then inclines it a
 little  inwardly, glides it along the inner side of the neck of the femur,
 and thus continues to direct it backwards, until it cuts through the skin
 in the  sub-ischiatic groove ;  he then  cuts out an  inner flap  about four
 inches long, in the  same manner as Delpech ; raises  up this flap, and
 then divides the capsule to the extent of half its circumference at least, 
-62            NEW ELEMENTS OF OPERATIVE SURGERY.

and  very near the cotyloid  cavity, a* if he were about to pass  trans-
versely through the middle of the head of the femur without attempting
to enter the articulation ; then places the limb in abduction, luxates it,
and stretches and divides the internal ligament; passes his knife upon
the outer  side of the articular head, and completes  the section  of the
capsule ;  arrives  at the tendon of tho glutei  muscles, and behind the
great trochanter; inclines his knife flatwise, grazes the outer surface of
the body  of the  bone, and makes a second flap as  much like the first
as possible.   All  the arteries  being tied, the two flaps are brought into
coaptation, taking care to leave the ligatures in the posterior angle of
the wound, which serves as a filter to the discharges.
   M. Larrey ( Clin. Chir., tome III., p. 613) has since described another
process.   The artery being tied, he cuts  the skin circularly, makes an
inner and outer  flap, disarticulates, and  then  finishes by dividing the
attachment of the glutei muscles.
  g.  Process of A. Blandin.—It appears  that when M. Larrey pub-
lished his method in 1803, the process  with two flaps had long been in
use with military  surgeons.   That which Blandin had  successfully em-
ployed in  1795, consisted in  first tying  the artery, and making a first
flap as M. Larrey  does ;  but instead of continuing from within outwardly,
like  the last-mentioned  surgeon, A. Blandin  cuts his outer flap  before
attacking the capsule, or proceeding to disarticulate.
  h.  Process of 31.  Lisfranc.—M.  Lisfranc (Arch.  Gin. de Mid., t.
II., p. 161)  makes use of a narrow knife with a double cutting edge ;
plunges it in from  before  backwards, and  outside of the neck  of  the
femur;  goes round the great   trochanter, and thus begins by forming an
outer flap of three to four inches long ;  brings  back the instrument to
the upper angle of the wound ; inclines its point a little inwards to glide
upon  the  gorge of the  bone; then immediately elevates the haudle ;
draws the fleshy tissues  inwards, in order that the  knife  may, without
again touching the integuments, strike below the ischium; he then cuts
all the tissues without  leaving the femoral bone, until  he encounters the
little trochanter ;  he now goes round this osseous projection, and  directs
an  assistant to grasp the  root of this  second flap by introducing  his
thumb into  the  wound, and thus  compressing  the artery ;  and finally
terminates the  section of the soft  parts on the inside the limb, as M.
Larrey  does ; and ties all the vessels, and  then proceeds to the disar-
ticulation.
   i.  Process of Dupuytren.—The surgeon  places himself on the inner
side of  the limb, and if he is ambidexter, makes use  of the  right hand
for the right limb, and the left for the left;  draws back the integuments
towards the pelvis, himself supports the thigh,  and  inclines it more or
less in  flexion, extension or  abduction; then makes a semi-lunar inci-
sion on the inside, with convexity downwards, and  which  commences
near the  antero-superior spinous process of the ilium, and terminates
near the  tuberosity of  the ischium;  at  first, he divides only the skin
which is immediately drawn back by an assistant; forthwith divides the
muscles in the same direction, and thus cuts out an inner flap from four
to five inches in length;  this  he causes to be raised up, and he then at-
tacks the capsule in the same manner as  M.  Larrey, cutting through the
articulation, and  terminating with his outer flap.  The successful issue
in the case of M. Hysern, is  due to this process.           """"— 
AMPUTATION OF THE LOWER EXTREMITIES.
263
  j. Process of Beclard.—Placed outside the hip-joint, Beclard com-
mences with cutting an outer and posterior flap, by plunging in his knife
obliquely  from without inwards, and from before backwards, from the
neighborhood of the iliac tubercle to the inner extremity of the sub-ischi-
atic groove, grazing as he proceeds  the  posterior surface of the neck
of the femur.  A second flap  is to be formed  in the same manner in
front, and the operator finishes with the  section of the capsule and the
disarticulation.  With Dupuytren and  Beclard, the artery was secured
only by making pressure upon it on the pubis.
  k.  Process of M. Guthrie.—Two semi-lunar incisions, the one inside
and in front, the other outside and behind, and extended from the  neigh-
borhood of the spine of the ilium nearly down to  the  tuberosity  of the
ischium where they united, characterize the process of M.  Guthrie.  This
surgeon cuts through the integuments  with  the  first  stroke and then
causes them to be raised up;  he then reapplies the knife on a line with
the retracted skin, in order to divide  the  muscles  obliquely from below
upwards ; thus arrives upon the joint after having formed two flaps, and
finishes like A. Blandin, Abernethy and Beclard.   It is evident that'the
process of the English surgeon differs from that of Beclard, only in di-
viding the tissues  from  the skin to the bones in place of dividing them
from the deep-seated to the superficial layers ; but it is precisely  in this
particular that it has in reality  some advantages.
  I. A large flap on the inside, and a small one on the outside.—In the
process of M. Kerst, which serves as the base of that of M. Manec, a
knife with a double-cutting edge, is plunged  from before inwards, and
as near as possible to the articulation.   Its point comes out  behind ; an
inner flap is then cut out, of sufficient length  to cover three  quarters of
the wound, and the articulation sometimes laid open by the same stroke.
The thigh is  placed in abduction, and the capsule and round ligament
divided ;  the bone is then luxated, and the operation completed by cut-
ting a small outer flap.   The artery is compressed  upon the pubis.
  m.  Process of  the Author.—1. A  postero-external  semi-lunar inci-
sion upon  a line with the great trochanter ; 2. An antero-external inci-
sion for a cutaneous flap of two inches in length, which is  raised up ;
3. The section of the muscular tissues from before backwards ; 4.  The
semi-circular section of  the capsule near the cotyloid border ; 5.  Luxa-
tion and, then  division of the internal ligament;  6. Separation  of the
limb posteriorly.
  III.  Ovalar Method.—The  ovalar method has not yet been applied
on living man for amputation of the thigh at the joint, but in  a very
small number of instances ;  it is, however, the one which obtained for
M.  Baudens  the  successful issue to which I  have referred in his case.
The two modifications which it embraces, have been made trial of on the
dead body, first by MM. Cornuau and Scoutetten, and afterwards by all
the young surgeons who are in the habit of exercising themselves  in our
amphitheatres, in the manipulations of operations.
  a. Process  of  M.  Cornuau.—The patient is  laid upon his  sound
side.  The surgeon placed  behind the  hip, is first to  make an oblique
incision, which is to be carried from above the great  trochanter back
wards, outwards and  downwards to below the ischium ; a similar inci-
sion is made in front and upon  the inside ; then with a second  stroke 
264
NEW ELEMENTS OF  OPERATIVE SURGERY.
for each incision he divides the muscles as  deeply as  possible ; attacks
the articulation on its  outer  surface at  the  same time that the limb is
placed  in abduction by an assistant, and  then divides the  joint from
without inwards as soon as the head of the femur is  luxated.   He then
at last,  while another aid  raises the two lips of the wound, makes the
section  of the inter-osseous ligament,  the inner portion of the capsule,
and of all the soft parts on the inside which separate the two first inci-
sions, or which  form the base of  the  V and of  the triangle which they.
had at first circumscribed.
  b.  Process of M. Scoutetten.—The operator  first plunges in the point
of his knife above the  great  trochanter ;  then depresses  its handle a
little in  order to divide all the  tissues as in  the  preceding method ; then
brings back the knife to the  posterior extremity of the first wound, and
returns  upon the  other side of the  limb  in order to unite this last inci-
sion with the apex of the first  wound.  If any  tissues  remain  between
the postero-internal part of the neck of the femur and the wound of the
integuments, the operator divides them and then finishes with the disar-
ticulation.
  E.  Dressing and Relative Value of the Different  Methods.—In res-
pect to these numerous processes I can only repeat what I have already
said on  amputation at the shoulder.  Almost all of  them are of  a cha-
racter that render them  applicable in practice ;  nor should  any of them
be adopted exclusively.   Nevertheless, as several of  them are only very
simple and natural modifications of the others, some of them in reality
may conveniently be dispensed with without any disadvantage.
  I. In the circular  method,  for example, which is incontestibly the
most  disadvantageous, and which  never should be  selected except in
cases  where the degeneration of the integuments has  involved the whole
circumference of the  limb nearly as high up as the hip, the process of
Abernethy and that of M. Graefe, differ only  in that  of  the  German
surgeon admitting  more easily  than the other of the union of the lips
of the wound.  The modification proposed by  M. Weitch,  has no other
advantage than that of permitting us in cases of fracture to remove the
limb first without proceeding to the  disarticulation of its upper fragment
until  afterwards   A  precaution which  I  would not  neglect  to take,
would be to  dissect and carefully turn back all the sound skin, in order
to divide  the muscles very high up and very  near their origin,  and to
take as  much of them away as possible.
  II. The ovalar  method is practicable  every  where, where that with
two flaps would  seem  to  be  applicable.  It makes a wound and flaps
almost as regular as  the circular  method, offers no obstruction to im-
mediate reunion, and enables  us to fill up very  accurately  the cotyloid
cavity.   The two modifications also which it  comprises have scarcely
any advantage over each other.   I should, however, prefer  that  the
cutaneous layer should be divided  lower down, and that of the muscles
higher  up than is recommended.   We should  thus  be enabled to effect
the approximation of the lips of the wound with greater ease, whilst
inflammation, reaction  and suppuration  would be moderated in their
intensity.  By  applying  to the  great  trochanter after the manner of
Ravaton and M. Malgaigne, (Man. de Mid. Opir., p.  354,) the longi-
tudinal incision which  constitutes  the point of departure in the process 
AMPUTATION OF THE  LOWER EXTREMITIES.
265
of M. Larrey in the  disarticulation of the shoulder, we  should  obtain
all that we could hope for from the ovalar method.
  III.  Among; the flap processes, those which comprise two, become in
some  sort a matter of necessity, when it is possible to give  them  the
same length, and when the soft  parts are equally degenerated in every
direction.  In  such  cases  the  process  of Dupuytren and that of M.
Guthrie are preferable to all the others by the security of the operation,
because they allow of our  saving  more skin  than muscles, and because
the flaps by being  formed obliquely and not on each side as in the pro-
cesses of A. Blandin, and MM. Larrey and Lisfranc, fill up more readily
and more completely the cavity left  by the head and neck of the femur
and great trochanter.
  IV. When the outer flap is cut in the manner of M. Larrey, it rarely
happens  that it does not  present a notch on its lower border, and that
it possesses a thickness  which  will correspond with that of the inner
flap.
  V.   The method with  a single flap should have  the preference,  where
the soft parts on one side are  degenerated  and those on the opposite
side sound.   In such cases the nature of the diseases indicates in what
direction the flap  should be formed, and which should not be placed on
the outside or posteriorly except where it is impossible to do otherwise.
For the inside and front I should prefer the  process of Lalouette to
that of Delpech, and much better still one of the modifications recently
proposed.   The process of Lalouette, after  the manner in which it is
performed by  M. Lenoir, gives a much more regular flap than that of
the Professor  of Montpellier ; but this flap is too  thick and  not suffi-
ciently large.  That of MM. Ashmead and  Manec is situated in such
manner, that dragged down by its own weight, it falls over of itself, so
to speak, upon the  whole extent of the bleeding  surface.   By  cutting
it from the  exterior to the interior, as M. Ashmead does, we  are more
sure of what we do ; the  ligature of the artery may be omitted, and we
preserve more  of the integuments than of the muscles.
   VI. I  proceeded in this manner with the two patients I have mentioned
above.   After  having dissected up the skin to the extent of three  inches
in front and  within, and  made a semicircular incision outwards and
backwards above the great trochanter, I proceeded to the section of the
muscular tissues,  and  disarticulated from before  backwards, without
paying any attention to the artery, which an assistant kept compressed
against the pubis ; the operation lasted only half a minute.
   VII.  The previous ligature of the femoral  artery, as recommended
by Lefebure, Moublet, A. Blandin and Brulatour, adopted by MM. Larrey,
Delpech, Orthon, and Roux, and rejected by Abernethy, and MM.  Baffos
and Guthrie, [also used by Dr. Mott. T.] is, as we have said, another
operation superadded to the  principal one.   Nevertheless, if in the flap
method  the  compression  upon  the pubis, or, what is as well,  by means
of the fingers upon  the root of  the limb, as we may do in following the
processes of Lalouette,  M. Lisfranc, and Delpech, and  even  the  ovalar
method, should not give  all the security desirable, the cutting down upon
the femoral  artery  under Poupart's ligament is, at the present day, an
 operation performed with too much facility  to prevent our commencing
   Vol.  II.                   34 
266
NEW ELEMENTS OF  OPERATIVE SURGERY.
our incision  at  that  point, in the event of our  not being disposed to
follow the recommendation of M. Ashmead.
  Nor can I perceive, unless the  patient is very much  enfeebled, or the
operation is going to be very long, how it can  be indispensable, or even
advantageous, to tie the other arteries  before  completing the disarticu-
lation.  The  fingers of intelligent assistants, applied over them in pro-
portion as they are opened, I have fully satisfied myself, are quite suffi-
cient to allow us to proceed on and finish the removal of the limb without
any apprehension.   These arteries, moreover, are the obturator on the
inside, the ischiatic externally and posteriorly, and then in front and
also externally, some  branches of the gluteal, or of the internal pudic;
it will be necessary, also,  if the previous ligature has been  used, to tie
the femoral artery a second time  near the surface of the wound, as well
as the profunda artery, in  order  to be enabled  to effect immediate union
of the little wound we have been obliged to make  at first.  M. Duber-
euil  (Tourettc, Essai sur  VAmputation  de  la   Cuisse, p. 18)  mentions
a patient  who died of hemorrhage in the  space of three hours, in con-
sequence of having neglected to  tie in this manner the femoral profunda;
and he recommends that,  to protect ourselves from such an accident, we
should lay bare the  femoral with the nail from below upwards, as high
as under Poupart's ligament.
  VIII.  The necessity of placing into as perfect  contact as possible
the two sides of the  enormous  wound  produced by the disarticulation
of the thigh, is disputed  by no one.  The  suppuration from so large a
surface  would soon  cause the  death of the patient by exhaustion, aud
would not fail to be accompanied by a violent general  reaction.  The
suture, whose importance Delpech has endeavored to enhance, has several
times been  made use of,  and we must confess that this is one of those
cases which  appear to be best calculated to justify its employment.  It
cannot,  it is true, be applied without pain ; but if the resource is useful,
should a little more or a little less suffering influence us in the presence
of such an evil ?   I would, however, remark, that it is not the  wound
of the integuments which it is especially important to unite, but on  the
contrary, that of the  deep-seated tissues ; and  that it is  to be feared,
that,  by means of the suture,  the matters that might accumulate at  the
bottom of the wound would produce serious mischief before they could
make their escape externally.   The adhesive  plasters, which have  the
advantage of causing no strangulation, readily allow, at the expiration
of a few days, of our bringing the lips of the wound into more accurate
contact than  we had placed them at first, if the base of the flaps should
appear  to be properly  united.   Without, therefore, absolutely rejecting
the suture, which is beginning at the present  time to get into some re-
pute  again in the south of France, I am of opinion  that we may in this
operation, in fact, that we ought to  dispense  with its employment,  ex-
cept  in those particular  cases  which the skilful  surgeon  will  always
know how to distinguish.
   \_Coxo-Femoral  Amputation; or, Disarticulation of the  Thigh.—M.
Larrey, a very few weeks before his death, viz., as  late as Jan. 3, 1842,
 (See Sitting of the Academy  of Sciences of Paris, of that date, in
Journ.  des  Connaiss., &c, de Paris,  Mars,  1842, p.  131,)  upon  the 
AMPUTATION OF THE LOWER EXTREMITIES.            267
occasion of making a report as one of the commission on the memoir of
M. Sedillot on coxo-femoral  amputation, still persisted in  the  opinion
which he had always entertained in favor of primitive  amputation.  He
said the thigh could be amputated in its totality as well in acute as in
chronic  diseases, and  that  this amputation, where required, should be
performed immediately after a wound, and not delayed ; that M.  Sedillot
had exaggerated the dangers of sanguineous revulsions upon the viscera,
as these could  be  overcome by general bleeding, cuppings with scarifi-
cations, &c. ; and that, so far as regarded  the danger of  spasm from
the section of  the  great  nervous  trunks, this  would be the  same after
the consecutive as after the  primitive operation.  M. Larrey considered
that, in all cases, the chances of success would be greater  if the ligature
was previously placed upon the femoral artery at the fold of the groin,
the value of which he had demonstrated in the course of his practice.

Successful Amputation  at the Hip-Joint.   By V. Mott, M. L\,Oct.
  7, 1824. ^See  Philadelphia  Journal of the Medical  and  Surgical
   Sciences.  Philadelphia,  1827, Vol. XIV., p. 101—104, with Plate.)

  It is  now generally understood that surgical operations are not to be
performed until all other curative  measures have proved  unavailing, or
the life of the individual cannot be saved, unless some part be sacrificed
Mott's amputation at the hip-joint.  Appearance of the stump when perfeotly healed. 
268
NEW ELEMENTS OF  OPERATIVE SURGERY.
for the preservation  of the  whole.   We have, nevertheless, reason to
rejoice, that even under exceedingly  unfavorable  circumstances, these
dreaded resources of our art afford a rational prospect of success, fre-
quently enabling us to  arrest or remove morbid  affections, otherwise
beyond reach of cure, and to prolong valuable lives in a state  of com-
parative case.   Were we disposed to enter upon such an inquiry, it
might be advantageous to determine how far the outcry against  surgical
operations, (doubtless just in numerous  instances,) has proved detri-
mental to the interests of humanity, by causing the knife to be withheld
in many cases  where an intrepid and skilful employment of it would
have been followed by the restoration of health, and the avoidance of
the excruciating sufferings so often endured for a long time previous to
the death of such patients.  Without discussing this topic, however, we
may be permitted to state our belief that a great number  of persons
are annually  committed to the grave, because proper surgical measures
are not enforced, and that these are as often withheld  from  timidity,
prejudice, or ignorance, as from any valid objection.
  Amputation at the  hip-joint is an operation but seldom required, and
always attended with  great peril, both to the life of the  patient and the
reputation of the surgeon ; but neither of these  circumstances are  suffi-
cient to justify any one in asserting that this operation ought not to be
performed, or that it may not in a majority of cases prove successful, if
it be not too long deferred.  The following case may  prove  serviceable
to the profession, by showing that the operation may be advantageously
attempted in a  patient who  would  otherwise have speedily sunk under
his disease.
  George Byles, a healthy boy, ten years old, broke his thigh about two-
thirds of its length from the  hip-joint; two days after, splints and ban-
dages were firmly, (and injudiciously)  applied, which  produced great
distress, and  were removed  at the  instigation of  the  boy.  Physick's
modification of Desault's splint was prepared by the  physician then
called in,  who  pointed out to  the father, previous to its application, a
projecting point on the outside of the thigh, which was the extremity of
the superior  fragment,  which, by  the  improper  pressure was nearly
forced through the integuments.  The bone being properly coaptated,
the long splint  was then applied.
•  About three  weeks subsequent to this  period another physician was
called  in, who recommended the  employment  of  the  inclined plane,
which was adopted, the  boards forming it having pegs at the side.  The
boy stated that during his confinement to this inclined  plane for several
weeks, he had in tossing restlessly about, injured the thigh on the inside
just above the condyle, which produced a sinuous opening leading to the
fractured bone.  It is most probable howeveer, that the sinus was formed
and pointing, when it was struck against the peg and opened.
   He was brought into the city of New-York  on the 7th of September,
1824, at which time we  first saw him.  His countenance was expressive
of much anguish, with a white tongue and feeble  pulse ; his right limb
was much enlarged on the outside,  resembling  a case of spina  ventosa.
To the touch it was hard and irregular, was exceedingly tender, and
when pressed  gave  excruciating pain.  The swelling  extended to the
great trochanter, gradually diminishing towards the top of the thigh. 
<
               AMPUTATION OF THE LOWER EXTREMITIES.          269

Opposite to the greatest enlargement was a sinus, discharging a thin #a-
nious fluid, leading to the middle of the thigh bone, which was perfectly
carious.  During two weeks succeeding his arrival in the city, medicines
were administered with a view of allaying irritation, and imparting tone
to the system, but hectic and night sweats, notwithstanding, supervened.
As ulcerations began to occur  by the side of the tibia, and all the symp-
toms became worse, it was  resolved to amputate at the hip-joint as the
only chance of saving the life  of the  patient.
   On the 7th of October, 1824, the patient, after having passed a com-
fortable  night, was placed on the table in order to be  operated upon.
An incision was made over the femoral artery as it emerges  from under
the femoral arch, and the  vessel secured by ligature.   While feeling on
the outside of the artery for the lesser trochanter, the pulsation of a ves-
sel apparently but little smaller than the femoral artery immediately be-
low the ligature, convinced is  that in  this case the profunda femoris was
given off above the femoral arch, as we occasionally find it.   This ves-
sel was taken up.
   Lisfranc's  knife was  then  introduced between the artery and bone,
and carried through close  by the neck of the femur towards the tuber
ischii, thus forming the inner flap.  The  external flap  was formed by
cutting from without inwards.  The  hemorrhage from the veins and
small arteries  was considerable when the incisions were made, and nu-
merous vessels were  taken up :  but  comparatively little blood was lost
during the operation, and the patient was put to bed shortly after it was
completed.   After the inner  flap was cut, some of the surgical atten-
dants examining the lesser trochanter, pronounced that the head of the
bone was  not diseased.   In order to satisfy the doubts expressed, the
bone was sawed  through  the lesser  trochanter,  when it was  found to
be of  the  consistence of cheese, being denuded of periosteum on the
outer side up towards the joint, and requiring to be removed, which was
afterwards done, as originally contemplated.
   It is scarcely necessary for us to enter into the detail of  symptoms
and treatment subsequent  to  the operation, as nothing occurred worthy
of note, except various  degrees of irritation of the stomach and whole
system, previous to the coming away  of the ligatures.  The  treatment
consisted in regulating the diet, and administering  anodyne and tonic
medicines according to circumstances.
   On the 15th of October, eight  days from the operation, two-thirds of
the stump  was  healed  by  the first intention.   Between the 17th and
31st of October, all the ligatures, seventeen in  number, were removed;
and by the 20th of November the whole  stump was  effectually healed,
and the  boy had become fat and lusty. There can be no doubt but that
this limb might have  been  saved without difficulty, had the proper treat-
ment been instituted when the accident occurred.  When it came under
 our charge, nothing short of the operation above related, could have saved
this boy's life.
   The  appearance of the stump after the entire recovery of the patient,
 is very  accurately represented in t*he engraving sketched by my friend,
 Dr. Bell, of New-York;  to  Dr. Frederick King,  I am  indebted for
 accurate notes of the progress of this case, which was under his espe-
 cial care after the operation. 
270            NEW ELEMENTS OF OPERATIVE SURGERY.
   [It  is a source of infinite satisfaction both to Dr. Mott and myself, to
have  an opportunity at this late hour, of rescuing another and more im-
portant surgical claim from oblivion, by the accidental acquaintance we
made' during the past summer with the venerable Walter Brashear, M. P.,
for many years an eminent planter of Attakapas, Louisiana, and a sena-
tor of  that state.
   To  our  countryman, Dr.  Brashear, who was a pupil of the  eminent
Dr.  Ridgeley, of the continental army of the revolutionary war, and
also a student at the University of Philadelphia, under Dr. Rush and
other famous men of that  day, are we indebted as is now  ascertained, for
the first operation, or amputation of the thigh at the hip joint or  coxo-fe-
moral articulation ever performed in America, and which was followed with
complete success.   This  occurred  as early as the year 1806,  only three
years after the illustrious Larrey had revived and perfected this operation
in the  campaigns of Napoleon.            *
   With that self-neglect  of one's own rights, that is ever  a  prominent
characteristic  of the  diffidence of men of  genius, and^ from his having
early in life withdrawn  from  active practice, Dr. Brashear  had never
published this case.   Dr. Mott therefore, had hitherto supposed that he
was  the  surgeon who in this country had first performed this important
operation.   With a magnanimity which ever belongs to him, and which
we trust will serve as an emphatic lesson to those who in their malignity
would  rob and calumniate both the dead and the living, Dr. Mott cheer-
fully abstracts  the  plume from his own honored brows, that can spare
many and much more like this, and affixes it upon the name of the gen-
tlemen to whom it rightly belongs.
   As it may doubtless become the theme of future discussion, we take
the opportunity of  placing here upon the record, a too brief account of
the achievement of Dr. Brashear as communicated in his own words, in
a letter we have had the honor to receive from that venerable surgeon.

                                 Philadelphia, August ISth, 1846.
   My Dear Sir,
    In conformity  to  promise, I now give you a brief statement of the
operation  which I performed in Bardstown, Kentucky, in August, 1806,
on the  hip joint.
   The  subject was a boy seventeen  years of age.  Without assigning the
causes  which led to the necessity of the  operation, the same  was, after
consultation with Drs. Harrison a,nd Goodlet, conducted in manner fol-
lowing :—first premising,  that in absence of any knowledge  of an estab-
lished mode for this operation, a common-sense reasoning as to its safety
and facility alone dictated the manner of performing it.  Therefore an
operation of the thigh in the ordinary manner was determined on, as re-
mote from the hip joint as circumstances might justify, (in this case about
mid-thigh.)  The amputation was performed, and the arteries  secured.
   The  next step was to make  an incision to and from the  lower end
of the  bone externally over the gre^t trochanter to the head of the bone
and upper part of the socket.  The dissection of the bone from the sur-
rounding muscles, was simple and safe by  keeping the edge of the knife
resting against the bone.  The  bone being disengaged from its integu-
ments  at its lower extremity, was then turned out at a right angle from 
AMPUTATION OF THE  LOWER EXTREMITIES.
271
the body, so as to give every facility in the operation, to separate the
capsular ligament and remove the head from its socket.  After the ope-
ration, nothing more than ordinary dressings were used, and in the course  (
of a short time the patient removed to St. Louis, where he was living
within a few years past.
                                 I am, very respectfully,
                                              Walter Brashear.
   Dr. P. S. Townsend.

   It may be proper to state from the verbal communications we have had
with  Dr.  Brashear, that the injury which led to tfre operation in ques-
tion was a fracture of the thigh, complicated with much contusion of the
parts, and which from bad management or neglect, or both, resulted in
the establishment  of an  extensive  and dangerous suppuration in  the
neighboring  tissues and inter-muscular spaces.  T.]
   [CONSERVATIVE SURGERY TO SAVE THE LIMB FROM
                         AMPUTATION.

  Among the great reformations which the brilliant march of modern
surgery may count as  one of its greatest triumphs, is the introduction
of what has  not  inappropriately  been denominated, by Mr. Prior, of
Woolwich Hospital, England, the conservative mode of treating com-
pound  dislocations  and fractures of limbs, whereby the human body is
saved from the deformity and mutilation of an amputation.   Dr. Hous-
ton, of Dublin (Lecture on Modern Improvements in Surgery, Nov. 4th,
1844;  London  Lancet, Dec.  28th, 1844, p. 393, et seq.) correctly ob-
serves, that in regard to amputations, the greatest modern improvement
is  the frequency  with which they are abstained from.   Amputations,
until very recently, we may  add, were for centuries performed in the
most reckless manner, and without the slightest attempt  being previous-
ly  made  to  save  the limb, so that cripples on  crutches from this cause,
were to be seen everywhere.   Sir Benjamin Brodie, in fact, states in the
last edition of his work on " Diseases  of the Joints," that  he owes to
this lamentable haste, (fortunate in its results  to him and to science,)
with which surgeons resorted  to amputations while he was a young man,
for white swellings, as soon as their character  was  determined, the mi-
nute knowledge he was thereby enabled to obtain of the  true pathology
of this disease, particularly in its earliest stages.
  Our museums, says Dr. Houston, (loc. cit., London Lancet, Dec. 28th,
1844, p. 394,) in this city, [Dublin,]  likwise bear evidence of the same
practice of early amputation ; and, he quaintly adds, those who possess
such preparations  of disease  will do well to take care  of them, as they
are not likely to get  many other similar specimens from the hand of mod-
ern surgery.  Which remarks, he says, apply also to extirpation of the
mamma and testes, ulcers of the legs, hernia, injuries of the  head, com-
pound fractures, dislocations,  &c. 
272
NEW ELEMENTS OF  OPERATIVE SURGERY.
  In respect to operations, then, continues Dr. Houston, (loc. cit.,) true
surgery rather avoids than courts them; and in this respect, unlike what
takes place in all other professions, the improvements introduced into it
cause a diminution in  the  emoluments derivable from the practice of
surgery.  It is a well-established fact, that the incomes of medical men
are much reduced from this cause, and yet, nevertheless, they persevere
with laudable disinterestedness in their endeavors to effect still  further
improvements.   Is not this, says Dr.  Houston, the  highest degree of
philanthropy ?   In this city, (Dublin,) more, perhaps, than in any other
in the world, is this statement regarding the avoidance of unnecessary
operations, true.   Tj\e diminution, he  continues, of surgical operations
in this  city, is our highest boast; and I make it thus publicly, to con-
trast  with one of an  opposite character, which I have heard as having
been uttered elsewhere, for the ignoble purpose of attracting students to
the  schools.  And I  do so still more especially, because I find that  the
records of the hospitals of Dublin  have been  pryed into, in order to
make  a case for the assertion of such a discreditable comparison.  But
although, in one sense, there is a judicious diminution in the number of
surgical  operations, in  another, there is  an increase.   Many operations
unknown in former days, are now in common practice.
  We may  state here, that discreditable practices like that mentioned
by Dr. Houston,  to depreciate the Dublin schools, are not, in our opin-
ion, confined to  that city.  To declare, however, that a great metropo-
lis, from its vast commerce with all  parts of the  world, its  extensive
class of laboring persons, and spread of the manufactures, arts, &c, all
growing out of an immense trade, is far better adapted to  a great surgi-
cal school, from the necessary frequency which  must exist  for operations
in an emporium of this kind, is with this  caveat what any  such metropo-
lis, or mart, however, has a right to, and should promulgate, when con-
trasting its advantages to  the student, over those of inland towns and
villages—but no further.
  In the  inflammation which follows  extensive  destruction of  the soft
parts and bones  in comminuted  compound fractures, we  must expect,
during the progress of exfoliation, where  that, and not reconsolidation
of the detatched fragments, takes place,  to find exhausting and burrow-
ing, fetid, sanious, and purulent  abscesses and  discharges ; over which
ensemble of accidents, even where  there are  gangrenous sloughs also,
and, as sometimes  happens with the tibia under such circumstances,  (P.
J. Cabaret, of Angers, Journ. des Connaissances Medico-Chirurgicales,
Paris, Janvier, 1844, p. 15, &c.,) a remarkably abundant  and prolonged
discharge also from  the  medullary canal of the injured bone, nature
will, nevertheless, often completely triumph, as in the case alluded  to,
though a man aged 45, and enduring all the  privations of extreme po-
verty.
   M. Lemonnier, of Mortain, (Manche, France,) has effected a  perfect
 cure by first intention, in a recent case under his care, (Journ. des Con-
 miss.,  &c., April 1844, p.  151-2,) where more than one  entire half of
 the tibio-tarsal articulation of the right leg was opened in a young man,
 (a laborer,) aged 18, by the stroke of a hatchet upon the inner ankle.
 The parts were  adjusted, and the teguments  brought together by adhe-
 sive plasters, covered  by lint and compresses,  a long splint on the inside 
AMPUTATION OF THE LOWER EXTREMITIES.            273
of the leg, reaching to below the plantar surface, and a bandage to pre-
vent the deviation of the foot, the whole being kept moist, without, how-
ever, removing the adhesive straps, by decoction of marsh mallows and
poppy.   The outer dressings were renewed after every few days, with-
out removing the  plasters.  At each time of dressing, there oozed from
the wound a large quantity of purulent,  foetid  discharge, of a coffee-
ground  color, which was shortly  succeeded by  a colorless liquid,  of
gluey consistence, resembling the white of  an egg, (synovia.)   The foe-
tor continued, and the surgeon  now very judiciously kept the dressings
wet with a weak dilution of chloride  of soda.   The plasters  were re-
moved successively as they  became loose,  and thus  replaced by others.
At the end of three weeks the wound improved, the pus became healthy,
the granulations appeared, and the synovial discharge  ceased.  At  the
end of six weeks the pains had ceased, and the wound was healed ; and
three months after he could walk perfectly, and had all  the natural
movements of the foot, extension, &c, without any deviation.
   This  case certainly shows that we should not be too  much in a hurry
to amputate where the articulations are laid bare, especially where  the
wound is made by a clear smooth incision,  and the constitution is good.
   Two  cases have occurred to Mr. Liston,  of London, (London Lancet,
Dec. 28th, 1844, p. 412. et  seq,) both in young  girls, one aged 17,  the
other 11, in which a tedious fistulous  opening on the inner side of  the
heel, ending in caries of the os calcis, were cured by laying open  the
diseased part down to the bone, by a T incision on the side of the heel,
dissecting up  the  flaps, and  trephining and  then scooping out the carious
portion of the bone, and dressing from the bottom with dry lint to  ex-
clude the air, but with lotions  externally, of  solution of iodine, viz.:—
Tinct.  Iodin.  3j., Iodide of Potassium, grs. x., and  water  Iviii.   The
new bone soon formed, and finally healthy granulations  filled up  the
deep cavity, ending in a perfect cure.  Mr. Liston  has found that  the
tarsal and carpal  bones thus vigorously  treated, will often enable us to
save the foot  from amputation.   The general treatment, also, must be
generous, to aid the formative efforts  of nature.
   Mr.  Shackles of the Leeds Infirmary, (England,)  reports a  highly
interesting  case (London  Lancet, May 10th, 1845, p. 535) of a girl
aged 16, who, caught  in machinery,  received a lacerated wound  three
inches  long, outside the right  patella, penetrating into the joint, and
easily admitting  the finger under the patella, with a large  contused,
lacerated  wound  also inside of the left knee, of which the integuments
were much destroyed, the vastus internus muscle considerably  lacerated,
the patella much ground down  as if rasped by a rough file, and with an
opening into  the joint an inch  and a half long; the synovia also had
escaped, and  mingled with the external  coagulum.   A large piece of
integument hanging  only by a shred,  was  detached,  after  which  strips
of dry lint were applied to the whole extent of the wound.   Upon this
dry lint, other strips  dipped in mucilage were arranged in such way as
to completely  prevent contact  with the air; outside the whole, a piece
" of oiled silk  was placed.   The same treatment for the wound of the
 other joint.   Patient  kept  quiet on the back.  The  dressings were not
 removed until at the  expiration of about eight days, when the suppura-
 tion began to show itself.   After  which, soft  dressings were used.   In
    Vol. II.                    35 
274
NEW ELEMENTS OF OPERATIVE SURGERY.
about a month, the right knee  was entirely  well, and all its  motions
restored.   In the other, the cicatrix did not finally heal for some months.
The diet was generally nourishing, and attention paid  to the bowels.
   We thus  see  what can be done  by occlusion of air, and mild, soft
dressings, judiciously unaccompanied  with any  straps or bandaging to
aggravate  by their  traction ; so in the cases of Mr. Prior, which we
speak of in our notes below.   Yet,  in former times, how readily would
surgeons have adopted a different course, and then rendered amputation
necessary,  or have at least caused anchylosis.   The success of this
mild treatment of the joints, as  in  Mr. Prior's and other  cases, are
adverse to the precipitate employment of hard, unyielding, stony encase-
ments, like the starch bandage,  at least in  such wounds.
   Mr. Jas. Prior, of the  Royal Naval Hospital, Woolwick, relates the
case (London Lancet, Dec. 21,  1844, p. 366, et  seq.)  of a laborer
whose elbow joint, struck by some machinery, was completely dislocated,
and the soft parts and ligaments so lacerated, and torn off and denuded
by the blow that the  bones  appeared to have been dissected clean by
the knife.   The lower part of the  humerus  and its condyles projected
to near three inches  backward so as to be nearly at right  angles to the
fore-arm, while the heads of the radius and ulna were driven upwards
and forwards, and what is singular, without any fracture of the articular
extremities, not  even of  the olecranon.  Mr. Prior, finding there  were
sufficient teguments  left sound to cover  the wound,  that the  brachial
artery and the nerves of the arm  were not injured, and  that there was
but little hemorrhage, reduced  the  bones and  replaced  the soft parts,
and thus neatly  closed the wound,  keeping it in that position  by  com-
presses, a roller and a padded splint, with the arm  moderately flexed ;
determining at once not to amputate, and to save the arm  if possible by
what he properly calls conservative surgery, too little  relied upon, as he
thinks, by many practitioners.  After  many weeks of suffering, during
which much inflammation existed in the parts and neighboring muscular
tissues, causing several considerable sized  abscesses, which were opened,
and as well as the wound discharged  abundant  quantities of pus ; and
after combating the  febrile and local symptoms and  pain by bleeding,
purgatives, poultices, fomentations  and free use of  opium  internally,
the wound, a long time  delayed  also in its cure by the  denudation of
the inner condyle, finally healed perfectly, and the limb ultimately was
wholly  restored in all its functions.  Mr. Prior thinks the elbow and
ankle joints might in many such apparently terrific  lacerations be both,
more frequently  saved  from amputation, and the knee also  perhaps in
many instances, notwithstanding the rather  unqualified  precept of Sir
A. Cooper to the contrary.  The  free porraceous  vomiting, noticed on
one day in the above  case by Mr. Prior, we consider to have been caused
by the liberal daily use of  opiate drinks.   We have  noticed this kind
of vomiting as a not unfrequent result of large anodynes, especially of
morphine.
   Mr. Prior has treated  several other remarkable  instances, where, by
his  plan of  surgical  conservatism,  fragments or extremities of  bones
denuded in contusions, fractures,  &c, even  for a length  of  time, have
been saved by mild  treatment  and by waiting for  nature, as he did in
those  examples, to shoot out the granulations slowly,  but surely, to 
               AMPUTATION OF  THE LOWER EXTREMITIES.           275

 form the new periosteum.  Another striking example is that of the left
 thumb of the engineer of a steamboat, (London Lancet, May, 31,1845,
 p. 611 a. 612,) which had received a violent contusion, and  by which
 the nail and  other soft  parts on the extremity of the  thumb sloughed
 so completely off as to  exhibit, when the dressings which were  applied
 around it for the first days were  removed, a perfect denudation of the
 last or second phalanx  from the  articulation to its tip.  The bone was
 also perfectly black and offensive.  Mr. Prior recommended amputation,
 but as the patient  begged to defer it, the  surgeon  concluded to try to
 save  the part and  did so, using  only  poultices.   In less  than half a
 month the bone had cleansefl and  granulations began to shoot out beau-
 tifully from  the  sound parts towards the tip  till  the  whole  bone was
 completely covered by  the new periosteum, so as to make a good and
 useful extremity  in less than a month—a perfect cure being thus  effected
 without  the  necessity of amputation, or even  exsection of any  portion
 of the bone.  This  is a very different  case, however, from that where
 destruction of the phalanges of the toes and all the metatarso-phalan-
 geal  articulating extremities  from gangrene, for example, is caused by
 their having  been frozen.  Exsection is then imperative,  (see our note,
 Vol.  I.)
   As another instance of what nature will do in restitutions of  severed
 parts, (see this subject  fully treated in our Vol. I.,) Mr. Prior mentions
 the case of  a boy, (loc. cit.,) who, in 1815, in the  vessel of  which he
 was then surgeon, had  about half the middle  finger of  the  left hand
 near  the middle joint so effectually and neatly  severed by the iron hoop
 of a cask which  fell on it, that  nothing but a shred of tegument of the
 size of a worsted thread was left, yet by soft  lint  dressing and adhe-
 sive plaster  around it, aided by splints, a perfect  restoration and union
 was effected.
  A case very similar to those above, and which fully corroborates the
judicious practice pursued by Mr.  Prior, in saving the  arm, recently
 occurred to M. Blandin at the Hotel-Dieu, Paris, ( Gaz. Mid. de Paris,
 Juin 14, 1845, p. 380.)  A young man, aged 22, in thrusting his arm
 through a window, completely tore off the integuments, and the tendon
 of the triceps down to the condyles of the humerus, with the synovial
 capsule  from the elbow joint as high up as its  attachment two  fingers'
 breadth  above the  olecranon cavity of the humerus, making an ovalar
flap which hung down upon the  fore-arm,  and completely  laid bare the
humero-cubital articulation, without however any dislocation or fracture.
M. Blandin, after freeing the parts from the clots of blood, and  finding
there  were no bits of glass in the wound, raised the whole flap up to its
place  and kept it there  by six interrupted  sutures.  The arm was kept
in a flexed  position.  Fever and severe pain and inflammation ensued,
producing such tumefaction of the parts, manifestly greatly aggravated,
however, by the bridling or traction of the sutures, that these last finally
tore out,  when immediate relief was obtained.  The  flap being after-
wards maintained in place only by a bandage, the absence of all traction
and pressure, led to the  rapid cicatrization of  the wound and a  perfect
cure in  fifteen days without  any further accident, leaving, however,
apprehension  of anchylosis.   These  facts prove how  correct was the
estimate  of Mr. Prior in his case of the  elbow joint, which was a far 
276
NEW ELEMENTS OF OPERATIVE  SURGERY.
 more dangerous wound, in taking care to avoid the accidents that occur-
 red to M. Blandin by applying only moderate pressure without sutures;
 for, as M. Guerin well remarks, (lb., loc. cit.,) the free dilaceration of
 the dense, fibrous and aponeurotic  and synovial tissues in such  large
 open  wounds, into the  joints, is itself the reason why such wounds do
 better than narrow ones ; because  this  dilatation  prevents the  subse-
 quent strangulation which must ensue when the parts expand under the
 action of inflammation.  The  same reasoning, therefore, is  correctly
 applied by M. Guerin in favor of the proscription of sutures in all such
 wounds.  In the case of M. Blandin  the arm was probably too  much
 flexed, and kept too permanently in the gut^r ; otherwise he would not
 have had to fear anchylosis.
   [The practice of making free  incisions into diseased joints, is now
 somewhat extensively resorted to, in consequence of the efforts of Mr.
 Gay of London, and will  doubtless be  the means  of saving many  limbs
 from amputation.   We have seen  several instances in which this plan
 has been  adopted, and  the  results  were indeed  most gratifying. To
 Mr.  Gay, however, does not belong the credit of  originating this prac-
 tice, as may be seen by  referring to the Appendix in the last edition of
 Cooper's  Surgical Dictionary.   It will there be  seen  that Professor
 Trowbridge of our own country, has  long been accustomed  to treat
 morbus coxarius in this  manner, carrying his incisions between the
 gluteus maximus  and medius  muscles, down  to  the bone, and  laying
 open the joint.   He has thus opened the joint in all stages of the dis-
 ease, and speaks  confidently of the safety and utility of this method of
 treatment.  Again, the  exsection of many diseased joints which were
 formerly  doomed  to  amputation, now obviates  the  necessity of this
 sacrifice to the patient, and even true anchylosis even of the large joints
 may  be remedied, by a resort to  Barton's operation.   But this matter
 will be more particuarly noticed under  the head of the Exsections.
                                                        G.  C. B.]
   [Artificial Legs.—After a patient has submitted to an amputation of
 his limb, he very naturally inquires of the surgeon what is the best sub-
 stitute he can suggest for him, and we know that this question has often
 given rise to much perplexity.   As to  the lower extremity, we now
 have it in our  power, to furnish every desirable information upon this
 point, and for this  we are indebted to Mr. B. Frank Palmer, the inventor
 of the artificial leg which has won the admiration  of the most prominent
 surgeons in Great Britain, France, and  this country.  During the  Great
 Exhibition in London, 1851, we had  an  opportunity of inspecting the
 large number of artificial limbs there presented, and we know that there
 was  but one opinion as to the vast superiority of Mr. Palmer's invention
 to any  hitherto  offered.   In a word Mr. Palmer  bore away the  palm,
:the adjudicators being among  the rest, no less than the  distinguished
 surgeon of  St. Bartholomew''s  Hospital, Mr.  William  Lawrence, and
 the  renowned veteran of the  Hotel Dieu, Roux, recently deceased.
 We  confess that after walking  some distance with  Mr. Palmer, we did
 not in the least suspect  that he had himself been provided with one of
 his own artificial limbs, yet such is the  fact, his leg having been ampu-
 tated just below the knee.   It certainly is one of the greatest triumphs
 of American ingenuity. 
AMPUTATION OF THE LOWER EXTREMITIES.
277
  We copy  from the  pamphlet issued by Mr. Palmer the following de-
scription of its peculiarities, remarking at the same time, that through
his politeness and liberality we are enabled to present to the reader an
internal  view of this  beautiful piece of mechanism.
  The articulations of the knee, an-
kle, and toes, are united upon a new
principle, and in such an improved
manner as to present the most natural
and symmetrical shapes and propor-
tions, avoiding all vacuums and ex-
crescences.  A successful imitation
of the ball and socket is introduced,
and the ordinary tenon and mortice
and metallic joints are  never used.
  It is  composed of the lightest ma-
terials compatible with strength and
durability.   The joints, by a novel
contrivance  of elastic cords, per-
forming the  office of  muscles  and
tendons, allow of an easy, graceful
motion, that  by a little  practice is
soon  made to correspond with the
other limb, and  so natural a gait is
in a  short time acquired, that the
loss of the real leg would hardly be
suspected.
   The joints, at knee and ankle, are
united  by  means of metallic bars
placed  vertically, and  immovably
fixed to the sides of the leg.  Through
the ends of these bars pass  smoothly
polished bolts upon which the joints
move.   All the joints are so con-
structed as to avoid the possibility
of  any  motion where  the metallic
 parts unite.   By this  arrangement,
and by avoiding the  rubbing of all
large surfaces, friction  is reduced
to  the lowest  point possible, thus
presenting   articulations  which  do
not require the application of oil or
other attention.   The bolts, instead
of turning upon mere tenons, or me-
tallic  plates, take  bearings in solid
wood (properly bushed)  across the
 entire  diameter of  the  knee  and
 foot, presenting a novel  arrangement at once strong and durable.
   The  Tendo Achillis  acts in  the   strictest  accordance  with  na-
 ture.   Being attached to the heel, and (by the application  of a new
 and  important principle)  caused to act  upon  a dead  point  in  the
Leg straight—internal vein. 
278
NEW ELEMENTS OF  OPERATIVE SURGERY.
leg  when  the  step  is  taken, it performs its proper  functions  without
tending to bend the knee or render the step insecure.
   Another tendon, slightly elastic, and of great strength, receives the
shock of sudden ex-
tension, and arrests
the forward motion
of the leg in walk-
ing, thus   avoiding
all  unpleasant
sound and jarring
sensation   conse-
quent upon a colli-
sion  of  the solid
parts of the knee.
   A  lever   and
spring, so  inserted
in the knee as to
act  in    harmony
with these  tendons,
render  the joint
self-acting  when
the leg is semi-flex-
ed as in  walking,
but are so arranged
as  to act   upon  a
dead  point when
fully flexed in the
sitting position, and
lose the power of
extension.   An im-
proved   spring in
the  foot   performs
the  twofold office
of regulating  the
ankle-joint and the
toes, and its action
is certain,  adequate
 and lasting.
   The  exterior  is
 covered   with  a
 strong material, in-
 dissoluble  fastened, which prevents the possibility of splitting.   This
 covering is fitted without perceptible seam, and the whole is then coated
 with a cement  impervious to water, which gives  an enameled surface,
 and color  so natural that the most delicately wrought hose and slipper
 are sufficient to conceal the work of art.
    It is adapted to every  form of amputation,  and successfully applied
 to the shortest and tenderest stumps.  If amputation be below the  knee,
 and the joint anchylosed, or too  short to retain the use of the  joint,
 perfect action  is given by an artificial joint without elongating the  thigh
 perceptibly.   Tho peculiar characteristics  of this  limb,  are life-like
Flexed Leg. 
              AMPUTATION  OF THE LOWER EXTREMITIES.           279

elasticity and flexibility, excessive lightness, adaptability, and perfection
of exterior appearance.
  We insert also the following  views
of Mr. Palmer which have  special ref-
erence to the comfort  and  usefulness
of the mutilated,  who  may desire to
avail themselves of his  substitute :
  " It is obvious that the artificial joints
and  tendons can never be made to act
by mere volition, still the well adjusted
substitute may be made to  respond to
the  movement  of  the living  member,
and  it  requires no argument to  show
that the mechanical limb may be moved,
by lever power as readily as the natural
one.   The  stump  may be termed  a
lever, which, aided by auxiliary  ap-
pendages attached to the thigh or body,
moves the false leg.   Upon the  length
and fitness, then, of the stump, depends,
in a great measure, the  success in loco-
motion.  The greatest  length possible
should  be  saved,  (except when varia-
tions of the rule  are demanded,) and
if the  living portion be radically de-
fective in  length or flexibility,  art,
though it  may  mitigate   the suffer-
ing,  can  never fully supply  the defi-
ciency.
  "  In  amputating  a  thigh,  the  con-
dyles of the femur  should always be
fully removed, but no greater portion,
unless the safety of the  patient demand
it.   The best amputation possible, is
of the leg, some ten  inches below the
inferior edge of the patella, though it
is always advisable to  amputate high
enough to secure a good flap, which is
very  important, as it  prevents all un-
pleasant sensations, such as  arise from
a slight tension of the thin  skin which           Exterior view.
is too often found to be the only cover-
ing of a protruding  bone.   If a stump must  necessarily be less than
four  inches in length, below the knee, amputate just below the tuberosity
of the fibula, so that  the knee may  be flexed  and an artificial joint
applied without exhibiting  a protruding stump.  This rule will apply
in amputation for anchylosis of knee, if the j'oint be not diseased ;
should it be  extended, however, (and  stiff,) amputate  above the knee.
Perfect use  of the knee joint should always be secured,  even  if the
stump is too short for use in  walking.
  " The stump should be tightly bandaged for several weeks previous to
 
280
NEW ELEMENTS OF  OPERATIVE SURGERY.
 the  application of the  new  limb, to compress and solidify the cellular
 substance  and give the stump conical shape.   The joints should be ren-
 dered capable of the fullest flexion and extension,  and then the patient
 may walk with much facility at the first attempt,maintaining naturalness
 and precision of step.
   " Often in  cases which admit of most favorable amputation (near the
 ankle) a most unwarrantable portion of the leg is removed, and not un-
 frequently  the knee is permitted to remain semi-flexed so long as to be-
 come incapable either of full flexion or extension, while in innumerable
 instances a healthy joint is found fully flexed, and  permanently useless
 for want of a little care in healing.  Such practice cannot be too strongly
 reprehended.  Amputation at the knee or ankle joints is a very objec-
 tionable practice, and cannot be  too speedily abandoned.  In this ope-
 ration  the  remaining condyles give enlargement and unfavorable shape
 to the end  of the stump, arid the extreme length interferes with a per-
fect  combination of the artificial mechanism.  Amputation of the foot
through the tarsus, is worse for the patient, also, than above the ankle.
Aware of the opposition  this  opinion will meet, we have  not ventured
to publish  it, until able  to give  the result of experience  in treating a
number of  cases.   This operation does not admit  of a neat or durable
substitute, and the leg is more encumbered than if amputated above the
ankle joint.   If removed through  the tarsus, and particularly if no more
of the bones than the astragalus and  calcis remain, as we have  seen in
several instances,  the point of amputation is invariably drawn down-
wards by the contraction of the tendo achillis, (its antagonistic muscles
being destroyed,) and the patient is rarely, if ever, able to support any
considerable  portion of his weight upon the  heel,  and the support is,
necessarily, upon a socket enclosing the leg.  The false foot and ankle
are less perfect, the natural heel cord does not perform its function and
an adequate artificial  tendon  is supplied with great  difficulty, if at all."
                                                       G. C. B.]
                    SECTION  TENTH

              OF THE EXSECTION OR EXCISION OF BONES.

  The operation of exsecting bones, though  already performed at the
time of Galen for certain  bones of the trunk, and, as would  appear,
for some of the articular extremities, was never actually introduced into
practice after fixed rules until  about half a century since.  It is per-
formed in the continuity as well as at the extremities of the bones, and
almost always with the view of preventing the amputation of the limb. 
EXTRA-ARTICULAR EXSECTIONS IN GENERAL.          281
                          PART FIRST.

              EXSECTION IN THE CONTINUITY OF BONES.

  In the continuity of bones exsection may be required, either for recent
compound fractures, ancient ununited fractures, caries, necrosis, osteo-
sarcoma, spina ventosa, or any other incurable organic  disease.
                           CHAPTER I.

             ON EXTRA-ARTICULAR EXSECTIONS IN GENERAL.

  When it is proposed to perform excision or exsection on the continuity
of the bones, we require a particular kind of instruments.  Those most
frequently in use among surgeons are : the cutting nippers, [or pincers,]
cutting pliers, saws of different kinds, the trephine, gouge and mallet.

                            Article I.

  The ordinary cutting nippers (plate 3,) answers sufficiently  well for
those points or plates of bone  that project, or which may readily  be
brought to the surface.  Its size and form  prevent our using  it in the
depth of wounds.   Among the cutting pliers are those of M. Zeiss, ( Gaz.
Mid. de Paris, 1838, p. 375.)   They are scissors with short, narrow
strong blades, armed with fine  teeth and long branches.  As they may
be introduced into narrow openings, and even into the depths of wounds,
they enable us to cut while they at the same  time saw through splinters,
fragments, and in fact the entire thickness of bones of a certain volume,
and thus allow us in a multitude of cases to dispense with the employment
of the saw.                                                     ,
                            Article II.

  M. Liston has substituted  for the ordinary cutting nippers, an instru-
ment still more simple and  not  less valuable, (plate 4.)   The cutting
pliers of M. Liston differ from the  cutting pliers which I have mention-
ed only in this, that their blades besides being shorter and narrower are
provided with a perfect cutting  edge.  The blades of M. Liston's pliers,
which are flat on one side and shaped into a deep bevel on the  other,
cut wonderfully well the phalanges, and  the bones of the metatarsus and
metacarpus, and could be used to make the section also of the ribs and
all boney fragments which do not  exceed these last in size, also in ex-
sections at the bottom of fractures whether recent or ancient.

                           Article III.

  Other osteotomes more powerful, and constructed after the same idea,
have been devised by M. Colombat and M. Manec.  Having occasion to
perform exsection on  the ribs in 1835,1 arranged an osteotome in such
  Vol. H.                     36 
282
NEW ELEMENTS OF OPERATIVE SURGERY.
 manner that its lower blade bent in the form of a hook, allowed the cut-
 ting blade to come down with all its power upon the rib without causing
 it to slip.  The  cock's comb  and the watchmaker's saw, the different
 kinds of hand-saws and amputation saws, are too well known to make it
 necessary to describe them here.
   But saws which allow of our operating with them in the depth of the
 tissues, and which have been specially invented for the exsections or ex-
 cision of bones, require in this place that we  should  give a short des-
 cription of them.

                           Article IV.

  The articulated or chain-saw invented and described by Aitken, (Prin-
 ciples of Midwifery, London, 1784,) (vid. plate 3,) erroneously attribut-
 ed to Jeffray, (Excision of Carious Joints, etc.,  1806,) who himself
 acknowledges that he borrowed it from Aitken, is not  less valuable for
 oxsections than for amputations.   Another saw which allows of  our  ex-
 secting bones wherever they may be situated, and in every possible way
 that can be conceived, and which acts on bones as the bistoury does on
 flesh, is that of  M. Heine, (plate 6,) composed of the chain-saw of Jeff-
 ray, mounted on a series of wheels, and which is moved by means of a
 crank, at the same time that the hooks (crochets or hasps) and  shaft
 admit of our fixing it or inclining it  in  any way we wish.  This saw,
which, according to the author, (Gaz. Mid. de Paris, 1834, p. 644,) had
in 1834 already been put to the proof on living man on fifty occasions,
has no other disadvantage but that of being very complicated and of
requiring a  certain  degree of practice in order to be properly handled.
The modification, however, which has been  made of it at Paris by  the
manufacturers Charriere and Sanson, has rendered it sufficiently simple
for all surgeons to procure and make  use of it.
  Toothed  rowels, mounted upon a  shaft analogous to  that of Heine,
were thus susceptible of being transformed into vertical saws  of differ
ent"diameters, under the names of Thompson's saw, M. Leguillou's saw,-
 &c.  But a saw which  surpasses these, in its advantages, is that which
is called Martin's, (PI. 7.) This is constructed with a shaft, having some
 resemblance to that of a trephine, whose crown should be replaced by a
 disc either flat,  (plane,) or convex, in form of a mushroon, and  the cir-
 cumference of which would represent a saw.   With this instrument we
 may  exsect  bones transversely, obliquely or  vertically, without  the  ne-
 cessity of their protruding beyond the skin.   We may even excavate or
 hollow them out, as artists groove out wood,  provided  we make use of
 the convex disc in place of the flat one.  A  glance at  the figure I have
 given it, will explain its mechanism and construction better  than a long
 description.  The small saws of M. H. Larrey, and of M. Rambaud, (PI.
 7,) also deserve consideration.
   As to the gouge, mallet, and different portions  of the trephine, and
 the rotatory saw  of M. Thall, (Arch.  Gin.  de Mid., t. I., p.  268,) I
 have nothing particular to say, or shall speak of them under the head of
 Operation with the Trephines.  The  same may be  said of rasps, levers
 and elevators, which we may also have occasion for. 
EXTRA-ARTICULAR EXSECTIONS IN PARTICULAR.         283
                            Article V.,

  The articles for dressing with which we should be provided, are gene-
rally sufficiently numerous.   Besides those which are demanded for every
serious operation, the exsection of the bones of the limbs especially, al-
most constantly requires also those which are employed for fractures.  We
must, therefore, have in advance, either splints and  bands, or pieces of
pasteboard and the bandage of Scultetus, or long bands, and also some of
the preparations  for making immovable bandages, (For all which, see
Vol. I., passim.)

                           Article VI.

  During the operation, also, it is frequently  important to put ourselves on
our guard  against hemorrhages,  and to have recourse to provisional
hemostatic means, as  in cases of amputation.  Forced to  act upon organs
whose mobility is increased, and where every movement sometimes oc-
casions violent pain,  the surgeon has  need also of intelligent assistants,
and a sufficient number of them.
                          CHAPTER II.

             EXTRA-ARTICULAR EXSECTIONS IN PARTICULAR.

  As to the consequences of the operation, considered under a point of
view purely pathological, they are the same as those for compound frac-
tures or amputations.

                 Article I.—Compound  Fractures.

  When in a fracture the extremity of one of the fragments escapes and
makes a projection through the lacerated integuments, if the  proper di-
latations and prudently directed efforts are not  sufficient to replace  the
parts, the exsection of the bone which protrudes beyond the wound  has
always been recommended and practised.  The operation, under such
circumstances, is one of the most  simple.   Two  assistants  grasp  the
limb, one the upper, and the other the lower portion, in order to increase
its curvature, and  make the boney points  protrude out more from  the
wound.   The operator enlarges the wound, if it should appear neces-
sary, protects the tissues by means  of a piece of linen or pasteboard,
and makes the section of the denuded bone, either with an ordinary saw,
or with any other instrument whatever, suitable to the form and position
of the part.   The same means are to be  recurred to, in a  multitude of
other cases.  If  the fragments are sharp and  prick the flesh, or if they
escape from the  wound on the least movement,  or are cracked or  de-
nuded to such degree as to  render necrosis  inevitable, their excision
would prevent many  accidents, and  evidently facilitate the consolida-
tion.  It is to the tibia and fibula, and to the bones  of the fore-arm, and 
284
NEW ELEMENTS OF OPERATIVE SURGERY.
some of the phalanges, that we are most frequently obliged to apply this
species of exsection.
   After wounds from fire-arms, when the bone, or principal bones of a
limb have been shattered or reduced to splinters, and the soft parts are
not too extensively laid open, instead of proceeding to amputation, it has
been  prudently  suggested, that we  should  first extract the detached,
boney fragments, and afterwards cause to protrude out of the wound the
angular fragments of the two ends of the broken bone,  in order to iso-
late  and exsect them.  In such cases, the  surgeon is almost always
obliged to enlarge  the primitive wounds, or even to  make new ones. He
makes his incision  usually in  the direction of the axis of the limb, at a
point which is the farthest distant from the vessels and nerves.  By
this wound, we cause the protrusion successively of the two  ends of the
fracture.  After having properly isolated them, we exsect the points and
all other parts that might interfere with  the  cure, proceeding  in  other
respects as has been  described above.
   From the sententiousness of certain passages in Hippocrates, relative
to exsection of bones,  it would  be easy to maintain, that  in  his time
they exsected every thing that was denuded in certain cases  of fracture.
This is the doctrine of  Celsus, Galen, Guy de Chauliac, Tagault, Pare,
the two Fabricii, (Jerome Fabrice, Opir.  Chir., pars 1, lib. 4, cap. 10,
et Trad. Fran^., p. 451,) Gourmelin, and Dalechamps.   Up  to the close
of the last century, however, we  find scarcely any  othors than Paul  of
iEgina, (Paul  d'Egine dans Dalechamps, Chir  Frang., ch.  107,) and
Severin, (Severin,  dans Ronet, t. I.,  p.  316,) who have  given extension
to the operation of exsection, by recommending  it  upon a more or less
considerable portion  of the  whole calibre of the  body of the  bones.   In
the defect of general  precepts on this subject we are indebted to the cus-
tom of publishing particular cases, for the knowledge we have  of  some
instances of fracture, where exsection has  been extensively performed
by skilful and enterprising men,  who have taken counsel only from their
inspiration, and whose boldness has been crowned with complete success.
   The first systematic work in which the recommendation of exsection
has been generalized is that of Pott, translated and  commented  upon by
Lassus, who refers back to  the precepts of Paul of Egina, and explains,
in a very precise manner, the excision of bones.   But Hevin abandoned
exsection to simple  relaxation  of the  muscles, though Bourbier  (De
Necessitate et  Utilitate, etc., 1776) had supported at Strasbourg a very
remarkable dissertation in its favor.   When the bone passes  out (passe)
death ordinarily ensues, says Courtin,  (Legons  Anat. et Chir., p.  696,
A. D, 1612,) while speaking of fractures of the  humerus.
   Bourbier sustaining his positions on the authority of the ancients and
of Rossius,  Diemerbroeck. Scultetus, Roueb, Siebold,  Munnicks, aud
Gaigniere, thus expresses  himself in his thesis: " Since it is certain,"
says he, " that the fragments of  the  displaced bones wound  and irritate
the neighbouring parts, let  us seek  in the nature of the disease  itself
the  treatment to oppose to  it.   We ought to  remove  by means of the
saw a portion of the projecting  bone sufficient  to  effect the reduction
immediately, and without any concussions or tractions.   Then the pain
will cease, and to the state of agitation which the patient is in  will suc-
ceed repose and  tranquillity.   The apprehension  that we shall have 
            EXTRA-ARTICULAR EXSECTIONS  IN  PARTICULAR.         285

accidents supervene, or that those which already exist will be aggravated,
will be alike dissipated."   It is  a very  difficult point here to pronounce
on the cases where we should procrastinate  or  recur to what Severin
calls efficacious surgery.
  1.  Without excision  would there be exfoliation of the fragments de-
tached from the body of the bones, but  which are still adherent to the
soft  parts ?  I have  seen splinters of  bone  that did not reunite, yet
retained their  vitality in  the midst of the  tissues.  I have seen such in
the thickmess  of the muscles of the fore-arm, and once in the lower
part of the arm, in the dead body, in  subjects  in  which the  fracture
had been consolidated for more than fifteen years.
  2.  What is the action of such fragments  on  the secretion of the callus
even when they must  pass into  necrosis, or when they  are  extracted,
what is their effect on the  shortening of the limb ?
  3.  If  they are of great importance  and ought to  be removed, how
are we to distinguish the cases  where  their presence would give rise to
accidents which  would endanger life,  or where their extraction would
have been  more  advantageous  than their  incarceration  within the os-
seous callus ?
  4.  What is  the influence of the continuity of one of the two bones
(the smallest especially) on the  preservation of  the length and straight-
ness of the limb and the reproduction of the parts destroyed ?
  If we remove  all the  splinters  and cut off the  ends in the body of
the bones, we may possibly indulge the hope of effecting  a consolidation
of the fracture, at least for the femur, humerus and tibia ; but what are
the signs which will  enable us to distinguish those cases where an op-
eration might result in a pseudarthrosis ?  Nor is any thing more known
of what  takes  place  in  relation to the shortening which occurs under
these last mentioned  circumstances.  We  find facts for and against the
propositions which I have just  enumerated.   M. A. Cooper  has found,
in excising a portion of the radius or some other bones in rabbits that a
void was left behind, and that  no  osseous reproduction was effected in
the place of the piece  removed.   Others  have seen the reverse of this,
and facts in practice authorize  us  to sustain  both  the affirmative and
negative of this position.  The course, also, which  surgeons take under
these circumstances is far from being uniform.   Some confine themselves
to extracting the detached  splinters  and fragments, while they replace
the adherent pieces with the hope that they may become united or that
nature will expel them.   The presence of such  splinters in the wound
at least  lessens, it  is asserted, the shortening of the  limb, by keeping
the ends of the  fracture  apart, and by serving  as a sort of mould or
nucleus for the reparative  callus.  G. Fabricius ^Bonet, t.  II., p. 185
and 1&8,) was a zealous partizan of this practice.   Others, on the con-
trary, dilate largely, extract all the detached fragments, empty the cavity
and cut off, when necessary, the ends of the  fractured  bones, in  order
to reduce the wound to a  simple state, and in the hope  that they may
thus prevent inflammations, consecutive abscesses, delay in the formation
of the callus and necrosis  ; also  the retention of the sequestra and the
interminable  fistulae which  they are so  often  the  cause of,  together
with  those tedious operations  which are  sometimes  necessary for the
extraction  of the splinters.  Le Dran and Bagieu, and especially Bil- 
286
NEW ELEMENTS OF OPERATIVE SURGERY.
guer, together  with  Schmucker  (Sprengel, t. VII., p.  320—327,) and
Theden, are great advocates of this method, which I have also frequently
employed with marked advantages.

                     § I.—Bones of the Hand.

   The importance of the smallest osseous piece to the hand, makes it
necessary that we should  never sacrifice it, except it be impossible to
preserve it.   So also it is better, in cases of fractures with crushing of
the  phalanges  or bones of  the metacarpus or wrist,  to  remove  the
splinters, and  to  exsect  or excise the  projecting points, and make tha
proper dilatations, than to amputate the part3 injured.  The forceps, cut-
ting pliers, scissors of Liston, rowel saw, that of the cock's crest or the
watchmaker's will suffice in such cases.   I have in this  manner  had it
in my power, in  removing  portions of the phalanges, metacarpus or
carpus, to save in a  great number of patients a thumb, a fore, middle,
or even the little finger itself.   The operation, in other respects very
easy, varies necessarily according to each particular case, and cannot
be described.

                  § II.—Bones of the Fore-arm.

  The memoirs of the  Academy of Surgery contain two  remarkable
facts (t. II., in 4to, p. 529 ; t, VI., in 12mo, p.  141)  relative to  the
extraction of splinters  from the  two bones of the fore-arm.   We find,
also, that  Bilguer removed a portion of the ulna which had the length
of four fingers' breadth.   La Franboisiere (Bonet, t. IV., p. 237) speaks
of a loss of substance in the ulna of the length of four fingers' breadth,
caused by the  extraction of splinters, which filled up  with  flesh, and
became so indurated as to take the place of the portion of bone removed,
without making any curvature in the fore-arm at this place.   The  ex-
traction of a very considerable portion of the ulna, without causing any
change in the form of the arm, was effected at that time  also by Dupuy-
tren,  (Champion,  These  No. 11., Paris, 1815.)  Here is a fact  not
less  remarkable :  a fracture of the body of the  radius  by a  fire-arm,
(a fusil charged  with  twenty large slugs, and the  barrel against the
fore-arm ;) the charge remains in the limb; on its palmar side contused
flesh, numerous splinters  and fragments on a level with the  surface,  (en
flute,) and denuded.  The  ulna  was laid bare above the fracture.   A
long incision was made  on the radius, in front and behind ;  the frag-
ments dissected on a  line  with the denudation, and exsected (by means
of a cultelaire saw passed into the two wounds) to the extent of an inch
and a half below, and two  inches above.  Extraction  of the  splinters
and fourteen balls.
   The contused tendons of the two radial muscles necrosed,  and some
abscesses supervened in  consequence of the slugs scattered throughout
the tissues; the wound healed in six months.  The three  last fingers
preserved their movements.  The wrist anchylosed.  The patient, who
was strono- and robust, resumed his  occupation  of mason.  There re-
mained between the extremities, in the  continuity of the radius,  an in-
terval of  five inches, which was occupied only by soft parts.   The limb, 
EXTRA-ARTICULAR EXSECTIONS IN PARTICULAR.         287
which preserved its straightness, though there was no reparation of sub-
stance, recovered as much strength as the other.  M. Champion was as-
sisted in this operation by M. Collignon and  M. Pellier of Nancy, who
was then there.
   Three men, says  M. A.  Severin, (Bonet, t. I., p.  316,  chap.  10,)
vainly endeavored to reduce a  fracture complicated  with protrusion of    »
the rajdius externally.   The bone-setter, Marc  Blaise, could not effect jttXwtis
his object.  The ends of the bones were exsected with a saw, and the
patient recovered.   Perhaps the difficulty here  arose from the tractions
not being made in the proper  direction.  Deschamps  (Ancien. Journ.
de Med., t. LXIX., p. 471) relates that it was determined to amputate
the fore-arm in a case where the lower fragment of the radius protruded
from the wound, and formed there  a draw-bridge, the parts had  been
placed in pronation; when  he  caused them to be placed back in demi-
supination, the bone suddenly entered (into its place.) M. Saint-Hilaire
(Considirations sur les Os de VAvant-bras, etc. p.  10, 1814)  speaks
of a patient in whom it became necessary to exsect the  two bones of
the  fore-arm which had  been  fractured  at  their epiphyses, and pro-
truded through the soft parts.
   Operative Process.—When the removal or excision of splinters and
fragments  becomes necessary in fractures of the fore-arm, the operation
must necessarily vary according as the bones protrude through the skin,
or are simply broken at the bottom  of the wound.   We may enlarge,
without  any  fear, the wound of the integuments.   We then  give  a
greater curvature to the limb, and surround and protect the root of the
fragment with linen, pieces of pasteboard, wood or metal, afterwards
exsect them with the saw where the whole thickness of the osseous cylin-
der  is to be divided, or with the cutting nippers or pliers, when  some
points of  bone  only are to be removed.  As a general rule,  it can-
not but be advantageous to  remove  a  large  portion of  the  bone, and
there would be an inconvenience if we  did not  give  ourselves plenty of
room in excising it.   The radial  and ulnar arteries, with their accom-
panying nerves of the same  name, and the median nerve, are the only
organs which it is important to avoid.   As  they are situated in front,
and nearer to the axis of the limb than the bones are, the ulna or ra-
dius ought, by preference, to be inclined  towards the  posterior or out-
side of this axis when we wish to  exsect them.
   All the points of bone being thus destroyed, we cleanse the wound of
the foreign  matters it may contain, and proceed immediately to the re-
duction by making the proper tractions and extension.
   If the bones do not protrude  externally, when it  becomes necessary
to remove any portion of them, we begin,  unless the  tissues  are exten-
sively lacerated, by enlarging the principal wounds of the skin as much
as possible in the  direction  of  the  axis  of the  limb.  By means of a
strong forceps, we  remove from the wound the  splinters  and fragments
which it may be thought advisable to sacrifice ;  and then  proceed to the
exciskn or exsection of the  extremity of the  two ends  of the fractured
bone, if they should be so sharp as  to  irritate  the soft parts, or seem
calculated  to  produce  any  mischief,  (accidents.)  During all these
manipulations, the  fore-arm should be held in a state of  flexion, and in
such manner that all its muscles may be as much  relaxed as possible. 
288
NEW ELEMENTS OF OPERATIVE SURGERY
The assistant andsurgeon, it will be understood, are to give to the fore-
arm all those inclinations and inflexions which  will enable it to check
the tension and tractions caused by the fracture.

                     § III.—Bones of the Arm.

  The exsection of a portion of the body of the humerus, in cases of
fractures, is one of those which we most frequently have occasion to
perform.   Science possesses a  very great number of examples of  this
kind.   Nevertheless, the formation of  a  pseudarthrosis was the result
of this operation in a patient of Theden, and  in the case of  Lelong, as
mentioned by M. S. Cooper, (Bourbier, Op. cit., § 8.)  Most frequently,
however, the operation has been followed by complete success.
  An infant eight years of age, says Diebold, (Diet, de Chir.,  t. I., p.
479,) a distinguished surgeon of Strasbourg, fell from a horse and frac-
tured the humerus  a little above the epiphysis ;  the biceps was torn, the
Done protruded about two inches, and  reduction could not be effected.
Twelve days passed on,  and gangrene had already attacked the muscles
of the arm.   Diebold being sent for to perform the amputation, confined
himself to exsecting about six  lines of  the  protruded  portion of bone,
when he  easily effected  a reduction.  It then became  necessary to ar-
rest the  progress of the gangrene, and to  favor the exfoliation of the
tendons and of the ligaments in the neighborhood  of the articulation,
when, after the expiration of six weeks, a healthy cicatrix replaced one
of the most frightful looking wounds.
   In the  case of & fracture of the surgical neck of the  humerus, noticed
by Sylvestre, (Ancien. Journ. Mid., t.  XXXIX., p. 275, 1773,) one of
the ends  of the bone protruded an inch and the other half an inch  and
they had been in this situation from seventeen to eighteen days, during
which time frequent attempts had been made at reduction.   Three of the
surgeons proposed amputation : the wounded  man was  exhausted.   Syl-
vestre being called in,  made, at different times, incisions  and  counter-
openings, and applied pungent  substances to the ends  of  the fractured
bone ; exfoliation of the upper  end of the bone took place ; the change
made in  the inferior end not having yet enabled it to detach itself imme-
diately, Sylvestre removed its carious portion "with the saw, effected the
reduction,  then kept  the bones in coaptation  by four immovable splints,
made frequent dressings, healed up the thirteen openings in twenty-seven
days, and consolidated the fracture in two months.  Bourbier speaks of
a fracture  of the humerus, situated immediately above the condyles, in
a boy aged eight years ; the upper fragment protruded through the  skin
on the inner  side of  the biceps, while the lower was drawn backwards;
Notchet, of  Laon, could not  reduce  it, notwithstanding a dilatation
 which he made of two inches extent, and repeated  efforts of extension.
 On the following day there was a violent pain, with  fever and subsultus
 of the tendons,  and the life of the patient in danger.  Five  physicians
 and surgeons united  decide  upon amputation.   Bourbier, who arrived
 on the  third day, proposed exsection, which was  performed by Gaig-
 niere.   An  inch  of  the bone  was removed $ when  the remainder was
 replaced with the greatest ease.   All  the  symptoms subsided, and the
 most perfect success crowned this  operation.  In  three  weeks a firm 
             EXTRA-ARTICULAR EXSECTIONS IN PARTICULAR.         289

cicatrix filled up the wound, and the callus  was already sufficiently
solid  to  allow of the patient returning  to  his relations.  M.  Belair,
(Journ. de Mid.-Chir. et Pharm.  Milit.,  p. 233, Mai, 1815, No. 2,) on
the twentieth  day of the accident, excised from 5 to 6 lines of  the up-
per fragment of the  humerus fractured near  the shoulder, because this
fragment, being denuded, pierced through the skin in  spite of the dress-
ing.  The patient recovered.
   In a case of fracture of the  humerus above  the condyles, noticed by
M. Vial, (Recueil de Mid.  et  de  Chir. Milit.,  t. IX., p. 271,1821,) in
a child of five years of age, the upper fragment protruded through the
flesh to the distance of fourteen or fifteen lines.  With these there was
also laceration of the brachialis internus muscle, of the inner border of
the biceps, of the branches  of  the  internal collateral artery, a  copious
hemorrhage, and a shortening of the  limb of nearly two inches.  Com-
pression of the  artery, efforts  at  reduction,  extension, graduated  com-
pression upon the integuments—in fact, nothing succeeded.   The tume-
faction and contraction of the muscles strangled the fragment with such
force, that it was  impossible to introduce a  probe between the parts.
After having  glided under the bone  a retractor of wood, cut in a cres-
cent  form,  a  portion  of it  14 lines  long was exsected.  The -wound
healed up in fifteen days, and the  fracture consolidated in thirty-three.
The movements of the arm were re-established  on the sixtieth day, with-
out any shortening of the limb!   A  comminuted fracture of the lower
extremity of the humerus, with protrusion of the fragments and  separa-
tion of the condyles, made it necessary to exsect the upper fragment
during the first  days.  A protrusion of a part of the lower fragment
took  place  at a  later period. A rigid diet, and bleedings renewed as
often  as  necessary,  arrested  the hemorrhages, which had  occasioned
much  uneasiness.  The  patient, who  has resumed his occupations, says
M. Charpentier, (Sociite des Sciences  Mid., de  Metz, p. 21, 1822,)
experiences only some difficulties in  the movements of extension of the
fore-arm.
   A child, aged  seven years,  fell from  a horse on  the  15th  of May,
1819, and fractured his left arm.  M. Heriot, who arrived from  Pont-a-
Mousson  two hours after the accident,  found the  humerus fractured
across its lower portion, and  so  near the  articulation, that the upper
fragment included a part of the olecranon fossa of this bone.  This frag-
ment, which had torn and penetrated through the tissues and skin upon
the fore-part of the arm on  the inner side of the biceps, made a protru-
sion of an inch in the bend  of  the  arm.  The  brachial artery  and  the
median nerve were found denuded and stretched  across the extremity
of the bone like the cords of the violin over  its bridge.  After having
satisfactorily ascertained that the tuberosities of the  humerus were  not
fractured, and that the portion of the bone  to which they belong was
entire,  notwithstanding  its shortness, M. Heriot proceeded to enlarge
the wound up and down, and  slit  open its borders transversely in the
bend of the arm ; this did not prove  sufficient; the reduction could not
be effected.  The angles of the humerus were now cut off with a strong
pair of scissors, with the hope of  liberating  the artery and nerve;  but
these last-named organs  were too  tensely  stretched to yield.  The sur-
 geon then made up his mind to tie the artery and  divide it, as also the
   Vol.  II.                   37 
290
NEW ELEMENTS  OF OPERATIVE SURGERY.
nerve, and to exsect with the saw, to the extent of an inch, the portion
of bone which protruded beyond the wound.
  Afer this operation, the reduction was easy ;  the  patient was placed
in bed, with the arm in a  position of semi-flexion, and the elbow slight-
ly elevated upon a cushion of oat chaff.   The borders of the wound were
brought together and dressed with  dry  lint, after which the limb was
covered with an  emollient poultice.  The  ligature came away on the
eighth day,  and the ends of the bone were  united  on the twenty-first
day.   The action of the muscles had dragged  the  lower fragment for-
wards, and it was found necessary to let it consolidate  in this position.
The inflammatory tumefaction  continued to the thirtieth day from the
accident.  The patient  could  at that time raise his whole  arm at once
in one movement.  At this period the fore-arm was placed in a gutter
£>f pasteboard, supported by a scarf,  in order to allow the child to walk
about.  Two months  and a half after the  fracture, extension could be
performed almost perfectly, and appeared to be in no way incommoded,
except by the  cicatrix of the  wound.  Flexion  could be performed to
two-thirds its extent, and  movements of pronation and supination  could
be executed the  same as in  its healthy state.   The  sensibility of the
Jimb was not impaired, and M. Heriot noticed  no other result from the
section of the median nerve, except a temporary pain in  the  fingers,
especially in the middle finger, of which in fact the  patient complained
at the time of the operation.
  M. Champion, who communicated to me the particulars of this impor-
tant case, guarantees its authenticity.
  The following  case, for which I am  also  indebted to M. Champion,
shows what should be done for the other extremity of the humerus.
  Oblique Fracture of the Surgical Neck of the Humerus.—The lower
fragment drawn upwards  and in front of the scapulo-humeral articula-
tion, raised up the soft parts above  the  acromion.   Attempts at reduc-
tion proved useless though the girl  was young (aged seventeen) and of
a lymphatic temperament.  The inability to effect the reduction  could
only be imputed to the impossibility of disengaging by the efforts at ex-
tension, the  lower fragment of the humerus, which  was  imprisoned in
the  fibres of the deep-seated layers of the deltoid which it had penetrat-
ed.   An incision was made into a sero-sanguineous extravasation on this
fragment, and the lower extremity of the fraqtured bone denuded to the
extent of eighteen lines.   This portion  was now exsected, and the cure
of the patient effected.  A great part of the motions  of the limb were
restored with scarcely any perceptible diminution of its length.
   Operative Process.—The humerus which  so often places the surgeon
under the necessity of performing  exsection upon  it  when fractured,
exacts during the operation precautions which it is scarcely possible to
systematize  under any fixed rules.   Both at its middle portion arid its
extremities it would always be most prudent to begin with the fragment
which projects backwards and outwards.  For in  these directions the
dilatation of the wound and  the incisions which we are under the ne-
cessity of making, compromise only the integuments or muscles.  In front,
on  the contrary, and especially on the inner  side, we should have  to be
on  our guard against the wounding of nerves and^ vessels of considerable
size.  Perhaps it would be practicable, after having thus given ourselves 
EXTRA-ARTICULAR EXSECTIONS IN PARTICULAR.         291
sufficient room, to incline the other fragment also in the same direction,
in order that we might exsect that also without incurring any additional
risk.   Nevertheless if the  tissues should  be  lacerated  upon the inner
side and in front, the operation  should be performed in that direction.
We must then accurately recal to mind the relations which the  brachial
artery, median nerve, ulnar nerve, and even the radial  nerve, have with
the ends of the fracture.  And it would not be until after having sepa-
rated or pushed them to one side or the other by incisions and tractions
skilfully managed, that we should undertake to apply the saw or cutting
pliers  upon the bones, taking care moreover when doing so to give them
during the operation a strong inclination, and to make them project as
much as possible beyond the integuments.
   Whether it be the fore-arm, or the arm, it is important after the exsec-
tion of the bones and the removal of the splinters has been completed, that
the limb, if it has been fractured through its whole thickness, should be fix-
ed in an apparatus which shall keep it immovable, while at  the same time
itadmits of the daily dressing of  the wounds.  The starch bandage which
perfectly fulfils this indication, is here of great advantage.  We should
therefore now  surround the  whole of the  fore-arm  and arm, from the
roots of the fingers to the shoulder, adding at the same time some turns
of spica, with a roller bandage interlaid with some pieces  of pasteboard
and saturated with dextrine, taking care to leave openings  at every place
opposite to the wounds, so  that at the time the desiccation of the dress-
ing is completed, the  whole limb may be maintained in the  position
which we desire it to have up to the termination of the cure.  [See note
Vol. I. on  the starch  bandages and their extreme danger  when not ap-
plied with  the precaution pointed out by the author.  See  also the case
of Mr. Dubowitsky, same volume.  T.]
   If, however, the fracture should not go through the whole thickness
of the bone, or if, as I saw in  1830, in the case of a man whose arm had
been traversed by a ball, the  half or two-thirds only of the calibre of
the humerus had been fractured, then after having completed the extrac-
tion of the fragments of bone, this bandage  would no longer be indis-
pensable, and the wound should  be treated like any other wound from
fire-arms.

                   § IV.—Bones of the Shoulder.

   It is seldom we are called upon to perform  exsection  upon the bones
of the shoulder in cases of  their fracture ; it should be fearlessly made,
however, where the bones are laid bare and present pointed fragments
at the  bottom of the wound.  I shall not hesitate, for example, in a case,
to excise the ordinarily too  acutely pointed extremities of the fragments
of a fractured clavicle, if they had lacerated  the integuments.   One of
the wounded of July, 1830, who was wounded by a discharge of fire-
arms upon the front part of his shoulder, received thereby a  fracture of
the clavicle, coracoid process  and head of the humerus, all at the same
time.   After  having  extracted from different; recesses  of the wound a
variety of projectiles and a great number of splinters, I removed by means
of the cutting pliers and cock's comb saw, the projecting points of three
bones mentioned, and the patient ultimately got well. 
292
NEW ELEMENTS  OF OPERATIVE SURGERY.
   The  acromion, notwithstanding it seems  by its relations to be indis-
pensable  to  the functions  of  the  arm, should nevertheless be  freely
exsected, in cases where it is fractured and protrudes through the skin.
After the  cicatrization of  the wound, the clavicle  supported  by  the
coracoid process would  take its  place completely.   As a proof of this
assertion I mention the case of a patient  who had the whole acromion
extracted out entire for necrosis without experiencing any perceptible
diminution in the strength or motions of his arm, and the case of another
man who  with an ununited  fracture of the  acromion  felt no sort of in-
convenience whatever from it.
   It is unnecessary to add that in fractures of the body of the scapula,
the osseous angles, are not to be spared but are to be exsected largely.

                     § V.—Bones of the Foot,

   The bones of  the toot, in cases of fracture, rarely  require exsection,
except there is also luxation at the same time.  In treating therefore of
the exsection of the extremities of bones, I shall be permitted to recur
for a moment to  what relates to them.   There are none others but those
of the metatarsus which can in  reality require  any attention  in this
respect on the part of the surgeon ; nor do they then  require anything
like the precautions which become necessary for the bones of the hand.
Thus  if a fracture  should take place in  any  one of the  bones of  the
metatarsus, it  would  generally be  better for  the maintenance  of  the
functions of the  foot to amputate  this bone with the corresponding toe,
than to exsect the two  fragments.  We should decide  upon this last
operation  only in the case of a fracture of the first metatarsal  bone, or
where the digital extremity of each one of the other  metatarsal bones
had been left unimplicated.  The exsection in such cases also should be
made with Liston's pliers, the rowel or the cock's comb  saw, or with
the cutting forceps.

                     § VI.—Bones of the Leg.

  In cases of  compound  fractures of the  leg, we may have  to exsect
the fibula or the  tibia, or sometimes both bones in the same patient.
  A.  Exsection of  the  Fibula.—Scultetus, (Arsenal de Chir., trad.
Francj., p. 104, 1672,)  by means of a cutting  pliers, exsected  a large
fragment of a fractured  fibula near its middle, which had  protruded
through the skin, and which, without this operation, it would  have been
impossible to  replace  in  its position.  The patient  got well  in four
months, and walked as well as if he had never had the leg  broken or
lost any portion of  bone.   The splinters removed from a fractured leg
in a case of Dupuytren, (Champion,  These No. 11, Paris, 1815,)  com-
prised the middle third of the fibula to the extent of three inches, yet the
patient nevertheless recovered.  It is quite rare, however, that exsection
of the fibula alone is indicated in fractures ; when  it is so, the  tibia
preserves the straightness of the limb.
   B.  Exsection of the Tibia.—The tibia on the other hand, is the bone
which surgeons have most frequently had occasion to operate upon under
such circumstances.  Every body recollects  the history of Pare, (Liv. 
            EXTRA-ARTICULAR EXSECTIONS IN PARTICULAR.         293

XV., ch. 23,) and the direction he gave R. Hubert not to spare him and
to leave no splinter in his leg.   Severin (Bonet, t. L, p. 317, § 954) had
repeatedly performed the operation.  In a case of fracture of the  tibia
from fire-arms a little below the knee, Scultetus (Arsen.  de  Chir., Obs.
93, p. 362,1672) exsected a portion of bone the day after, and another
on the third day; the first was performed with the cutting pliers, the
second  with a  trephine, (because the fragments  wounded the flesh.)
Diemerbroeck (Anatom., lib. IX., cap. 1., p. 770; trad.  Fran$., t. II.,
p. 604) was called to amputate a leg  which had been fractured in the
middle part, and where the upper fragment of the tibia had plunged into
the earth and was found denuded of its tissues and of its periosteum.  A
skilful surgeon proposed and performed the exsection of the portion de-
nuded which was two fingers in length.  The patient recovered without
any shortening of the limb.  In another case of the leg the tibia protrud-
ed the distance  of two fingers in breadth outside the integuments.  A con-
sultation being  had between Munnicks (J. Munnicks' Chirurgia, lib. IV.,
cap. 44, p. 325, 1715, in 4to.) and three of  his confreres, the exsection
was performed the day after by means of a saw.  The leg preserved its
original length, nor could the place be distinguished where the operation
had been performed. Four inches of the tibia removed in  this manner by
Van Swieten, (Aphorism de Boerlmave, t. L, § 343,) did not nevertheless
prevent the patient from recovering without any shortening of the  frac-
tured limb.   The same thing occurred in two patients mentioned by La
Motte, (Traiti de Chirurgie, t. II., Obs.  380,) though one of them had
lost eight inches of his tibia.   Bagieu (p. 441 a 457, t.  II., 1757, Ex-
aminer, &c.,) who opposes J'. L. Petit and  Duverney, relates at length
the case of  the Commissary Lavillurnois, who  wished him to cut off his
leg, but was cured by an exsection upon the tibia.  In a case  of  com-
minuted fracture of the two bones of the leg, Bilguer (Bilguer, Dissert.
sur VInulilite de Vamputation  des Membres, p. 125, § 36) exsected five
inches of the tibia, extracted useless and projecting portions of  the fibu-
la,  then adjusted the bones, and  cured his patient in four  months; the
leg, though  a little shortened,  did not pervent  the patient from  walking
or jumping with ease.
   Exsection of the tibia, below its middle portion, in a case of oblique
fracture, with a riding and protrusion of  the bone to the  extent of  more
than two fingers' breadth,  was  performed on the sixth day by Roueb,
(Bazieu, Examen de plus. Parties de la Chir., t. IP, p. 516,1757,) with
entire success.   Aselmeyer (Obs. sur un Allongement du Tibia, Gazette
Salutaire, 1763, No. 33) cites another example, as follows :—Compound
fracture of the leg, soft  parts crushed; exsection of the  tibia, which
was fractured and deprived of  its periosteum to the extent of five inches ;
there were found six to seven  splinters of the fibula, which were also re-
moved.    Six months  after the patient walked perfectly well, except,
says this author, that he required for this foot a heel a very little higher
than the other.   Lieutaud (Ancien. Journ. Mid., t. XXV., p. 254,1766)
who, sent for to a case of oblique fracture with protrusion of the tibia
to the extent of three  or four fingers' breadth beyond  the  skin, tried
dilatation and  efforts at reduction, and finally came to the  resection of
the fragment, makes no mention in this case of any shortening.  In  the
patient of Wilmer, (Cases and Remarks in Surgery, etc., London, 1779, 
294
NEW ELEMENTS OF OPERATIVE SURGERY.
  p. 213,) with a comminuted fracture irom crushing of the leg, exsection
  and extraction of the whole thickness of the bone was performed to the
  extent of four inches, yet the patient recovered as it would seem with-
  out any perceptible shortening.  A person had the tibia  fractured by a
  biscayan, [species of fire-arm,] and the bones were displaced and  pro-
  truded through the skin.  The surgeon, says Theden, (Neue Bemerkun-
  gen, etc., t. II., p. 44, 1782,) removed the splinters, then sawed the tibia
  above, below the ligamentum patellae, and afterwards  below at four fin-
  gers' breadth above the tibio-tarsal articulation.  The fracture apparatus
  was applied, and exfoliation took  place at each  end of the bone.   The
  cure,nevertheless, was completed at the expiration of twenty-two weeks.
  The callus was solid, and there  was no shortening.
   Exsection  of more than two  inches from the whole thickness of the
  body of the  tibia succeeded  also  in a case of Ch. Hall, (Letter to B.
  Gooch, Med. and Chir., Obs., etc., t. III., p. 79, 1773.)   The cure was
  accomplished in three months, and  the callus was completed and ossified
  at the end of five months.  The patient could use his leg very well, and
  it was but very little shorter than the other.  B. Gooch (Ibid., p. 82,
  1773)  adds in a note, that while  he was still at Norwich, he recommend-
  ed a similar operation, which was  attended with the most complete  suc-
  cess, and that a series of analogous facts have convinced him of the ad-
  vantages of this practice.  M. Gouraud, (Demonsir.  Principes  des
  Opir.  de  Chir., p.  160,)  in  the  case of a child, whose tibia had been
  fractured  obliquely, exsected an inch and a half of the bone, and cured
*  his  patient in thirty-three days  without any shortening.   M. Champion
  on the 4th of  June, 1838, exsected successfully  an inch and a half of
  the upper end of the tibia, which had been fractured almost transverse-
  ly, and protruded  more than two inches  beyond the skin.   In a patient
  operated upon  by Dumoulin, the exsection of the tibia near the articu-
  lation  of the foot was  followed by necrosis of the epiphysis.   Bagieu
  succeeded equally well in the following case :—A transverse fracture of
  both bones at one or two lines from  the articulation ; the foot thrown out-
  wardly and confined [in this position] by the  fractured extremity of the
  tibia after this had pierced through the whole extent of the capsule  and
  skin ; reduction was impossible; a lateral incision was first made, and
  afterwards exsection performed of the  whole of the tibia in order to
  disengage the foot.  There followed inflammation, purulent  collections
  and  at various  times sequestra of the greatest portion of that part of
  the tibia which remained fixed upon the astragalus, while the remainder
  of the bone became denuded  at a later period;  the cicatrix  took place
  by  anchylosis, and  the  patient was enabled to walk with  ease, (Exam.
  de plus. Part, de la  Chir., t. II.. p. 441,1757.)   A fracture  of the leg,
  complicated through the  imprudence  of the patient, with a wound and
  subsequent displacements, obliged Estor, the father, (Observation com-
  muniquee par Estor meme a M.  Champion) to exsect the portion of the
  tibia  which was denuded.  At  a later period, the epiphysis separated,
  and was  extracted. M.  A.  Cooper  ((Euvres Chirurg., t. II, p. 149)
  mentions a case of this kind, in which the consolidation of the tibia did
  not  take place, though  the fibula remained sound.  A similar fact was
  related to him by Smith.
    Josse (Bull, de la Fac. de Mid. de Paris, No 9, p. 309, 1819,)  who 
             EXTRA-ARTICULAR EXSECTIONS  IN  PARTICULAR.         295

exsected two inches of the right tibia  which  had been  completely
denuded, says his patient preserved the movements  of his foot.  The
tibia in a case being fractured obliquely below its lower third, protruded
to considerable  extent  through the skin ; fruitless efforts were made at
reduction, and  the soft parts were threatened with gangrene from the
pressure of the tibia upon  them.  An inch and a half of the bone was
exsected, and the splinters extracted by M. Maunoir, (Observations com-
muniquee a M. Champion par l'Auteur.  The cure, after some inflamma-
tory accidents, was effected in four months.  M. Josse (Mil. de Chir.
Prat., p. 321, obs. 29) says, his father, in a case, performed exsection
upon the tibia, because  the fracture had not yet united, after the expira-
tion of two  months and a  half, and because the operator was satisfied
that nature herself, would not effect the  union.  Five weeks after the ex-
section of two inches of the bone, the consolidation was complete.
   A fine opportunity of exsecting the tibia escaped M. Champion.   There
was a fracture of the tibia and protrusion through the skin.   The health
officer of  the place merely applied a  simple dressing.  M. Champion
being  sent for to the  village, saw  the young and unfortunate woman,
twenty-two days after the  accident.   The tibia which had been fractured
in its  lower fourth, had descended down to a line with the plantar sur-
face of the  foot, forming  a protrusion of four  fingers' breadth, which
was covered throughout the whole of this extent with fleshy granulations
formed upon its surface.  Exsection proposed and agreed to for the fol-
lowing day, was not performed, because the officer of health threatened
the  family to withold all assistance from them for ever, if the operation
was performed!
   C. Exsection of the  two  Bones.—A man had his right leg fractured
transversely at five fingers'  breadth above the tibio-tarsal articulation.
The ends of the bones protruded more than two inches, and their reduc-
tion could not be  effected  by several physicians  and surgeons who had
attempted it.  They were  about amputating the limb in the  solution of
continuity itself.   Rossius being  sent  for, remarked  that the foot was
sound, and that everything else should be tried before proceeding to that
extremity, and that they should begin by removing the  portions of the
bone that were  denuded of periosteum.   After having excised the pro-
jecting extremities  by means of a saw with very fine teeth, Rossius re-
placed the bones by  making a moderate degree of extension, and kept
them in place by a suitable bandage.  The  intense pains which the pa-
tient had  suffered, subsided, some exfoliations took  place, and at the
end of two months the wound was closed.   At the fourth month the pa-
tient  could  walk.  When Rossius (Consult,  et Observ.  Salul.,p. 93,
1608)  met him in town, the man ran up to him, and expressed towards
him the most lively sense of respect and gratitude.
  Though this  case was published only in 1608, by Victor Rossius, the
son of the operator, this  operation  had been performed a  long time
before, as one of the posthumous operations bears the date of  1580.
  Bilguer, (Opir. cit.,  p.  25, § 36,)  who speaks  of a case  where  the
fragments  formed a mass of three  layers  at the lower part of the leg,
says that  by means of deep incisions,  and the  exsection of the two
bones, a perfect cure was effected.  In 1776, a man fractured his leg in
the lower  third by falling from a horse.   The two bones plunged into 
295
NEW ELEMENTS OF  OPERATIVE SURGERY.
the grouna to the extent of three fingers' breadth.  The first dressing
was wretched, and left the bones protruding out, and denuded.   On the
fifth day,the Percys, the father and the son, were sent for, (Observation
communiquee par Percy d 31. Champion.)  They performed exsection
of the portion  in excess from the  upper extremities of the fractured
bones.  Perfect consolidation took place in two months, with a shortening
of twenty lines.
   D.  Operative Process.—If it is the  fibula which is  fractured, the
eversion of the fragments outwards and forwards, almost always allows
of our crowding the  lateral peroneal muscles backwards, and the ante-
rior muscles  of  the leg  inwards.  Though  there  are  no  large-sized
arteries nor nerves  in the neighborhood, we must, nevertheless, raise
up each  fragment, and keep  it so by means of a piece  of pasteboard,
<fec, glided under it, while with the  saw  directed  obliquely, we exsect
the upper fragment from above  downwards, and the lower one from be-
low upwards.
  In  ttye  case of fracture  of the tibia, the operation  is usually more
tedious.   This  bone, besides  being in itself much thicker, and  in  the
neighborhood of the anterior  and posterior tibial arteries, is also some-
times  difficult to  turn  into the  direction  which is mOst  suitable.   We
should not, therefore,  spare  our  incisions into the skin, when  we are
about to  exsect it.   As the fibula, however, possesses a certain  degree
of flexibility, we  may, by acting  on   the foot, which is  to be inclined
backwards, outwards, or forwards, according as is required, give ourselves
in most  cases  considerable room, and bring into view, without much
difficulty, that portion of  the bone which we wish  to remove.  Though
it will almost  always suffice  to exsect the protruding  portion of  the
upper  fragment, we  are  not, however, to respect  the  lower one if it
should project out too far, and if we can reach it without too much diffi-
culty.  Oblique fractures  of the tibia so rarely recover  without defor-
mities, and so  often  leave under  the skin, after their consolidation, a
point  or crest which gives occasion to incessant trouble to the patient,
that we  ought  never to  hesitate to  remove the projecting portions so
often as they are complicated  with wounds.
  As  with the fore-arm and arm, so after exsection of the bones of the
leg in  cases of fracture, the starch bandage is an invaluable resource  ;
and, as with the thoracic extremity, so is it equally necessary here that
openings  should  be  left in this dressing opposite  to each one  of the
wounds.

                  §  VII.—Exsection of the Femur.

   We already  find in Pare (Liv. II., chap. 5.; Bagieu, t. II., p. 509)
the case of a M.  de  Croy, who, having  had the splinters  which were
in his thigh  removed, got well of a fracture of the femur, with  the
exception of a  slight defect  only in  the movements of the  knee.   An
officer of  sixteen  years  of age, had  both femurs fractured ; the right
one was shattered to  the extent of about four inches ; the lower fragment
resembled a fork ; the upper  fragment, in spite of what was broken off
from it, and the five pieces that  were  taken from it through the wound,
rode so strongly on  the  other, that its reduction was impossible. Am- 
            EXTRA-ARTICULAR EXSECTIONS IN PARTICULAR.         297

putation  would  have been performed, had not  Lauquine (Journal de
Verduin, Avril, 1733, p. 97, 240) found  on  the fore-part of the upper
fragment a fissure  which penetrated into the  medullary canal, and ex-
tended upwards to  five or  six  fingers' breadth from the hip, a little
below the  great trochanter.  The fever and  diarrhoea exhausted the
patient.  On the twenty-eighth day  the wound was dilated, and the
upper fragment sawed up to above the fissure.   The portion sawed off,
and those extracted, comprised nine inches of the body of  the femur,
leaving only about ten to twelve fingers' breadth of this bone remaining.
The accidents ceased ; on  the third day permanent extension was made,
and a fracture box adjusted for  the  lodgment of the limb.  The cure
was effected in  seven  months, with a shortening of two inches.   The
patient could walk with firmness.   Exsection, also, had to be performed
in the  two following cases :—Fractures of the two femurs ;  protrusion
of the  lower fragment  through the flesh in a negro boy of twelve to
thirteen  years  of  age, attacked with tetanus.   Reduction was in vain
attempted  by the  surgeon  Philibert, (Poupee-des-Portes, Mai.  de St.
Dom.,  Obs. 2e, 1770.)  A containing bandage was applied for 24 hours.
At this period, an end of bone about an inch long was extracted.   Some
days after, the  same thing  was done  on the other thigh, with this dif-
ference, that the portion of  bone  which  protruded  had at  least  three
inches  length.   After the  extraction of the sequestrum, the muscles
seemed more pliant;  Philibert could now return the  feet from without
inwards, and place them in their  natural position.  The cure was com-
plete.  The negro did not limp ;  the thighs  were only a little arched in
their upper portions, which made him walk too spreading.  On the  upper
and outer lateral part, there was still  felt  near the great  trochanter
on each side, a rough and irregular swelling or slope.
   Operative  Process.—To exsect the femur in cases of fracture, it is
absolutely necessary to make the fragments protrude either  in front or
outwards.  We begin with  the  upper  fragment first.   An assistant
grasps the side of  the upper part of the thigh.  A second assistant sup-
ports the leg and the knee, which he inclines* in  an opposite direction.
After having sufficiently liberated and isolated the organs, and placed a
protecting body between the bone and the soft parts, the surgeon grasps
the point of the fragment with his left hand  in order to exsect with the
saw placed in his right.  Proceeding, afterwards, to the removal  of the
end of the lower fragment, he operates precisely in  the same manner.
At the upper third of the  thigh, however, it would be more convenient
to begin  by exsecting the  lower fragment, seeing that the  upper one
tends to conceal itself on the inside or in front, while the point of the
other projects outwardly.   The starch dressing here also co-operates as
a  containing bandage, in the success of the  operation after the exsec-
tion.

                       §VIIL— Other  Cases.

   The immediate exsection  of the ends of bone protruded through the
flesh is not always  possible though  indicated, as for  example  in the
intra-uterine foetus.  The  tibia was separated from its lower epiphysis
in an infant  of  six  months' pregnancy  At birth  the  upper fragment
   Vol. II.                    38 
298            NEW ELEMENTS  OF OPERATIVE SURGERY.
passed through the skin  in a direction outwardly.   It had lost its  peri-
osteum and presented a bad aspect.  Attempts  at reduction were aban-
doned because the borders of the wound  were  attacked with gangrene,
and that necrosis  had begun  to  make  its appearance.  The disease
rapidly extended, and death took place on the thirteenth day, (Carus,
Arch. Mid., t. XVI., p.  444.)   Would not exsection  have saved this
infant ?
  M. Schubert (Jour, des Progrcs, t. VII., p. 247)  speaks of an infant
born at its full term, and whose left thigh, fractured and carious, pro-
truded through the  flesh to the  extent of more than  an inch.  In the
case of an oblique fracture of the bones of the leg in a foetus, the pointed
extremity of the fragment of the tibia  pierced  through the  skin.  The
two bones, moreover, were adherent at their fractured extremity, so that
they formed a  large surface,  (Jour, de  Hufel., &c., Jour. Comp.  t.
XXVIII., p. 330.)   Exsection  would  also be  advisable if one of the
ends of bone, caught in the medullary canal of the  other, should occa-
sion accidents and could be diagnosticated.  J.  L. Petit ascertained on
the  dead  body that one of the ends of the  femur had caught in the me-
dullary canal of the other, that consolidation had taken place, and that
the  limb was lengthened near an inch.  M. Roux (Malad. des  Os,  edit.
de Lorus) also in a case  of fracture, in order  after exsection to  keep
the  ends of the bones united to  each other, effected  the  invagination of
the  lower end of  the  humerus  into the  medullary  canal of the upper
fragment, without its being  followed  by  any  unpleasant  consequences.
A fall on the arm, however, at  the expiration  of two  months, marred
the  success of this operation.

                    § IX.—Bones of the Pelvis.
                    •
  The cases that might require  exsection in  fractures of the pelvis are
not  by any means rare.  In the  case of a  boy aged fifteen  years, who
had been crushed against a stone butt by the wheel of a diligence, I was
obliged to exsect an inch of  the  right pubis  which protruded through
the  skin.   I was obliged, also, in  a man  whose pelvis had  been  frac-
tured by  a carriage, to remove the whole of the tuberosity of the ischium;
and I have frequently removed an inch or  two of the crest of the ilium
in consequence of similar injuries.  It is rare, however, that the opera-
tion will  succeed in this region,  because the internal organs are injured
to such  extent as to leave no  hope of preserving  life.  I  have,  how-
ever, seen two individuals recover after the excision of the upper bor-
der and  anterior spinous process of the  ilium.

    Article II.—Non-Consolidated (i. e., Ununited) Fractures.

  Sometimes in  fractures consolidation will not take place.  The two
ends of the bone become rounded off, and an abnormal joint is formed
in the continuity of the limb which almost totally destroys its functions.
Some authors, in order to remedy this accident, have proposed to place
the limb in a state of complete immobility, and  to employ certain kinds
of apparatus for a great length  of time.  Others have supposed  that it
would be better to pass a seton through this species  of  morbid articula- 
             EXTRA-ARTICULAR EXSECTIONS  IN  PARTICULAR.          299

tion.   Others again confine themselves to producing friction of the ends
of the bone against each other in order to create inflammation.  Somme
has succeeded by passing a  silver  thread around the  intermediary sub-
stance of the joint so as gradually to effect its  division.   M. Harts-
home has been equally fortunate in destroying it by caustic potash also
introduced upon the  extremities  of the fragments.  But in  such cases,
exsection is,  as we shall see, the resource which  offers  the best chances
of success.  White, who attempted  it first in 1760, in a case of non-
consolidated  fracture of the humerus, in which he brought the two ends
out and sawed  them off, and in another case afterwards in the tibia
where he confined himself to exsection of the upper end, obtained per-
fect cures in  both his patients.   M. Viguerie  and M. Langenbeck  have
met with similar good fortune in fractures of the  arm by following the
method of White.  Dupuytren confines himself to exsection of the upper
end, and to rasping the other.   Bowlans,  M. Pezerat, &c,  have also
•performed this exsection with success in ununited fractures of the thigh.
Some other surgeons  have not been so fortunate ; MM. Larrey, Rich-
erand, Boyer and Physick, relate cases where it has  been followed by
serious accidents and even  by death.  So that  we should  not decide
upon  it until  after mature reflection, and after having  satisfactorily as-
certained that the operation is necessary;  so much the more so, as the
difficulty for  which we perform this operation is sometimes  reduced to
an infirmity which can be supported  by the patient. In the thesis of M.
Caron, we have an instance of a man who had one of these fractures in
the thigh, and who could walk  without crutches.  In the patient  of M.
Kulnholtz, (Journal Compl.  des Sc. Mid., t. III.,)  the false articula-
tion was complete and scarcely affected the functions of the  limb.  M.
Cloquet (Arch.  Gin. de Mid.,  t.  XIX.,  p.  619) mentions  a case in
which the upper fourth  of  the  humerus had  been for a long time de-
stroyed, but  without  impeding thereby the  motions  of the  arm.  M.
Yvan (lb.) relates a similar case of the thigh. M. Troschel (Journal des
Progres, t. X., p.  257) mentions  three cases of  this kind  who  were
enabled to walk with ease by using the double gutter of tin, constructed
by the manufacturer Baillif.   I  have myself seen at the Central Bureau
a woman with one of  these fractures in the right thigh, and who is en-
abled to walk without crutches  by means of an  apparatus, though of a
very rude construction.   Analogous facts  are referred under the head
of Deformity from Diseases of the Bones,  (Vol. I.)  The surgical
treatment therefore of false  articulations is  exceedingly complex, and
requires to be examined in all its parts considered separately.
   [Effect of Utero-gestation in Fractures.  Among the causes which
may retard or prevent consolidation is the state of pregnancy.  Every
one is familiar with the fact that pregnant  women are  peculiarly  prone
to fractures ;  but a case is related, (Provincial Medical Journal, (Eng.)
Sept.  3, 1842—see also  Cormack's  London  and  Edinburgh Monthly
Jour., &c., Feb., 1843, p. 160,) in which a woman, a native of the West
Indies,  had fractured  both bones of the right leg near the middle, Sept.
23, 1839, in the eighth month of her pregnancy.  No pain or action
supervened in the  part, nor  any union, the interval between the frac-
tured surfaces  being occupied by a pulpy  substance,  until a few  days
after, Sept. 28, when  the  mother  having  had a comfortable  labor, the 
300            NEW ELEMENTS  OF OPERATIVE SURGERY.
work of ossific reparation  now  commenced, accompanied with  pain,
and  effected a complete cure by January succeeding.  The narrator of
the case, Mr. H. R. Oswald, considers that the completion of the child
was  the cause of non-deposition of earthy  matter in the mother's leg.
If that  were true, why, when  this process of building up  the child's
bones and tissues is  in such active  operation as it is during  utero-
gestation, should there  actually be an apparently  disproportionate pre-
ponderance of earthy over gelatinous  matter in the bones of the mother ?
for, as in this case, it  is precisely then that the bones are most brittle,
i. c, surcharged  with phospato" of lime, and the  reverse of mollities
ossium or a pretcrabundance of animal glue, <fec.   The more probable
fact  is, that if observation were attentively directed to this process it
would be found that fractures more frequently happen to the mother in
the earlier months of pregnancy, when more glutinous matter is required
for the foetus and  the mother's own osseous system  therefore  probably
called upon occasionally by the absorbents for a supply of tnis material.*
Hence the  brittleness then of her bones from too great a proportion of
earthy matter.  The suspension of any new reparative action whatever
in the mother during utero-gestation  is readily conceived of as a phy-
siological result quite natural and possible.  T.]

            § I.—Friction (or rubbing) of the Fragments.

  A fracture will  sometimes fail to unite  because it is in want of the
degree of stimulation  requisite for the  production of the callus.   The
limb then  appears shrunk  and enfeebled, and in some cases  assumes
the aspect of organs  affected with what M. J. Cloquet (Archiv.  Gin.
de Mid., t. I., p. 470) has described under the name of Local Scorbu-
tus.  Among the  patients whom I have  seen in this state, there  were
many of them who were young and robust  subjects.  The usual causes
of this condition are want of exercise, and the compression of the blood
between the fragments.   Time, the removal of all dressing, and a nutri-
tive (substantial) diet, and some frictions to the ends of the bones, gen-
erally suffice to bring about a cure.   Like Earle  and M. S. Cooper, I
have also noticed in such cases, that by leaving the limb without dress-
ing, the consolidation  will often ultimately take place of itself;  whether
the stimulus of necessity augments the activity of the ossific process,
as Hunter, ( Trans., t. XII., et Mim. Chir., etc., 1.1., p. 383 ; S. Cooper,
Diet. Chir., t. I., p. 480, coll. 2,) expresses it, or that relieved from all
kind of  uneasiness and  pressure, the parts immediately become the seat
of a more  active nutrition,  or that the slight  rubbing together of the
ends of the fragments, against each other, caused by the muscular move-
ments, create the degree of irritation which  the callus stands in need of.
  If this repose and  the  absence of dressing continued for a length of
time do  not answer, we can  then have recourse to actual frictions.  In
the lower extremities we first endeavor to  effect these by the action of
walking.  Ch. White  (Cases in Surgery with  Remarks, p. 73) cured a
fracture of the thigh by means t>f a cuish and the  exercise of the limb.
In a case of fracture of the  leg at  the lower  part, and which had not
consolidated  after two months  and a half of treatment, I effected  a
perfect cure by  making the patient walk by means of crutches.   I was 
EXTRA-ARTICULAR EXSECTIONS IN PARTICULAR.         301
led to this practice, says M. Champion, by  the  emaciation of the limb
caused by the pressure of the dressing.   The same practitioner also adds
that M.  Jacquier  of Ervy, promptly  cured a fracture  of the tibia  by
making his patient walk.  It is a practice  which I often follow at  La
Charite and I find it answer very well.
  Direct friction, which was  already in use at the  time of Celsus, (De
Re Med., lib. VIII., cap. 10, sec. 9,) has often been made trial of since.
Though Borm, (A. Berard, p. 43, These, 1833,)  Germain, (Proces- Ver-
bal de la  Soc. des Sciences de Liige, p. 57,  1773,) M. Hain, (Vallet,
Non-consolid. des Fract., Strasbourg, 1817.)  Ansiaux  (Clin. Chir., p.
323, 2d ed.) and others may have seen it fail; Derecagnaix, (in the leg,
Journal  de Corvisart,  an IX., p. 314,) MM. Vogel, (In the clavicle,
Diss. Medico- Chirurgicale, sur le Seton, p. 11, Strasbourg, 1815.  The
cure attempted in the sixth week by a surgeon-major.)   Parrish,  (Arch.
 Gin. de Mid., 2e serie, t. VI., p. 569,) Base Dow, ( Graefe und Walther,
Journal, t. XVII., p. 438,)  Sanson, (Diet, de Mid. et de Chir. Prat.,
t. II. p.  508,) and Delpech, (Clin. Chir.,  t. I., p. 250, 1823,) have
related instances  of its  success.  It is a resource, therefore, that may
be made trial  of in spite of the  sort of anathema fulminated against it
by Boyer, (Malad. Chir., t. III., p. 106.)   The  skin being unaffected,
the  fragments, when rubbed against each other, will not produce any
serious accidents, nor lead to the formation of abscesses,  unless they
are  moved without skill or method.   Before  proceeding in such  cases
to an actual operation, I would, instead of the small blisters eulogized
by Walker, (Journal de la  Soc. de Midecine.  A. Beclard, These, p.
43,) willingly apply a temporary blister.—(See Vol. I.) large enough to
 envelop  the whole contour of the fracture.

              § II.— Compression, Immovable Dressing.

   If the  pseudarthrosis, in place of being kept up  by the shrinking and
feebleness of the limb, appears  to depend upon an excess  of irritation
or tumefaction, it is then possible that the'compression which M.  Wright
 (Jour, des Prog., t. XV., p. 88,) says  he has found so advantageous,
may in fact be found  serviceable.   Nevertheless, I can   scarcely under-
stand, nor are  M. Wright's  observations  calculated  to demonstrate,
how this alone can cure  a false  articulation.  The  cures which  are  im-
puted to it, depended probably upon a more complete state of immobility
having been  given  to  the  limb, than had  hitherto been attained up to
that time. To effect that object we must  have recourse to the starch
bandage.  This last  resource  must be made  trial  of before all others,
and offers real chances of success, in cases where  during the treatment
we have never had it in our power to subject  the non-united fracture to
a state of perfect immobility.   Science  possesses on this subject facts
that are  already  numerous and conclusive.  Non-consolidated fractures
of the thigh  and arm, and of the leg and fore-arm, have been cured by
means of the  starch  bandage,  by  M. Larrey, M. Berard, jun.,  and  M.
 Macdowel, (Jour, des  Connaiss.  Medic, t.  II.,  p.  123.)  A  patient
 whose fore-arm, by  the  advice of Rust (Journ. des Progris, t. X., p.
 259,) had been  enveloped in Baillif's machine, solely with the  view of
 rendering the false articulation less  annoying, was "astonished to find 
302
NEW ELEMENTS OF OPERATIVE SURGERY.
himself cured at the expiration of three months when he was about to
renew the dressing.   A woman  who had had a false joint for more than
a year, was cured in  two months  by M. Thierry, (Experiences, t. I.,)
by the  application of the starch bandage.  Having been in the employ-
ment of this bandage since the year 1836, I have satisfied  myself  that
it enables us to cure without any  other operation, the great majority of
those false articulations  which succeed to fractures.  A woman aged
thirty-nine years, who already  had a non-consolidated fracture  of the
thigh, broke  her arm.  The ordinary  dressings  were made use of for
two months, without any benefit.  I then applied the dextrine bandage,
and  the  consolidation was effected completely.  Mdme  B * * *, whose
humerus had been fractured thirty months before, and continued movable,
notwithstanding the  treatment of many distinguished  surgeons  of the
capital, and  the employment of all sorts  of bandages,  made up  her
mind, in  May, 1838, to make trial also of the  dextrine bandage.   A
roller bandage was placed naked over the whole extent of the limb and
fastened by a spica around the chest.  Over this  were then placed two
layers  of turns of bandage with  pieces of pasteboard saturated with
dextrine ; the whole soon becoming dry was left  without being disturbed
for the space  of two  months, when at the  expiration of this period, to
the great  surprise of this patient, who  no  longer looked forward  to a
recovery, the fracture was found consolidated upon my removal of the
bandage.  The same thing occurred in a pseudarthrosis of  the thigh of
ten  months standing, and of which I have already spoken under  the
chapter on Deformities, (Vol. I.)
  By means of this bandage therefore,  properly applied, we may count
upon the cure of all  those false articulations, which are  not the result
of a want of excitation or of general disease, or a degeneration  of the
fragments, but which have  been  brought  about by the defect  of the
means to be employed to produce proper compression.   It ought also to
be classed under the head of the auxiliary means, or fracture apparatus,
to be used after the different varieties of operations of  which I am  now
about to speak.

                        § III.— The Scion.

  The  seton which was used to the fore-arm without a successful result,
by Cittadini, who proceeded afterwards to  the  exsection of the ulna;
and to  the humerus  in  a case related  by Lombard  (These No.  377'
Paris, 1814 ;) again to the humerus, by Earle  (Trans. Med.-Chir., t.
XII., et  Mimoires  de Chir.  Etrang., t. I., p.  376,)  who substituted
potash for it without any better success,  effected its  purpose but imper-
fectly when applied  to  the femur in  a patient of M.  Brodie  (Journal
Analyt. de Mid., t. I., p. 277, 1827,) and to the  patient mentioned by
M. Wardrop  (Mini de Chir. Etrang., t. I., p. 350.)  Beclard (Vallet,
p. 25,) of Strasbourg, also only  obtained partial success from it in using
it to the humerus ; while Ansiaux and M. McDowell (Journ. des Conn.
Med., t. II., p. 123.) in similar cases failed with it completely.   It is a
resource nevertheless deserving of commendation in all sort of fractures.
Thus Rigal de Gaillac (Sociili Mid de  Montpellier, Juin, 1812,) by
this  means cured an ancient fracture of the leg.   A similar cure was 
             EXTRA-ARTICULAR EXSECTIONS  IN  PARTICULAR.         303

obtained by M. Mott (New York Medical and Surgical Register, Vol.
II., p. 374,) and another has been  published by  M. Browne (Bulletin
de Firussac, t. XXL, p. 268.)  Hornier  (1812— Vallet,  p. 24,) suc-
ceeded with this operation upon the humerus.  Delpech (Clin. Chir., t.
I., p. 255,) effected a cure by this means in the fore-arm, 86 days after
the fracture, and M. Ducachet (Berard,  These, etc., p. 46,) at the expi-
ration of ten months.   A false articulation with a fibrous exudation had
been formed, while there existed at the same time an  abscess in the
calf.  By means of a tunnel-shaped wound, M. Weinhold  (Bull de Fi-
russac,  t.  XL, p. QQ,  1827,) introduced a conical formed seton into the
false articulation, and cured his  patient. A pseudarthrosis which had
existed  in the right femur for ten  years, accompanied with fistulas and
caries, was cured by the same means in the space of three  months, and
it succeeded equally well also in another case of false articulation of
the femur treated by M. PI. Portal, (Encyclograph. Mid., 1836, p. 311.)
Non-consolidated fractures of the  humerus  have been cured by means
of the seton  by Physick, (A. Berard,  Opir. cit., p. 45,)  Percy, (La-
roche, These, Paris, 1805,)  Dohldorf,  (The Lancet, 1829, Vol. II., p.
105.)   Stanfield, (Birard. p. 45,) PI. Portal,  (Encyclograph., 1836, p.
311,) and M. McDowel (Journ.  des Conn.  Mid., t. II., p.  123.)  Phy-
sick also is of opinion that he cured in this manner a fracture of the
jaw, which had existed for two years.   It is nevertheless a very uncer-
tain means, and one for which I should prefer to  substitute exsection,
where frictions and the starch bandage  had not answered,  and  it is one
moreover which is not  always unattended  with danger.  M. Weinhold
in applying it to the neck of the femur brought on caries and suppura-
tion in  the cotyloid  cavity and  pelvis, which  ended in the death of his
patient.  M. Harris,  (Arch  Gin de Mid., 2e ser., t. X., p. 220, 217,)
however,  states, that  in using it  to the fore-arm in one case after exsec-
tion, and  to the humerus in another, he effected  a cure  in both.  M.
Viricel  (Montfalcdn,  Mem.  sur VElat Actuel de la Chir.,  1816, p.
195,) after having abraded the osseous  surfaces with a file, introduced
a seton  according to the mode of Physick.   The greatest care bestowed
upon the patient could not save the patient  from death.   He died a few
days after the operation.   M. Seerig (Encyclogr. des Sc Mid., 1838,
p. 33,)  who succeeded with the seton in one case, was obliged to resort
to exsection, and in a second case lost his patient.

                   § IV.— Caustics and Rasping.

   Earle, after having rasped the humerus, applied caustic  potash to the
bottom  of the fracture, (Mid.-Chir.   Trans., t.  XII., and Mid.-Chir.
Trans., t. I., p.  384.)  There  was no exfoliation took place, nor was
there any reparative action established.
   M. Ilewson, (Journ. des Progrs, t. IX., p. U'O,) by excising the liga-
mentous tissues, and  cauterizing in the same manner, effected a cure of
a false  joint in the leg.   M. Lehmann  (Berard, These, p.  42)  succeed-
ed equally well by applying butter of antimony to the tibia.   M. Hulse
(Gaz.  Mid., 1834, p.  246) asserts that he has succeeded equally well
by using  simple irritating injections, and M. Mayor (Nouveau Syst. de
Dilig., p. 168, art. 2) procured the consolidation of a fracture of the 
304
NEW ELEMENTS OF  OPERATIVE SURGERY.
femur, by introducing upon it  through a canula, a punch heated to the
temperature of boiling water.  M. Hartshornc also asserts, (A. Berard,
These, p.  41,) that the application of caustic upon the skin is sufficient
to ensure success.  But all such remedies are inferior to the seton.  Ac-
cording  to (Verduc, Path., t. I., p. 412,) the cauterization by means of
sulphuric acid, of a  callus, mistaken for a fungus, caused the death of
the patient  in six months.   M. Barthelemy, (Diss, de Montpellier, et
Vallet, p. 31, who describes the  instrument,) who, in 1814, proposed
a grater in form of a saw, to be passed through a canula to the fragments,
in order to  scrape the ends of the bones, would incur  the same danger.
A case  of fracture had existed  in  the radius for the space of a year.
An incision  was then made down upon the bone.   Edfond (Journal de
Simmons, trad, par Masuyer, t. I., p. 405) then divided the periosteum,
and  removed  it  to the  extent of  an inch above and below the fracture,
without  disturbing the fragments.   Inflammation and consolidation suc-
ceeded,  and  the  patient was perfectly cured at the expiration of three
months.
   [Acupuncturation  for Ununited Fractures.—M.  Weisel (See Medi-
cal Times, Jan. 11, 1845)  cured an ununited fracture  of both bones of
the fore-arm, by acupuncturation with two long needles, first passed
through the  arm between the fragments of  the ulua, and left in five days
till acute inflammation was produced ; and secondly repeating the same
operation in 15 days after, between the fragments of the radius.  T.]

                            § V.—Exsection.

   A. Exsection, however much lauded and practised by an infinite num-
ber  of surgeons, in  cases  of ununited fractures, is, nevertheless,  still
censured by M. Gouraud, (Elimens des Prin. Opir., p. 164,) who con-
siders it a retrograde movement in surgery.  Sometimes, in fact, it be-
comes a very serious operation.  In a case of exsection of the two ends
of a femur,  communicated by M. Gable to  M. Vallet, (Vallet, These, p.
29,) it was  barbarous, and lasted over an hour ; the  patient, a young
and vigorous man, had  convulsions, and died in the evening.  Though
Callissen (S. Cooper, t. I., p. 478, et suiv.) relates two  examples of
success, Cline (Ibid., p. 482) states  that  with him the operation had
failed.  The patient  upon  whom M. Langenbeck succeeded, had a false
articulation of the humerus.  It was the same with that of M. Rodgers,
 (Rust's Handbuch der Chir.,ip. 541,) and  that also of  M. Fricke, (Gaz.
 Mid. de Paris, 1787, p. 155.)  M. Dupont  (Arch. Gin.,  t. II., p. 628)
was  not less fortunate in a similar case, and M. Liston  (Edinburgh
 Medical and Surgical Journal,Yo\. LX., p. 317) also cured his patient.
 But in a multitude of other examples, serious accidents  have supervened,
 or the result of the operation has been unsuccessful.  A patient operated
 upon by Boyer, (Boyer, t.  III., p. Ill,)  died from gangrene of the arm.
 Dupuytren  lost one of his in consequence of inflammatory symptoms,
 (Berard, Tluse, p. 52.)  Another patient (Gaz. Mid. de Paris, 1831,
 p. 289) still retained his false articulation four months after the opera-
 tion.   The young man operated  upon by M. Hewson, (Arch. Gin. de
 Mid.,  2e st'r., t. X., p. 225,)  died from purulent infection.   Though
 Andrew (Journ. de Mid.,  par  Simmons, 3e part., 4e sect., t. I., 1781^) 
EXTRA-ARTICULAR EXSECTIONS IN PARTICULAR.         305
communicated to Hunter, the details of a remarkable operation of this
kind, which he performed with success upon a fractured arm, and though
Physick  (Medical  Repository, of New-York, t.  VII., p. 122,  1804)
was  witness to a similar success, we sec that in the  patient  of Rossi,
(Elim. de Mid. Opir., t. II., p. 190,) a ball was found in the fragment
above the part exsected, and that it became necessary to resort to am-
putation ; and  that in  the  case  of Ansiaux, (Clin.  Chir., p. 323, 2c
edit., 1829,) friction,  the seton, and excision  all  proved unavailing.
Nor was M. Moreau (Champion,  These de Paris, 1815, No. 11, p. 51)
more fortunate.  But this process applied to the tibia by White, (Cases
in Surgery, p. 81—84, 1770,)  M. Harris, (Arch. Gin., 2e ser., t. X.,
p. 215,)  and A. Dubois, (Foussard, Dissert, sur les Fractures, p. 41,)
has succeeded very well.
   In a case of pseudarthrosis of both bones of the fore-arm, Cittadini
(Journ. Complim., t. XXXIL,  p. 157) was  enabled to effect a cure by
exsecting the ulna only.  MM.  Fricke, (Ibid.,) Holscher,  (Diet, de
Chir.,de Rust,) and Inglis, (Edinburgh Medical and Surgical Journal,
Vol. LX., p. 317,)  have been equally fortunate with M. Cittadini, in
non-consolidated fractures of the same portion of the limb.   But with
M. Warmuth, (Diet, de Rust, p. 544,) and M. Harris, (Arch. Gin. de
Med.,  2e ser. t. X., p.  217,) this  exsection failed.   Another surgeon
(Mim. Acad. Chir.,t. X., p. 84, in 12mo; t. IV. p.  626, in 4to,) sawed
off more than a finger's breadth  of the  lower  end of the femur, and
cured  his patient.  Dupuytren  (Sabatier, Mid.  Opir., t. IV., p. 461,
edit. Begin,) and Moreau, the  younger, (Champion, Traiti de la  Re-
section, etc., p. 67, 1815, &c, et Moreau, Essai sur VEmploi de la Re-
section des Os, p.  72,)  also  succeeded upon  the femur.
   The  operation on the femur succeeded  also with M. Viguerie, (S.
Cooper, Diet, de Chir.,t. I., p.  481,)  M. Pezerat, (Jour.  Compl.,t. V.,
p. Ill,) with Dupuytren, who gives two examples of it, (Berard, These,
p. 51.) and with M. Mott, who had  recourse to it when the seton to
which  he gives the preference, and with  which he  has  succeeded in
three instances, proved  insufficient;  but we have seen farther above that
this exsection has frequently failed.   The patient of M. Harris (Arch.
Gen., 2e ser., t. X., p. 215) did not recover until  after eight or  nine
attacks of erysipelas, and a year's treatment, while  that of M. Hewson
(Ibid., p. 225) died on  the sixteenth day.
   This operation performed also by Halgout (Essai sur VAmput. des
Membres, par Lambert, Paris, 1815,) of Boulogne, in presence of Percy,
in the  year  1803, for  a fracture  of five  years' standing, by  making a
long incision  on the outer side of the limb, also failed.  Death, preceded
by fever  and suffocation, and without any  action of consolidation, took
place at the end of a month.  Before  the operation the  patient could
walk only by the aid of crutches, and the thigh seemed to be held only
by the  skin.
  In a  case of non-united fracture of the  patella which had  existed a
month, it was the intention of M. A. Severin, (Corps de Mid., etc., de
Bonet,  t. I.,  §  953,) had the  patient consented,  to have pared  and
abraded the edges of the fracture, before tying them tightly  together
against each other.  M. A. Severin calls this operation harsh and diffi-
cult !  Should  the  pseudarthrosis be accompanied with a sequestrum
  Vol. II.                    39 
306
NEW ELEMENTS OF OPERATIVE SURGERY.
 and necrosed splinters between the fragments, we may confine ourselves
 to removing them, taking care at the same time to avoid the other por-
 tions  of the bones.  Faivre  gives an example  of  this upon the leg
 (Ancien Journ. Mid. t. LXVIII., p. 210 ;) the fracture had  existed 7
 months, and suppuration had taken place ;  some splinters, and one por-
 tion of the whole thickness of the bone of an inch and a half  in diame-
 ter, were extracted ; the parts were then  cauterized  with the hot iron,
 and the cure thus effected.
   Here is  another  case : A man  had  the  humerus  on  the right side
 fractured  into splinters on  its  lower third by  the discharge  of  a
 leaden ball,  which  penetrated  on  the inner side of the arm.   Three
 splinters of bone were extracted, which came from the inner and poste-
 rior portion ; after some days had elapsed, splints were applied.  The
 surgeon consulted  4 months after, found a sinuous wound, a number of
 sequestra and a sufficient degree of mobility at the  place of the fracture.
 Having  laid open  the  fistula above and  below, he  extracted  several
 pieces corresponding to the inner and  anterior surface of the humerus,
 to an extent of sixteen  lines.   The finger could  enter  the medullary
 canal of the two ends of the  bone, and bring away  marrow in a state
 of dissolution.   A sort  of provisional  or temporary  callus, which had
 already formed in front and on the outer side, though the arm was flexi-
 ble, gave assurance of  a perfect consolidation in a  short space of time.
   [A most remarkable case of pseudarthrosis was subjected to this op-
 eration by  Mr.  Bowman, of King's College Hospital, London.  So great
 was the deformity, that when the patient attempted to bear his weight,
 the fragments were so pressed downwards that the under one was bent
 forwards on the dorsum of the foot, and the end of the upper fragment
 actually rested on  this  part.   The resection overcame the deformity,
 but at the  last report, union was regarded as very  improbable, (vid.
 Fergus'son's Pract.  Surgery, p. 478.)   Mr. F.  thus   records  his expe-
 rience in this operation.  " I have seen resection of the  ends of the
 fragments in  three  instances.  One of the cases, was  in my own prac-
 tice and was  unsuccessful, the patient  having  died unexpectedly  some
 weeks after, when the wound  was  all but healed.  The other occurred
 to my colleague, Mr.  Partridge,  and  was successful in all  respects.
 The third occurred  with Mr. Gay, of the Royal Free  Hospital, and an-
 swered no  good purpose in the end, (op. cit. p. 479.)
  The resection of the ends of the bones failed in the instance in which
 it was performed  by  Dr. Henry H.  Smith  of Philadelphia.   Dr. J.
 Kearney Rodgers reported in the  N.  Y.  Med. Sc Phys. Journal, vol.
 VI. 1827,  a case of ununited fracture  of the humerus, which  was suc-
 cessfully treated by resection after failure  of  the seton.  In the Amer.
 Journ. Med. Sciences, vol. XVII. N.  S. 1849,  Dr.  Brainard, of Chi-
 cago, has given the particulars of a case of ununited  fracture of the
 femur cured by resection, denudation, and retaining the ends of bone by
rmeans of wire.  G. C.  B.]
 se' B. Appreciation.—We see from the example  which Science  is  al
 pgiady in possession of  what we have to hope  for  in  practice  from ex-
 yi<j\tion  of the bones in cases  of ununited fractures.   Wherever the
    •darthrosis is sustained  by some constitutional disease in the indi-
     al, the operation will be unattended with success.  There will be a 
EXTRA-ARTICULAR EXSECTIONS IN PARTICULAR.         307
chance of success on the contrary when there is an hydatic affection of
one of the bones, of which Dupuytren has  met with an example (Journ.
Hebt., t. XII., p. 97,) or where some carious or necrosed point of the
extremity of the fragments, is the only impediment to the  formation of
the callus.  It would also be the only efficacious resource in an ancient
oblique fracture, where the point of one of the extremities of  the bone,
had become imprisoned in the thickness  of the muscles, as  happened in
the patient of M. Earlc, (S. Cooper, Diet, de Chir.,) in one of those of
Dupuytren, in that of Boyer, and as it would seem  in that also of M.
Pezerat.   If  the  fracture, whatsoever may have been  the  primitive
cause, shall have become  reduced to an affection altogether local, and
shall  have  not united purely  because  its two fragments have cicatrized
separately,  then  also is  exsection still the most efficacious remedy.
Nevertheless,  we should never decide upon this step until we have  ma-
turely considered all  its  dangers.   Being under the  necessity of pene-
trating  into the centre of the limbs, and of detaching and dissecting the
muscular tissues to a very considerable extent,  we transform the infirm-
ity into a fresh compound fracture with a deep wound.  From whence
the danger of suppurations, erysipelas, inflammations of all kinds, caries,
necrosis, and'even purulent  infection  of phlebitis, as is proved by the
facts  collected by M. Kirkbridge, (American Journal  of Medical  and
Surgical Science, November, 1835,) and those of  M. Troschel, (En-
cyclograph. des Sc Mid., p. 33.)
   C.  Operative Process.—The difficulties of the operative process in
exsection of the bones in cases of false articulations, are very different
in different parts of the limbs.
   I.  Bones of the  Fore-Arm.—If the  pseudarthrosis should be situ-
ated in only one of the bones of the fore-arm it would be unnecessary to
perform exsection.   When this operation is indicated,  there  is at first
an arrangement  in the limb which allows  of its being easily inclined in
one or  another  direction.   It is unnecessary to add, that  where there
are wounds or fistulas connected with the fracture, we  should, in order
to reach the bone, confine ourselves to their dilatation, unless they should
be  too  unfavorably placed  for our doing so.  In  the  contrary  case,
which will be found the most common, we should make an incision upon
the integuments on the most superficial  surface of the  ulna or radius.
The bistoury,  therefore, should be applied upon the  posterior and inner
side of the fore-arm for the first of these bones, and to the outer and
slightly to the posterior side  for the second.  This incision, whose mid-
dle should correspond to the fractured part of  the bone, ought to have
an extent of two to three inches.   In order to detach  gently  all  the
soft parts which adhere to the bone within  and without, the surgeon
places the arm in a state  of flexion, and thus brings  out to the external
surface the two  ends of  bones to  be  exsected.   If there  is  found to
exist  between them a  solid bridle, we  can, after having detached the
soft parts from them, easily glide underneath a  small splint, which will
serve as a support, while we in the mean time successively remove, with
the saw, the two portions of osteo-ligamentous substance.  The samo
operation having been performed upon  the  radius, where  a little more
precaution is necessary, to avoid the artery  and tendons of the thumb,
the limb, after having arrested the hemorrhage and cleansed the wound, 
 308             NEW ELEMENTS OF OPERATIVE SURGERY.

 is straightened and placed in an  immovable bandage and then dressed
 in the same manner as if it was a recent fracture.
   II.  Humerus.—If the fracture of the arm should be situated upon its
 middle portion, the incision should by preference be made on  the outer
 side of the.limb; in wliich  place it would  implicate only the integu-
 ments, cellular tissue, aponeurosis, and a few branches of  nerves.  The
 cephalic vein, besides, could be  easily pushed aside.   At  the  lower
 fourth of the humerus, however, we should have to be  on our  guard
 against the radial nerve.  In order to divest  the points of bone of the
 tissues which adhere to them, it  would be necessary to graze very close,
 and not to come too much in front, for fear of wounding the brachial
 artery and median and ulnar  nerves.
  If the  fracture  should be situated near the elbow, it  would be better
 to make  the incision  on the posterior  surface, taking care  not  to  go
 down as  low as the synovial cavity, but to prolong the cut a little more
 above.   If the longitudinal division  of the triceps should not  suffice,
 there would be little danger in uniting to it a transverse incision on one
 or both sides of it.  If, in bending  the arm  on  its anterior face, there
 should be more difficulty in making one of the  fragments protrude than
 the other, it would be prudent first to exsect that which presents itself
 and to dissect and saw the other afterwards, after having brought it out
 by means of a hook, or lever, or the fingers.
  In the upper fourth of  the humerus, a  false articulation could  be
 reached only through the deltoid muscle.  It is  in this place that the
 operation might be exceedingly  embarrassing,  and attended  with real
 dangers.   Dupuytren, (Gaz. Mid., 1831, p. 289,) in making an inci-
 sion of six inches for an affection of this kind,  encountered serious dif-
ficulties.   Accidents supervened, and four months after, the false articu-
lation was still there.
  III.  clavicle.—A false articulation in the clavicle is not to  be treated
by an exsection of the bones.   A patient, whom I have met with, and
who had  this infirmity from infancy on both sides, experienced no incon-
venience  from it, and  could perform without difficulty the most severe
labors.   M.  Lanctuit  (These de Strasb., Avril, 1823)  says that  M.
 Bouchet  saw a patient in whom half the clavicle was wanting, but whose
 corresponding arm, nevertheless, was not wanting in vigor and activitv.
 If, however, contrary  to all probabilities, a fracture of  this kind should
 be transformed into an  annoying  malady, and exsection should  be decided
 upon, the surgeon would  make a horizontal incision on the antero-supe-
 rior surface of the bone; as the  subclavian vein  is found directly under-
 neath, it would be advantageous to  draw the  ends of  the fracture for-
 wards, by means of an elevator or blunt hook, and to hold them iu this
 raised position until the saw should have exsected them.
  IV. The  leg.—It is in the leg that exsection  for pseudarthrosis is at-
 tended with  the  greatest  degree of embarrassment.   The tibia should
 always be laid bare on its antero-internal side.  We cautiously detach
 the muscles behind and on the outer side, grazing as close as possible to
 the posterior surface of the bone, in order to avoid with greater securi-
 ty the corresponding  posterior  tibial artery.   In the upper  half of the
 tibia, it  would be  difficult to perform exsection  without joining a trans-
 verse  incision to the  longitudinal one.  But perhaps a single incision 
EXTRA-ARTICULAR EXSECTIONS IN PARTICULAR.         309
however, would  then answer, if we gave an oblique direction to it from
above  downwards and  from before backwards.  The exsection of one
of the  ends of the bone having been  completed, we could  proceed to
the other also through the same wound.
  In order to lay bare the fibula, it would be necessary to penetrate be-
tween  the peroneus longus and brevis and the extensors of the toes, for
which  purpose a single incision will always be found sufficient.  Its ex-
section, moreover, which would present  fewer difficulties than that of
the tibia, will have  no occasion of being as extensive.  Let a callus be
once established in the solution of continuity of this last mentioned bone,
and the fibula in its turn will inevitably become consolidated.
   V. Femur.—As  false joints in the  femur may exist in every part of
its continuity, exsection here will have to be performed after rules which
must necessarily vary.  This bone, however, from the great trochanter
down to the  knee,  is to  be laid  bare upon its antero-external  side,
dividing successively the integuments, the sub-cutaneous  fascia, the fas-
cia lata, and  the triceps  muscle.   The surgeon having flexed the thigh
inwards and  backwards,  and caused  the lips of the wound to be kept
apart by an assistant,  would have  no difficulty in soon coming down
upon the fractured angle of  the femur ; and has nothing more to do than
to  isolate the two fragments with his  bistoury, to the extent of an inch
upon each extremity, and then to insert underneath the splint or the pro-
tecting compress, in order  to put  the saw into movement and terminate
the exsection.
   [Numerous cases of ununited fracture have of late been treated, both
in  Europe and  this country, by Dieffenbach's method of  inserting ivory
pegs into the divided ends of the bone.   Severe constitutional symptoms
have occasionally followed, and in one case of pseudarthrosis in the fe-
mur reported by  Mr.  Mackenzie  (Assoc.  Med. Journ.  Feb. 10, 1854)
the operation, was  near  proving  fatal.  In this city, experiments have
been made of merely perforating the ends of the bone, without inserting
the pegs, and for this method, an  equal  amount  of success has been
claimed.  G.  C. B.]

          §  VI.— Containing Means.—Braces and Cuishes.

   When pseudarthroses of the humerus  and fore-arm are incurable,
or that the  patients do not wish to have them operated  upon, they may
be wonderfully  relieved by the use of a brace.   M. Champion (These
de Paris, No. 11,1815, p. 52) has contrived some of tent cloth (or tick-
ing) and small whalebone, which have been found exceedingly advantage-
ous.  Briot (Hist, des Progres de la Chir. Milit., p. 411,1817,) in three
of  his  patients,  found  great benefit from the employment of two kinds
of  half-gutters, of iron plates, padded on the interior, and fastened by
tresses, which the patients  arranged  or tightened at pleasure.  I have
already remarked, that in Germany, surgeons  used  with advantage in
such circumstances, the apparatus  of the equerry, Bailly, (Rust's Maga-
zin, B. XV., Heft 2; Journ. des Progres, t. X., p. 257.)
   False articulations  of  the femur have some inconveniences of a more
serious character.   If, however, there  are  some who oblige the patient
to support himself, and walk  with crutches, as in  the cases cited by 
310
NEW ELEMENTS OF OPERATIVE SCRGERY.
   Lambert, (Lambert,  These  citie, p. 38,) Lions (These de Paris, 1804,
   No. 139, p. 39,) and Sue, (Sne, Observations, A-c\, sur quelques Mala-
   dies  des Os, p. 18, 21, 22;) there are others, who by means of a cuish,
   or with or without a cane, enable their patients to walk with ease, (See
   Vol. I.)   I daily meet, says M. Sentin, (Letter to M. Champion, March
   9, 1833,) a man with a false articulation in the upper part of the thigh
   who  is  enabled to walk by means of a very badly  constructed piece of
   mechanism.  A soldier, who had a pseudarthrosis  in  both  bones of
   the leg, could hold himself erect very well, but he could not walk except
   by means of a very hard bootikin.  The tailor, with a fractured femur,
   who  could carry his foot to his shoulder, both in front and behind,  and
   who  could, according to Saltzman, (Reisseissen, Diss, de Artie Analo-
   gis, cap. II., § 5, 1718,) who mentions this case, use  this leg for the
   purposes of walking and  standing, as  well as the other, except that he
   limped a little, from  its being shorter, shows what great power nature
   has under such circumstances.
     I have elsewhere  spoken (See Vol. I.)  of the case related by Sue,
   (Reflex, sur quelques Maladies des Os, par Sue, an XII., 1803, p. 164,)
   of a man, who, notwithstanding he had a false articulation of the thigh,
   could walk in the streets  with no other aid than his cane.   Mockren
   (Obs.  Mid.   Chir., cap. LXXL, 1682) and Boyer (Delpech, Diet, de
   Mid., t.  III., p.  451) have also noticed the facility with which some
   patients  are enabled  to walk by means of a cuish.  But sometimes the
   cuishes  are more  injurious than  useful.  In the case cited by Sue, the
   power  of walking being rendered impossible, when the two ends of the
   bone encountered each other, obliged the patient to lay aside the cuish,
   which caused this approximation.
     At the uppor extremity of the  humerus or femur, false joints do not
   require  an operation.   The seton, cauterization, or  exsection in  this
   place, would be attended with too  much difficulty or danger.   Besides
   which, the pseudarthrosis there is not  accompanied with as serious in-
   conveniences as it is in the middle of the bones.  I have met with  two
   patients in whom fracture of the surgical neck of the humerus had not
»  consolidated, but who were scarcely conscious of its presence.

             Article III.—Exsection for Deformed Callus.

      With the view  also of repairing, i. e., to pare or flatten down, shape,
   adjust, <fec.) a deformed callus, many authors have proposed or performed
   upon it the process of rugination (rasping) or exsection.  Paul of Egina,
   (Dalechamps, Chir. Frang., p. 467,787, 788, 790, 791, Chap. 107, 108,
   109,) who recommends, and also describes different kinds of exsections
   for compound fractures or deformed callus, was censured on that account
   by Guy de Chauliac, who, according to a quotation in Boyer (Maiad.
    Chir., t. III.,  p. 107,) complains  that a philosopher was nearly killed
   by the consequences of such an operation, " because he could not content
   himself with remaining a cripple," but the question of Hevin, who asks
   if there ever will be found a patient courageous enough to sustain it or
   a surgeon bold enough to undertake it, can now be responded to by a
   multitude of facts.  According  to M. Oesterlen (De la Rupt. du  Col
   p. 124,) after having broken the callus, he exsected with the saw to the' 
             EXTRA-ARTICULAR  EXSECTIONS IN PARTICULAR.        311

extent of three lines from the inner and outer portion of the two pieces
of the bone.   The exsection of a projecting portion of the femur above
the knee, after the consolidation of a vicious  callus, was also performed
upon  the famous Ignatius  Loyola, at the age of twenty-eight, (A. D.
1521.)  An  old surgeon, (Hildanus, in  Oesterlen, lieu cili, p. 189,)
in a case of fracture of the femur from  a fire-arm, recommended the
rupture and excision of the callus by means of the cutting pliers.  Albu-
casis, according to Oesterlen,  had  also advised to take  off  the callus
with  a cutting instrument when it should become hard  like a stone.
Gardeil, (Traduction des  (Euvres d1 Hippocrates, t. I., p. 300,) states,
that he divided the  bones  of the fore-arm on one of his nephews at the
point of an old fracture, and that he  succeeded perfectly.  Though in
the case of a femur which had united  at a right angle, Wasserfuhr,
(Rust's Magazin fur die  Gesammte Heilkunde; Journal d?Hufeland,
1816, Octobre,) only separated it with  a saw, M.  Riecke, (Bui. des
Science. Mid., Journal  Analytique, December, 1828, p. 466 ; or Arch.
Gin.  de Mid., t.  XVIIL, p.  105,) in  a case where  the  thigh was
shortened eight inches, did not hesitate  to employ  the saw, gouge and
mallet.  A perfect  consolidation was established in the  space of eight
months.  An  exsection of four fingers' breadth from the body of the
two bones of each fractured leg, whose consolidation had been attended
with  excruciating pains, was  performed  with success in 1685 or  1686
(Journal de  Mid., in continuation  of that of Laroque,  p. 58, 1686.)
A young man had a callus in  the femur of the size of the head, with
the fragments also riding over each other.  M. Winehold,  (In the
Journal d'Hufeland, 1816, cap. V., p. 25 ; and Journal Analytique, No.
VIII., p. 240,1828.—Arch. Gin. de Mid.,t. XVII., p. 445,) by means
of a trephining needle  introduced a seton  between the  fragments, and
effected a cure without  the necessity of proceeding to  exsection.  But
the operation of  exsection here evidently  blends itself with what  I
have said of rupture of  the callus in another  chapter.
   [Dr. Parry, of Indiana, has reported a  successful operation to remedy
a deformed callus, (Amer.  Journ. Med. Sciences, Vol. XXIV., 1839.)
We have lately seen some interesting cases of this kind in the practice
of Prof. Muller, of Philadelphia.  The report of an  operation by Dr.
J. Rhea. Barton, is contained in the Phil. Med. Examiner, Vol. 1st,
1842.   G. C. B.]
   In speaking of the straightening of limbs  curved at an angle in con-
sequence of fractures viciously  consolidated, I neglected to speak of an
operation of this kind which was performed with success by M. Warren.
This operation, which in reality belongs  to  exsections, was performed
by M. Warren on the tibia; while M. Clemot and  M. Barton had hitherto
applied it only to the femur.  The leg was bent at quite an acute angle;
M. Warren exsected from this boney angle a wedge-shaped  fragment,
then straightened the limb, and easily effected its  consolidation.   It is
not solely with a view of rectifying  a deformed limb and of giving it
more or less length, that we sometimes find it  necessary to excise certain
portions of a vicious  callus.   After the cure of fractures, boney points
or angles may project under the skin, and become the source of pain and
of ulcerations that are difficult to heal.  Exsection in such cases is not,
in my opinion, sufficiently often performed.  Meyranx,  a physician of 
312
NEW ELEMENTS OF OPERATIVE SURGERY.
 some distinction, broke his leg.   After the consolidation  the point
 of the lower fragment of the tibia projected under the skin in the form
 of a very acute elongated ridge.   An'ulceration which would re-open
 whenever he took a little more exercise than usual, together with almost
 constant pains, were the consequence of his  infirmity.  An incision of
 two inches' length and which would not necessarily have comprised any-
 thing more than the integuments, would have allowed  of this  projecting
 crest to be removed with a single stroke of the saw  or cutting  pliers;
 but the patient, who died two years after, could  not  bring  his  mind to
 submit to it.   When we reflect upon the frequency  of this  deformity
 after  oblique  fractures  of the leg, and the annoyance U occasions, and
 upon  the simplicity and little danger of the operation, it is difficult to
 withhold our surprise, from the fact that science  possesses so few exam-
 ples in which its exsection has been performed.
  The humerus, especially its lower  part, is sometimes the  seat of a si-
 milar deformity.  A woman who entered the hospital  of La Charite for
 a comminuted fracture  at three fingers' breadth above the elbow, ulti-
 mately got well; but when the wound had cicatrized and the engorgement
 of the soft  parts had subsided, it was found, that in  the consolidation
 which had taken place,  one of the  fragments projected under the skin,
 above the outer condyle in  the  shape of a sharp long crest.  As this
 ridge caused  pain and interfered with the movements of the  fore-arm,
 the patient was the first to desire its  removal.   I divided the integu-
 ments and aponeurosis to the extent of two inches, in a direction paral-
 lel with the axis of the  humerus and upon  its outer  border.   The lips
 of the wound being then held apart and  pressed down, I found it easy
 to isolate the boney  projection and to excise it with the cutting  pliers.
 The  borders  of the  wound approximated  together  in some  degree of
 themselves, and reunion was effected by first intention.
  In its application to a deformed  callus, exsection of the  bone is still
one of those independent operations which cannot be  restricted  to  any
prescribed rules.  In most of the cases the projection of bone to be re-
moved will answer  as our guide ;  in other cases the surgeon is only to
recollect  the point where he can most easily reach without danger to the
bone which he wishes to excise.  It is moreover manifest that inasmuch
as they do not destroy the continuity of the  bone, these lateral excisions
and the removal of simple ridges or abnormal projections of the callus,
are far from involving the same dangers or constituting an  operation as
 serious as that of exsection  in cases of compound or non-consolidated
 fractures.  When once  terminated, for example, they  require no other
 attentions than those of simple wounds.   The healing up of the solutions
 of continuity  which we  are obliged to make, is generally  effected with
 promptitude, and requires no aid from the apparatus used in fractures.

 [Case of Deformed  Leg,  from unsuccessfully treated Fracture
  cured  by  an  operation performed by  John Rhea  Barton, M. D.
  (See Philadelphia Examiner, Jan.  8th, 1842, Vol. II., p. 16, with a
  plate.)

  About  half-past seven o'clock, P. M., on the 18th of December, 1838
 while in charge of the deck of the U. S. Ship Ohio, then at sea, Lieute- 
EXTRA-ARTICULAR EXSECTIONS IN PARTICULAR.
313
nant----fell from the horse block, about four feet high.   The weather
being cold and boisterous, he was heavily clothed in a  pea jacket, &c.
His  foot became  engaged in a coil  of  rigging on the deck, while the
body was carried forward, and the right tibia was fractured transversely
at about its lower  third, and the fibula at about two and a half inches
above the ankle.
   A 'gale of wind, then commencing, lasted several days.
   He was placed in his apartment on the orlop deck, where the circula-
tion  of air  was  very  much  interrupted,  and probably much vitiated by
the number of persons breathing it.
   The limb was  set by the surgeon.  He  suffered very much from the
motion of the ship, and in the night was attacked with  severe spasms in
the limb ; and he distinctly felt the fragments slip upon each other.
   On the 5th of  January, 1839, the ship  arrived at Mahon, and on the
following day, the nineteenth after the accident, the patient was moved
on shore.  During the transportation  from the ship he suffered  great
pain from the moving  of the  ends of the broken bones on each  other.
   He remained in bed eight weeks, and when he got up,  the limb was
still  flexible at the point of fracture.  Getting out  of bed was at first
very painful, and usually  occupied  fifteen minutes.
   When he got up he  was urged to exercise the limb, and three or four
weeks afterwards to bear his weight in a  degree upon it.
   In consequence of the  accident, and its  unsuccessful treatment,  the
upper  fragment  of the tibia  rides the  lower
one, overlapping it about half an  inch,  form-
ing  an obtuse angle  which presents  inwards.
The limb is shortened a half inch ; there is a
concavity inwards, on the outside of the leg, as
might  be the case if the fibula were pressed
inwards against the tibia at its lower third;  the
flexor  muscles are thrown out of their normal
line  of action, and the external condyle  of the
femur  seems to  be, in a measure, alone in  the
essential constitution of the knee joint, the in-
ternal ligaments being elongated, and the knee
thrown inwards.   (See the  Cut.)
   The  patient suffers no pain ; and the only
inconvenience complained of is, that  his foot-
ing is not certain when at sea, and that he suf-
fers under pain and weakness in  the  jknee on
taking unusual exercise on shore.
   For the purpose of  removing this inconveni-
ence, and correcting the deformity, the patient
came to Philadelphia, and  after having been
carefully examined at different times, and at
considerable intervals, by Drs. Thomas Harris,
W. E. Horner, J. Randolph, W. S. Ruschen-
berger, J. Rhea  Barton, and Paul B. Goddard,
anxiously submitted to an operation.
   Lieutenant----is  a  native  of  South Carolina; he  is thirty-four
years of age, about five feet eight inches  high, of nervous sanguine tem
   Vol. II.                   40
 
314
NEW ELEMENTS OF OPERATIVE SURGERY.
 perament, light eyes, ruddy complexion, and, with the exception of an
 attack of fever on the coast of Africa, in 1824, has enjoyed uninterrupted
 health.   He does not use tobacco in any form.
   For a month he has regulated his diet with a view  to  the  operation,
 eating moderately of meat once a day.
   Having procured an airy, comfortable apartment, and made the neces-
 sary preparations, he submitted to the following operation, performed by
 Dr. J. Rhea Barton, assisted by Drs.  Norris, E. Peace, Paul B. God-
 dard,  W. P. C. Barton, and Ruschenberger.
   Oct. 18th, 1841.  Weather clear and cool.  Ten minutes before com-
 mencing the operation, the patient  swallowed thirty-five drops of  lau-
 danum.   He was placed upon the table at twelve o'clock.
   Two incisions,  three inches  in length, were made over and parallel
 with the internal and external margins of the tibia, three inches apart
 at their upper extremities,  and two and a half at their termination.
 These  two incisions  were  connected by a  transverse cut, made a little
 below  the nearly square projecting  end of the upper fragment  of the
 tibia ;  the three  incisions  describing  the letter  H.  The  flaps thus
 formed, consisting of the  skin  and  subjacent cellular tissue  only were
 raised  up, exposing the  fragments of the tibia at their  point of union.
 The adjacent muscles were separated from the bone by  the handle of
 the  scalpel ; the  periosteum, very  near the  lower termination  of the
 upper  fragment, was divided by the scalpel; a small saw, somewhat in
 the form of a carving knife, about ten inches long in the blade, suddenly
 tapered into a point of two and  a half inches long, and rounded at the
 extremity, was next employed, and a slice of bone, less  than a line in
 thickness, removed from  the extremity of the upper fragment.  The
 saw  was carefully worked  in the same line of direction and  in the same
plane,  frequently removing it to clear its teeth by a sponge, until  the
lower fragment  was divided  nearly through.  What  remained was for-
cibly fractured—a short, stout spiculum, adhering to the  posterior por-
tion  of the lower fragment, and which was afterwrards removed.
  Upon examination it  now was found, as  was anticipated, that trans-
verse bridges of bone connected the tibia and fibula together above and
below the seat of  fracture—having been formed there after the injury
for the wise purpose  of  supporting the  weakened  limb—and prevented
the upper and projecting portion from being brought in  a normal line
with the  lower  fragment.   These bony bridges  were removed by  the
aid of a chisel and strong nippers ;  and by the  same means the ends of
the two fragments of the tibia were  adjusted  and  finally brought  into
perfect coaptation.  The operation occupied nearly an hour.  No ves-
sel required ligature ; and the loss of blood did not exceed eight ounces.
  The  edges of the wound were brought together, and retained by  ad-
hesive  straps.  Lint, spread  with simple cerate, was  placed over them.
The  limb from the toes to the knee was then covered by successive turns
of a  roller.  The patient was now carefully  removed  to  bed.   A soft
square  pad, two inches thick, was placed over the external malleolus'
and  a similar one  close to the knee joint; upon these was laid a splint
two  and  a half  inches wide, to  which  the  two fragments of  the tibia
were confined by a few turns of a roller applied at the  proper points.
A soft  pillow, covered with oiled silk,  was made to half encircle  the 
             EXTRA-ARTICULAR EXSECTIONS IN PARTICULAR.         315

 limb, by the aid of splints in a splint  cloth, and the whole  secured by
 tapes.   [Dec. 21st, the patient was walking  around  his  apartment,
 aided by a cane.   T.]

 [On  the  Value of the Seton, as  a  Remedy  in Ununited  Frac-
   tures, Illustrated by Cases.  By Valentine Mott,  M. D.   (From
   the Transactions of the  New-York Academy of Medicine, Vol. I.
   Part.  I.)

   The  surgery of the  present day is pre-eminently  utilitarian in its
 character ;  and the efforts of its most successful cultivators are marked
 by a  desire to establish, by accurate philosophical deduction  from the
 well  ascertained  facts which constitute our art, the true and real value
 of our therapeutic resources and operative  procedures, rather thau by
 the introduction  of novel operations  of equivocal  value.  But  a few
 years ago, every new number of a  medical  journal introduced to our
 notice some innovation  in mechanical and operative surgery ;  surgeons
 seemed determined to secure immortality by novelty, and our manuals
 of operative medicine have  become clogged and unwieldy by the accu-
 mulation  of various novel processes  which, for the most part, lack in
 utility what they  claim in originality.
   Time, which determines the value of men as well as of their  inven-
 tions, has given us a mass of experience, in the way of well ascertained
 and authentically recorded facts, which, if closely studied and thoroughly
 elaborated, will serve as the  only firm and certain  foundation on which
 to build the advanceifient of our science.  " We know too well," remarks
 a  recent writer,  " how  enormous is the  quantity  of facts which have
 been  accumulated in every department of medicine  during the last two
 thousand years;  the most pressing  want which our science at present
 suffers, is the reduction of this vast mass  into separate groups, and the
 establishment  of certain defined principles. *****  It is probably
 only by the assistance of the statistical test that we shall finally  arrive
 at fixed conclusions respecting the efficacy of various modes of treating
 a disease, and the prognosis to be formed respecting the issue of various
 diseases."—(Bisset Hawkins in Cyc. Prac. Med.)
   The leaders in the various departments of medical  science  have al-
 ready adopted this mode of  study, and results have been obtained of
 which we all enjoy  the  benefit.  In  the department of pure medicine,
 the researches of Louis  on Phthisis,  of Boulliaud on Pneunomia, and of
Andral and Chomel on Typhoid Fever, have placed" them  at the head of
the philosophical  investigators of that branch of the healing art.   The
statistics of Collins, of Lee  and  Boivin,  have added  much to the  cer-
tainty of obstetrical science; and, in our own  department of  surgery,
the celebrated tables of Malgaigne on Hernia, and the enlightened labors
of Norris,  of Philadelphia, on the  Statistics of Amputations,—of the
ligature of large arteries, and of the results of the treatment of ununited
fractures, have  secured for them an enviable celebrity throughout the
scientific world.
   The sura of each  individual's experience in the treatment  of disease
constitutes  the basis of his judgment, and stamps the value of his indi-
vidual opinion, in a given case.  The truth of this  proposition will be 
316
NEW ELEMENTS OF OPERATIVE SURGERY.
 admitted on a close examination ;  for no individual is capable of accu-
 rately appreciating the recorded  experience of others, except by mea-
 suring and  comparing it with his  own personal knowledge—which, in
 the end, gives all its practical value to medical learning.   As the per-
 sonal experience, then, of each individual—the most valuable portion
 of his knowledge—for the most part must die with its possessor, it fol-
 lows that  our science consists alone of  those facts  which have  been
 placed upon  record, by individuals, to serve as the basis  of  inductive
 reasoning, and of statistical analysis.   These facts are valuable in pro-
 portion to their ascertained authenticity, and the character for  accuracy
 of the observer.   It is the duty then of every medical man who is anxious
 for the legitimate advancement of his science, to do his part, however
 humble, by placing on  record such facts as may have fallen beneath his
 notice, for we may  rest assured, that however trivial  they may be, if
 accurately observed, posterity  will acknowledge their value.  They will
 take their.appropriate  place in those statistical results on which in future
 time  medicine will rest its claims to take  rank as one  of the  exact
 sciences.
   I have made the foregoing remarks by  way of apology for laying be-
 fore  the  Academy  the result of my experience on  a subject which has
 recently undergone statistical investigation,  with the view of placing on
 record, should the Academy deem them worthy of a place in its  archives,
 some cases which have  never been heretofore published.
   I refer to the use of the Seton, as a remedy for Ununited Fractures,
 an operation which the world  owes to an American surgeon—the illus-
trious Physick, of Philadelphia ; and which  the  researches of another
American  surgeon, Dr. Norris, have statistically  proved to be,  in the
present condition of surgical  science, the  most certain remedy that we
possess for that unfortunate occurrence.
  It is worthy of remark that  the  elaborate and valuable  paper of Dr.
Norris forms  the  basis of the  article on " Ununited Fracture," in Nos.
XI. and XII.  of  the Cyclopaedia of Prac  Surgery, which, completed
by T.  W. King, Esq., constitutes  the latest monograph on this subject,
which we have from  an English authority.  The conclusions arrived at
in this article, with  regard to  the  camparative value  of our  remedial
 means, drawn from the tabular view of one  hundred and fifty  cases,
 compiled by Dr. Norris, are embraced in the following quotation :—
   " Of forty-six cases  in which the seton was  employed, thirty-six were
 cured, three partial cures, five  no benefit, two died.
   " Of thirty-eight cases in which  resection was employed, twenty-four
 were cured, one partial cure, seven no benefit, six died.
   " Of thirty-six cases in which pressure and rest were employed, twenty-
 nine were cured, one  partial cure, six no benefit.
   " Of eight cases in which caustic was employed, six were cured, two
 received no benefit.
   " Of eleven cases  in which frictions were employed,  eleven  were
 cured.
   " Of eleven cases in which other methods were employed, viz. iodine,
 injections, hot iron and  amputation, seven were cured, one received no
 benefit, two died, and one remains uncertain."
   Under the  head of seton are embraced its varieties, viz. the conical 
             EXTRA-ARTICULAR EXSECTIONS IN PARTICULAR.         317

seton of Weinhold, the silver wire of Somrae, the double seton of Op-
penheim, and the variation  adopted by Scerig.   Under the head of re-
section  are included all  cases  in  which the ends of the  bones were
scraped, rasped, or excised.
  The opinion  expressed by Nelaton, perhaps  the most recent  surgical
authority  amongst  the French, in  his incomplete work on Surgical Pa-
thology, will give an idea of the appreciation  of the  various remedies
in use by  the  surgeons of France.  After enumerating the resources
mentioned  above, he states  that " in  the present condition of science
it is  impossible to  determine which  of these  remedial  means would
deserve our preference in a  given case," and proceeds to quote  the
following  opinion  of W.  A.  Berard: " When  a fracture  is found  to
remain  ununited after the lapse of the  usual  period, reapply  the ap-
paratus, give it all the additional solidity possible, and renew it at long
intervals ;  seek, meanwhile, for any constitutional cause in your patient
which could prevent union, and remove it if possible.   If  these means
are insufficient, make use of blisters and  other irritating  applications
to the limb over the seat of the  fracture ; if these fail, resort to friction
of the fragments, and  replace the apparatus.   If you are still unsuc-
cessful examine carefully if your case present any indications (such as
caries, necrosis, &c,  at the seat of the  fracture) which  would render
resection preferable  to the employment of the seton.   Should  this in-
dication  fail,  pass  a seton between the  fragments,  and if necessary
saturate it  with irritating substances;  apply caustic to  the  fragments,
and if there is still no consolidation, resection  remains to be tried."—
Vol.  i. p. 684.  Velpeau concludes that the seton  " is a very uncertain
means, and one for which I should prefer to substitute exsection, where
frictions and the  starch bandage had not answered, and it is one more-
over  which is not always unattended  with danger.  M. Weinhold, in
applying it to the neck of the femur, brought on caries and suppuration
in the cotyloid  cavity  and pelvis, which ended in the death of his pa-
tient."—Am. ed., vol. ii. pp. 689, 690.)  If M. Velpeau was influenced
in his opinion as to the danger  attending  the  use of the seton by the
case of M.  Weinhold, which he quotes, we  fear he has  been  led into
error.  In  the only account of  this case to which we  have access, it is
distinctly stated that  Prof. W. " was unwilling to try any operation, as
the symptoms clearly indicated chronic inflammation, if  not actual sup-
puration of the hip  joint.    The  patient, however, had heard of his
cures, and  was  determined to take the  chance.  He  died of hectic at
the end  of six  weeks."—(Ed.  Med.  and Surg.  Jour., vol. xxvii. p.
399.)  Surely this case should  not detract from the merits of the ope-
ration ;  it is the only unsuccessful case reported in the essay of Profes-
sor Weinhold, in which four successful cases are related, three of which
involved  the  thigh-bone.  Professor  Gibson,  of Philadelphia, states
that he has operated in ten  or twelve cases with  the  seton, and  has
uniformly found it  more or less successful.—(Surgery, 1811, vol i.  p.
336.)  These cases are not contained in Dr. Norris's table ; it is to be
regretted that  they are not  recorded  in a more  tangible form.  Dr.
Physick is  said, by Prof. G., to have twice tried the seton in the thigh ;
and to have expressed  himself as  fearful that it would  not succeed in
any case of the kind. 
318
NEW ELEMENTS OF OPERATIVE SURGERY.
   An  interesting fact is mentioned  by Prof.  Colles  of Dublin,  in  his
lectures, from which it would seem that we have a therapeutic resource
in these cases which is not generally recognised by authors.  " An army
surgeon  told me," said he, " that while quartered in the West  Indies,
he once had five or six  cases of ununited fractures  together, and they
were long enough under his care to have been, in the  ordinary course of
things, united three times over;  these men,  with their  regiment, em-
barked for Europe ; on their arrival the surgeon  inspected all the men,
and on examining these men who had  fractures so long without  union,
he found all their fractures united, without the patients or himself being
at all conscious of when the  union had taken place, as their attention
had not been aroused by the  occurrence of pain,  or peculiar feeling of
any kind."
  Electricity is said to have been used with  good effect in producing
consolidation in some cases ; I have made use of it on several occasions
without benefit.
  I shall  now proceed  to  detail  some cases in which  I have used  the
seton :
   Case I.  In  1817, after having employed in vain, pressure combined
with rest, blisters, and  electricity, in an ununited fracture of the tibia,
I passed a seton between the  eads of the bones.   At  the end of three
months the cure was perfect.
  This case is reported in the Med. and Surg. Register of  the New York
Hospital, Pt. II., v. i. p. 375.
   Case II.  In 1819, after employing the means enumerated in Case I.,
I made use of  the seton in a fracture of the  femur, which had failed to
unite.  It was allowed to remain  three months.   At the end of  a year
the bone was found  firmly united.
  This case is also recorded in the Hospital Register, as well as a third,
of the humerus, in which the result of  the employment of the seton was
not certainly ascertained.   I have reason to believe,  however, that this
case  was also cured.
   Case IV. A. B., of Florida, thirty-five years of age, of  a good con-
stitution, and in the enjoyment of excellent health, in 1822,  received an
injury in which he fractured the tibia and fibula of one his legs ;  in both
the bones the fracture was simple.   He was treated with the limb in an
extended position, and  during the treatment  no  unusual circumstance
occurred.   At the end of six  weeks, on examining the limb to see if  the
bones were in  a state of consolidation sufficient to allow the splint to be
removed, it was found that the fibula was firmly united,  but that the tibia
was as movable as at an early period of the injury.
   He  was directed to remain quiet a few weeks longer, to give an oppor-
 tunity for union to take place.  This not being accomplished, he came to
 New York, after the lapse of seven months from  the receipt of the  in-
 jury, and placed himself under my care.  At this time his general health
 was good;  he had attempted  to use the leg for some weeks, by means of
 crutches, and bearing a slight weight upon it gave him but  little  pain ;
 the bone yielded, however, at the fractured  point by the least pressure
 upon  the foot.
   A strip of blister plaster an inch  and a  half  in  width was"  applied
 around  the limb, at the seat of the fracture, several different times. 
            EXTRA-ARTICULAR EXSECTIONS IN PARTICULAR.         319

Shocks of electricity were from time to time  resorted to.   The ends of
the bones were repeatedly rubbed  together  briskly; and  he was di-
rected to add to the irritation about the point of fracture by more active
use of the limb.
  These means were faithfully tried for several weeks, but without the
least appearance of further  consolidation of the  fracture.   The  seton
was now  proposed to him, as the means which promised best success;
he readily consented, and it  was accordingly introduced.   An  incision
was made on each side of the limb, and on  repeated trials it was  found
impossible to make a pointed stilet penetrate the ligamentous attach-
ment  of the fragments ;  an  ordinary  gimlet  was then employed, and,
through the hole thus made, an  eyed  probe  was passed, containing a
skein of silk.   The limb was then placed in  carved splints, and kept
extended on the heel;  sometimes it  was shifted on the outside, and
flexed.
  Very little pain or inconvenience attended or followed  the operation.
He was allowed to continue his  ordinary full diet  without interruption.
  After the lapse  of six weeks the bones began  to  be firm, and  from
this time I began to remove the seton, thread by thread, until it was all
taken  away—by which  time  the bones were perfectly consolidated.
The whole time occupied in the treatment, from the introduction of the
seton until the union of the bones, was about two months and a half.
   Case V.  George Westerfield, a boy aged  twelve  years, was sent on
to me from Ohio, in  1826, with  an ununited fracture  of the  right os
brachii of eight  months' standing.  His general health was good, and
no cause could be assigned for the want of consolidation of the fracture,
except the difficulty of keeping the parts in apposition.   The seat of
the injury was about the middle  of  the bone,  and the fractured  ends
were conical, and separated  from each other at least an inch ; no pain
was experienced on  rubbing them together, and there  was free motion
in all directions.  With the ordinary  seton needle I passed  a  seton
through the arm, as  nearly as possible between the  separated  ends of
the bones.   The arm was afterwards  encased  in  splints,  and  kept as
quiet  as possible.  After the more active inflammation had passed  away,
he was allowed to carry it in a sling,  properly secured and protected.
Weeks, and even months passed away without any evidence  of  union
at the fractured  ends.  At the end of  six months, as there was not the
slightest prospect of amendment, I withdrew the seton, and  allowed
the sinuses to heal.   After waiting for some weeks, with no evidence of
change, I determined to try a second seton ; this was again introduced,
and of larger size, and after  continuing it for several  months  without
benefit, it was also removed.
  I now put him  into the  hospital  for further  treatment; and  after
stating, in consultation with  my colleagues, the history of the case and
the practice that had been pursued, it was determined, as  the only al-
ternative of amputation, to try exsection of the ends of the fragments.
This was accordingly done by Dr. J.  Kearney  Rodgers,  who  followed
me in my tour of attendance.  In addition to  sawing off the ends  of the
fractured bones, Dr. K.  passed  a silver wire through each end of the
sawed bone, and after twisting the  ends  together, brought  them out of
the wound through a canula.  The wire from one end of the bone wore 
320
NEW ELEMENTS OF OPERATIVE SURGERY.
 out in a few days, and it was removed from the  other a short timo after.
 JNo great degree of inflammation  followed  the  operation, and  in a few
 weeKS, as the wound  healed, the os brachii became  firmly consolidated.
   This is the first time, as far as our knowledge extends, that  the ends
 of the bones have been connected by the wire suture after the operation
 of exsection.  As will appear in the next case I have  successfully adopted
 the same practice, and it has been also tried in numerous cases by New
 York surgeons; I am not aware that there is a single  case on record
 in which it has failed.
   Since the introduction of this operation into the  surgical practice of
 our city,  M. Flaubert, of the  Hotel-Dieu  of  Rouen,  in  France, has
 adopted the same method with  perfect  success, and  M. Malgaigne in
 his Operative  Surgery has given to him  the credit of  originality in this
 operative  process.  He  may be correct with regard to  the originality,
 but we know that we can claim the priority of years, for the surgery of
 our  own country.
   Case VI.  James Norton, a middle-aged man, of good  constitution,
 was  admitted to  the N. Y.  Hospital in  April, 1830, with an ununited
 fracture of the humerus  above  its  middle, of three months' standing.
 The  ends of the  fractured bone were widely separated, and could not be
 approximated.   A seton  was passed  through  the limb  on the  10th of
 April, and allowed to  remain until the 28th of September without pro-
 ducing the slightest benefit, when it  was withdrawn.  Resection  was
then practised, and the fragments  retained in contact by the suture of
well annealed iron wire.   Two or three  weeks  after the operation the
wire came away, the arm became gradually stronger, and on the 15th of
December, when he was discharged, the  uuion was complete.
  I attribute the want of success which followed the use of the  seton in
this case, to the  separation of the fragments.  It is reported by Dr. A.
 C. Post, in the New York Med. Jour., i. p. 275.
  Case VII. L. M., aged fifty-five years,  of active habits,  although rather
corpulent and phlegmatic, fractured his right femur at its upper third,
in January, 1833.  After the lapse of ten days, at which period the in-
 flammation had subsided, his limb was placed in the double inclined plane.
 No unusual circumstance occcurred during the ensuing five weeks ; the
 patient was very tractable and obedient,  evincing the most earnest desire
 to get well.   On examining his limb, however, at the commencement of
 the seventh week, to my surprise, and the great disappointment of my pa-
 tient, it was found that no union had taken place at the seat of fracture.
 He was requested to remain quiet for two or three weeks longer, to which
 he cheerfully consented.  At the end of  this time I found the bone still
 ununited.  The limb was now removed from the double  inclined plane,
 and four thigh splints substituted, with pillows for a support.  In  this po-
 sition it was kept for  about ten days;  each day the dressings  were re-
 moved and the ends of the bones briskly rubbed together ; friction with
 camphorated spirits was afterwards applied to the thigh and leg, and the
 bandages and splints reapplied.
   After this, the limb was restored to the inclined plane,  and the patient
 requested to remain in bed, aud use  generous  diet.  This course  was
 steadily pursued for six weeks, at the end of which time I found  upon
 exmination that no union had taken place. 
            EXTRA-ARTICULAR EXSECTIONS IN PARTICULAR.         321

  Believing that no benefit would arise from any further delay, I now
proposed the  introduction of a  seton, to which he readily  consented.
Some considerable difficulty attended the operation, from the lower frag-
ment of the femer being drawn, as usual, behind the upper.   To securely
lodge the seton between the fractured ends, I was obliged again to re-
sort to a large spike gimlet in the form of a bit, to make a passage for
the eyed probe, as it was impossible to pass a stilet between them.
  A great deal of  inflammation followed the operation, with profuse sup-
puration, and  hectic fever,—which continued for several weeks and ex-
hausted the patient very much—so much indeed that I thought at times
that I should be obliged to remove the  seton  altogether.  With tonics,
however, and an invigorating treatment, after a time the hectic symptoms
declined, and  the suppuration abated.
  In about seven weeks from the introduction of the seton, I found, on
careful examination, that  some firmness was perceptible at the seat of
fracture.  This gradually  increased, and when it had sufficiently advanc-
ed, I began to remove the seton,  thread by thread, until it was all taken
away.
  From the first introduction of the  seton, until the fracture  was per-
fectly consolidated, about three months elapsed.   He was now permitted
to get about gradually, upon crutches, wearing as a protection four short
splints about  the thigh well secured with tapes, and a roller bandage ;
the splints  were continued for some  time after he commenced  walking
about, and  were then laid aside.
  After nearly a year  of  great suffering, when full of cheerfulness and
hope of recovery,  this unfortunate gentleman again had a fall, and re-
fractured the femur at the newly united parts.
  He was placed again in bed, and the limb  put in the double inclined
plane, and treated upon ordinary principles.   At the end of six  weeks
after this accident, the bone was found firmly united, and he passed from
the use of crutches to a cane,—as in  every day  cases—and, after all the
difficulty and delay which it was his  misfortune  to experience, he has
no  more shortening of the  limb than occurs in the  most  ordinary
cases.
   Case  VIII.  G. T., a ship carpenter,  aged 44, of a vigorous constitu-
tion and athletic* frame, in  the year 1824 received an oblique simple frac-
ture of the right femur—a little above  its middle.  After the usual an-
tiphlogistic treatment for ten days, the limb was treated in  the extended
position with  Dessault's  apparatus.   A fair amount of extension had
been applied to the limb for the  usual period, and upon examination at
the expiration of six  weeks, no  union  having  taken place, my advice
was requested.
  I found the  patient in good health, lying in the apparatus, which ap-
peared to have been fairly used ;  the  limb was, however, shorter than I
have been in the habit of making, with Boyer's apparatus with the screw
attached, and I found that the fractured ends had slipped by each other
considerably.  Free, and  indeed rough motion, was given to the frac-
tured ends of  the bone daily, for several days, and the limb kept stead-
ied in the same splint, without, however, using the least extension.  De-
cided pain and tenderness having been induced by this treatment, I en-
deavored, by extension, to bring  the limb nearer its proper  length, but
    Vol. II.                    41 
 322            NEW ELEMENTS  OF OPERATIVE SURGERY.

 without success.  It was then  left in the same apparatus,  four short
 splints having been  placed  in the thigh  over  the  many-tailed  bandage
 very  tightly applied.  He was also directed to use a nutritious and sti-
 mulating diet.   Six weeks having elasped without  the least appearance
 of bony union, it was determined forthwith to introduce a seton between
 the fragments.
   Upon making an incision  on the anterior part of the thigh, down to
 the seat of the fracture, it was  found  impossible to pass a stilet or any
 pointed  instrument between the ends  of the bones, so close was their
 connexion.  I therefore, as in other cases, used a small gimlet, and fol-
 lowed it with a bit containing an eye. into which the seton was passed,
 and drawn through.
   Much inflammation followed the  operation, and a copious suppuration,
 for three weeks.   When  the discharge  was reduced  to the ordinary
 amount from a  seton, and  the wound  had healed to a  mere  fistulous
 opening, he began  to think that his sensations  warranted him in believ-
 ing that the bones  were growing together.  In this he was correct, for
 after  about seven weeks the  firmness of the  limb had so far advanced,
 that it was thought best gradually  to remove the seton.   In eight weeks
 from  the time of its introduction the bone was firmly consolidated.
   The limb was shortened  about  an  inch, and the  foot considerably
 everted.
   Case IX. The following  interesting and unique case which recently
 came  under my notice (1814), leaves no  doubt in my mind of the exis-
 tence of the non-union of  an intra-utev'me fracture.
   F.  G., a female  infant, four months old, in excellent health, and in
 every other respect perfect and well formed, and nursing a very healthy
 mother, was brought to my house in consequence of a distortion of one
 of its feet.  Upon examination  I  saw, at once, that there was a consi-
 derable mobility of the leg  about  two  inches above the ankle-joint, and
 that this joint, as well as  the foot, was  perfectly  normal.   On a more
 careful inspection I found the tibia and fibula ununited at this  point,—
 that the end of each bone could be distinctly felt,  and that this unnatu-
 ral joint was the cause of all the distortion of the foot and leg.  No
 pain  whatever  seemed to attend the  free  movement of the unnatural
joint, and the mother assured me that it had been so from its  birth.
   My first attempt was to render the false joint as immoveable as pos-
 sible  ; for this  purpose I applied a roller around the limb, and then en-
 cased it in pasteboard, retaining this by a second roller.  This appara-
 tus was kept accurately applied during several months, and at one time
 I had great hope  that the bones were being united, as there was a de-
 cided degree of firmness about the false joints.
   As this  plan failed, I tried rubbing the ends of the bones together
 for a few times, and  then with a splint  and bandage kept the limb quiet
 for several weeks.
   No benefit following this, I applied a narrow  strip of  blister plaster
 around the  leg, at two or three different times, keeping  the apparatus
 constantly applied.  Acupuncture  about the ends of the bones was used
 with  galvanic electricity, but all to no good purpose.  I regret now that
 I  did not try scarifying the  ends of the bones with a tenotomy knife, as
 since suggested by Prof. Miller, of Edinburgh,  but it did not occur to
 me. 
            EXTRA-ARTICULAR EXSECTIONS IN  PARTICULAR.          323

  I now urged the seton, but it  was some  months  before  the mother
would  consent to its use ; when she  did  consent, I felt less willingness
to apply it, than in any case I ever  met with.  This arose  from the
difficulty of satisfying myself of the  exact course of the arterial trunks,
as well as of the  position of the  ends of the bones, on account of their
abnormal condition, and the consequent derangement of the soft parts.
It was my  intention to use but one seton for the two bones,  which I ac-
complished  after much difficulty, and great care, by  means  of a long
needle  in a stiff  handle with an  eye near  its point.   After deciding
upon the spot for passing the seton, it was very speedily done, and to
my entire  satisfaction.  The  infant  seemed to suffer very little pain
from the operation, and the inflammation and  suppuration which fol-
lowed  it were slight.   After the  seton was passed, the  foot and leg
were secured as before.
  In about four weeks the bones were quite firm, and  from the general
practice which I  have adopted, in other cases of ununited fracture, I
began  to remove some threads  of the seton.   At this time, from what
cause I knew not, violent  inflammation suddenly came on in  the vicinity
of the  seton, and involved the whole leg.  This shower of  trouble in a
few  days swept  away all the uniting material, and left the  ends of the
bones in their original state  of mobility.
  The  seton of course was removed at once.   If it had happened that
the  seton  had been removed before this  " tornado" of inflammation
supervened, it is my firm belief that this curious case would have ter-
minated favorably.
  No argument or persuasion would induce the mother to allow the
seton to be re-introduced, or  to try  any other remedy.  This child is
now (May  9th, 1851,) about eleven  years old, a fine healthy  girl, with
the tibia and fibula still  ununited.   At the request  of her parents, I
sawed  off the ends of the tibia about three weeks  since, and connected
the ends of the bones together by a silver wire and canula.   The wound
has entirely healed by  the first intention, except where the canula pass-
es.   The result will  be the  subject of a future communication  to the
Academy.

                            CONCLUSION.

 • I fear that I have already presumed upon the patience of the Academy,
and shall therefore pursue  this subject no  further at  present.  It was
my design to present, by way of  actual  demonstration of the relative
utility  of the  seton,—a critical analysis, in a tabular form, of all the
cases on record in which it has  been employed; setting  forth, in the
unsuccessful  cases, the  apparent  causes  of the failure, and  the circum-
stances under which  it has most frequently  succeeded, with the view
of determining, as far as the facts on record will permit, the nature of
those cases  in which its  use is indicated, or otherwise.  This table is
in course of preparation, and I shall  take the opportunity  of laying it
before  the Academy in a short time,  with the practical inferences which
our further investigation of the subject may justify.  My present impres-
sion is  this, that the seton will only  succeed in those cases of  ununited
fracture in  which the  ends  of the bones  are in actual contact, or very 
 324            NEW ELEMENTS OF OPERATIVE SURGERY.

 nearly so ;  and the facts  would seem also to justify the opinion that,
 in those cases in which the ends of the bones  are not in contact, there
 is no operation which promises better than the resection of the ends ot
 the fragments, and their union by means of wire.

                  Article IV.—Organic Lesions.

  Exsection  for caries, necrosis, &c, though  less frequently performed
 than for the cases we have just spoken of, is nevertheless very often in-
 dicated.   Apart from the  'observations of Tenon, (Exper. sur VExfol.
 drs Os, 3c  Mem., 1758, 1759, 1760,) who had  the boldness to remove
 in this manner the great trochanter ; of Moreau, ( These, Paris, 1803,)
 who, in 1793, excised a  considerable portion of the tibia;  of Percy and
 Laurent  (Diet, des  Sc. Mid., t. XLVII.) who state that for a caries,
 or rather without doubt for a necrosis of the leg, they have destroyed
 this last bone by means of the saw, or trephine, to the extent of eight
 or ten inches, and  removed  the  entire fibula;  of Beclard (Bull, de la
 Fac.  de  Mid., t.  VI., p. 353) who, following the counsels of Desault,
 also ventured to extirpate by exsection the upper third of the fibula for
 a spina ventosa; of Hey, who relates in his work many operations of
 excision of the bones of the leg and arm ; of M. Couty of La  Pomme-
raye, who has published an exsection of almost the entire extent of the
humerus ;  French classical authors  scarcely make mention of this kind
 of operation, which was again performed a few years since with com-
plete  success  at  the Hospital Beaujon, for a very extensive necrosis of
the tibia.  The surgeon, compelled to conform himself to circumstances,
and to vary the operative processes according as the limb has preserved
or lost its natural  forms, and according to  the extent and seat of the
disease, lays  bare the bone by means of longitudinal incisions,  or when
it  becomes necessary, by cutting  out  at  the expense of the soft parts,
one or more  flaps of sufficient size, and  of variable shape.  The dis-
 ease being  exposed to  view he  now makes use of the saw or the tre-
phine  ; in other cases of the gouge and mallet; the saw, when the bone
is  cylindrical or not very large  ; the trephine  when it is a large bone
 and difficult  to isolate,  or when it presents a great degree of thickness,
 or, in fine, when  the  surrounding parts do not admit of the use of the
 saw;  the chisel, when he wishes to remove only a few laminae, or a part
 only of the calibre of the diseased bone.   We may employ also the cut-
 ting pliers or any other  instrument which the skilful operator will know
 how to devise.  M. Seutin (Soc.  des Sciences Mid. et Nat. de Bruxel-
 les, December, 1829)  who  has extracted with  singular success almost
 the entire fibula, had recourse to the trephine to separate its upper ex-
 tremity and  divided the other with a curved saw.  It is in such cases
 that the flexible or chain saws are especially serviceable.
  Not only may exsection  be performed upon tha middle of the limbs
 for the organic diseases described farther back ;  but also upon the trunk
 cranium, sternum, ribs, clavicle, vertebrae, &c.

                        § I.— The  Cranium.

   The excision of the bones of the cranium, for caries, necrosis, or de- 
            EXTRA-ARTICULAR EXSECTIONS  IN  PARTICULAR.         325

generation, has  often been  performed ; and it is this which has served
as the point  of departure for the operation known under the name of
trephining.
  The instruments we  employ in such cases, are the rasp, the chisel,
the gouge, M. Hein's saw, M. Martin's osteotome, and the different sorts
of rowel saws and the trephine.
  For superficial  carious affections, whatever may be their extent, we
confine  ourselves  .to the  use  of the  rasp.  Having laid the diseased
parts bare by means of the proper incisions, the surgeon, holding the
cutting plate of the rasp in his left hand, and embracing its handle with his
right hand, proceeds to scrape and grate the carious or necrosed surface,
until he has completely removed it, and perceives red points and a gran-
ular aspect, and no longer a  yellow or livid tint, at the bottom of the
rasped surface.   With  M. Champion, I cannot understand how Duver-
ney  and Richter  should have recommended  to  rasp  the bones with a
piece of glass, rather than with the rasp properly so called.
  If the bone should be  degenerated to more than a line in  depth; or
if, as almost always happens, the case is one of necrosis rather than of
caries, it  would be difficult to come down to the seat of the mischief by
means of the rasp  alone; in such cases we might have recourse  to the
chisel or gouge.   But the strokes required upon these produce a fearful
concussion, on which account surgeons usually prefer the use of the tre-
phine instead  of the instruments in question.
  A resource which is sometimes preferred to all the above, when  the
disease  has not penetrated through the thickness of the cranium, is the
red  hot iron.   This practice, however, is now proscribed from surgical
practice  in  all cases wherever the cranium does not present an extreme
degree of thickness. Thus no one would venture to apply the  actual
cautery to the frontal,  parietal, or even the occipital bones.  The mas-
toid processes alone rigidly admit of its application.  The caloric which
would  soon be  communicated  thereby to the membranes or the brain,
would give rise to accidents  more serious than  the disease itself.
  M. Hein's  osteotome, and M. Martin's saw, have, at the present day,
put it in  our power to remove  a part or the whole of each  one  of the
bones, which enter into  the composition of the cranium, without the ne-
cessity of recurring to  the  chisel, gouge, mallet, trephine or hot iron.
The first  of these instruments, in fact, is arranged in such manner,  that
the diseased bone, after the soft parts have been detached from it, can
be removed layer by layer, to any depth and to whatever extent may be
desirable.  That of M.  Martin, for which we may, in a case of necessi-
ty, substitute  Thompson's or  Charriere's saw, enables to circumscribe
the whole of the  diseased bone, in a circular, quadrangular,  triangular
or rhomboidal disc, and to remove it by penetrating, or not, down  to the
dura mater, according as the  state of the parts may require, or may
allow us to dispense with  doing so.  With these two instruments, we
may and can in fact take out the part of the bone diseased, in the same
manner as we would a portion of diseased integument, in making use of
the bistoury.
  It must be  remarked, however, that  the instrument of M. Heine, so
efficacious in  the  hands  of  its author, and of Jaeger at Wurtzburg, re-
quired an hour and a half's manipulation to remove a necrosis from the 
326            NEW ELEMENTS OF OPERATIVE  SURGERY.

forehead, in a  patient of M.  Ricord, (Gaz.  Mid. de  Paris, 1834, p.
644-648.)
  It is unnecessary, after the  operation, to round off the borders of the
osseous division with  the lenticular knife or rasp.  We should restrict
ourselves to  the removal of the points, angles, or thin scales of bone,
if any  should exist, which would seem  calculated  to irritate the  soft
parts.   While approximating  the  flaps  of the hairy scalp, I would not
recommend that their edges should, in every point, be brought into exact
coaptation, and I regard it as a precept of the highest importance, that
we  should  dress such wounds  from the bottom, with small balls of lint,
for  some weeks, and not endeavor to  effect immediate union.
  Very extensive portions of the cranium  may bo removed in this man-
ner, without seriously  compromising the life of  the patient.  Verduc,
David, Soulie, and Lapeyronie, mention the cases  of individuals who
had lost a fourth, or third part, or the half of  the vault  of the cranium,
by necrosis or the operation  of the trephine, and who, notwithstanding,
enjoyed good health.   We must learn in the memoir of Quesnay, what
we may hope for from an operation of this kind, which  Roger, Guy de
Chauliac, and De Vigo, among the ancients, had  it would seem already
formally advised, as Celsus had in fact before them, and which  Percy
since has taken  special pains to bring into repute.
  Nevertheless, I would not  recommend that the exsection of the bones
of the  cranium  should be performed without being  specially indicated.
Marchettis, Theden, Wurms,  and Brahery, (Champion, Traiti  de la
Resection, p. 28,) who profess to have employed it with success in  epi-
lepsy,  have  had very  few imitators, notwithstanding  the  remarks  of
Odier,  of Geneva, (Manuel  de  Mid. Prat., p.  180,) and  some other
modern authors.
  An important circumstance,  and one which ought to restrain the ardor
of surgeons in such  cases, is, that nature herself, alone, often triumphs
over caries  and necrosis of the  bones  of the cranium.  Because  the
bones of the  cranium  are denuded, and in contact with  pus, or have
been for a long  time  exposed to the action of the external  air, we are
not, therefore, necessarily to  conclude, that we  must  undertake their
excision.  [This is a truth,  as I have remarked in a note, in  Vol. I.,
that every practitioner of experience has had occasion to verify.  T.]   I
have elsewhere (Traiti des Plaies de Tele, Paris, 1834) related nume-
rous facts in confirmation of this assertion, and  I could at present  add
to them a multitude of others.  It has so often  happened to me to see
wounds of the head, of all sorts and of all dimensions, from cuttino" or
blunt instruments, simple or  compound fractures,  ordinary causes or
fire-arms, lay bare the entire surface  of the bones, pass into suppuration
and remain with their lips separated during the whole period of the
cure, and to allow of our recognizing with the probe as well as by means
of the  eye or finger, the  sonorousness and perfect denudation of the
bone;  and afterwards  to observe the surface of this  bone gradually
recover its  vital forces, and  become adherent to the soft  parts in the
same manner as if it was a common wound, and without being attended
with the least  exfoliation;  that I cannot  too  earnestly recommend to
surgeons to rely greatly, in  such  cases, upon  the  efforts of nature.  I
shall again recur to this subject in speaking of the trephine. 
EXTRA-ARTICULAR EXSECTIONS IN PARTICULAR.         327
                     § II.—Bones of the  Face.

  There is scarcely any  other  part of the face than the  bones of the
two jaws whose exsection has been treated of under the head of special
operations.  The other bones of the face, however, also present occasions
for the operation of  excision or exsection, when affected with caries,
necrosis or degeneration, for which reason I shall commence with them.
   A.  The  Orbit.—If some point alone on the contour  of the  orbit
should be degenerated, we could remove it without interfering with the
eye, and often in fact without  implicating the  corresponding  eye-lid.
The os unguis, the  ascending process of the superior maxillary bono
and the ethmoid, have often been removed in cases of fistula lachrymalis.
I shall  speak  of this  further on under the head of this last mentioned
disease.
   The supra-orbitar  arch was completely  necrosed  in a woman, who
would have willingly  submitted to its removal, had not her advanced age
and the visceral derangements under  which  she was  laboring at the
same  time, deterred me from undertaking it.   M. Stark (Coulon, De la
 Carie des Os, Wurtzburg, 1833, p. 23) or M. Heine however (Gaz.
Med. de Paris, 1834, p.  644) appear to have once performed  this ope-
ration successfully.   There are two different modes in which this opera-
tion may be performed ;  that is, either  by raising up on the forehead a
semi-lunar flap from  the eye-lid  which  is to be allowed to fall in  place
after  the operation by its own weight, or by bringing down upon the
eyelid a flap of the same  form  from  the  forehead, which is afterward?
to be  raised up to its place.  The bone being thus laid bare, should then
be removed with cutting pliers or the mushroon-shaped saw of M. Martin,
rather than writh the osteotome  of M. Heine.  The  gouge and the mallei
might also be  employed,  if there should remain any angular projections
to be removed.  The concussion  upon the cranium in this region would
be too  slight to make it necessary to proscribe the  use  of these last
mentioned instruments in such  cases.
   The inferior border of the orbit being  less prominent than the superior.
would therefore be less easily  submitted to the operation of exsection.
It is, however, rare that  this  part is attacked with caries or necrosis,
unless a portion of the maxillary or of  the malar bone also participates
in the degeneration.   Many  surgeons,  among  whom we  may  mention
Jaeger, MM.  Dietz, (Coulon,  Opir.  cit., p. 28,)  Syme  of Edinburgh,
and Dieffcnbach, appear to have  performed this operation with success.
A large sized callus  of the malar bone  was  successfully removed by
Severin, (Mid. Eff.,  p. 315, § 953 ;)  Bordenave also, after having ex-
tracted several sequestra from the two portions of a carious malar bone,
succeeded in effecting a cure of his patient, (Acad, de Chir., t. XII., p.
53.)
   B.  Without speaking  of the cases where the malar bone  has  been
removed conjointly with the superior maxillary and inferior border of
 the orbit, I will remark that the zygomatic wall of the maxillary  sinus,
 and the entire zygomatic arch itself have been exsected by myself in
 two different cases.   One of the patients had had the malar bone carious
 and necrosed for more than two years.   Having laid bare the parts by 
328
NEW ELEMENTS OP OPERATIVE SURGERY.
means of a crucial  incision, I removed  the  greater  portion of the dis-
eased  bone with the musbroon-shapcd saw and the rest with a few clip-
pings of the chisel.   The whole of the malar bone and almost the entire
lower  border of the orbit were thus extirpated.  In  the other I applied
the point of a very strong pair of scissors at  the fistulous  opening which
existed on the outside of the dental arcade, and divided the whole wall
of the  sinus forwards,  then  backwards, and  finally upwards, without
involving the parts of the cheek  properly so  called.
  C.  The  zygomatic arch  which  was  formerly removed  by Loyseau,
(Observai. de. Mid. et de Chir., 1617, p. 34,) has also  been exsected
by M. Heine or M. Jobert, (Gaz.  Mid.,  1834,  p. 644;)  and  I have
met with two patients in whom it had li'on for so long a  time in a state
of necrosis, that it would have been proper to  have submitted it to the
same operation.  We may  readily understand in  these  cases, that the
arch being laid bare by means of a transverse  incision, which could be
transformed into an  L if the  disease had extended  to a great distance
in front, and could afterwards be dissected  above and below, and the
bone removed or detached by  means either of  Listen's pliers, the chain
saw, that of M. Martin, or even the gouge or  mallet, &c.
  D. Nobody appears to have more boldly or frequently  performed ex-
sections upon the bones  of the  face than M.  Dieffenbach.   In  a note
published by him in 1838.   (Experience, t. II.,  p.  55)  he relates
eighteen examples of these operations, which however in the  first, sec-
ond, third, fourth, eighth, ninth,  thirteenth and eighteenth  cases, relate
only to the removal  of the  alveolar border.   In the sixteenth we per-
ceive that this surgeon, in order to remove a cancerous tumor with the
greater  part of the bones of the nose and  orbit,  was obliged to dissect
up in the manner of a mask all  the  soft parts of the face.  In the
twelfth  he had to remove also a great portion of the malar bone.   His
ninth case had to lose thus almost the entire vault of his palate.   But
these are kinds of exsection  for  which every surgeon who  undertakes
them must devise and arrange his own operation.
  E. All the exsections  of the bones of the  face have this peculiarity
which distinguishes them from exsections of the cranium;  namely, that
if the nature or extent of the disease seems  to require  it, we may as-
sociate with them cauterization with the red  hot iron, and perform them
either by means of the chisel, gouge, trephine or different kinds of saws.
  [Surgeons have expressed  their views as  to the  comparative merits
of the pliers, chisel, gouge and mallet, in no measured terms, as may be
seen by the following extracts :
  " The  instruments employed  by  some  surgeons, particularly the
French, were barbarous  to  a degree   sufficient  to  shake  the nervous
system to its centre,  and thereby in a weakly person, to  diminish those
powers of life so necessary to  recovery, after the shock of  so severe an
 operation as thi3  is, even when  performed by the most  skilful hands.
 I allude to the chisel, gouge, and  mallet with which  they used to punch
 out the bone, u every stroke  of  the mallet causing  the  most exquisite
 pain to the patient."  (O'Shaugnessy, On Diseases of the Jaivs, p. 44.)
 Mr. Liston remarks: " How such instruments could at  this  period be
 selected  for the purpose, I cannot comprehend.   If one were desirous
 of protracting an operation, and  adding to the patient's sufferings,  of 
             EXTRA-ARTICULAR EXSECTIONS IN PARTICULAR.         329

jarring the bones of the  face and head, and jumbling their contents, no
more effectual means could by  any  possibility be  contrived."   Mr.
Butcher says that the chisel and mallet can seldom be required ;  " they
cause great jarring, and if possible should not be used."  (Dub.  Quart.
Jour. Med. Science, Aug. 1853, p. 36.)   Contrast  with the above views
of the subject, the following of Prof.  Gross.   " Mr. Liston has declaimed
quite eloquently against  the chisel,  and in favor of the pliers in this
operation ; probably, because the latter instrument  was  his own inven-
tion, and one of his well  known hobbies!   I have used  it on two occa-
sions, upon the upper jaw, but it failed so utterly  of its purpose, and
produced such a  terrible noise and crash, that I never think of it, with-
out horror.   The  chisel  may have its faults ; it  may  jar and shake  the
head ; but I  should be loth  to  believe that it  could possibly jar and
bruise the parts as much as a pair of the  best pliers, however carefully
and  gently managed."  (On Excision of the Maxillary Bone.    West.
Journ. Med.  8c Surgery, Sept. 1852, p. 204.)  The chisel was preferred
also, by Gensoul, Lisfranc, and Robert.  The pliers, unless well tem-
pered, are very liable to break, as we  have seen in more than one  in-
stance.   G.  C. B.]
  If the solutions of continuity are not too much complicated with con-
tusions or lacerations, we may then also make trial of  immediate reun-
ion.   In some cases in fact we shut  up the wounds immediately  by  the
aid of anaplastic  means.  We should  be wrong,  however, to rely  too
much  on these last  mentioned  resources.  To however  little  extent
suppuration may  seem necessary or inevitable, it is  much better to dress
the wounds flat, or at least to preserve an opening for them at their  de-
pending parts, rather than bring them  together into too close coaptation.

                     Article V.—Lower Jaw.

  Wounds from fire-arms, accompanied with comminuted fractures, have
long since proved that considerable portions of the lower jaw may be
destroyed without causing death.

                          §  I.—Indications.

  Caries or  necrosis of this bone also have frequently  necessitated its
destruction, and  yet the  persons  who have been thus affected have
usually been  re-established in health,  without  even  having any great
degree of deformity  result from the  loss.  Hippocrates  had already
furnished an  example  of this kind.  Rhazes (Lib.  XXVIII., p. 329;
id., 1509) relates another case  with all  the details that could be  de-
sired ; and Mesue (De JEgritudinibus  Oris, in  fol., c. 3, De  Vulnerib.
et Ulcerib.  Gengiv.)  also gives the case of a partial  exsection of a
carious inferior maxillary.  F. Plater (Bonet Corps de Mid. t. III., p.
148) mentions the case of a young girl who had a part  of her jaw car-
ried away by a projectile, and could yet eat (macher) with the remain-
der ; Boyer (Bibl. de Planque, t. IV., p. 656,  in 4to)  relates the case
of a patient who recovered after having the jaw  destroyed by the wheel
of a mill; Runge (Coll. de  Halter, trad., t. I., p. 146, Obs. 7) says
his father cut out a part  of the lower jaw for a sarcoma, whose roots
   Vol.  II.                     42 
330            fc£W  ELEMENTS OF OPERATIVE SURGERY.
 were implanted in the bone ;  Faudacq  ( Tr. des PI pur Armes-d-feu,
 p. 226, 1746)  speaks of a jaw carried  away by a  ball, and which was
 partially reproduced, and Manne (Mai. des.  Os, p.  159) says the same
 of  the  chin.  A woman  had a tumor  in  the  right cheek ; J.  Burlin,
 (Coll. Acad.,t. VII., p. 500,) being consulted, found  a caries  at_ the
 base  of the jaw near the ear, and  removed  it by a proper  operation ;
 a callus which became changed  into cartilage, admitted of the functions
 of the jaw being restored to  the same condition they  were in before.
 Gooch (Gazette Salut., No.  28, p.  2,  Col. 2., 1775) excised to the
 extent of an inch from a carious lower jaw, and Mosque (Journ. Mid.,
 t. LXXL, p. 507, No. 10) effected a cure of a cavernous exostosis of
 the lower jaw.  If the individual who lost half  his jaw by necrosis,
 found  it  impossible to perform mastication,  the  other patient whom
 Schmucker (Rougemont,  Chirurgie du  Nord, t.  I., p.  192)  speaks of,
 and who had his jaw carried away entire by a cannon ball, was com-
 pletely  restored.  One of  the most remarkable  cases is that mentioned
 by Guernery (Mim. de VAcad, de Chir., t. V., p. 164,  1819)  at  Bi-
 cetre ; the lower jaw exfoliated entire, and was  reproduced  to such ex-
 tent as  to  perform mastication !   V. Wy (Journ. de  Desault,  t.  II.,
 p. 48) speaks of a patient who lost almost the  entire lower jaw either
 from  spontaneous  causes  or  by art.  Two  similar cases are related in
 the Journal of  Desault, (Ibid., ou t. I., p. 107, et t. II., p. 179.)  Cho-
 part and  Louis have also made exsections upon the lower jaw,  \en fail
 Vextraction, not meaning, of  course, the totality of the jaw.  T.]  with
 success, (Chopart, De Necrosi Ossium, 1776.)  In a negro, says Walker,
 (Acad'. Roy ale de Chir., t. V., p. 246,) in whom it became necessary
 to remove the two branches, and a  part of the body of the jaw, mastica-
 tion was ultimately re-established.   A woman who Rayger  (Ibid.) saw
 at Bourges, had lost the right half of her jaw.   Wepfer speaks of a pa-
 tient upon whom amputation of  one side of the jaw had been successful-
 ly performed in his time.  The  patient that Belman (Acad,  de  Chir., t.
 V., p. 245) speaks of, had lost two-thirds of the jaw. Finally, M. Larrey
 (Clin.  Chir.,t. II.)  mentions  the case of a soldier, who had had tho
jaw  almost  entirely  destroyed  by  a discharge of fire-arms, and who is
 still living.  Even  at  the present  day we may still see at the Invalides
 many individuals who still carry the traces of similar mutilations.
  Nevertheless, facts of this kind had remained without application, until
 Dupuytren, (Legons Orates, t. IV.,) in 1812, came  to the determination
 to amputate almost the entire  body of a cancerous lower jaw, by a
 method entirely new, and which has been received into practice under
 the title of a surgical  conquest.  Since  then, this  operation has been
 repeated a great number of times by the same  surgeon, afterwards in
 Germany, England,  America and  France, by  MM. Mott, Richerand,
 Lallemand, Delpech, Roux, Cusack, Martin, Gerdy, Magendie, Colquet,
 Wardrop, Lisfranc,  Warren,  Gensoul,  Graefe, Walther, Wagner, Ran-
 dolph, and myself.   [See the  Table below.  See also Dr. Mott's Cases
 of Exsections of the Jaws, in the General Remarks  on Exsections.  T.l
  It is not for necrosis only that the operation is performed, but also and
 especially for cancers, and all those organic affections which, in the  jaw
 as everywhere  else, can only be cured by the extirpation of the parts
 which are the seat of them.   Though it might have seemed  difficult to 
            EXTRA-ARTICULAR EXSECTIONS IN PARTICULAR.         331

have relied upon any prospect of success if the exsection  was extended
beyond the first molar teeth, seeing that in that case the attachments of
the genio-glossus, genio-hyoideus, mylo-hyoideus and digastric muscles
being destroyed, the tongue acted upon by the glosso-pharyngeal mus-
cles would necessarily be drawn backwards, and close up the pharynx
so as  to cause suffocation, yet has experience only partially confirmed
these  apprehensions, Dupuytren went beyond the  first molar teeth ; in M.
Richerand's case, the whole body of the bone was removed.   I have in
two cases exsected this  bone up to the canine teeth.   After  the dress-
ing, no precaution was taken to fix the  tongue in front, yet  no  unpleasant
consequences  resulted  from  it  in  this respect.   M. Capelleti  (An-
nates  Univ. de Mid. d' Omodei. vol. Ixxxvi, p. 39)  who has published a
long memoir on this subject, relates that the exsection of two-thirds of
the lower jaw was completely successful in the case of a woman who was
pregnant.  Not less successful were the cases of  the two  patients oper-
ated  upon by  M. Syme.  (Ed. Med.  and  Surg.  Journ. vol. cxxxvii, p.
382.) I also twice removed, at the Hopital de la Charite, in 1839, the
right  half of the lower jaw in two women  who both recovered.  Oper-
ated upon after my method by M. Sanson, for a cancer which occupied
the left side of the lower jaw, the patient of whom M. Tigne (Bull, de
la Soc Anat.  1838-39, p. 302) speaks, appears to have done exceedingly
well.
   M. Walther [it is said, in fact,  the totality,  (Arch.  Gin. de Mid.
t. II., p. 466^3 but  I do not know what  proof there is  of it]  and M.
Graefe  according to M.  Pattison, and afterwards M. McClellan, have
removed almost the entire jaw, and yet their patients recovered.
   [Dr. Geo. McLellan  removed the entire  lower jaw in a state of ne-
crosis.   " In a few weeks, the  periosteum secreted a hew and slender
plate of  bone, which kept the chin prominent, and maintained  a tolerable
shape of the  original  entire circle of bone, from joint to joint, on each
side.   The  angles  were very  obtuse, indeed, almost deficient, but the
little  girl grew  up to become a fine-looking woman with  a very narrow
lower jaw, and deficient teeth  below.  Some of my friends  thought I
must  have left a thin  plate of sound bone  behind  at the  time of the
operation;  but  they  were mistaken.  (McLellan's surgery, p. 357.)
Dr. M. insists on the importance in  such cases of leaving as much of
the periosteum as possible, in order that we may have a regeneration of
osseous  instead of ligamentous matter.  Mr.  Stanley has  reported a
similar case which came under his care at St Bartholomew's Hospital.
Dr. Ganwesky of Westphalia, in  September 1838, removed  the entire
lower jaw for necrosis, and  a new jaw was partially formed afterwards,
which though not  very useful in mastication, nevertheless served to
prevent  any disfigurement.   (Hartmann's Med. Journal, Leipsic, Vol.
XXXIX. No V.)
   The entire lower jaw has also been removed, for necrosis, by Heyfelder,
Mr.  Perry, Dr.  Carnochan, M.  Maisonneuve, of Paris,  and Pitha, of
Prague.   Mr. Cusack,  of Dublin, informed  the  writer, June 2d 1853,
that some fifteen years  before, he had, for osteo-sarcoma  extirpated the
entire bone, and that  the  patient died a week  afterwards, during his
absence  from'town, in a supposed eoileptic fit.  In Prof. Syme's "  Con-
tributions  to  the Pathology  and Practice of Surgery, page 21, is the
report of a case in which this  surgeon removed the entire  lower jaw 
332
NEW ELEMENTS OF OPERATIVE SURGERY.
for osteo-sarcoma.  The patient  died  suddenly the next day, as was
supposed from suffocation produced by the retraction of the tongue.
  In  1850,  Prof.  Ackley, of Cleveland, removed the entire  lower jaw,
for osteo-sarcoma, and  the  patient survived the operation  some two
years.  We have seen the removed bone, now in his possession.
  Dr. Signoroni, of Padua,  on  the  27th  Sept. 1842,  exhibited to the
Medical  Congress of Padua, a  patient in  perfect health, from whom,
bv successive operations, he had, for osteo-sarcoma extirpated the entire
lower jaw (Annali Univers. de Medicine,  1843, also, Phil. Med. Ex-
aminer, Vol. VII. 1844, p. 96.)
  For many years, Walther,  of  Bonn, has had  the credit of having
successfully' removed  the  entire  lower jaw,  and as his claims have
recently  been disputed, we  are happy to  be able  to place before the
reader the following extract from a letter  of Dr. J. E. Webber to Dr.
Perkins of this city.  Dr.  W.  is a nephew of Walther, and is  well
known personally  to many  surgeons  of this  city.   He thus  writes:
Suffice it to say that I myself am acquainted with eye  witnesses, yet
living, who saw the case before the operation—during the operation—
and  after the operation and subsequent recovery, and there  is at this
moment  in  the hands of the  eldest  son  of Walther, a distinguished
physician at  the capital of Bavaria, a written account, minute in its de-
tails, affording a complete history of the  case ; which report, written
by himself,  at the request  of his father a few days subsequent to the
removal of the bone, will be published among the collected papers of
Dr. Walther which his family are  about giving to the world."
  Dr.  Mott  informs us that there is now in this  city an individual,
whom he has examined, and who  says that  his entire lower jaw was
removed by  Mr. Hutton, of Dublin.  G. C. B.]
  If the disease is situated  on  the  right  rather than on the left, or on
the left rather than the right, it is practicable to leave intact the op-
posite half of this bone, and to remove only the side which is affected,
as has been done by MM. Mott,  Colquet, Jaeger, Blanchet, Roux,  &c. ;
in such cases, we can  have  no  apprehensions about the inconvenience
which has been mentioned.   And it is still less to be feared where we
can  remove  the whole  of the  disease, and still preserve one  of the
borders of the jaw.
   It is certain, however, in other  cases on  the contrary, that the tongue
is drawn with great force backwards and upwards as soon as its anterior
attachments are divided.  Dupuytren always warned his pupils of  this ;
and  Delpech, who has made  it the subject of some interesting  remarks
imagined that it might  be prevented by passing a thread of gold or one
of the sutures of the wound through the tongue near its fraenum, at the
moment of dressing, and fixing it  to the teeth which were situated near-
est to the extremity of the fragment of bone  preserved.  Perhaps  there
might occur here another  thing beside  retraction.   The  os hyoides
and the  base of the tongue suspended to the  chin, furnish to the larynx
and oesophagus every facility of dilatation for the passage of the air and
aliments.  But having no longer now any attachments in front they yield
completely to the action of  the other muscles, as well as to the pressure
of atmospheric air, and leave the pharynx to collapse from before back-
wards, and the posterior fauces to close up from below upwards without 
             EXTRA-ARTICULAR EXSECTIONS IN PARTICULAR.         333

there being any means of re-establishing the equilibrium.  This explains
why M.  Lallemand  was obliged to perform  tracheotomy in  one of his
patients, and how  those of MM. Ehrmann, Schuster and Begin were
attacked with asphyxia.
   [This  retraction of the tongue  doubtless  destroyed  the patients of
Messrs. Cusack and  Syme, after the removal  of the entire  bone, and
Dieffenbach states in his Operative Surgery that he has witnessed this
accident several  times, and that one of his patients, the first evening
after the operation, was nearly suffocated before discovered.   In a case
where we removed the symphisis, together with a great  portion of each
side of the jaw, our patient was nearly suffocated from this  cause, and"
for some time afterwards this  tendency  to retraction of the  tongue had
to be narrowly watched.  In  another case, we took  the precaution to
secure the tongue before commencing the  operation, yet the moment its
attachments to the bone were  severed, so great was the retraction that
this patient also was  nearly suffocated.  We have  twice disarticulated
the lower jaw and several times removed the symphisis  and body of the
bone, but have never lost a patient from the operation.  G. C. B.]

                      § II.— The  Operative Process.

   Four moaes of performing the exsection of the lower jaw are now re-
ceived into practice  : 1. exsection of the middle portion ; 2, exsection
of one side ;  3, exsection of the lower border ; and 4, exsection  of the
superior border.
   A.  The Body  of the Jaw.—When the disease involves the chin only,
the operation is generally easy and very simple.  There are two modes
of performing it.  If all the  soft parts are sound we restrict ourselves
to their division on the median line from above downwards from the free
border  of the lip to the  thyroid  cartilage,  and then to dissecting off,
while reversing them outwards, the  two flaps thus formed by this first
incision.   In  the contrary case two incisions united upon the larynx in
front should be made to circumscribe a  V or a triangle  which would in-
clude the whole of the disease.
   I. The dressings, as in hare lip, are  composed of needles,  threads, a
chafing dish filled with coals,  and cauteries and all  other objects neces-
sary to the more delicate kind of amputations  and dissections.  Three
assistants at least are also required.
   II.  First  Stage.—The patient is placed upon a chair or upon a bed
slightly elevated. If the objection to the  sitting  posture be that  it ex-
poses the patient to syncope, the horizontal might lead to suffocation
from the blood.  The assistant placed behind, with one hand, turns the
head slightly  backward, and  with  the other  seizes the angle or right
side of the lower lip at the moment the  surgeon is about to  commence
the incision.   The  latter  grasps with the two first fingers of the left
hand the free border of the  same lip in  the opposite  direction;  then
makes, with a convex or straight bistoury in his right hand, the proper
incisions;  seizes  successively the two sides of the  wound and detaches
them to a sufficient extent from the seat of  the disease, taking care to
commence on the right side.   This being done, he detaches the muscles
and all other  soft parts  which adhere to the borders and inner surface 
334            NEW ELEMENTS OF OPERATIVE SURGERY.

of the bone, endeavoring meanwhile to avoid the insertion of the genio-
glossus  muscle.   M. Ulrich is in an error in advising that we  should
here detatch the  parts  down  to the periosteum, for if that were even
possible, we should in this manner favor necrosis in the fragments of bone
to be preserved.  Having isolated the bone on each side without touch-
ing the muscular attachments at its middle portion, Delpech glided a gor-
get underneath to protect the tongue during the action of the saw.
   III.   Second Stage.—We might, also, as some practitioners advise,
and as I myself prefer, reserve the last mentioned  stage of the opera-
tion for the conclusion, and saw through the jaw before thus dissecting
off the tissues.  A handle-saw, or one of the ordinary kind even, if ne-
cessary, or the articulated saw  if we prefer, will execute this part of our
purpose.  A tooth on each  side of the confines of the  disease should be
extracted, if they have not already  fallen out, or threaten to be in the
way of the action of the saw.   The  operator, holding in one hand the
anterior  portion of the diseased mass, applies his thumb a little behind
it and upon a sound portion of the bone, held firmly also near its angle
by an assistant, in order that he may direct the action  of the saw, which
should, as nearly as  possible, strike  between two of the alveoli, and be
moved from above downwards, or from below upwards, according as may
be most  convenient.  This first division  being completed, an assistant
seizes with his  hand the diseased tissues.   That of the surgeon is now
placed  behind.  A second  movement of the saw finishes the  section of
the bone, which is to be  depressed, in order to  make  it project out in
front, while other assistants separate, draw back and carefully protect
the soft parts of the  face and neck.
  IV.  Third Stage.—There now remains nothing more to be done but
to detach the diseased fragment  from the tissues which  occupy the inte-
rior of the mouth, by directing the bistoury flat-wise and perpendicular-
ly  upon  the  posterior surface of the chin.   At the same moment an as-
sistant, having a piece of linen around his hand, seizes the tongue by its
point, and drawing it outwards, thus prevents the symptoms of suffoca-
tion, and  enables the surgeon to apply a cautery heated to white heat
over the whole extent of the  bottom of the wound, or every where at
least where any arterial branch can be found.
   V.  Fourth  Stage.—By means of two or three points of the twisted
suture we unite the two lips of the  solution  of continuity, the  inferior
angle of which should be left open or have inserted into it a meche, (See
Vol. I.) in order to give free exit to the suppuration which ensues.   Ad-
hesive plasters, plumasseaux, compresses and a sling bandage (See Vol.
I.) complete the dressing ; sometimes we  add also some small  balls of
coarse lint, placed behind  the tissues of the face in order  to fill up the
void left between the  fragments of bone.  M. Gensoul, apprehending
that the  cicatrix by being placed on the median line might, after the
cure, by its retractility, flatten the  chin too much, proposes to place it
upon one side; but this  precaution  would  be of no use and would not
prevent the accident which suggested it.
   If the tissues in front of the bone were all sound, we would be ena-
bled, by raising up a large  semilunar flap  from  the supra-hyoidean re-
gion, to the mouth, as M. Roux has done, (Jour. Hebd., t. VII.,  p.  806,)
to avoid implicating the continuity of the lip, and without thereby ren-
dering the operation more  difficult. 
EXTRA-ARTICULAR EXSECTIONS IN PARTICULAR.         335
  VI. —When the loss of substance is not considerable, it is well to re-
place the fragments of the bone in  contact, and as Delpech has done,
keep  them immovable by  fastening a metallic thread  around the ante-
rior teeth.   In the contrary case, this  precaution would, to say the least,
be useless.  The species of noose  through  the  inferior  surface of the
tongue,  recommended by  the  Professor  of Montpellier, could only be
advantageous, where this organ should continue to be violently retracted
towards  the throat.   Some persons consider  the  bandage superfluous,
and confine themselves to the suture and adhesive  plasters, which gives
more liberty to the parts, and  enables  the surgeon  to examine better
every step of  the reparative  process.  But all this must be contingent,
and left  to the pleasure of  the surgeon.
  VII.   The sub-mental artery, the  sub-lingual, very rarely the ranina,
and the branch which terminates the inferior maxillary, together with
the coronary artery of the  lips, are  the  only  ones  which the instrument
encounters, that require some attention.   Some  of the first mentioned
are too difficult to come at in the midst of the tissues,  to attempt to ap-
ply the ligature to these.   Possibly the application  of cold water, and
sponges wet with vinegar, might enable us to control  the  hemorrhage
they give rise to, and allow us to dispense with the use of the hot iron.
Nevertheless,  as Dupuytren constantly  made use of this resource with
success,  prudence, at least, if not  necessity, justifies  its employment.
The three  last mentioned arteries cease to  bleed spontaneously, and
scarcely ever require our interposition.   In one case M.  Graefe  met
with  a hemorrhage from the  dental  artery  in  the  centre of the bone.
In such cases  a  peg  of wood or wax,  as was used by M. Magendie, or
any compressor whatever upon the  point, from which the blood appeared
to escape, might be made use of, if we did not wish to have recourse to
the actual cautery.  Finally, instead of a vertical incision, or two incisions
united at their lower extremity, it  may become necessary, should the
disease have extended to a great distance towards the  neighborhood of
the angles  of  the jaw, to divide transversely  each lip  of the wound be-
low the inferior border of the jaw.  In a patient, who had the chin shat-
tered by a discharge  of a  pistol  ball, and in whom it became necessary
to exsect the jaw, as far back as the molar teeth, I was  obliged to dissect
to great  extent the two flaps of soft parts on each side, in order to ena-
ble me afterwards to unite  without  any effort the two lips of the wound.
   B. One of  the halves of the Jaw.—When the amputation is to com-
prise only one of the sides of the jaw,  the operation is somewhat different
from the one we have just described.
   I.  M. J. Cloquet began with the  vertical incision, which has been de-
scribed above; then made a second, which extended from the commissure
of the lips to  above  and behind  the  angle of the jaw*; and dissected,
as he reversed outwards and downwards, the very  large  flaps of soft
parts thus  traced out; then detached the tongue from  the inner surface
of the alveolar border, and terminated by the section  of the bone first
in front  and then behind at the origin of its ascending  portion.
   II.  The Author.—Operating on an old man  for a  sarcoma, I began
with  a horizontal incision,  extending  from the left labial commissure to
the  summit of the corresponding mastoid process, and  which I trans-
formed into a T incision by means of  a vertical one carried down to the 
336
NEW ELEMENTS OF OPERATIVE SURGERY.
great horn of the os hyoides.  I had thus two triangular flaps, which I
dissected, and turned  back, the  one  in front and the  other behind.
After having sawed through the  bone near the symphysis, I proceeded
to detach from it the soft parts behind and underneath.  Having raised
up the angle of the jaw, and isolated the ramus, I cut  through  the neck
of its condyle with the flat rowel of M. Martin.  The fragment could
then be separated on the inside, and depressed, and removed  with the
sarcoma, which,  moreover, extended under the tongue, and to near the
pharynx.
  III. M. Molt  proceeded in a manner somewhat different.  He began
with a ligature upon the carotid artery upon the diseased side,  and  only
afterwards  proceeded to the amputation of the jaw.   His first incision
was made to extend from a point in front of the ear, on a line  with the
condyle, (obliquely downwards and forwards,) so as to form a semilunar
line with its convexity  backwards, (and then brought still further for-
ward, and finally upwards,) to a point above the chin, under the labial
commissure.  [We  have interpolated this passage a  little to  make it
more full and clear.  It will be seen that even in the greater exsections,
Dr. Mott now makes but one incision ;  that for tying  the carotid being
a small incision, altogether separate and distinct, and  forming in fact a
preliminary operation in itself.  T.]  The  integuments, the lower  part
of the masseter muscle, and the parotid gland were then  reversed upwards
and forwards.  A second incision, beginning  at the upper extremity of
the first, and passing below the ear, and reaching to the anterior border
of the sterno-mastoid  muscle, enabled to lay  bare the whole extent of
the diseased mass.  By means of  a small saw, he was  enabled  to divide
the jaw in front on a line with one of the lateral  incisor  teeth.   With
another saw, which  was smaller and made expressly for the purpose, M.
Mott  effected  the  section of the ramus  of the jaw  immediately below
its two superior processes, and finally did not terminate with the removal
of the whole diseased mass, until  after having carefully detached from
it the internal pterygoid  and mylo-hyoid muscles.  In this last stage,
he advises that we should make a  complete  division of  the inferior max-
illary nerve before making any traction on the bone, also that we should
not forget that the lingual nerve of the fifth pair is in the neighborhood.
  Upon the supposition  that it may be  necessary to  disarticulate  the
bone, which  M. Palmi  appears to have  been  the first to  perform,  viz.,
in the  year  1820, and which  operation  has  since been  performed by
MM.  Graefe, Mott,  Dzondi, Withuscn, McClellan, Liston, Langenbeck,
Syme, Dupuytren, Cusack, Jaeger,  Anderson, Gensoul, Warren,  Lisfranc,
Fricke, Lallemand, and Helling; the process of M. Mott would answer
full as well as for the  exsection which  we  have just  described.   That
which I have  employed would still better  fulfil the indication in such
cases.   A third  incision, brought  down from in front  of the ear to the
mastoid extremity of the first incision, would easily enable us to reach
the articulation, without  making it necessary to tie  the  carotid artery
previously.   It is, however, evident  that, in these cases, the nature and
extent of the evil must at every moment modify the particular rules of
the operative process ;  so that every surgeon is in some sort the inventor
of his own process at the moment  of the operation.
  IV.   Process  of M. Graefe.—},!. Graefe,  (Graefe's  C. F. Bericht 
            EXTRA-ARTICULAR EXSECTIONS IN PARTICULAR.         337

vber das Clinische, Chirurgisch und Behre, in Rust's Magazin,) who,
like M. Mott, first tied the left carotid, then made an incision from the
commissure of the mouth to the  posterior border of the  lower jaw ; a
second incision, of a crescent shape and terminating in the two extremi-
ties of the first, included a portion of the diseased skin ; a third incision,
prolonged  from  the  posterior angle of the  two  first, and approaching
the meatus auditorius externus, was  extended  upwards to beyond  the
cond3rle.  The maxillary bone, laid bare by dissection, sawed upon the
median line, and then detached on the inside from the surrounding tis-
sues, was now  disarticulated.  The  sutures were then inserted, and a
speedy  cure  followed; nothing  remained on the cheek  but an opening
of two  fingers' breadth, through  which the tongue could be seen, and
from which the saliva occasionally oozed.  M. Rust, who saw the young
girl seven  years after, dragging out a miserable existence, said that no
one would  be tempted, after such an example, to repeat the same opera-
tion ;  in that he  was deceived.
  V.  Process of M.  Cusack, attributed  to  M. Lisfranc—M.  Cusack,
who performed  this  operation at Dublin  four times in 1825, proceeded
thus :—
  The first case, \3th of May, 1825, was one of osteo-sarcoma.   The
totality of  the jaw was tumefied, and all the  teeth on the left side loose,
the angle and ramus  of the maxillary seemed both  affected at the same
time.   The patient was seated on a chair, with  his  head turned to the
right.   A first incision was brought down from the labial commissure
to the base of the jaw;  a second extended from the zygomatic arch to
the angle of the  bone ; a third,  extending upwards  and outwards from
the inferior extremity of the first, united  it to the second.  The masse-
ter being raised up,  it was ascertained that the disarticulation alone
would be sufficient, as the  coronoid process,  separated from  the rest of
the bone, had been previously removed.  The disarticulation was effected
upon the outer side of the  bone, there were no vessels divided, and the
patient got well.
   Second case,  June 3d,  1825.—The tumor extended from the neigh-
borhood of the  articulation to  the small molar tooth on the opposite
side.   It was of very large size, and  occupied the whole of the  sub-
lingual space.  The bone was first sawed through, near the small molar
tooth on the left side, with the chain-saw.  The incisions  were made as
in the preceding case; but M.  Cusack could  not  immediately accom-
plish the disarticulation.   He made  another section of the  bone, and
disarticulated the remainder.  Five or six arteries were  tied, and the
operation lasted  fifty-five minutes.  The patient recovered, and scarcely
any deformity was perceptible.
   Third case,   October 1th, 1825.—The degeneration  occupied  the
whole right side  of the bone, and formed a mass much more voluminous
than in  the preceding case.  The bone  had undergone a  solution of
continuity,  and the general health was greatly impaired.  A first  in-
cision extended from  the commissure to the anterior side  of  an opening
which existed on the  cheek.  A second incision, which was vertical, sat
out from the termination of the first.   A third, parallel with the line of
the symphysis, circumscribed a flap which, adherent on its lower part,
was now dissected off.  The tumor was now exposed, with  its ragged
  Vol. II.                    43 
338
NEW ELEMENTS OF  OPERATIVE SURGERY.
and  fungous  aspect.  The surgeon divided  the  bone at a point where
a tooth had been extracted.  The opening of the tumor was then cir-
cumscribed by two  incisions, which united together behind and above.
At this point of union there terminated another incision, which had been
made in a line parallel with the direction of the glenoid cavity.  After
the dissection, the maxillary  bone transformed into  a  cancerous mass,
intersected by  numerous  fissures, was  removed  by piecemeal.   The
hemorrhage was not abundant, and the cure was promptly completed.
   VI.  M. Anderson first  sawed through  the bone on  a line with the
angle of the mouth.  Having perceived  that the  medullary  membrane
was diseased, he determined"to  proceed to the disarticulation.   He di-
vided the cheek from the  commissure to the masseter, detaching this
last from the  bone.   Raising up the tissues,  he  found great difficulty in
separating the coronoid process from the temporal  muscle.  During the
tractions, the bone broke,  which enabled  him with ease to separate it
from the deep-seated tissues, and to remove  the fragments by means of
the forceps and scalpel.  There  were only two arteries to tie.  The
wound was united as in a  hare-lip, but the patient died at the expira
tion of thirteen  days.  An effusion was found in the chest.
   C.  Appreciation.—Whenever we amputate, instead  of the chin, one
of the halves  of the lower jaw, the facial artery must necessarily be di-
vided.   In the operation of M. J. Cloquet, it  was  divided at  the mo-
ment of making the transverse incision, and then  again in turning back
the flap ; but in the last step of the operation, it could, if  necessary,
have been avoided.   In proceeding like M. Mott, we  inevitably divide
it on  its passage upon the external  surface  of  the bone.   When the
disease does not extend beyond the angle of the jaw, it is evident that
the process of the French surgeon  claims the preference.  But when,
on the contrary, the degeneration  has extended  very high up towards
the temporo-maxillary articulation, we  are  more  certain, by imitating
the American professor,  of laying bare the whole disease, while we at
the same time save the parotid gland and  its duct.   His process would
apply equally well to disarticulation, if it should be preferred  or become
necessary.  In  operating after the manner of M. Cusack, or in following
my process, we are placed still more at our ease.
   The previous ligature upon the  carotid, as practised by MM. Palmi,
Mott, Cusack, Walther, Graefe, Gensoul,  and  Warren, can become in-
dispensable only in a very small number of cases : as, for example,
where the saw is to act  transversely,  and very near the temporo-max-
illary articulation;  even  then we can most usually dispense with it.
The temporal artery, (which was  once divided in  England,)  the inter-
nal maxillary, the external carotid, and the inferior dental, which run
along by the  side of or turn round the posterior border and neck of the
condyle, where they are found upon the inside of the ramus of the  max-
illary bone, could easily be held aside by an intelligent assistant, at the
moment when, after having made  the section  of the jaw in front, the
operator should wish to disarticulate it behind,  and detach it from the
tissues which adhere to its inner surface.
   The ligature applied to them  separately afterwards, would be a last
resource that would protect us from every danger, and  the compression
of the  primitive carotid is a thing so easy that we have no occasion to 
EXTRA-ARTICULAR EXSECTIONS IN PARTICULAR.         339
disturb  ourselves on  that  subject. ' [It is probable that the author
means here by la compression  of the primitive  carotid, a ligature upon
it; if he means to rely upon pressure made  on  the carotid'tubercle of
Chassaignac, it could not be effected without difficulty or danger.  T.]
After having filled up the space which separates  the  two ends of the
bone with lint, agaric,  or pieces of sponge, we must unite its borders by
means of a sufficient number of needles and twisted sutures, in the same
way as after a simple amputation of the chin.
  D.  Consequences.   At the  first announcement  of this operation, it
was  thought that  there  would result from it a very great degree of de-
formity, and an impossibility of performing mastication : nothing of this
kind has happened.  In Lissier, the first patient operated upon by Dupuy-
tren, almost  the entire body of the bone was removed.   Nevertheless it
is  at the present day scarcely perceptible.  It is  the same with almost
all the  other persons  operated upon who have survived, not excepting
even  that of M. Ehrmann.  Cellulous granulations soon develop them-
selves between the fragments of the bone, and are  not long in establish-
ing there a  sort of fibrous or cartilaginous mass, which ultimately ac-
quires a  degree of solidity almost equal to  that of the jaw which it re-
places, and between whose two halves it forms a solid union.
  It is, however, to be remarked that the patient of M. Lallemand was
not so  fortunate.   In him the two ends of the bone remained movable,
so that he is obliged to wear an artificial chin.  But the loss of substance
had  been considerable.   The  wound  may  rest fistulous at its inferior
angle, as  in the patient of M. Graefe, and in this manner by the dis-
charge of saliva exhaust  the strength of the patient. One of those I ope-
rated upon  was in that situation when an erysipelas carried him off  on
the twenty-second  day of the amputation.  In a patient operated  upon
by M. Richerand, I have  seen the tongue remain drawn back in the
mouth and  prevent  the  admission of the food.   Death ensued on the
twenty-eighth day, and appeared to be  produced by suffocation. Perhaps
the same result took place in the woman operated upon by M. Magendie
at the Salpetriere in 1830,  and who suddenly perished in the night.
  After  the ablation of one of the lateral portions of the jaw, the  fixed
point of the genio-glossi muscles  having  been preserved, there is less
danger  to be apprehended of  retraction of the tongue.   But  then a de-
viation of the prominence of the chin, sometimes quite marked, is almost
inevitable.   This is what took place in the patient operated upon at the
hospital of  Perfectionnement  in  1826, and what  was remarked also in
the  cases related by MM. Mott, Gensoul, Lisfranc, &c.
  E.  Amputation of the jaw, however, is a fortunate acquisition of mod-
ern  surgery.  The dentist Koecker, who has asked the question if it is
ever indispensable, would not have the right to censure it in so formal a
manner except  he had a good remedy for cancer.  Incomplete as it is,
the following table shows what we have to hope or fear at present from
such an operation:—


DTdearthns:   ^  CaSeS~15  CUTQS> \ Legons Orales, etc., t. IV.
Mrtf, Q         o  j-   *•  i *•    ( New York Med. and Phys. Jour.
   3  deaths        disarticulations,     Yol> L  ^ ^  ?>  m^ and
                                 (   Private Communication. 
340
NEW ELEMENTS OF OPERATIVE SURGERY.
 Richerand, 2 cases—2 deaths.

 Delpech, 2 cases.

 Lallemand, 2 cases—1 disaticulat-
   ed, cancer cured.

 Roux, 5 cases—2 cancer, 1 necro-
   sis.

 Cloquet—necrosis, sarcoma, f. g.
 Gerdy, 3 cases sarcoma—2 deaths,
   1 cured.
 Gensoul, 2 cases—1 cured, ligature
   of carotid:  Disarticulation ; 1
   death.
 Martins, 1 cure.
 Goyrand, 1 cure.
 Magendie, 1 case—1 death.
 Cusack, 8  cases — 4  disarticula-
   tions—3 cures, 1 death.
 Wardrop, 1 case.
 Warren, 2  disarticulations—1 ex-
   section, 1 cure.
 Graefe, 5 disarticulations—the wo-
   man cured.
 Lisfranc, 7 cases—4 deaths, 1 cure,
   2 disarticulations.
 Walther, 1 death.
 Wagner, 1, half the jaw.
 McClellan,  2 cases — 1  cure, 1
   death.
 Randolph, 1—necrosis—right half
   of the jaw.
 Beauchene, 1—cancer—return  of
   the disease.
 Begin, 1 case—cancer—death.

 Gambini, 1—necrosis—cured.
" Scoutetten, 1—cancer—cured. (?)
 Fricke—cancer, disarticulation—
    cure.
 Regnoli, 1—cancer—cured.

 Ulrich, 1 cure.
 Clot, 2 cases cured—left half.
Observed by me in 1821.
Mem.  des  Hop. du Midi, t. I., p.
  615.   Bull,  de  Ferussac,  t.
  XII., p.  320.
Arch.  Gin. de Mid., t. I., p. 123.
 Lafosse, Clinique, St. Eloy, p. 18.
Lane  Fr., t.  II., p.  320, Journ.
  Hebd., t.  VII.,  p.  306;  and
  Private Communication.
Published  by  me,  Arch.  Gin.,
  1827.
Arch.  Gen., 2e ser., t. IX., p. 58,
  Sept.,  1835.

Lettre Chir.,  p. 57,1833.

Journ. Hebd.  Univ., 1835, t. XII.,
  p. 229.
Ibid.
Journ. de Physiologic
These  de  Kock, Jaeger.   Journ.
  des Progres, t. VI., p.  273.
The Lancet, April, 1827.
Journ.  des  Progres,  t.  X.,  p.
  256.
Rust's Magazine,  etc.,   These  de
  Kock.
Pauly, Bulletin  Clin., t. I., p.  463  ;
  t. II., p. 11,18, 73,201.  Gaz.
  Mid., Sept., 1838.
Jour, de Graefe and Walther.
New  York Med. and Phys. Jour.,
  Vol. V.

Pattison, Burns' Anatomy, p.  499.

Jour, des Prog., 2e ser., t. III., p.
  268.   Medical and Surg. Jour.,
  Nov.,  1829.
Piedagnel,  These; Jour.  Hebd.
   Univ., t. II., p. 43.
Reverdit,  These  No.  85, Paris,
  1837.
Bull, de Fir., t.  XVI.,  p. 90.
  Arch., t. XV., p. 273.
Reverdit,  These,  1837,  No. 85.
Gaz. Mid., 1837, p. 13.

Jour, des Conn. Mid.-Chir.A II
  p. 330.                    '   *'
Bull, de Fir., t. IV., p. 100.
Jour. Hebd., 1835, t. II., p. 293. 
EXTRA-ARTICULAR  EXSECTIONS  IN PARTICULAR.         341
Clot—cancer cured.
Duverney—necrosis—cured.
Velpeau, 7 cases—4 deaths.—1829,
Hetling, 1—osteo-sarcoma, disar-
  ticulation—cured.
Monod, 1 death.
Earle, 1—spina-ventosa—cured.
Anderson, 2 — disarticulation —
  death.
------another cured.
Textor, 2; caries.

Jaeger, 5 disarticulations—1 death.

Dzondi, id. 1 death.
Ricord, 2 cases.
Palmi, 1—disarticulation, death.
Michon, 1 death.
Syme, 1.
Convers, 1—necrosis—cured.
Granger, 1— sarcoma—a  woman
  —cured.

Lherminier, 1—sarcoma—death.
Blandin, 1—cured.
Percy, 1.
Blanchet, 1—necrosis—cured.

Langenbeck, 3 cases—2 cured, 1
  death.
Kuhl, 1 death.
Withusen, 3 cases—1 death.
Perry,  1—necrosis—woman  aged
  twenty years — extracted,  re-
  generation, cure.
A.  Robert, 1—■cancer—death.
Bouyer de  Saintes, 2 cases—suc-
  cessful (?)
Syme, 2 new cases—1 left side, 1
  middle—cured.

Fischer, 1—from fire arms.

Baudens, 1.

Mursinna, 1.

Cappelleti,  1 woman pregnant—
  was two-thirds cured.
Ehrmann, 1—death—asphyxia.

Schuster, 1—death—asphyxia ?

Liston, 2 osteo-sarcomas.
Compte-Rendu, 1832, p. 50.
Mai. des Os, t. I., p. 198.
1831, 1837.

Encyclog. Mid, 1836, p. 104.

Communicated by the Author.
Encyclog. Mid., p. 47.

These de Kock.

Gaz. Med., 1833, p. 383.
Coulon, These, p. 28.
These de Kock, Jaeger.   Heine,
   Gaz.  Mid., 1834,  p.  644.
   Coulon,  These, p. 28.
These de Kock.
Gaz. Mid., 1833, p. 647.
These de Kock, 1831.
Communicated by the Author.
Opir. cit.
Gaz. Mid. de Paris, 1835, p.  45.
Ibid., 1835, p. 413.

Communicated  by  the  Author,
   1836.
Gaz. Mid, 1837, p.  671.
Acad.  Roy. de Mid., t. II.
Nouv. Bibl. Mid., 1828, t. II., p.
   180.


• Coulon, These, p. 28,
Encyclogr. Mid., 1833, p. 233.

Communicated by the Author.
Bull, de VAcad. Roy.  de  Mid.,
  t.  III., p. 42.
Edinb.  Med. and Surg. Journ.,
  Vol. CXXXVIL, p.  382.
Textor, Neuer Chiron., Vol.  II.,
  p.  358.
Lancette Frang., 15 Sept., 1836.
Jour, de   Graefe  and  Walther,
  Vol. IX., p. 598.
Ann. Univ.  di Med.  d' Omodei,
  Vol. LXXXVL, p. 39.
Arch. Mid., de Strasbourg, No. 5.
Rack, These, Strasbourg,  9th  of
  July, 1838.
Jaeger,  Opir. Risect., 1832, 
342
NEW ELEMENTS OF OPERATIVE SURGERY.
 Jaao-er,  Opir.  Resect., etc., p. 1'
\   2, 14,15,16.
1810—Deaderick—1 cure, exos-  ^
  tosis.
1817-18—A.  Cooper —2  cures,
  exostosis.
1818-24 — Crampton — 2  cures,
  osteo-sarcoma.
1823—Klein—2 cures,  osteo-sar-
  coma.
1824—Dybeck—1 return. (?)
1824—Eckstrum—1 death, osteo-
  sarcoma.
1S25—Lizars—1 cure,  osteo-sar-
  coma.
1827—Hodgson—1 return (?) os-
  teo-sarcoma.
1827—M.  Awl—1  cure,  osteo-
  sarcoma.
1827—Arendt—1  cure, osteo-sar-
  coma.
1828—Wilhelm—2 cures,  caries.
1831—Dietz—2  cases,  1  fungus
  cured.

  Out of about 160 cases, there  are nearly 40 deaths.   Amputation of
one of the sides of the jaw, though it should extend to the articulation,
promises also to be an equally valuable resource in a good number of
cases.   It is, however, difficult to conceive  that its total ablation would
be actually  followed by success, and permit the patient to be  restored
and preserve the  faculty of swallowing.  We can imagine that after its
exfoliation, new examples  of which have  been related by MM. Snell
and Gambini, matters might pass otherwise.  The necrosed sequestrum
does not separate until the system has more or less completely supplied
its absence, by the creation of a new tissue, so as to render the deformity
much less perceptible.  We can appreciate also that the forced extraction
of the sequestrum, again performed in 1830, by Dupuytren, is far from
being subjected to the same operation as amputation properly so called,
and that on this subject there can be no fixed process.
   [M.  Sedillot refers  to  a  serious  complication, not  mentioned by
writers, and which is  liable to  occur after  the complete removal of the
body  of the lower jaw.   The rami are  carried  forwards, inwards and
upwards, by the temporal  and pterygoid muscles, pressing against the
alveolar arch and causing severe pain  and  ulceration.  In two cases
he observed, this  accident  contributed  in  causing the death of the pa-
tients.  In such cases he recommends the  entire removal of the bones,
or their resection just below the origin of the coronoid  process.  ( Op.
cit. p. 487, vol. 1st).   G.C. B.]

                §  IV.—Anterior Surface of the Bone.

   If  the bone should only be superficially affected, we might, as Delpech
advises, and ought, in fact, not to  remove its  whole thickness.  Should 
            EXTRA-ARTICULAR EXSECTIONS IN PARTICULAR.         343

it  be a necrosis, we  then lay.bare the part by  one of tho processes
described farther back ; then, after having applied the handsaw or the
concave rowel-saw from above  downwards, to extract the third or tho
half, or in fact the entire table of the bone, and to remove every portion
that is diseased, we  reunite the borders of the wound by means of the
suture.  In cases of sarcoma, the  portions of the lip and the soft parts
of the chin which  are degenerated, having been circumscribed by a V
incision,  should  be  removed at the same time with the  anterior tables
of the bone.  Here  the  sides of the wound would have to  be dissected
and separated to some distance on each side, to be afterwards  approxi-
mated and united by the suture.

                       § V.—Dental Border.

   When  the degeneration does not comprise  the entiro vertical dimen-
sions of the bone, as  for example often  happens in cases of epulis and
parulis, we are not obliged to divide the whole height of the  bone.   I
have operated upon three patients in this state.
   The process which I have followed,  is of easy  application, and sure.
If necessary, detach the inside of the lip or cheek  down to the lower
border of the jaw bone, without  touching the skin.   With a cutting in-
strument, in form of a cutting forceps, curved  almost at  a right angle
upon its border, I embrace  the  whole  tumor through the  mouth, and
remove it, taking care to make  the section below in the  sound part of
the bone.  One cut ordinarily suffices ; but we make two or three suc-
cessively, if the disease has reached to a great length  along  the  jaw,
[meaning of course the alveolar or dental border.  T.]  The tumor be-
ing now secured  by the fingers, forceps or erigne, may be  detached  by a
few cuts  of the bistoury or scissors, should it  still  be retained by some
bridles of the gum.   No hemorrhage ensues,  and  no dressing is re-
quired ; an astringent gargle is to be used, and  that comprises  all.
   Dupuytren, MM. Barton, Lallemand, and A. Berard, (Diet, de Mid.,
t.  XVIII., p. 452,) have also performed this operation,  but by another
process.   M. Barton, by dividing the lip vertically on the middle of the
tumor, in order to make a T incision reversed, by means  of  a lower in-
cision parallel with  the border of the jaw, formed two  flaps, which
were raised up, one to the right and the other to the left.   He  was then
enabled by the saw to divide the bone  horizontally, and then vertically
in front and behind, upon the alveolar border, in order to complete the
isolation of the tumor.
   This process which I had recourse to, [the author does not, I think,
mean that he first introduced it into practice.   The  operation  had  been
repeatedly performed many years  before in this  country,  at  least, by
Dr. Mott.  T.]  in the  year 1831, with M.  Sabatier, upon a woman
sixty-five years of age, and which M.  Berard has  also adopted, would
not become indispensable unless the disease had proceeded to great ex-
tent, and in that case, I should at present prefer  commencing with the
horizontal incision rather than with the vertical incision  of the integu-
ments.  As to the trephine, which  M.  Lallemand  had recourse to, I do
not think it ought to be employed in any case.   All the patients treated
by the process  I have described, were restored ;  not one of them died. 
344
NEW ELEMENTS OF OPERATIVE SURGERY.
                       §  VI.—Lower Border.

   T!i3 diseases which sometimes render exsection of the jaw necessary,
 m \y comprise only the half or two inferior thirds  of the height  of this
 bono.  Here also the excision of  the diseased portion only should be
 substituted for complete exsection.  A young man had an encephaloid
 tumir, of the size of the  fist, which included  the  chin, and descended
 to the os  hyoidcs.   After having,  by repeated  incisions, separated it
 from the lip and neck, I detached it a little from  the subjacent tissues.
 Then causing the lower lip  to be raised up, I directed the saw to the
 root of  the  incisors, and  removed without difficulty the whole  of the
 chin, while leaving  untouched the dental border.   The patient, after
 presenting the promise of entire  recovery, died at the end  of three
 weeks, but there was found  an enormous encephaloid abscess  in the
 right lung, and a purulent effusion in the pleura.
   The different  kinds of osteotomes and  rowels  would also come  into
 use here ; but unless the disease should be situated rather  in the side
 than in the projecting points of the jaw, the hand-saw should  have the
 preference over that of M. Heine, which, on one occasion was employed
 with success by M. Walther, (Gaz. Med. de Paris, 1834, p. 644, 645.)
 If the soft parts should be sound, we should form a large flap, semilunar
 in shape, with its lower border free, and which should be dissected up
 from the sub-hyoidean  region, towards the  face, and wliich  would  only
require afterwards to be allowed to fall down  in its place, in order to
 close up the wound.   If on the other  hand, however,  the integuments
would have to be taken away with the tumor, it  would be necessary to
cut around and dissect them off  in such manner as  to admit  of our
elongating their flaps, as in  the  anaplastic method of Franco,  and  to
proceed afterwards in the same manner as for an ordinary anaplasty.
  The advantages of these partial  excisions of the jaw are too evident
to require from me  any further exposition  of  their  merits.   Easy and
prompt of execution, simple in their consequences, rapid in their cure,
and producing but a trivial deformity,  are  the  advantages which indis-
putably belong to them, and which cannot  be said, to the same extent,
of the exsection of the whole height of any part whatever of the same
bone.
   [Exsection  of the  Lower  Jaw.—M.  Begin, in a memoir,  " sur  la
 Risection de la Mdchoire Infirieure, considerie dans ses rapports avec
 les fonctions du Larynx et du Pharynx, (see Seance of the Academy of
 Sciences of Paris, 20th Feb.  1843,  in  the  Journal des Connaiss.,  &c.,
 de Paris, Mai, 1843, p. 214,) feels himself authorized to  come  to the
 following conclusions :—
   1. That after the  exsection of the entire jaw, the tongue, os hyoides
 and larynx may be gently and gradually drawn backwards, so as  to
 cause asphyxia  after  a  lapse of  time, at which  it  would be supposed
 there would no longer be any reason to apprehend such  a result.
   2. That this accident may be prevented, by fixing the os hyoides, by
 means  of the  tongue, upon  a sort of artificial jaw, until nature  'has
 caused new adhesions  to the parts.
   3. Finally, that by abstaining from forced means of reunion from one 
EXTRA-ARTICULAR EXSECTIONS IN PARTICULAR.         345
side to the other, and by using only simple containing dressings, which
excite neither erythism in the nervous systen nor retraction in the mus-
cles, the surgeon favors the cure  without exposing himself to the risk
of rendering the deformity greater or more difficult of reparation.
  These rules, though they might prove advantageous in extreme cases,
in which the totality of the jaw on both  sides is removed—cases, how-
ever, excessively rare—have never been found necessary in the practice
of the  American surgeon (Dr. Mott) who was  the first to exsect  the
lower jaw for osteo-sarcoma, and who has  performed, doubtless, more
of these operations, both upon that and the upper jaw, than any  other
practitioner.
  The entire left half of the lower jaw, in a case of spina ventosa, was
amputated and disarticulated with a perfectly successful result, leaving
little or no deformity, by M. V. de Lavacherie, professor at the university
of Liege, (Belgium,) as we learn  from his treatise.  Memoirs et Ob-
servations  sur quelques Maladies des Os  Maxillaires,  Sec, Brussels,
1843.   (See also  Journ. des Connaiss., Paris, Juin, 1844, p. 241.)
The  same  physician informs us that he has also performed the  same
operation of amputation and disarticulation  of the right half of the
lower jaw for osteo-sarcoma.  This, however, ended fatally immediately
after the operation, in consequence of hemorrhage, which, though it
did not exceed a pint, was too exhausting in consequence of the hemor-
rhages which had daily attended the disease for some time.   And this
unfortunate result occurred, too, notwithstanding the surgeon had adopted
the precaution of tying the primitive carotid the day  before, which,
unhappily, did not  prevent the tumor from bleeding more or less from
the time of the application of the ligature until the operation was per-
formed on the day succeeding, and which operation, therefore, naturally
terminated  as has  been stated.   (Loc. cit., p. 242.)  For extensive
tubercles on the jaw, he has found  compression succeed in  one  case
perfectly.
  A man aged sixty-eight, with a spina ventosa of the left side of the
lower jaw, and  who had been operated upon  for a carcinoma of the
lower lip six  years  before, had the greater portion of the left side of
the jaw removed, (Lond. Med.  Gaz., Oct. 11, 1844,) by Dr. S. Chis-
holm, at Inverness, (Scotland,) in June, 1844, and recovered so  per-
fectly that he walked home, sixty  miles, two months after the exsection.
The portion of bone removed, extended from the side of the symphis to
the articulation—not, as we understand, including  the rather difficult
and dangerous process of disarticulation  of the jaw itself.
  M. Blandin (Gaz. Mid.  de  Paris, Juin  14, 1845, p.  381) very re-
cently  removed, in a female, the  whole left  ramus and  a part of the
body of the jaw, as far as to the  middle of  the  commissure of the lips
on the  opposite side ; managing so as to save the principal  branches of
the facial  nerve, and  thus to preserve the integrity of the  movements
of the  face.   [In an operation performed by Prof. Mussey in 184P5, the
symmetry of the mouth was perfectly  preserved by avoiding the facial
nerve, his  incisions  having been commenced below its transit, as well
as the  duct of Steno.   (Trans.  Amer. Med.  Association, Vol. III.)
G. C. B.]   In exhibiting this case  to the Academy  of medicine of
Paris, June 10,1845, M. Blandin expressed,apparently, much agreeable
  Vol. II.                   44 
346
NEW ELEMENTS OF OPERATIVE SURGERY.
 surprise to find substituted, in place of the exsected bone, a spontaneous,
 fibrous, bridle-like  production, which occupied nearly the whole of the
 space left by the exsection, and which seemed to unite the  two frag-
 ments.  The consistence of this bridle, he remarks, appears to be similar
 to that of the jaw of young infants, who have not yet breathed.
   This fibrous, or rather  fibrocartilaginous  substance, has  long been
 familiarly known in this country, ever  since the operation of exsection
 of the lower jaw was first introduced into surgical practice here by Dr.
 Mott.  T.]
  This operation of Dr. Mott, it would  appear, is now become domicili-
 ated even in India.   Mr. R. O'Shaughnessy, of the Gurtharhattah Dis-
 pensary,  in a treatise on the Diseases of the Jaws, Extirpation, Ampu-
 tation, Sfc, Calcutta, 1844, relates that he had then performed the ope-
 ration  of removal of the upper or lower jaw five times successfully, in
 one of which  the  osteo-sarcomatous tumor of the lower jaw was as
 large as a child's  head, requiring the  extirpation of the whole jaw on
 both sides, except the ramus of the left!   This is close upon the heels of
 what civilized  Europe or America can boast of.  In his operations on tho
 upper jaw, we  perceive  that he disapproves of the extensive incisions of
 Mr. Liston, but nevertheless continues  upon the erroneous plan, as  Dr.
 Mott conceives it to be, of making  his incision extend from the zygoma
into the centre of the commissure of the  mouth, instead of the straight
 single  and simple perpendicular incision of Dr. Mott, from near  the
inner  angle of the eye  and along the ala of the nose  into the mouth,
near the median  line  of  the  upper lip.  Mr. O'Shaughnessy  prefers,
however, to  make  all  his exsections with Mr. Liston's bone  nippers,
using the saw only to divide the malar process where  the  malar bone
may be saved.  T.]
  [Dr. Ilullihen,  of Wheeling, Va. has  successfully  applied Barton's
plan of exsecting  a  wedge shaped piece of bone, to remedy deformities,
in a case, where in consequence of the distortion produced  by an exten-
 sive burn upon the neck and lower part of the face, the lower jaw  had
become " bowed slightly  downward, and  elongated, particularly at its
 upper  portion, which made it project about an inch and three-eighths
 beyond the upper jaw.  This  lengthening of the jaw had taken  place
 ontirely between  the cuspidatus and first bicuspid tooth of the right
 side, and between the first and second bicuspids of the left."   A wedge-
 shaped piece of bone was  removed from  between the abnormally  sepa-
 rated teeth, and then by bringing the cut surfaces, on each side together,
 the jaw was restored to its proper length.  The full report of this case,
 with  illustrative drawings, may be found in the Phil. Med. Examiner,
 March 1850, or an abridgment  of it  in the third  American  edition of
 Mr. Miller's Principles of Surgery, by Dr. Sargent, p. 399.   G. C.  B.]
• 
EXTRA-ARTICULAR EXSECTIONS  IN  PARTICULAR.         347
 DR. MOTT'S  CASES  OF  EXSECTIONS  OF THE LOWER JAW.

No I., 1821;  Nov. 17th  and 18th.—Case of  Osteo-Sarcoma—in which
  the right side of the lower jaw was removed successfully after tyin^
  the Carotid Artery.   By  Valentine Mott, M. D., Professor of  Sur-
  gery in the University of  New-York:  (See New-York Medical and
   Physical Journal, Vol. L, No. 4; Oct, Nov., and Dec, 1822, p. 385__
  364.   Four plates.)

  Catharine Bucklew, the  subject of the following operation, was an in-
teresting young woman, aged  about  seventeen  years, of a healthy ap-
pearance and good constitution.
  She says that about two years since, a swelling commenced behind the
last molar tooth of the lower jaw, attended  with  acute pain about the
angle of the jaw, that continued  about three weeks ; at which time it left
her without any evident  resolution of the inflammation.   At this period
there was no inflammation  of the integuments, nor could any pus be dis-
covered either on the cheek or about the bone within the mouth.  Some
domestic applications were made to the cheek, but the tumefaction con-
tinued to increase, and assumed a smooth, hardy, and bony character.
  About twelve months  after its commencement she applied to a physi-
cian in New-Jersey, who advised her to apply blisters to the cheek, and
the use of topical applications  of caustic to  the tumor, together with a
general antiphlogistic constitutional treatment.  After having submitted
to this course for two months without experiencing any benefit, she  came
to this city, and became  my patient.
  The first molar tooth came away early in the disease, and the second
soon followed;  then, three or four of  the other teeth of  that side of the
lower jaw.  She states, that  previously to this disease she had never had
a decayed tooth.
  No fluctuation  was to be  felt at any time  in the tumor.   She had no
constitutional symptoms as the effect of this disease, nor any inordinate
headache on that side.  The lymphatic  glands of the neck were  how-
ever swollen, during the  continuance of the inflammation  in the early part
of the disease;  but they disappeared  as soon as the pain subsided.
  When she came under my care, the tumor extended from the root of
the coronoid  process  to the second  bicuspid tooth, elevated nearly an
inch above the level of the teeth, and spreading considerably wider than
the alveolar process.  Its appearance was  smooth,  and to the touch
somewhat elastic, though firm.  An incision on each side of the alveo-
lar margin, with a scalpel, enabled me pretty readily to remove the tu-
mor with a gum-lancet to the level of the jaw-bone.  The tumor, on ex-
amination, contained  many cartilaginous and osseous spiculae, and in the
substance of it was imbedded one of the molar teeth in a perfectly sound
state.
  About three weeks after this operation a small portion, of the size of
a nutmeg, which had  granulated and grown rapidly, was taken off, and
soon after she retired to  the country, and  remained in a very comforta-
ble state for several  months.  The tumor began now to re-appear, and
continued to increase gradually  in every direction. 
348               NEW ELEMENTS OF OPERATIVE  SURGERY
[Plate 1.]
                                       No.  I.

  Jhis drawing exhibits the appearance of the face before the operation was performed.  The
rotundity of the right cheek will be observable, and the integuments below the under eye-lid,
on the stretch from the size of the osteo-sarcoma.

                                       No. II.
  Represents the side of the  face after the tumour was  removed, and before the parts were
closed.    a The part at which  the jaw-bone was divided near the chin.     b Condyloid  pro-
cess, where separated by the saw; the coronoid process being  drawn up by the temporal
muscle.     c The side of the  tongue.     d Sub-lingual gland.    c Molar teeth of the right
Buperior maxilla.    / Inferior  portion of the parotid gland, with  a plane of fibres of the
masseter muscle turned up.     g g Portions of the common integuments. 
EXTRA-ARTICULAR  EXSECTIONS  IN PARTICULAR.           349

                         [Plate 3.]
[Plate 4.]
                                     No. III.
  This figure exposes the appearance of the tumour upon the inner surface.    a Cuspidatus
and first bicuspis teeth,  b Lower jaw where divided anteriorly.     c Bone at its posterior di-
vision,  d Furrow produced by the teeth of the upper jaw.    e e Two  superior portions of
the tumour covored by the membrane of the mouth.   // The remainder of the inner surface
of the tumour, dissected from the parts within the mouth.
                                     [No. 4.]
                   The appearance of the patient after her recovery. 
350             NEW ELEMENTS OF  OPERATIVE SURGERY.

  The tumor, at present, (Nov. 10th, 1821,)  has the  same  firm  and
slightly elastic feel which characterized it in the early stage, involving
all  the right side of the inferior  maxillary bone.  Projecting outwards,
it produces great convexity of the cheek: upwards  it divides into two
portions, the outer and longest reaches up to the os malae, and between
the two is a considerable furrow, formed by the teeth of the upper jaw,
which occasions  an abrasion and  constant discharge; the latter, though
offensive, does not appear to be acrid or irritating : downwards it comes
nearly in contact with the thyroid cartilage; inwards it extends  beyond
the middle line  of the mouth, pushing the tongue and uvula very much
to the left side, having the velum pendulum palati of the right side at-
tached to it in its whole  course.   The  inward portion is considerably
raised above the level of the tongue when  the mouth is opened.
  The posterior extremity of the  tumor has encroached so much upon
the passage leading into  the posterior  fauces, and the pressure of the
lower parts upon the larynx is so considerable as to render deglutition
very difficult;  and from the great difficulty of mastication, she has been
compelled for some time to subsist upon liquid aliment.   Her speech is
considerably interfered with in consequence of the displacement  of the
tongue.  She experiences no pain in any part of the tumor.
  The gradual increase of tho disease rendering  mastication and deglu-
tition more difficult  and distressing, she  is very desirous  of knowing
if an operation could not be performed which might extend to her some
chance of life ; observing, that with the constant growth of the  tumor,
such as has taken  place  for a  few weeks past, she would not  be  able to
swallow anything in a short time.  Fully aware of the dangerous nature
of the novel operation her case requires, she is determined to submit to
it, and hazard the consequences :  the uncertain result of which I careful-
ly explained to her2 and  informed her,  that  she  might die during  the
performance of the operation ; but that I believed it to be both  practi-
cable and proper.
  After preparing the system  for about a week with  light diet, and the
exhibition of several doses of neutral salts, to obviate any great  degree
of inflammation, the operation  was  commenced about 11 o'clock on the
morning of the 17th.
  As most of the important branches of the external carotid artery
would  be  interfered with in the  course of this operation, I believed it
most prudent to pass a ligature around  the primitive trunk as a first and
preparatory step.  This would not only enable me to go through it with
more safety to the patient, but  appeared the most important of all means
to avoid inflammation.  Indeed, inflammation was much to be dreaded,
from the immense extent  of the external incision, and the violence which
would necessarily be  done to the  tongue, palate, and pharynx.
  From these considerations, I felt it doubly important to intercept the
current of blood through the common carotid, and from what I had ob-
served to  attend the application of ligatures to the large arteries of
the extremites, in cases of severe injuries,  by preventing inflammation  I
thought great  advantage would  attend it in this  case, as I am satisfied
will be fully shown.
  An incision about two inches and a half  long was made a little below
the thyroid cartilage on the inner edge  of  the  sterno-cleido-mastoideus 
EXTRA-ARTICULAR EXSECTIONS IN PARTICULAR.         351
muscle, and after exposing the carotid, a single ligature  was passed
under it and tied.   It was deemed most proper to tie the carotid, in this
situation, in order to prevent the second part of  the  operation from in-
terfering with the first  incision.  Very little  blood  was lost, and only
one small cutaneous branch at the lower angle of the wound required a
ligature; yet she became pale and almost pulseless during, and imme-
diately after, the operation, notwithstanding her position was recumbent.
She submitted to the operation with great  firmness and resolution, but
her mind soon became agitated and perturbed to a great degree, and it
seemed altogether  impossible for  her to regain her former fortitude.
The operation was suspended, and some cordial was administered, but it
failed to remove from her mind the presentiment that any  further pro-
ceeding at present would be fatal.  In this state of remarkable agitation
I resolved not to proceed, and informed her that  with such fears as she
then entertained, the result was to be dreaded.  The wound was  then
dressed, and she was put in bed, faint and exhausted.
  After recovering a little, I apprised her that this was only preparatory
to the most important part of the operation, and that what had been done
would prove of little or no benefit to the disease, and urged her serious-
ly to consider of it, and if possible make up her mind  to submit to the
performance of the remaining part, which should by no means be defer-
red longer than the following day.
  One o'clock, P. M.—She is still pale, and in a cold sweat;  pulse has
not recovered itself; and when asked,nodded that she felt some uneasi-
ness.
  Seven o'clock, P. M.—Much more collected ; pulse natural; no un-
easiness  whatever, except  some obtuse pain about the wound in breath-
ing, and in  swallowing saliva ; no increase  of  heat; left a student to
watch with her through the night, and again took leave, earnestly recom-
mending to her private consideration  the expediency of submitting to
the remainder of  the operation.
  18th.—Seven  o'clock. A. M.—Found her this  morning in a very com-
posed state of mind; having slept well, and free  from fever.   Upon put-
ting the question, would she submit to the remainder of the operation ?
she nodded assent with much apparent decision,  and said she was deter-
mined to undergo it.
  At ten o'clock, finding my patient cheerful and resolute, she was again
placed upon the table, and in the presence  of Wm. Anderson, surgeon,
the late Dr. Hosack, and a number of other gentlemen, the operation was
continued.   Feeling for the  condyloid process, an  incision was  com-
menced upon it, opposite the  lobe  of the ear, carried  downwards over
the angle of the jaw in a semicircular direction along the lower part of
the tumor, as  it rested  upon the thyroid cartilage, and terminated at
about half an inch  beyond the angle  of the  mouth,  on the  chin.  The
termination of this  incision upon the chin, was just above the attachment
of the  under lip to the bone, and the mouth was  thereby laid open.   I
now extracted the second incisor tooth of that side, as it was in a  sound
part of the bone,  and, after separating  the  soft  parts from the side of
the chin, and laying bare the bone, I introduced a narrow saw, about
three inches long,  similar to a key-hole  saw, from within the mouth,
through the wound, and sawed through the jaw-bone from  above down- 
352
NEW ELEMENTS OF OPERATIVE SURGERY.
wards.   The lower part  of the  tumor was then laid bare, by cutting
through the mylo-hyoid muscle, and the flap of the cheek carefully sep-
arated and turned up over the eye.  This exposed fully to view the whole
extent of the  tumor as it rose upwards to  the os malae.  After  the in-
teguments were carefully dissected from the parotid gland, the masseter
muscle was detached from its insertion, until it came to the edge of this
gland, then separating a thin plane of the fibres  of this muscle, I now
readily raised the parotid, without wounding it at this part.   The maxil-
la inferior was now laid bare just below its division into two processes, and
it appeared sound.  To facilitate the sawing of the bones, it was neces-
sary to make a second incision,  about an inch long, close to the lobe of
the ear, and terminating at the edge of the  mastoid  muscle; then  with
a fine saw made for the purpose, smaller and  more convex than Hey's,
I began to saw through the bone, obliquely  downwards and backwards,
and finished with one less convex.  The latter part of  the sawing was
done  with  great caution, to avoid excruciating pain from the laceration
of the inferior maxillary nerve.   When the bone was sawed  through,
the two processes were observed to be split  asunder, and the  coronoid to
be drawn up by the action of the temporal muscle.
  An elevator was now introduced where the bone was divided  at the
chin, by  which the diseased portion  was  raised, when, with  a scalpel
passed into the mouth, the tumor  was  separated from the  side of the
tongue, as far back as the posterior fauces, from the velum pedulum pal-
ati and pterygoid processes. This loosened it very much, so that it could
be turned  upon the side of the neck.  It  was then separated from the
parts below the base of the jaw, and also  from the pharynx, and detach-
ed  at  the  posterior angle, carefully avoiding the trunk of the internal
carotid and deep-seated jugular vein, both of which were exposed.
  The diseased mass, being now separated above and below, was turned
up, the pterygoid muscles detached, and the third branch of  the fifth
pair of nerves divided from below, a little  above  the foramen  at which
it enters the bone.  By this manner of proceeding, with a constant ref-
erence to this nerve, I apprehend my patient was saved from much acute
pain, and the nerve more safely divided, than at an earlier stage of  the
operation.
  At several periods of this operation, the curved spatulas, used  in my
operation upon the arteria innominata, were found very useful, particu-
larly  in  elevating the parotid  gland, and  keeping the tongue steady,
whilst the tumor was being separated from it.
  Very little blood  was lost during this operation.  Two arteries only
of any size were divided, the facial and lingual; and these only required
the ligatures at the branch extremities ; but each end was tied for safe-
ty.   Another small artery behind, and a little underneath the posterior
angle of the jaw, yielded some blood and  was tied.
  The flap of the cheek was now brought down, after waiting  a few
minutes  to observe  if any hemorrhage should come on, and  secured in
close apposition by three sutures, and adhesive straps.   Lint, a compress,
and the double-headed roller, completed  the dressing.   She was  made
as comfortable as possible upon the  table, and directed to remain  a few
hours  to recruit, and to be more convenient in case  any hemorrhage
should make it necessary to remove the dressings. 
            EXTRA-ARTICULAR EXSECTIONS IN PARTICULAR.         353

  At eight o'clock in the evening, I found her removed to a bed, and in
a comfortable  situation.   Some reaction of the circulation  had taken
place, but there had been no hemorrhage.  The  pain from the operation,
she said, was  less than she expected.  For the first  time, since the op-
eration, she sipped three tea-spoonfuls of cold water, and gave evidence,
by a nod, that she could swallow.  Directed one hundred drops of tinct.
opii to  be given, if any  twitching, more pain, or restlessness, should
supervene.
  19th.—Seven o'clock, A. M.—Found her quite free from fever and
irritation, and, in every respect comfortable.  Swallows cold  water by
the tea-spoonful with but  little  inconvenience.   Did not take the tinct.
opii last night.  Slept several hours during the  night.
  Twelve o'clock, at noon.—Is comfortable ;  skin  moist;  pulse less
frequent, and  soft; directed an enema to be administered of  soft-soap
and water; has  a little  more  difficulty  in swallowing, but  none in
breathing.
  Nine o'clock, P. M.—As well as  in the morning.   Enema operated
three times, and  relieved her.   Pulse frequent, but not tense.   She has
taken about two ounces of cold water by the tea-spoonful since daylight.
   20th.—Seven o'clock, A. M.—Had  a very comfortable night.  This
morning, instead  of nodding, she answers " yes" and " no" to the several
questions in an audible whisper.
   Nine o'clock, P. M.—Much as in the morning.
   21st.—Nine o'clock, A. M.—As comfortable as yesterday morning
   Nine o'clock, P. M.—No niaterial alteration.
   22c?.—Nine o'clock, A. M.—Directed an enema  to  be administered
 as before. Allowed her to take, in addition to  her cold water and teas,
 some thin chicken soup :  is in every respect doing well.
   Nine o'clock, P. M.—Tumefaction of the lips and cheek very trifling,
 not enough to effect the least change in the eye-lids of the right eye.
   2od.—Is in every respect comfortable.
   2-ith.—Eleven o'clock, A.  M.—Makes no  complaint;  dressed  the
 wounds ; union by adhesion has taken place in the whole extent, except-
 ing about the ligatures and sutures.  Suppuration having come on about
 two of  the sutures, they  were removed.  Pulse about 120.   Renewed
 the adhesive straps with  lint interposed between them and the wound,
 and the double-headed roller.
   2bih.-—Every way comfortable.   Pulse 120.
   2Gth.—Says she has no complaint to make.   Pulse 80. Directed her
 to take a small dose of sulphate of magnesia.
   21th.—Speaks audibly, and says she is very well.   Pulse about 84.
   28th.—As  well as  before; dressed  the wounds ;  removed  the  two
 sutures at the upper part near the ear; wounds appear healed  at every
 part, except where the ligatures remain upon the arteries.  Pulse 80.
   29th.—Feels very well;  speaks  distinctly ;  takes freely of soup and
 other thin food.  Pulse 100.
   Dec. 2>d.—Ligature from the carotid came away, and the other three
 ligatures from the upper wound.   A small collection  of matter  was
 evacuated from under the integuments in the  lower wound, which was
 produced by the  irritation of the ligature.
   4th.—Speaks  and swallows very well;  wounds  just healed.  Has
   Vol.  II.                    45 
354
NEW ELEMENTS OF OPERATIVE SURGERY.
used for some days a wash of spirits and water to the mouth, with a
view to correct some fcetor of the saliva, and cleanse the mouth.
   6th.—Found her dressed and sitting in an adjoining room, reading by
the fire ; looks and says she is very well.   Tho bandages being all left
off, the only deformity apparent is a little  more tumefaction of the right
cheek than the left; wounds just  well; can move very readily the sound
half of the under jaw.  Permitted her to chew some animal food.
   10^/i.—Wounds all healed ;  makes no complaint.
   March, 1822.—To-day having  visited her, I found scarcely any per-
ceptible deformity.  The right cheek appeared, upon close examination,
to be a little more depressed than the  left.  I felt from within the mouth
some osseous deposit to have commenced  at the two situations at which
the bone was divided.  Her  health in every respect is perfectly good,
and she enjoys the free use of the left side of the lower jaw.
   Nov.  5th.—I have  repeatedly heard of and  seen  the patient during
the past season, and she continues to enjoy uninterrupted health.

No. II.—May 15, 1823. Case  of Exsection and Disarticulation
   of the  Lower Jaw in the negro Man  Prince, (See New York
   Medical and Physicial Journal, Oct.,  Nov. and  Dec.; 1823; Vol.
   II., p. 401-405.  One plate.)

   In this case the disease was of prodigious  magnitude, and the bone
removed at the articulation on the right side.
27�27492 
            EXTRA-ARTICULAR EXSECTIONS IN PARTICULAR.         355

  Prince, a colored man, aged eighteen years, was  sent me from New
Jersey, with an osteo-sarcomatous tumor, embracing the lower jaw-bone
from  the  articulation of the right side, as far  as the alveolar socket,
supporting the first molar tooth of the left.  It presented an appearance
in size equal to that of his head.
  At the age of twelve an enlargement of the bone showed itself about
the  situation of the second molar tooth of the right  side.   This was at
first considered a gum-bile, but it gradually increased, dislodging one
after  another, the teeth  in  its neighborhood.  When it had arrived at
the  size of a walnut, a lancet was put into it, but no pus or fluid issued.
In 1818, when as large as  a goose-egg, it was again opened, and a
small quantity of blood and matter was discharged.  During its progress
it was slightly painful, until  some  time  before the operation, when it
became the cause of much uneasiness.  Latterly two or three small open-
ings had  taken  place within the mouth, attended with a discharge of
pus and ichor, by which were denuded several boney spiculae.  Externally,
near  the  most depending part, an  ulceration  of  the skin had taken
place, from which had been discharging  daily for some weeks several
ounces of thin matter, and through which a probe would readily pass to
some distance into the substance of the tumor.
  The size of the  tumor in the mouth was such as to reach completely
over  to the left  cheek, carrying the tongue along with it, so that the
latter lay flatwise between  the tumor and the cheek.  Deglutition was
extremely difficult, and confined to liquids in small  quantities.  These
glided along  between the tongue and  left cheek, when the  head was
very  much inclined to the left side.  No appearance of  fauces could
be observed upon opening the mouth.
  From  the long  continuance of this disease, and the great emaciation
which attended  it, very  little hope  could be entertained  from so for-
midable an operation as would be  required for the removal of such an
enormous mass.  Still, as I knew he would soon perish with it, and being
very desirous himself  to take what little chance there was, I determined
to give it him, and accordingly performed the following operation :—
  May 15th,  1823.—At  noon of this  day, I tied  the right carotid
artery, a little above  the clavicle.   He bore  the  operation with great
firmness, and  appeared to be but little  exhausted  by it.   After resting
and refreshing himself with a little wine, he wished  it to be continued.
  An incision was now commenced at the lower edge of the jugum  tem-
porale, and carried in a semicircular direction over the most prominent
part of the tumor, and terminated opposite the first molar tooth of the
left  side.  Another incision  of the same  form,  but of less extent,
below this, left a large  piece of integument in  which was situated the
ulceration.  (See Plate.)  The  flaps being dissected from the tumor,
the second bicuspis tooth of the left side was  extracted, and  the bone
here sawed through at a sound part, with the saw which I had provided
for  the other cases.
  Raising with an elevator the bone where sawed through, the diseased
mass was  cautiously  dissected from the tongue, palate  and pharynx,
until  the joint upon the right side  was exposed ; the capsular ligament
was now divided on  the inner  side, by which the bone was easily re-
moved from its articulation.   In  the course of this part of the operation 
356
NEW ELEMENTS OF  OPERATIVE SURGERY.
very little blood was lost, it being necessary only to apply four ligatures.
This would seem to answer in the negative the query put in the former
case concerning hemorrhage.
   The patient was much exhausted by this operation, which, from the
great extent of the  disease,  necessarily occupied a considerable  time.
His exhaustion was also to be ascribed to his previous state of debility.
   After his recovery from the  exhaustion the flaps were brought together
by several  interrupted sutures  and  adhesive plasters, and  the double
headed roller being applied, he  was put to bed.
   The tumor weighed twenty-two ounces avoirdupois.
   Three o'clock.—Has continued to recover gradually from the shock
of the operation.
   Five o'clock.—Fell into a sleep of about half an hour, and has awaked
much  better.   Pulse  regular and distinct.
   Eight o'clock.-^-Pulse 140, and regular ; skin cool and moist;  signi-
fies by a nod that he is more  comfortable than he expected  to be.  Has
spoken pretty distinctly for several things, contrary to particular orders;
swallowed some water from the spout of a tea-pot  without much diffi-
culty.  Requested two pupils to remain  with him during the night.
   16th.—Ten  o'clock, A. M.—Slept most of the  night quietly, only
taking a little  cold water once;  skin of  the natural temperature ; pulse
120, and stronger than last evening.   Nods that he is much more com-
fortable ; ordered  him to take a little  cold  water  occasionally when
necessary, but to take it as seldom as possible.
   Ten o'clock, P. M.—Pulse 124, .and fuller ; skin pleasantly warm ;
articulates  that he is quite comfortable, and  feels  refreshed from his
sleep ; has had considerable sleep through the day, and is now sleeping
very quietly.   Swallows very well when the  fluid is conveyed into the
posterior fauces by an elastic tube and bottle.  He introduces the tube
himself as far as is necessary, for the  purpose of  swallowing  without
producing any action of  the  lips or muscles of the face.   Contrary to
orders, got out of  bed to  have an evacuation from  his bowels and pass
urine, which he accomplished without difficulty.
   17th.—Ten o'clock, A. M.—Has had  a good night; pulse 120 : skiu
nearly natural; swallows with  more  difficulty, and some of the liquid
passes through the wound.  Removed the bandage and adjusted all tho
dressings anew, as they had  become wet.  Takes soup and chocolate
as his drink ; bowels have been moved again  spontaneously ; has  a
slight cough.
   Nine o'clock, P. M.—Says  he is as comfortable  as in the morning ;
pulse  124;  has slept a good deal in the course of the day,  and says he
feels much strengthened by it.
   18th.—Ten o'clock, A.  M.—Passed  a good  night, and says he  is
quite  as well as yesterday ; swallows better ;  pulse"l30.
   Ten, o'clock, P. M.—Not as well as in the morning ; pulse from 135
to 140 in a minute ; coughs more frequently; respiration  considerably
hurried ; is very restless, and feels  very  faint at times.  In the course
of this afternoon,  during a very heavy thunder-shower, he fainted, and
appeared to be threatened with  immediate dissolution ; but  after a short
time revived, by the use of volatiles and fanning ;  says he  feels consid-
erable pain on the left side, which prevents him from taking a full in- 
            EXTRA-ARTICULAR EXSECTIONS IN PARTICULAR.         357

spiration ; indeed, every breath  is painful, as is evinced by the distress
of his countenance.  Ordered a blister to be  applied immediately to the
side.
   19th.—Ten o'clock, A. M.—Is much relieved by the  drawing of the
blister ; slept a good  deal during the night; had  one fainty turn in the
course of the night.  Dressed the wound this morning ; more than two
thirds of the wound  had united by adhesion;  breathing much  better ,
pulse from 132 to 140 ; cough less troublesome  ; swallowed some choco-
late very well.
   In the course of the day his cough and breathing became more trou-
blesome, with great anxiety and restlessness; and at four o'clock in the
afternoon, in one of his  turns of faintness, he expired.
   Not being able to attend to the  dissection, I requested my friend,
William Anderson, Esq., Surgeon,  to examine  the body the next morn-
ing :  who has  obligingly handed me the following  particulars :
   " The wound appeared healthy,  and had united by adhesion through
most of its course.
   " Dissection.—Upon  raising the sternum, there was found in the an-
terior mediastinum a massy deposit of coagulable  lymph  through  its
whole extent.   This was of a yellowish hue, having the exact appearance
of pus, but wanting its  fluidity.  In the cavity of the pericardium was
contained a pint of yellow serum,  and each lung exhibited marks  of
high  inflammation throughout their whole extent, the surfaces of both
being of a  deep purple,  and  in some places of a florid hue.  There was,
however, in no place any adhesion between the lungs and the sides of
the chest."

Exsection and Disarticulation of the  Entire Half of the Lower
         Jaw.  By Dr. Mott, at New-York, Nov. 23, 1844.

   The operation was performed between Ik and 2£ P. M. Saturday, Nov.
23, 1844.  The patient, a  young  gentleman by  the name of William
Edgar Baker, native  of, and clerk  in a respectable mercantile firm in
this  city, and aged 25  years, was stout, of rather thick set frame, full
sanguine temperament,  florid full  face, broad  neck and chest, but dark
hair and eyes, and altogether inclined to embonpoint.
   About a  year since, his uncle told me, Mr. Baker complained of pain
in the right side  of the lower jaw which  soon  began to swell and so
continued until  it reached  its present magnitude—being apparently  a
uniform enlargement of the  whole  of the middle part of the base of the
jaw on that side  which, with the  induration of the superincumbent tis-
sues, periosteum, aponeurosis, fascia? and muscles, give it to the eye and
feel  the  form of a spindle-shaped, consolidated, and apparently almost
boney or semi-cartilaginous tumor throughout, perfectly unyielding to
pressure, and  about  three inches through in its transverse diameter, or
that through its middle, and five to six inches in its longitudinal diame-
ter or that in a line with the base of the jaw, tapering each way as it
reaches the angle of the jaw at one end and  near the symphisis of the
chin at the other.
   Dr. Mott, the first surgeon  who accurately described and attempted
the  formidable operation of exsection of a part or  of the whole half or 
358
NEW ELEMENTS OF  OPERATIVE SURGERY.
 more  of the  lower jaw as the remedy for this insidious and formidable
 disease, and who pronounced this case to be one of the same kind as the
 twelve to  fifteen  others for which he has operated upon during the last
 twenty-six  years, denominates it osteo-sarcoma, which left to itself ter-
 minates in  a malignant morbid  growth of the osseous and other struc-
 tures  implicated, finally resolving itself into an open carcinomatous ul-
 ceration, caries, and destruction of the parts.   He does not pretend to
 assign  any  particular cause for  this malady.  In the present case the
.uncle  told  me young  Baker had, as  indeed his whole appearance, com-
 plexion, frame, &c, indicated, enjoyed the most perfect and robust health
 from his infancy. He had never known him in fact to have suffered from
 any disease, and he  had never had any affection whatever, except that
 some months back he had been attacked with a  slight erysipelatous in-
 flammation  in one of his  legs—I think he said in the calf, which, how-
 ever, soon  subsided without ending in suppuration or ulceration as one
 might  have imagined it would have done, as a natural drain in a person
 like this patient evidently inclined to  a rather gross and plethoric habit.
   I asked  him  particularly if the  erysipelas had ever attacked his face
 and head in the form  of St. Anthony''sfire, as I could readily conceive
 that in the  form of angioleucile,  involving, as it does, the thick,  muscu-
 lar, and aponeurotic and periosteal tissues and the bones themselves at
 the  base of the cranium, causing distressing pain and tension of those
 parts,  this  serious  variety   of erysipelas (so well described by M. Vel-
 peau in Vol. I. of this work)  might result, especially when abundant
 sanguineous and cathartic depletion had not been made use of, in precise-
 ly such a disease as this osteo-sarcoma.
   But this  patient  had also been  particularly abstemious and temperate,
 though not  (his uncle said) a tetotaller, or not at least as to food.  It
 was very evident  that he had not much stinted himself in good  eating.
 There  may be  something  of hereditary taint in this case, as the father
 had been operated  upon also for an osteo-sarcoma of the upper jaw some
 years  since.
   First Stage.—In all those severe cases  requiring extensive exsection
 of the lower jaw, Dr. Mott has  laid  it down as a principle, (See our
 Notes  to Velpeau's Operative Surgery, Vol. I.) to take up the primitive
 carotid as  a preliminary and indispensable step, in order to cut off the
 dangerous  hemorrhage which  would otherwise ensue from its principal
 branches.
   Accordingly, he proceeded to apply a ligature upon this vessel, an ope-
 ration  in which he is  so practised, (this making, I think, the 22nd time
 of his  applying it,)  and  which  at the time he first performed it in this
 country was itself deemed  one of very considerable importance, but now,
 as is seen, made by him who first projected it as indispensable in the ex-
 section of  the  lower  jaw,  a mere appendage to this operation and one
 of very subordinate character.
    With great rapidity of manipulation, he  made at once with the con-
 vex-edged  scalpel  (convex bistoury, as the French  call it) a deep inc*
 sion of about two and a  half inches long, entirely through the whole
 thickness of the integuments, platysma myoides and  cellular tissue, and
 which was  so neat, perfect and complete  in  itself that it  immediately
 exposed the entire aponeurosis of the inner  edge of the sterno-cleido- 
             extra-articular exsections  in  particular.         359

mastoid muscle close and parallel to  which inner edge and comprising
nearly the whole of the region of the middle  third of that muscle, this
incision had been made.
  As soon as this was made by Dr. Mott, a few movements of the blunt
flat handle of the scalpel quickly separated  the tissues so as to reach the
sheath of the primitive  carotid, under which in a few moments more he
insinuated the American blunt artery hook  armed through  the eye at the
extremity where it is screwed on to the stem  of the instrument, with a
strong twisted double silk ligature.  As soon  as  the blunt end of the
hook could be made  to work its way though the connecting fibro-cellular
tissues so as to be felt and seen on the inner side of and close to the ar-
tery, the surgeon unscrewed this curved  portion from the  stem by some
few turns of the handle, and then drew the curved  portion out, leaving
the artery above the ligature  clearly identifying the vessel by its size,
pearly color and  distinct strong pulsations, and after ascertaining that
it was cleanly separated  from its attachments,  it was firmly tied and the
threads left uncut.
  This preliminary  operation  consumed only about fift°en minutes.
The patient was then allowed to rest awhile—not however longer than
ten or fifteen minutes more, which would scarcely  be called  a stage or
premier temps, though I  have for convenience so denominated it.
   Second Stage.— The surgeon now  proceeded to the  principal opera-
tion, the first step of which consisted in the free, bold, curvilinear inci-
sion, which as the tumor was on the right side, was  made with the left
hand.  This  curvilinear  incision he was the first to project in these ope-
rations upon  the lower jaw, as he was the first to project  the operation
itself of exsection of this jaw for osteo-sarcoma.
  This incision, which was of great  length, commenced  at the jugum,
in front of, and  about opposite  to, the meatus auditorius  externus.  It
was then carried downwards over the most bulging part of the tumor
behind the  angle of  the jaw, and thence continued  along the  lower part
of the tumor, in a semicircular direction, was brought suddenly upwards
by a short curve, and terminated  upon  the chin, within an inch of the
margin of the lower lip, so as to open into the mouth, opposite the in-
cisor tooth adjoining the cuspidatus—and  so as to preserve completely
and leave intact the  commissure of the mouth.  This incision is the one
which Dr. Mott adopted, in his very first case  of exsection of  the lower
jaw, in a young  lady of this city, in 1821, (See supra,)  and  one great
object he then had in view was  to save the face on the agglutination of
the borders of  the wound, as much as possible from deformity ; which
it effectually  did, besides being by far the best kind of incision for these
cases, as tbe  convex border when freely dissected upwards, forms there-
by a flap of  a  semicircular  and oval  shape, which  when cicatrization
takes  place conceals the line of the wound below the base of the jaw.
This flap also by being turned up during the operation is out of the way,
and gives a more ready access to the subsequent steps of  the operation.
The shape of the whole  incision in  this case was as near as could be,
that of a'long blunt hook, (mounting  upward at the termination of its
point near the lip,) lying obliquely downward  and  inward, i.  c, diago-
nally on the  side of the neck, with  its curve, the longest portion  cor-
responding to the straight stem of the  instrument, and  the shorter or 
360
new elements of operative surgery.
 more curved portion in front, constituting more properly the hook itself.
 Without the least delay, the surgeon now proceeded  to dissect the flap
 upwards uutil finally it was detached from the tumor above.  This open-
 ed into the cavity of the mouth and laid bare the masseter muscle.   The
 next  step was carefully to determine the extent of the tumor forward
 upon  the chin.  This  being ascertained, by  dissecting  the  soft  parts
 from  the chin a little way until  the  bone appeared sound, the  incisor
 next the cuspidatus was extracted.   Room was next made by detaching
 the .s >ft parts below the base of the jaw,  near the chin, and from within
 the mouth, so as to  enable a probe  to be  introduced from within the
 mouth, and brought out below, by which a chain-saw was introduced be-
 low  the bone, and  tho jaw sawed  through from  below upwards.   The
 tumor  was now dissected  along  tho  side of the  tongue  and  from the
 pharynx.  As the dissection progressed, the masseter  was carefully de-
 tached from above the tumor, where it was sound, so as to preserve this
 sound and  upper portion  of the muscle, the lower part where it was at-
 tached to the tumor, being  in a diseased state and of course removed
with that mass.  The  exsected  end of the  divided  diseased bone in
front, afforded an excellent purchase for the hand, and the surgeon  after
resting, (at the request of the patioat,)  a  few moments, proceeded to
 detach completely all the  remaining adhesions of the sound portions of
the tissues and  connections both above and below and as near the  jaw
as could  conveniently be   done, without leaving unreinoved any of the
degenerated structure.  This diseased mass was thus isolated as per-
fectly as possible.
  A number of arterial branches were here necessarily divided, and the
hemorrhage in consequence exceedingly profuse, notwithstanding  the
ligature on the primitive  carotid.  Dr. Mott, in reflecting upon this cu-
 rious  phenomenon, and the one not perhaps  less so, that in two cases
where he rested 24  hours between  the tying of the carotid and the ex-
 section of the bone, he found comparatively speaking, no hemorrhage
whatever, considers  that  the first could  be in part explained in  this
manner.  When the operator after the ligature on  the carotid, as in  this
 case, proceeds at once to  the dissection and exsection of the bone  from
its connections, the distal  portions  of the cut branches of the  primitive
carotid not having  had time to contract or collapse, as it were, are yet
loaded with blood,  from the great vascularity of this neighborhood, and
 the current wliich has been for so long a time setting into and  upon the
 diseased growth.   They therefore  still retain their abnormal  diseased
 calibres, several of them  in  fact  which  would scarcely be  noticed, if
 they possessed only their  normal size,  appearing  as in this patient to
 have attained the diameter of a crow-quill, as for example, a branch of
 the internal maxillary, and one that a surgeon who was present thought,
 (erroneously  however  Dr. Mott  thinks,)  a branch of the superior  thy-
 roid.
  The consequence is, that on dividing these branches and  ramuscules
 there spouts from them a  strong, forcible, and continued stream, but not
 per saltum, as from  other arterial vessels, because the vis a tergo, in
 consequence of the ligature on the primitive truuk, is now cut off.  This
 steady, powerful, and voluminous stream, which in several spurted with
 great  force to the distance of  6 or  8  feet, spattering to  a considerable 
extra-articular exsections in particular.         361
 extent the operator and his assistants, is calculated to excite considera-
 ble  surprise  at first.   Dr.  Mott's  explanation is  this, that the cut
 branches are acting not only under a certain  portion of their inherent
 and natural contractile power, but under that of a reflux venous current
 into them. Whereas, when an interval of 24 hours has taken place after
 the ligature has been placed upon the carotid, its distal branches, i. c,
 those  above the point of arrestation of the blood have had time to con-
 tract in  proportion as the blood in those channels gradually passes from
 them into their corresponding veins, in its onward course to the heart.
 The calibres have  then, as it were, time to be effaced  by the natural
 systole of the artery, the walls themselves  of the vessel probably (a3
 some  late experiments would  prove,) becoming  partially agglutinated
 by the exudation of a plastic lymph.
   We think this explanation both plausible and philosophical.  Yet Dr.
 Mott  prefers to proceed at once to the exsection, immediately after the
 ligature  on the artery, because it makes one  operation, and  therefore
 avoids the increased danger of a double operation, and because it is bet-
 ter to  accomplish the object in view at once, if the nervous  system will
 admit  of it.   In four cases however, Dr. Mott says he has tied the ca-
 rotid on  one  day, and on tho next, removed the jaw, and in  the greater
 number of cases he has performed both operations on the same day.  He
 is well satisfied that  the  hemorrhage is less when the  artery has been
 secured  the day before the bone is removed.
   Having left the isolation of the coronoid and coracoid processes of the
 jaw and the disarticulation of  the  jaw itself as the last step in this for-
 midable  operation, the surgeon, from the loss of blood and the necessa-
 rily  painful  nature  of the extensive dissections  that had been  made,
 (though  this  singularly heroic youth, as  all remarked, scarcely  ever
 winced, or moved, or twiched a fibre of his face or uttered even a sigh,)
 thought it best now to rest for a few minutes.
   Third  Stage.—Some 15 to 20 different vessels having been now tied,
 in the  course of the operation, and one of the lymphatic  glands having
 been wholly  removed,  and  the  parotid divided in its whole length
 where  the commencing extremity of the incision had passed over it, Dr.
 Mott proceeded with great caution and firmness to separate the extrem-
 ity of the coronoid process  from the close attachment of the fibres of the
 temporal muscle inserted upon it, and finally  completely unbridling it
 from beneath the zygoma, reached in the  same manner by a firm, steady
 and rapid dissection  close  to  the  surface of the bone,  the neck, and
 finally  the articulating surface of the condyloid process  and that of its
 socket, the glenoid cavity, immediately in front of the meatus externus
 of the  ear, in doing which he was particular  to carry the knife close to
the bone, until he reached the articulation.   This may be considered an
important step to be observed by every operator,  in  order  to avoid
wounding the internal maxillary artery.  In the course of these dissec-
tions the  trunk of the portio dura nerve was  also  necessarily  divided as
 well as many  smaller nerves and vessels.
  In separating  the branches  of  the lower jaw from its connections
 about the temporal bone, it  may easily be conceived that not only con-
 siderable strength in the fingers and knife are required,  but  also great
 care in the movement of the instrument, for even when held as flatwise
  Vol. II.                  46
/ 
362
NEW ELEMENTS OF OPERATIVE SURGERY.
 and close as possible  to the surface of the  bone from which the firm
 fibrous and  periosteal adhesions are being detached, it  would be a very
 easy thing for its edge  to sever by some slight slip of the blade, some of
 the important vascular  and  nervous trunks  in  the  immediate neighbor-
 hood, as for example, the internal maxillary, as just stated.
   It is a singular fact that the only time  at which I could observe that
 this patient, (whose cool moral courage astonished all present,) uttered
 an audible moan was on placing  the ligature upon tho inferior dental
 artery.  The pain  must  have arisen from comprising some small fila-
 ment of nerve in the ligature, though care had  been taken  to  exclude
 the inferior maxillary nerve from the ligature.   As soon as the operator
 had reached the  articulation  of the jaw  the capsule  of the joint was
 speedily divided, and the whole bone down to its  exsected extremity
 instantly removed, together with all the diseased tissues upon  it.   The
 patient now presented in truth a frightful appearance,  yet he was  calm,
 still and collected through the whole of this trying  scene.  Nor can we
 suppose that the wine or brandy and water  which he occasionally took
 during the operation, and which had now lasted  over an  hour, had con-
 tributed to give  him any artificial power of enduring  such agony of pain
 as he must have  felt, with such unparalleled sang  froid and serenity.
 Before  the operation in fact, he  took only  20 drops  of  Magendie's
 solution of morphine, and a very little wine and water.   He was fully
 conscious and sensible through the whole of it, until the enormous cavity,
 and destruction  of  parts was  made  in the side of his  face  and head,
 appearing like some terrible wound, or as  if the operator had been dis-
 secting a human being alive and cutting his  throat, he continued to talk
 composedly, and  to  reply with the  utmost coolness possible to every
 question put to him.   The appearances now it would be difficult for any
 but an artist to depict.
  The enormous wound, exposing the tongue, upper-jaw and  fauces and
 right side of the  throat  up to the  styloid  process of the temporal bone,
 was now thoroughly sponged out with warm water, and a thin compress
 wet with warm water, and of  sufficient size, placed over  the raw sur-
face, and the flap brought down  nearly upon it, while  warm dry cloths
were gently applied outside over the  whole ; all which was judiciously
done  by the operator,  in order to  know the  worst of any concealed
hemorrhage, and to  encourage  it to appear, so that it would  not after-
wards be necessary  to cut the ligatures and re-open the wound aftei; the
sutures had been some hours inserted.
  In about half an hour, as there appeared to be no exudation of blood
whatever, the flap, after being held up a short time, was brought down
and neatly adjusted  to the lower border of the incision and fastened
accurately in its  proper position, especially below the vermilion border
of the lip, by a sufficient number (in all some 6 or 8)  points of inter-
rupted suture.  When the whole was properly placed in  coaptation, the
general contour of the face seemed now so natural in size and  form, and
the line of the wound was so little visible, that  one could scarcely re-
alize that there existed so much havoc and destruction of parts beneath.
  The incision upon the  carotid was also brought together, in the same
manner by two or three  sutures,  and  the  patient let to remain on the
table upon which he had  been bolstered  up, and where he  had  been 
            EXTRA-ARTICULAR EXSECTIONS IN PARTICULAR.         363

Operated upon.  Being now,  as  was to be expected,  somewhat  pallid
and  languid,  and the pulse  greatly reduced  in  frequency and  force,
though there was no actual syncope, this was met by a more liberal use
of warm wine  and water.   But  he  exhibited constantly the  same im-
perturbable calm and resolution which  he had during  the operation;
because he believed, as he said  before the operator began, and when he
took leave of  some of his young friends the day before, upon a higher
power than man.  It was  this  serene christian  faith and resignation
which was the true secret of  his incomparable and heroic courage.   I
have  seen such demonstrations, but none of so high  an order, on the
dying couch, from the same blessed consolation, which none  but  those
who have  imparted to them this priceless boon, and  through  divine
grace, can realize or enjoy.  And I have often said,  that if  any thing
were wanting  to convince me of the power of religion  on the heart, and
of the constant supervision  of the divine  Creator over human actions,
and the link between Him and the immortality of the soul, it would be
these sublime  moral spectacles in the hour of overwhelming tribulation
and unutterable anguish, and when reliance, and hope alone in our Al-
mighty Father, can disarm death and every mortal sorrow of their sting,
and  make us  triumph over every worldly desire  and the grave  itself.
This  patient recovered perfectly in a few weeks, nearly the whole wound
having healed by the first intention.  T.]

 Case of Exsection of part  of the Lower Jaw for Osteo-Sarcoma,  at
   Newark, New-Jersey.   By  Dr. Mott,  Thursday, Dec.  26,  1844.
   (Drawn up by P. S. Townsend, M. D.)

   The  patient H----, was aged about 35.   This was  a genuine case of
the malignant disease known  as osteo-sarcoma, but confined  almost ex-
clusively to the alveolar processes on the  left side  of the lower jaw,
which was the part exsected.
   The  patient was of rather tall, slender  make, pale  and  thin—with
dark hair—and of nervo-bilious temperament.   About two years  or
eighteen months before, during a quarrel,'he had received a severe blow
directly on this part of his jaw, from a man who knocked him  down.
About a year ago, the gums over this portion  outside began to show a
spongy livid appearance from the alveolar process, and its  periosteum
beneath having become previously inflamed and  swollen.  The  tumor
pushed the cheek out in this part, and its size was that of a pigeon's egg.
The warty bed of long fungoid  shoots, or vegetations, on the side of
the gum in front, had a very peculiar appearance, being generally about
a third to a half an inch in length, and in some places loose with fissures,
separating  them down to their roots, allowing of an  opportunity when
these roots were held apart, to notice the carious  foetid  portions  of the
alveoli, which were not yet wholly destroyed.  Such however, had been
the devastation within a year, that the three or four teeth which corres-
ponded to this part were so loose that they could  easily be moved with
the  finger, and of course  as readily taken out.  The surgeon, (Drs.
 Darcey, Pennington, Campfield,  &c, of Newark, being also present,)
 commenced his curvilinear incision at his  usual place in front of the
 meatus auditorius externus, and brought it down outside and under the 
364
NEW ELEMENTS OF OPERATIVE  SURGERY.
angle and base of the jaw close to tne latter, till coming to near the
symphysis of the chin, he terminated the division  below the border of
the lower lip.  The upper border of tho wound,  and sufficient of the
lower being  dissected  off to insulate the jaw and its tumor and  tissues,
and two or three vessels tied in the course of this  dissection, the chain-
saw was passed by a sharp thick  probe, first behind  the  front part
of the jaw, and that portion sawed perpendicularly from below upwards—
not however, without some difficulty from the saw  becoming pinched in
the bone.  In a few minutes after the same  saw was introduced in the
same manner, a little behind  the angle of the jaw,  and that portion saw-
ed obliquely  upward and forward—the last cut of  the saw reaching up
to near the  fungoid tumor—but evidently  outside of  the degenerate
structure, as the fresh, wholesome surface of the sawed bone  showed.
  The diseased portion was thus  completely isolated and exsected, being
about 3 inches in  extent along  the base of the  jaw, and less above.
After waiting a while  for any bleeding from the small vessels to cease,
and tying such of  the vessels that  required it—the  flap was brought
down, and the ligatures and straps applied in the usual manner.
  The patient  showed  much moral courage as well as physical force for
one so thin, pale,  and  apparently delicate  in  frame, as  he sat up in
a common chair, his head only supported behind, during  the whole oper-
ation.  The  hemorrhage for a temperament like this  was considerable,
but not important,  and there was not  the least syncooe or collapse,—
the pulse being almost unchanged by the operation.
   Feb.  26,  1845.—Having  read over on this  date  the above  sketch
to Dr.  Mott, he said  the patient had long since gone home quite recov-
ered.
   In alluding  to the cauliflower appearance  that the  soft parts  or gum
in this patient exhibited, Dr. Mott said that it possessed somewhat more
of the fungoid character than most cases of osteo-sarcoma.

 Claims of Dr. Mott  as the Author and Projector of the Operation of
                  Exsection .of the  Lower Jaw.

   We  cannot  permit  ourselves  to believe  that any surgeon of rank,
possessing the high moral character  which it  is presumable should, or
we might say must,  necessarily belong to  at  least the distinguished
members of  the medical profession, as the  guarantee of eminence and
respectability, would willingly or wilfully deprive  another of the honor
that belongs to him.
   It is therefore through sheer  inadvertence or ignorance, which some
might  call culpable, of the  true facts of the case, that must have per-
mitted a surgical  gentleman, while giving a public lecture in  the capital
of Dublin, at  a  public  medical  school, and his  subject  too,  On the
 Modern  Improvements  of Surgery, (See Lecture on that subject  by
John Houston, M.  D., M. R. I. A., introductory to a  course of Lectures
 on Surgery in the School of Medicine, Park  street, Dublin, delivered
 4th of November, 1844, and published in the  London  Lancet  for De-
 cember 28th, 1844, p. 393, et seq.,) to promulgate, as it were, ex cathe-
 dra,  and " by  authority,"  to  the rest of the  world, the  following
 sweeping eulogy, without a single word of qualification  in behalf of
 any other individual whatever:— 
             EXTRA-ARTICULAR EXSECTIONS IN PARTICULAR.         365

  " The grand exploit of amputating  the  lower jaw, even  from its
articulations, the boldness of which  has been only equalled by its suc-
cess, has now become a standard operation in surgery.   Persons afflicted
with the distressing and  loathsome disease [showing a drawing of it]
for which  this operation  is  undertaken, were formerly allowed to die
without  any idea being entertained of the  possibility of savino- them ;
but NOW THAT A GREAT  MIND, RELYING ON A  SOUND  KNOWLEDGE OF
the capabilities of the  human  frame, has set the example  of ex-
tirpating the diseased mass  in loto,  many surgeons have  fearlessly
followed in  the path thus  laid  open for them, and have derived honor
from the success which crowned  the  enterprise.  The success of this
operation—both  as regards  immunity from danger, rapidity of conva-
lescence, and the useful quality of masticatory apparatus which follows—
is almost incredible.
   " Mr.  Cusack (i. c, of  Dublin,  has  operated  twelve times, and here,
showing them)  [i.  c,  the audience] are the preparations, casts and
drawings of the whole series.  Now, in all  these cases there has been
but one  death, and that not  as  the  result of  the operation, but from
erysipelas."
   After  giving  the case  of a recent similar operation by Mr. Cusack,
as an illustration, Dr.  Houston concludes thus :—
   " And shall I not call  this a modern improvement in surgery, when
the great author and  champion of it is seated amongst us in this room."
(Loc cit., p. 394.)
   To  whomsoever, therefore, the  honor of  this great trumph belongs,
mutatis mutandis, the eulogium ought to apply equally well in Dr. Hous-
ton's conceptions, who, doubtless,  would not desire to diminish one iota
of  it, because a name by different  orthography  from  that of the justly
respected  Mr. Cusack, should  happen to be found by a species of ana-
plastic substitution, to  dovetail more completely than his with the historic
facts in the case.
   We say cheerfully with all our heart,palmam  qui meruit ferat !   We
will also shut our eyes  too  against such mis-interpretation as the ap-
parent intentional  suppression of all other names connected with this
matter than that of Mr. Cusack might naturally suggest, for the author
of the lecture is since, we regret to hear, deceased.

Extract from  the  Report of a Committee, upon the subject of Osteo-
   sarcoma  of the Lower Jaw to a  Medical Society of New-York,
   April 1st, 1830; D. L. Rodgers, M. D., Chairman. (See American
   Journal  of  the  Medical  Sciences:  Philadelphia, 1830, Vol. VI.
   p. 533,-534.)

   The committee to whom was referred the subject of " Operation upon
the Lower  Jaw," for  " Osteo-Sarcoma," report, That they have  dili-
gently examined the subject submitted to their inquiry, and have  found
much  difficulty in fixing the date of the different operations, and in set-
tling the priority of claims.   The operations for removing the  lower
jaw for osteo-sarcoma has  been so frequently  performed, and so well
established, that it  is  deemed unnecessary  at this time to discuss  the
propriety or practicability of the operation; we shall therefore confiue 
366
new elements of operative  surgery.
our investigations to the subject particularly referred to your committee,
viz.   " To whom are we indebted for the introduction of this operation."
In the examination which your committee have bestowed  upon this sub-
ject, they have not  been able to find in the  records of surgery a single
case in which a portion of the lower jaw was removed for  osteo-sarcoma,
or even a proposition to that effect prior to the year 1818.  In the Diet.
des Sciences Midicales, for 1818, the  operation for removing the lower
jaw for the cure of osteo-sarcoma is seriously proposed, and an allusion
is made to several  cases  which  proved fatal, and the casts of which
are to be  seen in the College of Medicine  at Paris.  But no  intima-
tion is there offered of the operation ever having been  performed  for
the removal  of this disease.   The credit of first removing the lower jaw
has generally been given  to M. Dupuytren.   It is true this  distin-
guished surgeon removed a portion of  the lower jaw for  a  "  Cancerous
Affection of  the Gums" in 1812.  This case was  reported by M. Lis-
franc  to the  Faculty of Medicine at Paris in 1813.  This report of M.
Lisfranc is republished  in the Diet, des Sciences  Midicales, for 1818,
t. XXIX., p. 430, who describes the case .throughout as a case of can-
cer, and accurately  describes its origin, extent, and  connections, under
the name of " Carcinome."   It is evident  from the silence that  was
observed upon the subject by the French writers, that it was not consid-
ered of much importance, as the case  was  found among the archives
of the Faculty of Medicine, and  not  brought forward until the year
1818.  It is mentioned in general among  the diseases of  the lower jaw,
in connection with  caries, osteo-sarcoma, &c, and it was at this time,
when  relating the operation of M. Dupuytren, that a removal of a por-
tion of the lower jaw for osteo-sarcoma was proposed.   The operation
of M. Dupuytren was for a different disease, and of smaller extent when
compared to those  performed for osteo-sarcoma.   It is evident that
this  operation  of M. Dupuytren cannot give him a prior  claim to the
removal of the lower jaw for osteo-sarcoma.  If the removal of a por-
tion  of the  bone is to  establish  the claim, then  Dr. Whitridge  might
with  as much propriety claim originality, as he extracted one-half of
the inferior  maxillary  bone for a necrosis ;  Decker removed  two-thirds
of the lower jaw,  and his  patient recovered.  (Medico-Chirurgical
Review, No. 28, p. 532.)   These operations were performed anterior
to the one performed  by M. Dupuytren, and thus far he has no claim
to originality, as there  exists no  greater resemblance between the ope-
rations of Decker and Dupuytren, than in the operations of the latter
and those of Professor Mott.
  Professor Pattison, who witnessed the operation of the French sur-
geon, makes the following remark:—" Dupuytren, when I was in Paris,
removed a considerable portion of the  angle of the jaw in a case where
a cancerous sore  was  situated  over it.   The extent of this operation
was however trifling when compared with those executed by Dr. Mott."
(Burns' Anatomy of the Head and Nek, Pattison's edition,  p. 485.)
   From the authorities which your committee have had it in their power
to consult, they are well satisfied that the  operation of M.  Dupuytren
should not be ranked  with  those formidable cases  reported by Mott,
Graefe, and  Lallemand.  Mr. Burns, in his  work on  the  Anatomy of
the Head and Neck, makes no mention of an operation for the removal
of the lower jaw for the cure of osteo-sarcoma. 
r*
•
             EXTRA-ARTICULAR EXSECTIONS  IN PARTICULAR.         367

  The first account given of this operation was by Professor Mott in
1822, (New-York Medical and Physical Journal, Vol. I.)  This ope
ration was  performed on the 19th November, 1821.  The case  was a
young woman, " aged seventeen years, of a healthy  appearance  and
good  constitution."   The  Professor  gives  a detailed and interesting
account of the disease.  From the  great extent of  the  morbid  parts,
the vascularity of its structure, and the great danger from inflammation
to be  apprehended  he considered it a necessary preparatory operation
to cut off the current of  blood by securing  the carotid artery in a liga-
ture ; the healing of the wound, and the rapid recovery of the case, is
doubtless much indebted to this  preparatory treatment; at all events
it was of great advantage in preventing an useless  loss  of blood—by
this means  preserving the energies  of the  system, and favoring the
rapid closure of  the wound.  Your  committee are conscious that many
surgeons  have removed  portions of the lower jaw without this precau-
tion, and  have had  cause to  regret  their bold exhibition of surgical
skill; nor do your committee believe that it is necessary to secure the
carotid  artery by ligature in every case in which a portion of the lower
jaw is removed, as several cases  are  reported in which  the operators
omitted it;  some of these cases were attended with terrible hemorrhage,
while others were too insignificant to afford much blood!  As an auxiliary
in preventing inflammation, no one can for a moment  doubt its influence,
who has witnessed the effect of cutting off the circulation from inflamed
parts.  This was in every  respect a successful  case, and at this  date,
(1830,) she [the patient] lives in the  enjoyment of good health, which
is the strongest testimony that we have to offer in favor of the operation.
Professor Mott has performed this operation six times—four of which
have been successful.

   [In connection with the subject of Dr. Mott's exclusive claims, as the
first surgeon who ever exsected the lower jaw for osteosarcoma, we here
subjoin  his recent letter to Mr. Liston of London, (See New York Jour-
nal of Medicine, No. 15, Vol. V., November, 1845, p. 413,414.)

          Letter from Prof. Mott to Dr. Liston, of  London.

       To Robert Liston, F. R. S., Prof., &c.
   My dear Sir,—The great object in all our  investigations ought to be
truth.  In no profession is it more  important than in the healing art.
Our noble profession, if exercised upon this basis, becomes an ornament
and blessing to our race.
  From  the distinguished  position  you are in, and the thousands  who
listen to your admirable lessons, and witness the skilful movements of
your knife in surgical operations, your opinion of a point of practice, or
the author of an  operation, will be powerful and lasting.
  You are in common with all men tenacious of your own rights, and I
cheerfully believe will magnanimously award  what is just and right to
others.   I appeal to  you  therefore as a professional friend, to weigh me
in  the balance of justice, and  I shall have great pleasure in awaiting
your decision.
   I claim for myself and for my country originality in the  operation of 
5t)°            NEW ELEMENTS OF OPERATIVE  SURGERY.

exsection of the lower jaw at the temporo-maxillary articulation, and in
different proportions for osteo-sarcoma.   I avow and  declare  solemnly,
that [before my first exsection  of the  lower jaw  for  osteo-sarcoma] 1
never saw, read, or heard of anything of the kind ever having been done
in any country.  There are surgeons now living in this city who saw my
first operation, and all  of them  will  cheerfully testify to the truth of
what I assert.
  Far be it from me to presume to say that other surgeons may not have
thought of the same expedient, and since executed  the same  operation
without the least knowledge of what had been done by me ; of one thing,
however, I am certain,  that an eminent surgeon  now in Paris, informed
me  that he took  the printed sheets of my first case with him to  Paris and
told M. Dupuytren of them; he (Dupuytren) requested a translation to
be  made,  stating,  that in a few  days he  would give a clinique on  that
subject.   The translation was made by my friend and handed to Dupuy-
tren.  He gave his lecture with my case in his hand, but made no allu-
sion to it.   My firm belief therefore is, that my operation for osteo-sar-
coma was performed before those  of this eminent surgeon [for that affec-
tion.]
  Some two or three years after the publication of my first  case, I read
an account of several cases which were operated upon  by my friend Dr.
Cusack, of Dublin.  Knowing as I do personally that distinguished sur-
geon, it never occurred to me to say anything in relation  to this subject
in all our intercourse in Dublin and Paris.  From whom  he derived the
idea, therefore, I know not; it may also have  been original with  him.
This, however, can only be answered by Dr. Cusack himself.   As  you
have stated in your lectures published in the Lancet, that  Dr. Cusack
was the first to perform the operation of exsection of  the lower jaw for
osteo-sarcoma, I have felt constrained to make to you  this  statement in
justice to myself.
  My first  operation  was  performed on the 17th November, 1821,  and
is published at length with plates  in the- " New York Medical  and Phy-
sical Journal," vol. I.,  p. 385.
  Since that period  I  have performed  the operation  seventeen times.
In three instances  the bone was removed at the temporo-maxillarv arti-
culation.  In one of the cases, the  bone was sawed through at tlie first
bicuspis tooth of the opposite side.*
  All surgeons of reading or observation must be aware  that from time
immemorial, either large portions or even the  totality of the lower jaw
have been removed or destroyed  by  violence, various accidents, and in
later times by gun-shot wounds, fire-arms, &c.  It has also long been fami-
liarly known that  partial or total destruction of  the lower jaw has been
spontaneously produced by the morbid processes of caries, necrosis, &c.
Thus nature herself, in  these latter cases particularly, pointing out as it
were to the surgeon, from the perfect restoration to health that has  suc-
ceeded to such disasters, that he himself might venture to follow in her
footsteps.
  For the great historical details, we refer to Velpeau's  Operative Sur-
gery, vol. III., Paris edition, 1839.
* See this case, with plates above, being that of the negro Prince. 
EXTRA-ARTICULAR EXSECTIONS IN PARTICULAR.         369
  But lastly, we repeat  and aver, that the exsection  of the lower jaw
of even a fourth part, much less a half or two-thirds of it, for any form
of sarcoma involving the whole  texture  of the bone, has never in our
opinion been performed by any surgeon, past or present, until by myself
at the time above stated.
  The onus probandi that my claims are  unfounded rests with others.
For my part, I know of no record in existence now, nor did I know of
any at the time I performed the operation, as I have already said, which
can in the slightest degree militate against my pretensions.
  Even admitting that M. Dupuytren did exsect a portion of the lower
jaw, prior to myself, it is conceded by Velpeau, who pronounces his oper-
ation altogether new, and a great triumph in surgery, that it was per-
formed for cancer and not for osteo-sarcoma.
  Indeed we find that so eminent an authority as M. Ribes (Diet, des
Sciences  Midicales, tome XXIX., page 431, Paris  edition) also posi-
tively asserts upon the testimony  of M. Lisfranc, who assisted at and
published an account of the above  operation of  M. Dupuytren in 1812,
that it was a cancerous degeneration; and  shows furthermore that M.
Ribes himself so considered it, he, in his preliminary observations on the
lower jaw in the same work, speaks in the following prophetic language,
in reference to the pleasing  anticipation that this exsection for cancer
would ultimately pave the way for a similar operation for  the cure of
that hitherto intractable  and fatal malady, osteo-sarcoma.  His words
are as follows: " These facts lead to the hope that fungus, or osteo-sar-
coma of the lower jaw, a disease so formidable, that it has in many cases
been  vainly attacked with the iron and fire, will  henceforward since the
operation performed by M. Dupuytren be removed by amputation  of  a
portion more or less considerable of the lower jaw, without the danger of
any accident, and if the disease is local, with a  certainty of success."
   We are also aware that M. Begin's (Diet, de Med. et de Chir. Pra-
tique, Paris, 1835, Vol. XIV., p. 259)  states that Dr. Fischer appears
to be one among the first who has performed the exsection of the inferior
maxillary bone at the temporo-maxillary  articulation.  His  operation
dates in the year 1795, and furthermore, M. Begin remarks (Idid.) that
he  has been  sucessively imitated by Mursinna, Graefe, Mott, Dzondi,
McClellan, Liston,  Jaeger, Dupuytren,  Walther  de Bonn, and  MM.
Gensoul and Lisfranc.
   So far  as the  disarticulation of this bone is  concerned,  M.  Velpeau
(the most accurate living authority in relation to  the history of surgery)
distinctly asserts that M.  Palmi was the first individual who first disar-
ticulated the lower jaw.*
   For ourselves we  can assert, that without attempting to imitate any
of our predecessors, the  disarticulation  of the  lower jaw,  whore we
have  resorted  to this, has been performed by us purely in reference to
the exigencies of the  case and presented while exsectiug  this  bone for

  * Dr. W. H. Deadrich, of Athens, Tennessee, published in the sixth volume of the "Ameri-
can Medical Recorder" for 1823, an account of an operation by which he removed the lower
jaw from the angle to the centre of the chin, for a large cartilaginous tumor, which ocoasioned
great difficulty in swallowing and breathing  The patient was a lad fourteen years old, and the
operation was performed  in 1810.  This boy had a speedy recovery.  This was made public
two yoars after the publication of my first operation.—V. M.
   Vol. II.                    47
i 
370
NEW ELEMENTS OF OPERATIVE SURGERY.
 osteo-sarcoma, and  that we claim priority and originality both for the
 exsection for osteo-sarcoma, as well as for the single curvilinear incision
 below the base of the jaw, by which the  operation is accomplished.
        With considerations of the highest respect,
                 Believe me to be, truly your friend,
                                            VALENTINE MOTT.
   New York, Sept. 30,1845.

   Another  case of exsection by Dr. Mott, viz., that of the ends of an
 ununited fracture of the os brachii, will be found above, under the head
 of Ununited Fractures—Exsections.
   To these are to be added  for years past various other exsections,
 almost  invariably with a  happy issue, of portions both  of the  upper
 and lower jaws, their dental borders, &c, &c, which he has not deemed
 of sufficient importance to publish the details of.  T.]

   [We  subjoin the  following from among the  cases in which we  have
 exsected the lower jaw.  We have found  but one example recorded
 analagous to Case 1st, and  in that the jaw was removed  by  Mr. An-
 thony White, of Westminster Hospital, London, and is reported by Mr.
 South in the 3d volume of  his edition  of  Chelius.   Cases  III. and IV.,
 are  interesting from the  fact, that extensive  plastic operations  were
 likewise required, as well as from other practical bearings.
   Case I.—Caries.—Peter H.  Fowler,  of  Montgomery  Orange Co.,
 N. Y., came under my care in February, 1848.   From the history of the
 case I learned that, in the  latter part  of  December,  1847, Mr. F. had
 experienced considerable  uneasiness about the left  angle  of the jaw,
 which he  attributed to the irritation excited by the  fangs of a decayed
 molar (last) tooth, and  which were removed by his attending physician,
 Dr. Evans, of Walden.  This proceeding, however,  afforded no perma-
 nent relief;  his face began to swell, his breath to become offensive, and
 in a  short time several openings communicated externally with the bone.
 At the time  of my first visit, Feb. 19th, the lower part of the left side of
 the face was greatly swollen, and presented  a  fungoid appearance.  On
 making  free incision into the swelling, exit was  given to a considerable
quantity of matter, resembling that which usually is found in the  vicinity
 of a diseased  bone.  A probe, passed  through the  openings,  at  once
struck upon the denuded bone, which was evidently  in a carious condi-
 tion.  The patient thought  he  could distinctly  feel a loose portion of
 bone, but  in this he • was mistaken. A careful examination led  us to
 conclude that the bone must be in a carious  condition, from near the
symphisis to the angle of the jaw, and to propose  its removal.   Feb.
 26th, with the assistance of  Drs. Evans, Crawford and Eager of Mont-
 gomery, and Phinney of Newburgh, I  proceeded to operate.   During
 the week which had passed since my last visit, the  patient's condition
 had become  much worse, for he was now  strongly threatened with suf-
 focation from the quantity of matter which ran down his throat, when-
 ever he attempted to sleep.  This, together with the  cough which was
 excited  by the same cause,  rapidly exhausted  his strength, and gave a
serious aspect to his case.   Supposing the disease  to be limited to the
 points  above specified, my  first  incision  was made  through the  enor 
            EXTRA-ARTICULAR  EXSECTIONS IN PARTICULAR.        371

mously swollen cheek, from the angle of the jaw, in a horizontal line, to
a point about three quarters of an inch below the commissure of the lip.
The knife was passed directly down to the bone, and the latter cleared
as rapidly as possible from the soft parts  by  which it was surrounded.
The hemorrhage from the facial vessels was small, and  no ligature was
necessary.   On reaching the  inner angle of the jaw, we found a large
pouch of most offensive  matter, which had burrowed between the pteiy-
goid muscles and the bone, and which  so encroached upon the pharynx
as to add to the danger of the impending suffocation.  This was scooped
out, and our exploration continued  along the inner side of  the  ramus,
which was found to be in such a ragged condition, as to leave no doubt
in the minds of all present as to the propriety of its removal.  Another
incision was, therefore, made from the  zygomatic process along the pos-
terior margin of the  ramus, till it met the outer  border of that which
had been made along the base of the jaw.  Considerable  difficulty was
experienced in our attempts to  disarticulate the bone, as the condyloid
process was immovably bound to the glenoid  cavity by a deposit of bone.
This was finally'ruptured, and the  operation completed.   The only
hemorrhage with which we had to contend  in the latter part  of our
proceedings was occasioned by a plunge  of  the  patient,  which nearly
upset me, and caused me to divide, either the  main truuk or one of the
largest branches of the internal maxillary artery.   Owing to the retrac-
tion of the vessel, it was found impossible to apply a  ligature ; but the
bleeding was easily restrained  by pressing a piece of  sponge into the
wound.   On account of the  absolute  impossibility of ascertaining the
boundaries of the  disease before we commenced, the  operation was
necessarily protracted, and, we need not add, severe.  Our patient was,
of course, greatly prostrated ;  not, however, by  hemorrhage, .for that
was but trifling,—but from the shock which so formidable a proceeding
must almost invariably  produce.  For some months after the operation
he continued to improve in strength.  The symptoms of impending suf-
focation, and the cough  which  had previously harassed him, immedi-
ately disappeared.  The tumefaction of the face, however, not only con-
tinued, but, in a few weeks, began  to increase.  Abscesses still formed
occasionally around the  eye and temple, which were opened, when they
discharged a  large quantity of  matter.  Indeed, the whole  progress of
the case up to the present time  (March 15th, 1852) has been so pecu-
liar, that we are tempted to insert in this  place  the  following extract
from a letter of Dr. Evans, his attending physician, dated Sept. 2,1850.
  " The operation was  performed Feb. 26th, 1848.  The wound never
healed; fungus  granulations  filled it, and the adjacent parts seemed to
degenerate into a similar fungoid condition.  This  gradually extended
over the neck, and now, two  and a  half  years since the operation, it
reaches within an inch of the clavicle.  The  glands on the  other side
of the neck are enlarged and very hard.  Their size varies considerably
at different times.   The skin  over  the neck  is hard  and  unyielding,
which causes his head to be constantly bent forwards.   This _ indurated
condition of the parts about the trachea, by the stricture which it pro-
duces, seriously affects his  respiration. For the  last eight  months he
has been obliged to  sleep in  a chair, 4n the erect position.  Fungus
growths  sprouted  from the different  points  where the  abscesses had 
372
NEW ELEMENTS OF OPERATIVE SURGERY.
been opened.   His present condition, compared with that which he pre-
sented one year ago, is as follows : the abscesses on his temple  and in
the vicinity of his eye, are slowly improving.  The fungus on the lower
part of his face and neck, extends  over a larger surface, and continues
gradually to spread.  The  glands  on the other side of his neck, one-
half larger.  His  general  health  rather better, which he attributes to
the use of Lugol's solution  of Iodine, which  he  commenced taking last
spring.   A few  days since  I put him  on Iodide of Iron.   I  think his
lungs still retain their integrity.   Every winter ho runs down, and comes
out quite feeble in  the spring.  During the summer  he again recruits.
In the winter he is troubled with indigestion, when his  respiration is al-
ways worse, the agony sometimes  being  intense.   You recollect that
Prof.----and Dr.----considered his disease cancer.  Time has shown
that they were mistaken.  Pus  always has, and still  does  form in ab-
scesses.  It is never thin and  ichorus, but always of a good character.
From the present condition  of his throat, and the effects of  winter upon
him, I doubt whether he can survive another  spring."  This patient is
now, April 1855, in perfect health.
  Case II.— Osteo-Sarcoma.—On  the 25th of March, 1848, I removed
the  left  half of  the lower jaw, from the chin to  the  articulation.  The
patient, aged 14, a son of Mr. J. P. Cole, of Wantage) Sussex Co., N. J.,
was  affected  with  osteo-sarcoma.  The tumor, of  three years growth,
commenced near the left angle of  the jaw, and at the time of my visit,
had  attained the size  of  a goose  egg.  It gave rise to no pain, but its
growth was rapid, having in six* months before the operation increased
more than in the previous two and a half years.  With the assistance
of Dr. Cooper, and several physicians  from  the adjoining towns, I pro-
ceeded tp operate.  An  incision was  commenced  beneath  the zygoma,
and was carried along near the posterior border of  the ramus and infe-
rior edge of the base of the jaw, to a point below  the chin.  The he-
morrhage from the facial veinV was considerable ; but with that from the
facial artery soon subsided.  No ligature to this artery was required.
Only one vessel, a branch from the internal  maxillary, was tied.  The
bone was divided by a saw  at the symphisis, and the dissection carried
to the articulation.   Though the patient had been insensible to pain, from
the  use of chloroform, yet when  the operation, which  lasted about 25
minutes was completed, he appeared to be greatly prostrated.  He soon
rallied, however, when the wound was lightly dressed, and with the ex-
ception of a slight erysipelatous  attack of  the wound, his recovery was
rapid.   I saw the  patient two and  half years after the operation, when
he was working in  the hay  field,  in perfect health.   The trifling defor-
mity remaining was indeed  surprising.   A firm fibro-cartilaginous band
supplied the place of  the removed  bone, and his power of mastication
was most excellent.  Four  years have now passed since the operation,
and as we  have recently been informed, his health is in every respect
perfect.  The tumor, which involved  nearly the whole body of  the ra-
mus, is now in the Museum of the  College of Physicians and Surgeons,
N. Y., and has  been  pronounced by able pathologists  to be a beautiful
specimen of osteo-sarcoma.
    Case. III.—Carcinoma.—Mr. Nolty, of Newburgh, about 45 years
of  a<re.  Had  submitted two  or three times to the excision of a small 
            EXTRA-ARTICULAR EXSECTIONS IN PARTICULAR.         373

rjortion  of the  lip and bone, affected  with  carcinoma, before he came
under my care.  In every instance, shortly after the healing of the wound,
the disease had returned.  At the patient's  urgent request, and against
my own judgment, on the 30th August, 1848,1 removed the entire low-
er lip, together with  a portion of the symphisis.  A new lip was formed
by  cutting  through the cheeks on each side  from the commissure of the
mouth.   These incisions extended  through  the whole substance of the
cheek, except the lining membrane, and  extended about an inch and a
half on each side.   The portion of the cheeks  divided, immediately re-
tracted, leaving sufficient of the lining membrane to form the vermillion
border.  This  membrane was  divided close to the level of the inferior
margin of the  upper part of the wound, and reflected over the borders
of the upper part of the lower edge.  Then the cheeks were detached
from  the bone towards the angles of the jaw, and drawn  together in the
median line.   The patient was seen some months afterwards by one of
the most eminent surgeons in N. Y., who pronounced it the best speci-
men of cheiloplasty that he had ever seen.   Some time after this, the
disease again  appeared.  He submitted to  another still  more extensive
operation by  another  surgeon, and after lingering in a miserable condi-
tion for nearly a year,  died.
   Prof.  Gross, in his very able Report on the results of  surgical opera-
tions in malignant diseases, Trans. Amer. Med. Assoc Vol. VI.  p. 181,
remarks, that the above is one of the most  remarkable cases  on record
showing that life may be prolonged in these instances by repeated ope-
rations, no less than five having been performed on this patient between
1844, and 1851, the date of  his death.
   Case III.—Osteo-Sarcoma.—Miss Fowler, aged 18, of Milton, Ulster
Co., N. Y., first  perceived an enlargement on the right side of the sym-
phisis some few months before  I saw her in the spring of 1850.   Its
growth was rapid ;  but she suffered no pain.  At the time of the opera-
tion (in March, 1850,) the tumor involved the  parts from the first molar
on the  right to the bicusped on the left side.  An incision  was made
across  the  under surface of the base of the lower jaw ; the soft parts
were then reflected, and the bone was divided through sound portions of
the bone.   In this case, I had a large  needle, armed with a strong cord,
ready to use in case of retraction of the tongue, but from what occurred
 when  the tongue was  severed from the bone,  (the patient being nearly
 suffocated,) I shall never again remove the whole of the symphisis with-
 out having properly secured the tongue.   Chloroform worked  admirably
 in this case.   For some 12 hours after the operation, I thought I should
 lose  my patient from  hemorrhage ; not from any particular artery, but
but from a general oozing from all  the  divided parts.  This, however,
was finally checked, and the patient in a few days left Newburgh (where
the operation  was  performed)  with  the wound healed.  Four weeks
 after the operation I had  the pleasure of dining with her, and was sur-
 prised  to see her powers  of speech  and mastication, which,  of course,
 were  at first, entirely destroyed.  For a  few days, indeed, she took her
 food through a large gum elastic tube passed into the throat.  This pa-
 tient is now, we  believe, in perfect  health, and scarcely any deformity
 has resulted from the operation.  In this  case  I was ably assisted by 
d74            NEW ELEMENTS OP  OPERATIVE SURGERY.

my friends, Drs. Gardner, Drake and  others, of Newburgh, and Dr.
James L. Van Iugen, of Schenectady.
   Case IV.—Carcinoma.—Peter Space of Sussex Co., N. J., consult-
ed me in the early part of August,  1850.  For,two or three years he
had suffered from a carcinomatous  affection of the lower lip, which, al-
though once excised, had now involved in one mass of destruction, not
only the soft parts covering the bone, but the bone itself from the second
molar tooth on the right side to the first molar on the  left.   His condi-
tion was truly deplorable.  His sufferings were great, not only from the
pain with which he was harassed, but from the offensive discharge which
ran down  his throat whenever he  attempted to sleep.  The odor, too,
which he was obliged constantly to inhale, was most disgusting.   The
glands of the neck were free  from disease, his pulse was about 80, and
there was every reason  to believe from his appearance, that, contrary to
his wishes, his  life might be  prolonged  for sevoral months.  He was
candidly told that all he could expect from any operation, would be the
removal of the huge mass of disease from the situation it then occupied,
to one which would perhaps be more tolerable, a cure being entirely out
of the question.  He was anxious for the  operation,  and on the 12th of
August, assisted  by Dr. Alexander Linn, of Dickertown, Dr. Winfield,
of Middletown, and Dr. Cooper, of Wantage, I removed the affected
parts.  The patient, without my knowledge, had during the day taken
large doses of  opium to blunt his  sensibility to pain during  the opera-
tion, and whether it was owing to this cause or some other, I know not,
but chloroform served only  to render  him  boisterous, and we were
obliged to discontinue  its use.  Though  I had taken the precaution to
pass a strong cord  through the tongue, and had intrusted this to an as-
sistant, still the  moment it was separated  from  its attachments  to the
bone, its retraction was so violent, that  in the act of suffocation, he fell
backwards to  the floor, carrying  with  him some two of the assistants
who were supporting his head.  I immediately seized  his head with my
left hand, and pressed  it forwards and downwards, while with my right,
I grasped the  cord, and pulled  the tongue out of his mouth.   At this
stage of the operation, matters presented  truly a frightful appearance,
and  for a few  moments I was very apprehensive of a fatal termination.
The tongue having been properly secured, the patient again rallied, when
I endeavored,  by detaching the  skin from the neck to cover by a plastic
operation the huge cavity I had formed.   To effect this, however, I was
obliged to loosen also  that covering  both  upper jaw  bones, which was
drawn downwards to meet that taken from the neck.  In this manner I
succeeded beyond  my own expectations in accomplishing the object in-
tended.  After securing the  tongue and  dressing the wound, I left the
miserable patient in the care of  Dr. Linn, who, with Dr. Cooper, kindly
attended to the subsequent treatment of the case.  On the  25th August,
13 days after the operation, Dr. Linn thus wrote me a letter, from which
the following is an extract:
   " I am happy to be able to  inform you,  that our patient, Space, is do-
in"1 well.   When I visited him the next day, (after  the operation,) I
perceived the integuments on the right side of the face were somewhat
discolored, and  in a few days a considerable portion  of them sloughed
out  leaving the mouth of very uncouth dimensions.  In  all other re- 
EXTRA-ARTICULAR EXSECTIONS IN PARTICULAR.         375
spects the case is doing well, union by the first intention  having taken
place throughout.   His general health is good, and the deformity of the
face, though great, far less disgusting than previous to the operation."
   On the 28th of January, 1851, some five and a half  months after the
operation, Dr. Linn wrote me again, as follows:
   " I am sorry to inform you that y<aur patient, Space, is in a most de-
plorable condition.  A few weeks after I had  discontinued my visits,
(his face having nicely healed, and  there being no appearance of a re-
turn of the  disease, when  I dismissed  him, cured,) I found ulceration
had commenced in the mesial line, below the tongue, involving the glands
in  the  vicinity.  The whole  of the anterior  part of the neck, from the
tongue to the top  of the  sternum, is one diseased mass, covered by a
most foul stinking ulcer.  A  number of the glands  in  the vicinity have
suppurated, and then healed.  There  are many enlarged glands about
the thorax.   His general health is failing, and altogether he is the most
pitiable object imaginable."
   He died in less than a year  after the operation.—Was the operation
justifiable  in this case, on the  grounds for which it was undertaken ?
If not, did the success obtained in Dupuytren's first case, (Lesier,) in
1812, offer any encouragement  to my patient ?  Let  those who are dis-
posed  to condemn my operation carefully peruse that to which we have
alluded, and in which the celebrated French  surgeon is said to have op-
erated for Carcinoma.  G. C. B.]

                     Article  VI.—Upper  Jaw.

   Encouraged  by his  first successes, and by the instances of destruc-
tion of the sinus  and  certain  serious lesions  of the  upper  maxillary
bone, which  had cured spontaneously, Dupuytren soon conceived that
the upper jaw also might  be exsected.   It appears likewise that\Acol-
uthus (Mem. de VAcad. Royale de  Chir.,t. V., 1819, had already\per-
formed this  operation,  in  1693, for a tumor of the face, and that\his
patient had recovered.  Camper also speaks of a patient in whom tfye
upper  maxillary  bone came  away entire, and who, however, survived.
Ruysch, (Obs.  Anat. et Chir., Obs. 48, p. 67,in French,) in extirpating
a fungous excrescence  from  the palate, removed, at the same time, the
carious bone which gave origin to it, and cauterized the  bottom of the
wound.  In a case of sarcoma, of the  size  of two fists, mentioned by
Planque, (Bibliot. de Mid., t. XXIII., p. 70, in 12mo,)  the cheek was
divided in order to excise the tumor, and two or three teeth and a portion
of the corresponding bone removed with it.   The patient recovered.
The partial exsection of the upper jaw, in a case of fungus of the sinus,
had also been performed by David, (Sprengel, t. VIII., p. 281,) and by
Beaupreau, (Acad, de  Chir., in 12mo., t. XII., p. 56,) who, however,
removed only the alveolar border.   Siebold (Annates de Mid. d'Altem-
bourg, Fevrier, 1808) also relates one  of the most remarkable cases
of this kind.   The  tumor, which occupied the left maxillary fossa, had,
in the space of twelve years, acquired such volume.and assumed an aspect
so revolting, that the  magistrates had the patient  confined to his  own
apartments.   In 1800 this  tumor  extended from the right canine tooth
to the left molar, occupying  the whole of that portion of the alveolar 
376
NEW ELEMENTS OP OPERATIVE SURGERY.
border, and  made a very considerable  protrusion externally.   After
having  separated  it from the  upper lip, its exsection was made with
the saw, and the  tumor extirpated  entire.   The pain and  hemorrhage
were much less than had been apprehended ; the maxillary sinus, which
was divided  into  two cavities, having been laid open, was cauterized
with hot iron, and  in six weeks the patient left the hospital perfectly
cured.  Bidlooand Desault, however, who  had also both conceived the
possibility of this  operation, and which moreover  had been performed
by  Deschamps in 1804, and by Klein in 1805, (Jaeger, Op. cit., p. 12,)
confined themselves to recommending it without, however, ever having,
as it appears, performed it.

                         §  I.—Indications.

  These ideas though vague and imperfectly defined, take away however,
as we  perceive, all the merit of invention from  the moderns on  the
subject which we have under consideration ; and which subject moreover
is, in reality  divided into two parts, that of the exsection and that of
the disarticulation  of the bone.
  M. Pillard, (Lancette  Frangaise, t II., p. 264;  Clin, des Hopitaux,
t. III., p. 81,) asserts, and the bulletins of the faculty establish the fact
that Dupuytren, (Bulletin de la Fac de Mid., t. VII., p. 21,)  had re-
course to the first of these operations in 1819 and to the second in  1824.
M. Pillet, (Lancette Frangaise, t,  II., p. 284,) who maintains  that up
to that time M. Gensoul alone had performed this last operation, asserts
that the patient of  Dupuytren died at the  Salpetrierc, and that a portion
of the jaw had been left behind.   It was in  the year  1826,  that M.
Lizars who also claims priority in this operation, first proposed it,  and
afterwards in 1827, 1828 and 1830, performed it with success.  But as
it appears to me, too much importance has been given by all parties to
this dispute.  From all times past, there have been performed exsections
of some portions of the upper jaw ; in our times we have gone farther;
more at least, and  that comprehends the wholo  question.   Though  this
bone should have been removed in its totality, which is not easy to prove,
even that would  not merit the title of an  invention.   This discussion
therefore does not  deserve any farther attention to be given to it.   The
merit of M.  Gensoul consists in having devised a process by which we
are enabled  according to fixed and  precise rules, to disarticulate  the
jaw, instead  of excising or amputating it in the manner this operation
has been performed by Dupuytren, MM. Wattman three times in 1820  ;
Graefe three  times in 1823, Textor, Robinson, Jaeger, Chelius, (Jaeger,
 Op. cit., p. 12—13,) and Liston and all the other surgeons of whom I
am about to speak.
   [As Prof. Syme  still claims priority in this operation, we have thought
proper, notwithstanding our author's dismissal  of the question, to pre-
sent the following  facts:
   Dr. Jameson of Baltimore, on the 11th of November, 1820, removed
 an enormous fungoid tumor involving nearly the  entire  body of the
 maxillary bone.   The carotid was  tied as a preliminary measure.   Full
 details of this case are given in the American' Medical  Recorder, Vol.
 TV. 1821, p. 222.  Accompanying the report, is a graphic illustration 
EXTRA-ARTICULAR EXSECTIONS IN PARTICULAR.         377
of the appearance of the patient  before  the operation.  Three months
afterwards, he was in perfect health.   In August, 1823, Dr. Alexander
W. Stevens, of this city, removed  a large portion of the upper jaw for a
disease of the antrum, and  seven years  afterwards his patient was in
perfect health.  (Velpeau's Surgical Anatomy with an Appendix, by
John W. Sterling, Vol. II. p. 518, N. Y.  1830.)   Dr. Stevens claims,
and  we believe justly, that he was the  first to operate upon  the  now
established principle, of cutting through  the sound and not the diseased
parts.
  Dr.  David L. Rodgers, of N. Y., in May,*1824, successfully removed
the greater portion of the upper-jaw affected with osteo-sarcoma (N.  Y.
Med. 8f Phys. Journal, Vol.  3d.)  Mr. Lizars of Edinburgh,  in 1826,
proposed  the entire  removal of the upper-jaw, and described  at length
the plan adapted to this purpose.  (A System of Anatomical Plates, &o.
Part XX., 1826.)   In December 1827, he attempted to carry  this  plan
into  execution, for the  removal of a medullary sarcomatous tumor of
the antrum, but was obliged  to  desist on account of the  hemorrhage.
On  the 26th  of May, 1827, Gensoul,  of  Lyons removed the entire
superior maxillary bone, with the whole of the palate bone.   His patient
recovered.  (Lettres  Chirurgical sur  quelques  Maladies  graves du
Sinus  Maxillaire, 8rc,ip. 18.)  On the 1st of August, 1829, Mr. Lizars
performed his second  operation which was completely successful, and
yet,  in  the face of these facts, and  those  recorded by our  author, we
find  Mr. Syme in 1848  using the  following language: " In that year,
(1829,) I proved, by the  operation, the  practicability of removing the
upper-jaw, and  established a  plan of proceeding, which, without  any
alteration  except as to the subordinate details, has  since been adopted
by the profession!"   G. C. B.]

                     § II.— Operative Process.

  In  certain  cases  Dupuytren confined himself to exsection of  the
alveolar border only, by means of the cutting pliers, or the gouge and
mallet; in other cases he has  found it advisable to execute  certain in-
cisions  upon the  face, in order to effect the more complete removal of
the osteo-sarcom, and many of  his patients who -were thus  treated were
well cured. One of those of M.  Gensoul was perfectly re-established.
M. Syme,  (Lancet, 1829, t. II.,  p. 677,) who made trial of this operation
in the  beginning of the year 1829, for a  cancerous  tumor  of very  con-
siderable  volume, thought it advisable to make a crusial  incision, one
of the branches of which terminated at the corresponding  commissure
of the  lips, then to dissect off,  and turn back  the  four flaps, and to
exsect the tumor by means of a saw and chisel, and a very strong scalpel.
At the expiration  of some  months, vegetations of a doubtful character
led to the  apprehension of a return of the primitive disease.
  The three successful cases of M.  Lizars, in two of which  he  pre-
viously  tied the carotid,  having been  obtained in diseases,  and by
processes  of various kinds, cannot serve as a basis for the operative
manual.   The cure of his two first cases also, was only temporary.   In
disarticulating the upper jaw,  M. Robert, (Gaz. des Hop., 1834,)  fol-
lowed very nearly  the process of M. Gensoul; while M. Sanson,  (Rev.
  Vol.  II.                 48 
378
NEW ELEMENTS OP OPERATIVE SURGERY.
 Med., 1834, p. 313,) confined  himself to excision.   M. V. Mott having
 performed  this operation  fourteen times, must also have been obliged
 to employ various processes.
    A.  M. Gensoul asserts (Lettre Chir., etc., p. 12—49,1833,) that he
 has removed the maxillary, malar and palatine bones:  that he has eight
 times extracted and several times excised the first of these bones; that
 in one case he removed  the pterygoid process itself down to its base ;
 that six of  his patients recovered, and that in two others the cancer re-
 turned.  This is his process: A quadrangular  flap raised  up on the
 orbit and forehead ; four strokes  upon the chisel, one on the summit of
 the external orbitar process, one on  the  zygomatic arch, one on the os
 unguis, and ascending process, and the fourth on the middle of the jaw
 below and under the nose, to detach or to disarticulate  the bone, after
 which some cuts with  the bistoury to complete the division of  the soft
 parts, constitute the whole operation.
   B.  M. Lisfranc  laid  bare the  facial  tumor with a V incision, cut
 through the naso-palatine septum with M. Colombat's pliers, and termi-
 nated the operation with  the gouge and mallet.   In 1823, M. A. H.
 Stevens, [of New-York,] for a similar case made use of a flexible saw
 which he inserted through the bone by means  of a puncture;  while in
 1824, M. Rogers, [Dr. David L. Rogers, of New-York,] who removed
 the jaw on both sides down to the pterygoid processes, scarcely found it
 necessary  to  divide the lip.   To the cases of this operation  already
 known, it is necessary to add the one which  M. Piedagnel, (Bull, de
 Fer., t. XV., p. 294,) observed in 1818,  in the  service of Beauchene,
 that which  M. Lafont, (Arch. Gin. de Med., t. XXVIL, p. 264,) com-
 municated to the Academy, the successful case of M. Syme,  (Edinb. Sr
 Surgical Jour., t. CXXXVIL, p. 382,) and that of M. Georgi, (Bull.
 de  Fer., t. X., p. 83.)  M. Guthrie, (Encyclogr. Med.,  1836,  p. 42—
 44,) who has performed it three times  was obliged in one of his  pa-
 tients to take away at the same time the malar bone, os unguis and in-
 ferior turbinated bone.   M. Warren has  also perfectly succeeded in his
 cases.   Though M. Regnoli, (Compte-rendu  de la Clin., etc., 1837,)
 removed only the  alveolar border, and   M.  Serre, Encylogr. Mid.,
 1836, p. 104,) confined  himself to the excision of the wall of the sinus
 maxillare, M. Stilling, (Journ.  des Progres, t.  X., p 239,) is of opinion
 that he removed the whole bone.   M. Krimer, (Ibid., t. II., p. 5 ; t.
 III., p. 239;  Bull, de  Fir., t. XX., p. 217,) and M. Samel have noticed
 something still more interesting:  in  their patients  the teeth have been
 reproduced!
    C.  The  Author.—I also have  had occasion to perform exsection of
 the upper  jaw in a woman aged  forty-five years.   All  the molar teeth
 of  the left side had been extracted or destroyed.   An opening capable
. of admitting the extremity of the finger, allowed of an easy  explora-
 tion of the interior of  the maxillary sinus, which was covered  with
 bleeding vegetations.  The borders of this sinus also in a fungous state
 were hard and lardaceous, and  blended  with the surrounding tissues.
 Many portions of  necrosed bone connected with its outer and  anterior
 walls were noticed in the midst of the  degeneration, which extended
 back to the  velum of the  palate, in front to the incisor teeth, and in- 
EXTRA-ARTICULAR EXSECTIONS IN PARTICULAR.         379
wards to near the  median line.   The operation was performed in the
fore part of July, 1829, at the Hospital of Saint Antoine.
  First  Stage.—An incision commenced at the commissure of the lips
and carried  obliquely  upwards, outwards and backwards, as far as the
temporal fossa, between the external orbitar angle and the external ear
enabled me to avoid with certainty the duct  of the parotid gland, and to
raise up in front, after having dissected it,  a triangular flap comprising
all  the soft parts  which cover the malar bone and the canine fossa.
  Second  Stage.—With one stroke of the saw applied immediately un-
der  the orbit, I divided the projecting portion of the zygoma, and  pene-
trated into the sinus;  by means of a very strong scalpel, shaped like  a
pruning-knife, I divided, after having  extracted one of  the incisor teeth,
the jaw  in front, so  as to unite the second section with the first;  by  a
third cut I prolonged  the incision from the hard parts to the molar tu-
berosity.  By this means I cut  round all the lardaceous tissues, a great
portion of the necrosed bones, and the totality of the facial  walls of the
sinus.  With  the point of the same instrument introduced into  the inte-
rior of the mouth, I  divided  the  horizontal portion of the  vault of the
palate in a direction parallel with the median line.  I then returned to
scrape the floor  of the orbit, and made use of the dissecting forceps to
extract several lamellae which remained behind, and which belonged to
the.  palatine  bone, the posterior wall of the  sinus, or to the  orbitar cav-
ity  itself.  In one part, I was obliged to penetrate to the zygomatic fos-
sa,  and  in another, into the interior of the orbit.  I could then satisfy
myself that the bones  which divide this last cavity  from the antrum
highmorianum  had been destroyed, for the finger, carried to the bottom
of the wound, raised the globe of the eye forwards, and reversed it un-
der the upper eyelid.
   Third  Stage.—Under the fear  that some fungosities or fragments of
diseased bone  might have  escaped my researches, I applied the red-hot
iron over the whole extent  of this large excavation.  After having filled
the  wound with  small balls  of lint, I united the two lips  by  means of
four needles and the twisted suture, and supported the whole by a sim-
ple  containing bandage.   The general and local symptoms, which were
quite serious  for two days,  soon  subsided.   On the fifth day the whole
wound was cleansed,  and I removed the two last points of  suture.  At
the  end  of eight  days the suppuration had  ceased to become foetid.
When I quitted the service of the hospital three weeks after, the interior
of the mouth was of a healthy color,  scarcely sensitive, and in  progress
of cicatrization.  I learned that this woman returned home before being
completely cured, and  that, in some months after, her primitive disease
returned.  In a  patient whom  I  operated upon in the same hospital in
1830, and  in whom nothing more  was required than the excision of the
left alveolar border, the cure was completed on the twelfth day, and the
patient has remained  perfectly well ever since.
  III. If, however, the disease  should  seem  to require that the whole
bone should  be removed in the manner of a tumor, the process of M.
Gensoul  would  offer real advantages, not in  respect to the form of the
flap, but as to the mode by which the jaw is to be extracted.   In other
respects, whether we use the chisel, saw, rowels, modern osteotomes or
the trephine, the incision  of the  soft parts, such as I  have  described it 
380
NEW ELEMENTS OP OPERATIVE SURGERY.
farther back, slightly modified if the state of the tumor should make it
necessary,  will most  usually be found  to  answer; it is difficult, as it
seems to me, to imagine one more simple and easy.  The crucial incision
employed by M. Syme, incurs too great a risk of wounding the duct of
Stenon, and does not offer any greater certainty of laying bare the parts
that we  wish to  remove.  The employment of a small sickle-scalpel
(vid. supra) was also found  by me to be exceedingly useful, and  seems
calculated  to give great  assistance under  such circumstances.   If  the
alveolar  border only should  be affected, we should be enabled also, by
means of the cutting pliers, to remove the whole disease  without making
any incision into the lips.  In  the contrary case, should it become ne-
cessary, we ought to divide  the tissues on each  side, following the ob-
lique line, which I have described above.   This operation, moreover, is
one of those in which  the manual  must, in a measure, be regulated by
each particular case, and one in which we should guard ourselves against
being restricted by any rules that are too rigorous.
  The extraction of a simple sequestrum comprising the greater part of
the bone, an example  of which occurred in the service of  M. Roux, in
1829, does  not, either  in  the upper  or lower jaw, leave near as great a
deformity as the  operation  of exsection.   A  new  production  almost
always  ultimately  succeeds  to *the ancient one and it would be in such
cases, only  that we might, perhaps, with MM. Krimer and Samel or Sam-
uel, admit the possibility  of the reproduction of some of the teeth.
   [Numerous  cases of the exsection of  the upper jaw have been report-
ed both in  the American  and European journals, but as there are  doubt-
less many  unsuccessful cases  which have not been placed  on record, it
must be a matter of great difficulty  to arrive at any thing like an accu-
rate conclusion as to the  mortality following this operation.   Mr.  Henry
Smith in his work on Operative Surgery, estimates this mortality at about
one in  four cases, and as to the ultimate effects, it is stated by Prof. Gross
in his very able Report  On the Results of Surgical Operations in  Ma-
lignant  Diseases  (Trans. Amer. Med. Association, Vol. VI., p. 289,)
that of eleven cases operated on by  Lizars, Syme, Robert,  Scott, Earle,
Guthrie and Hetling, only one was was completely successful.  Mr.  Lis-
ton condemned any operative interference in encephaloid disease, un-
doubtedly  one of the most common forms of the affections  involving the
superior maxillary bone,  and it is reported, that of seven operations per-
formed by  this distinguished surgeon, in only one instance did the  mal-
ady return, and prove fatal.  Mr.  O'Shaugnessy  states that between
1827, and  1836, this  operation was performed fifteen times, and out of
the fifteen there were eleven deaths.  This want of success Mr. Liston
attributes  to  the  " foolhardiness"  of the  operators in attempting  to
cure  what he regards as an incurable malady.  Of seven cases of exci-
sion of the upper jaw  by Prof. Gross, four terminated fatally ; two from
a recurrence of the disease,  one from pneumonia, and one from dysente-
 ry, in  one  there is a relapse, whilst  two appear to have entirely recov-
 ered.   One of these two cases  was non-malignant, while the tumor in
 the other  possessed all the physical properties of encephaloid ( Op. cit.
 p. 190).  In view of the discouraging results following the exsection of
 the upper jaw for encephaloid  disease, a different operation has been
 tried  both by Dr.  Mott and myself.  Both  primitive carotid arteries 
EXTRA-ARTICULAR EXSECTIONS IN PARTICULAR.
381
were  tied  for  the purpose of arresting the progress of the disease and
prolonging the lives of the patients, and the effect has been most gratify-
ing.   Nearly seven years have elapsed since we performed this°opera-
tion  on a lad 13 years of age, affected with a disease of the antrum, of
the malignant  nature  of which  Dr.  Mott who saw the patient, had no
doubt.  There was an interval of three weeks between the operations, and
the morbid growth, which distended  the cheek, and protruded from the
nose and mouth, at once became shrivelled, and soon disappeared.  The
young man is now in perfect health, and engaged as a clerk in a hardware
store  in this city.   Within the last  year he has been exhibited by Profs.
Mott  and Parker, to their classes in the University College, and the Col-
lege of Physicians and Surgeons.   Prof. Syme has proscribed the oper-
ation  of exsecting tumors of the upper jaw in the  following cases, viz :
1st, those that grow from the gum, or alveolar region, and have not ex-
tended  their roots beyond these limits ;  2d, those of a malignant kind,
which originate from or  extend  to the base of the cranium; 3, cysts,
containing  serous fluid, developed within the substance  of  the bone, and
existing either independently or in connexion with teeth remaining la-
tent in the jaw;  4, abscesses of the  maxillary antrum.  An enlargement
at the root of the nose ; an obstruction of the nostril on the  affected
side, especially if it has  appeared  at an early stage of the disease, and
is attended with the appearance of a polypus in the cavity ; or displace-
ment  of the  eye-ball outwards or forwards, he regards as an insupera-
ble objection to the operation. ( Contributions to the Pathol, and Practice
of Surgery, p.  254).  G. C. B.]

                   [Exsection  of  the Upper Jaw.

   In  February, 1843,  (Cormack's London and Edinburgh Monthly
Journal, Src, June, 1843, p. 495, &c.,)  Mr. Syme of Edinburgh, states
that he removed, in a man aged 26,  a singular tumor of five months'
growth, which occupied  nearly the whole left side  of the upper jaw up
to the orbit, involving also the antrum which was  found on its anterior
wall,  to have been reduced to a shell of bone  from pressure  of  pendu-
lous bodies of an  epulotic character  growing within it, and similar in
consistence with like vegetations upon the gum and palate.   A curvili-
near incision, with  convexity downwards, was made through  the cheek,
from  the prominence of the cheek  to the angle of the mouth, and the
malar, nasal and palatal connections  of the diseased mass successively
divided, the external parts which readily united,  scarcely leaving any
deformity visible.   Mr. Syme is in error in dating either the curvilinear
incision, or the  present mode of detaching the  osseous parts in such ex-
sections, as having commenced with  or taken their origin or departure
from an exsection he made of the  superior maxillary  bone, in 1829,
(Edinburgh Medical and Surgical Journal, July, 1829.)   Dr. Mott had
many years before that date always  adopted the curved incision in ques-
tion in his exsections of both the upper and lower jaw bones,)  see his
cases at the end of this volume,) also Prof. Velpeau  was, we  believe,
anterior to Mr.  Syme iu this matter, (see his letter to Dr. Mott, also Dr.
Mott's Remarks appended thereto, Preface to Vol. I. of this work.)  It
is inexact,  therefore, for Mr. Syme to  assert, (Cormack, ib., loc  cit., p. 
382
new elements op operative surgery.
 496) that in operations either on the upper or lower jaw, it had hitherto
 " always seemed necessary to make a double or complicated incision, so as
 to permit the formation of a flap  exposing the fore-part of the  bone."
 Mr. Liston may have done so, (Loc. cit., p. 497,) but at all events this
 has never been the practice  with  Dr.  Mott.  Nor in ordinary cases has
 Dr.  Mott  generally found  it  necessary to  divide the cheek at  all as
 Mr.  Syme  does, in order to  have space to remove " tumors  of the gum
 and lower part of the superior maxillary bone ;" the raising of the lip
 up, and dissecting it upwards to the proper extent, from its connections
 with the jaw at its bucco-maxillary groove, commissure or attachment
 being quite sufficient for the clean exsection  of the whole alveolar pro-
 cess  to, or considerably above its union with the superior maxilla, which
 operation, in many osteo-sarcomatous enlargements is frequently all that
 is required  to arrive at the sound portion  of the  bones, provided the
 operation is performed early in the disease.   In a  delicate little girl,
 aged 7, of West India birth, and therefore more liable to possess, as she
 did, a highly organized nervous temperament, Dr.  Mott, in a case of this
 kind, was obliged, from tho hot season and the danger of spasms, to make
 three successive halts or short stops in the operation, which he would,
 under such circumstances always enjoin ; as it is surprising how quickly
 the little patient thus refreshed by a few moments on the bed or its pa-
 rent's lap, (as in this case,)  and a mouthful or two of wine and water,
 and some pleasant stimulating salt to the nose, was invigorated, and how
 much better enabled to sustain the mutilations which  were to be  made,
 and which, it must be confessed, are calculated to produce  much pain.
 Dr. Mott, as he genenally does in such cases, where the incisors, cuspid,
 bicuspid and one or two molars only are involved in the livid, fungoid,
 hypertrophied border of one side only, began by extracting the teeth
 which were loose and easily  detached, then plunged a very narrow-blad-
 ed, sharp, straight bistoury through the mass at the posterior  extremity
 of, and quite above, the diseased  soft parts and degenerated  alveoli.
 Immediately inserting a stiff, straight, narrow  saw, of corresponding
 shape and width of  blade, through this aperture, he rapidly sawed from
 above  downwards;  then doing the same on the other extremity of the
 diseased parts in front, the mass thus  bounded by the two short,  trans-
verse and perpendicular divisions, was readily exsected by a curved saw
 which  united the upper  extremities of these divisions, by scooping out,
 as it were,  all the altered structures, making horizontally to the extent
 of from two and a half to three inches, a curved connecting cut with its
 convexity upwards, and completely through the healthy bono, and above
 the disease.
   [The upper jaw has been removed  for the purpose of extirpating a
 supposed disease of  the antrum, but which has proved to  have a very
 different origin.  Professor  Syme has reported, in the Edinburgh. Med-
 ical and Surgical Journal for October 1832, p. 323, a case in which he
 extirpated  the upper jaw, but  the morbid growth, instead of being  at-
 tached to the antrum, was found to adhere not only to the whole  of the
 upper and lateral margins of the left pharyngeal opening of the nostril,
 but also to the base of the skull.   This patient died very suddenly and
 unexpectedly, on the morning of the thfrd day after the operation.
   Mr.  Prescott Hewett, of St. George's Hospital, London, after removing 
EXTRA-ARTICULAR EXSECTIONS IN PARTICULAR.         383
 the upper jaw, discovered that the morbid growth had no connection with
 it, but was situated behind it, being attached to the pterygoid process,
 and filling the sphenoidal sinuses.  This patient died very soon after the
 completion of the operation.   His death was attributed by Mr. H. to the
 use of chloroform, which, by suspending the irritability of the glottis, per-
 mitted the blood to enter the trachea, which, with the bronchial tubes was
 filled even to their minute ramifications with frothy blood.  In both of
 the above cases the nose was filled with a polypus of a fibrous character.
 Mr. Hewett's interesting case may be found fully  detailed  in the 34th
 volume of the Medico- Chirurgical Transactions, p.  43.  It is well calcu-
 lated to illustrate the  difficulties which sometimes  attend the  diagnosis
 of morbid growths in the superior maxillary regions.   A case, however,
 occurred  at  the Hotel-Dieu, of Rouen, in  which M. Flaubert, the son,
 correctly diagnosticated the nature and attachments of the tumor, which
 was situated in the posterior part of the  pharynx, and ramified in the
 sinuses of the ethmoid and sphenoid bones.  He removed the bone with tho
 object of facilitating the extirpation of the morbid growth, with the full
 knowledge that it was not itself involved.   This operation was perform-
 ed  in 1839, and is fully reported in the Archives Generates, for August,
 1840, p. 436.  It was completely successful, so far as the operation was
 concerned, but sufficient time had not elapsed at the time of the report, to
 learn the final result.  It is stated that the fibrous character of the tumor
 encouraged them to  hope for  a perfect cure.  Now this  fibrous char-
 acter is precisely that which Dupuytren regarded as rendering a polypus
 of the nose certainly and speedily fatal |f allowed to proceed.  During
 the past year (1853,) M. Maisonneuve  removed the upper jaw to facili-
 tate the extirpation of a morbid growth  having its origin posterior to
 the maxillary bone.   G. C. B.]

 No.  IV.—July Sth,  1841.—A nasal  operation for  the removal op
  a  large tumor—-filling up the entire Nostril, and extending to the
  Pharynx.—By Valentine Mott, M. D.  (See the American Journal
  of the Medical Sciences, Philadelphia,  1843.  New Series, Vol. V.
  p. 87-91.)

  When the following operation was announced in the No. of this Jour-
nal for January, 1842,1 was not  aware that any one  had operated in a
similar case.  It having been asserted that Professor Syme, of Edinburgh,
had performed the same operation, I immediately addressed a letter to
him on the subject, describing my case, and requesting to know if he had
met with anything like it.   He promptly and kindly replied,  and states,
" you will find'a  case  somewhat  similar, in the 9th Report of the Ed-
inburgh Surgical  Hospital, published in  the  Edinburgh Medical  and
Surgical Journal, for  1832, the 34th Vol.  There  is  another  recorded
by M. Flaubert, of Rouen, in the Archives  Gen. for August, 1840."
  The case, which was published in the Edinburgh Medical and Surgi-
cal Journal, for 1832, is of trifling extent  compared  with the one we
have described.   The operator first divided the upper lip to  the septum
nasi, turned the flaps aside, and detached the  lip from  the  jaws so as to
expose the tumor  without detaching the columna or ala of either side.
This he did,  " to  obtain  sufficient room for  extracting a large fibrous 
384
NEW ELEMENTS OF OPERATIVE SURGERY.
polypus, which projected both externally and into the pharynx, but did
not succeed."  He says, " afterwards, when the symptoms had become
much more urgent, I removed the superior maxillary bone, as the only
means of relieving the patient from the disease."
   M. Flaubert, of Rouen, in 1840, performed the  formidable operation
of exsecting  the superior maxillary bone  for a large fibrous polypus of
the left nostril, extending to the pharynx.  Various attempts to remove
this morbid mass  were made with wires  and ligatures,  by the operator
and his father, with partial success only.  This  patient recovered com-
pletely with very  little deformity.   (See Arch. Gin. de Mid., for Au-
gust, 1840.)
  Yesterday, I received a small sheet published by Professor Syme, and
extracted from the London and  Edinburgh  Monthly Journal,  for  Sept.,
1842, containing a second operation for nasal polypus.   He  found this
case of a malignant character, and after cutting off the projecting portion
of the tumor,  the patient was informed that  nothing more could be done
for his relief,  and was discharged from the  hospital as  incurable.  No
evulsion was at any period attempted.
  After a short time, the patient returned  in  consequence of repeated
bleedings from the tumor, and urged for the sake of  his family to have
some operation performed, to give  him any chance  of  having his life
preserved.
  Professor Syme says, " I resolved to try what could be  done for the
poor man's relief.  An incision was made  through the  upper lip, from
the nostril downwards to the mouth, and  the flaps  were then separated
on each side from the gum, so as to afford free space for examining the
attachment of the tumor.   It then appeared that the growth proceeded
from the septum by a narrow neck not  larger  than a fourpenny  piece,
immediately above the connection of the cartilage to the bone, and that
there was consequently no  difficulty in completely rooting out the dis-
ease.   I cut through the  septum a little way above the lower margin, so
as not to interfere with the columna, divided the bone with pliers, and
separated the remaining cartilaginous attachments.  The surfaces  of the
wound were then  brought together, after torsion of the coronary arteries,
and retained  by stitches of the interrupted and twisted  suture.  In the
course of a few days, there was hardly any  perceptible trace of the op-
eration, and the patient has since continued  perfectly well."
  These are the only three cases of this operation, as far  as we know,
on record. Two  by  Professor Syme, and  one by  M.  Flaubert; they
have all been  successful, and they are all original.  In some particulars
they are similar, and yet they are  all different.   The bones  in all  the
cases were perfectly sound.  They are different  from what are under-
stood by the uper-jaw operations, as performed by Gensoul and others
of Europe, and many surgeons of our own  country, in  which there is
disease of the boney structure, and  generally malignant.   The present
operation, we think, ought to be denominated the nasal, to distinguish it
from the ablation  or exsection of the upper jaw, for malignant disease of
the bone or antrum, or  both.
   My operation was performed without the knowledge of either Syme's
or Flaubert's, and appears to me to be  more extensive  than theirs, and
is as  follows:— 
            EXTRA-ARTICULAR EXSECTIONS IN PARTICULAR.         385

  Augustus McBurth, cabinet-maker, aged 32, born in Schoharie county,
New-York, ten years ago  felt a stoppage in his left nostril,  accompa-
nied with a dull aching pain, which was much aggravated on takino- cold.
About one  year from the  commencement of these symptoms, a tumor
made its appearance in the nostril of the same side.  At first, it was of
a deep red color ;  but it gradually assumed a lighter  hue, and would
occasionally project beyond the anterior opening of the nasal fossae,
especially in damp weather.   At this  stage of the disease, he  came to
this city, and placed himself under the care  of a surgeon, who  made
several  attempts to remove it by forceps ; but such was  the hemorrhage
that accompanied each attempt, that it was deemed unsafe to  make any
further trials to remove it.  After remaining  in the city three days, he
went to an  adjoining state, where several  trials were  made to remove
it by means of a ligature; but as each unsuccessful  effort seemed to
impart only fresh vigour to its  growth, he determined  to submit to no
further  treatment, except to have portions  of it removed from time to
time, when it  should become inconvenient from  its size.  In  1836, he
removed to this city, where parts of it were from time to time removed
by forceps  and ligature, each attempt being  attended  with  much pain
and hemorrhage.   His sufferings had now become so exceedingly acute,
that for one year he could not sleep in the recumbent position.  There
was a feeling of distension, conveying the sensation of  a wedge forcing
forward the jaw bone.   In March, 1841, he gave up his business, and
urged by the intensity of his sufferings, he was induced  to submit to  one
more trial for its removal  by ligature.  The wire  was in his nose for 11
days, but no benefit resulted from its application.   He  thinks that from
first to last, at least 500 attempts were made to remove it, by about 50
practitioners.   In June he applied to  me for relief.
  The tumor anteriorly and posteriorly, was  so firm  and  dense that
very little impression could be made upon it even when firmly grasped
by the forceps.  After trying several times to get a wire through the
nose about the posterior part  of the tumor, and getting firm hold of the
anterior part  with forceps, and  the part below the  palate  with  the
vulsellum, without being able to  make the least impression on it, 1 de-
termined upon the following operation, having for years been  in  the
habit of recommending a similar  one for  the removal of the  inferior
turbinated  bone, when affected with carcinoma.
  On July  8th, 1841, I  commenced an incision through  the soft parts  a
little on the outside of the mesial line of the internal  angular process
of the os frontis,  and  extended it  downwards to the upper  lip which
was divided about three lines from the angle of the mouth.   Two flaps
were  then  reflected ; the inner including the cartilaginous parts of the
nose, and the tissues covering the os nasi of the left side ; the  outer lay-
ing bare the  bone as  far as  the  infra-orbital foramen. The  anterior
part of the  tumor was now somewhat more distinctly seen, and the nasal
cavity was further exposed, by sawing vertically through the os nasi,
as far as the transverse suture, so  as to avoid the descending plate of
the ethmoid.   The superior maxillary bone was  now divided in a  line
from  the upper part of this cut to a point opposite the  second bicuspis
tooth, and  on  a level with the  floor of the nostrils.   Another section
was made from the termination of the last, extending  horizontally  in-
  Vol.  II.                 49 
386
NEW ELEMENTS OF  OPERATIVE SURGERY.
(Fig- 1.)
Fig. 1  gives a go
 wards towards the vomer.   The osseous parts comprising the  os nasi,
 a considerable portion of the superior maxillary  bone, and the os spon-
                  giosum iuferius were then detached.  The connections
                  of the tumor were partially separated;  but the disease
                  was so extensive, that a part  had to be  removed
                  through the anterior opening, before the posterior at-
                  tachments could  be liberated.  These having been
                  detached, the  larger  portion  of this  extensive dis-
                  ease, which passed into the pharynx  and completely
                  plugged up  the posterior nares, was  removed by in-
                  troducing through  the mouth  a large  curved vulsel-
                  lum and forceps, and seizing the mass as it  descend-
                  ed into the  pharynx.
                    After the operation, gave sol. sulph. morph. gtt. x.
                  Evening.—Comfortable, and complains of but little
                  pain.
                    9th.  Had slept  well, and  is much pleased with
                  the  freedom of  breathing;  no  febrile excitement;
                  pulse  only 69.   Comfortable  in every respect,  and
              rood does  not  complain of soreness  of the  wound, around
•view~of tho direction of which there  is  but little swelling; has taken some
tharte CwkhS thehch«k chicken broth ; bowels not  having been moved,  or-
turne'd aside;—the dot- dered an enema.
ted lines  indicate  the   10th. Had slept tolerably well, but at intervals dur-
thebon°e3the sawins cf ing the night suffered considerable pain ; some tume-
                  faction of the face to-day, but  not more than is usu-
ally attendant on an operation so severe.   No febrile excitement, pulse
being only 60, but somewhat wiry;  free  evacuation from the enema
last evening ;  another enema ordered ; diet light.
   11th.  Passed tho night well; feels comfortably :  swelling of the face
less ; and complains  of nothing  but a stoppage  of the  nostril, caused
by  a slight oozing of blood ;  pulse  62 ; bowels have  been naturally
moved;  allowed to take any light nutriment.
   12th.   Symptoms as yesterday.
   13th.   Feels comfortable in  every way ; swelling of face disappear-
    ing. 2.)     *n£ ' aPPetite g°0(i '■>  nas  s^pt "well during the night;
               pulse 64 ;  bowels free.
                  17th.   Pulse 64 ; appearance in all respects greatly
               improved; tumefaction of the  face  has very much sub-
               sided ; removed the dressings, and took away the  su-
               tures ; wound entirely healed by adhesion, except at  the
               points, where the   ligatures  remain;  reapplied short
               strips of adhesive plaster.
                  22d. Removed the plaster, and pulled  away  three  li-
               gatures.   The patient  feels desirous to go out, and  ex-
               presses  great  gratification at his  entire  freedom of
               breathing, and rapid progress towards recovery.
                  May 29th, 1842.   There is  no appearance of any re-
               turn of the disease, and the patient enjoys better health
               than he has  done for ten years, and works at his trade.
                  The accompanying figure (Fig. 2) is an accurate like-
 
             EXTRA-ARTICULAR  EXSECTIONS  IN  PARTICULAR.         387

ness of the patient, taken from the life ;  and the  line of the cicatrix
in the  soft parts, as exhibited at the present time, July, 1842.
   [We copy from Braithwaite* s Retrospect, Part XXVIII. p. 146, the
following analysis  of the  reports  of M.  Heyfelder,  Prof, of Clinical
Surgery at Erlangen, and of Mr. Butcher, Surgeon to Mercers Hospital
■ Ireland.  The former was published in the Rev. Med,  Chir. de Paris,
May, 1853, and the latter in the Dub. Quart. Journ. of Med. Aug. 1853.
   1. M. Heyfelder gives two cases, in which he extirpated both superior
maxillary bones, and from the particulars given, he appears to be among
the first of those who have  performed this operation, if not the first.
The disease,  in  both  cases, was  of a cancerous nature, and  a relapse
followed ;  but the result, so far as the operation  went, was quite satis-
factory.  One of these cases will serve to illustrate both.
   Case.—A. Schmidt, set. 25, co.me to the Clinique, June 13th, 1844,
suffering from a tumor  of the face, which, from his account  had com-
menced a year ago, in the posterior part of the palate, and had gradually
involved both superior maxillary bones.   The nose was pushed upwards,
and flattened; the palatine arch  was  depressed towards the tongue ;
the face was affected  with cedcmatous swelling; both respiration and
deglutition  were  impaired,  speech was  embarrassed, and  the sleep
broken.   The teeth, though  loosened, were sound ; only two  incisors
were wanting.  The tumor  appeared  everywhere hard, uneven, and
insensible to the touch, and did not pass beyond the boundaries of the
superior maxillary  bones.  The  constitution  was good; lancinating
pains had been felt in the tumor only during the last few weeks.
   Dr.  Heyfelder concluded that the tumor was  of an indolent malignant
character, and that  the  only remedy consisted in the entire removal of
both maxillary  bones.   The operation was performed June 23, 1844.
The patient  being seated in a chair, the head resting against the chest
of an assistant, two incisions were made from the external angles of the
eyes to the  labial commissures, and the included parts were reflected
upwards to the internal angles of the eyes and to  the ossa nasi.  The
flap thus formed was raised towards the forehead, until the infra-orbital
ridge was exposed.  Then the chain-saw of Jeffray was passed through
the spheno-maxillary fissures, and the malar  bones were divided ; the
maxillae were next  separated  from the ossa nasi;  the vomer and the
thinner bones  were cut with strong scissors ;  after which a  chisel, ap-
plied with moderate force to the  superior  part of the tumor, was suffi-
cient to effect its separation.   The accessions of syncope prolonged the
operation, which, however, did not last longer than three-quarters of
an hour.  Very little blood was lost;  torsion and compression sufficed
to arest the  hemorrhage.  Two  hours afterwards the  edges of the
wounds, from the angles of the eyes to the corners of the mouth, were
united  by twenty-six points of  suture,  and  cold lotions  were applied ;
there was no reaction  nor swelling; the patient could  swallow water
and  broth.  Four days after the  operation it was remarked that the
wounds had become almost entirely united by first intention.  ^ In six
weeks  the patient  was presented  at the  Physico-Medical Society of
Erlangen, and on August the 25th  he was discharged.
  The following  was his  condition :—There  was  no deformity of the
features ; in  the  mouth  there was seen along the median line a fissure 
388
NEW ELEMENTS OP OPERATIVE SURGERY.
thirteen lines long and three lines broad ; the extirpated parts had been
replaced by the tissue of a cicatrix, firm and solid at the circumference,
but somewhat softer near  the fissure ;  the  soft palate and the uvula
were in their  natural  place ;  deglutition  was free, and the tongue in a
better  state than  formerly; the nose had resumed its usual form and
direction; the face,  which  before  the operation was monkey-like, once
again possessed a human expression.
  The microscopical examination of the  tumor showed  that it was of
cancerous nature.  Six months afterwards, the patient, in good health,
went to work in the fields ; but in the summer of 1845, Dr. Heyfelder
was informed that another tumor was forming in the forehead.
  2. Mr. Butcher relates a case in which he removed from a youth the
whole  of the right upper jaw, together with the  whole of the  palate
bone of the  same side.  The disease was  a large fibro-vascular  tumor
springing from the  antrum.   The patient  recovered without any diffi-
culty and with little  deformity.   Mr. Butcher, also, analyzes the expe-
rience  and opinions  of other  surgeons  with respect to this operation,
and ends with the following practical remarks :—
  The  practical point deducible from the  opinions and  experience of
these eminent surgeons is, that it is by no  means necessary to adhere to
any particular line of incisions ; a knowledge of anatomy, and the shape
of the tumor, in short, the attendant circumstances of the case wili modify
thein, and determine their course and extent.
  In conclusion,  there are  few points  to which  I wish  especially to
direct  attention ; and  first, with  reference to tying the carotid artery,
as insisted on and put in practice by Lizars, in his operations on  the jaw.
Experience has proved that this  proceeding is altogether unnecessary.
The bleeding will  be but trifling after once the flaps are  formed, if the
surgeon is  not  rash in the use of the knife ;  when detaching the tumor
and bone from  its  posterior  connections, the edge of the  instrument
should be kept close to the osseous tissue, and then the internal maxil-
lary artery  will not be endangered.   All soft attachments  should, if
possible, be torn  down with  the finger,  and the  very depression and
gentle  wrenching of the mass  from its bed with the forceps will tend to
lacerate the vessels entering from behind, and  still further avert bleeding.
It is an  important object to  prevent, as  much as possible, the blood
flowing towards the throat in the early  part of the  operation, hence
the advantage of the sitting posture, and of  beginning with the division
of the  cheek bone before the nasal process of the upper jaw bone itself
is attacked, as illustrated in my case.
  In operations  performed for the removal  of  either a portion  or the
whole  of the superior maxillary  bone,  I do  not conceive  we can avail
ourselves of the use of chloroform.   I agree with Mr.  Stanley, that
there is a serious objection to  its administration ; fer inasmuch as by its
influence  in annihilating sensibility  the  irritability of  the glottis is
weakened, if not wholly lost,  so there must be danger of a trickling of
blood  from the mouth into the  glottis, without the excitement of a cough
to expel it from the windpipe.   The amount of this danger may be con-
sidered small, but it is sufficient to know  that the  apprehended evil has
once occurred.   Severe as the  pain of these operations may be, it had
better be endured than the risk of suffocation incurred, which must be 
            EXTRA-ARTICULAR EXSECTIONS IN PARTICULAR.         389

regarded as a possible occurrence from the filling of the pulmonary air
tubes and  cells with blood.   As to the division of the bone, cases will
seldom  occur where the chisel and mallet will be required ; they cause
great jarring, and, if possible, should  not  be used.   So likewise may
saws be dispensed with, for well-formed cutting pliers and  powerful
scissors, if the operator possesses the required strength to use them;
and by  the adoption of the latter, the  section can be completed with
such comparative rapidity, that the sufferings of the  patient are greatly
diminished, and the shock abridged, while,  at  the same time, be it re-
membered, if the  instrument is  steadily  handled, the bone  may  be  as
evenly divided as  by any other means, or, practically speaking, suffi-
ciently so to permit healthy repair of the cut edges, a fact very remark-
ably exemplified in the case of the young man I operated on.
   As to the use of chloroform in this operation, we can only say, that
we have seen it used by Prof. Ackley, of Cleveland  with  the happiest
effects, and  Prof.  Gross, in his interesting report  on  Excision of the
Maxillary Bone (West. Journ!Med. 8c-  Surg. Sept.  1852,)  states that
he has resorted to this agent in every severe case of amputation both of
the upper and lower jaws, that has come  under his observation, and that
he has had no cause to regret  the practice.   He adds, " If proper care
be taken to compress the vessels as  soon as they are divided, and the
head be placed upon a low pillow, no danger can ensue from  this source.
   I certainly have never witnessed any,  and  until I do, I shall not hes-
itate to continue the practice,  whatever others may say and  do."
   M. O'Shaugnessy cautions  us against removing any portion of the
healthy skin, as the want of it is much more likely  to be complained of
when the cure is completed, than of there being too much, if the whole
has been left.   (Op. cit. p. 30).
   The late Prof. Horner has reported in  the Med. Examiner, vol. vi.
N. S. 1850. p. 16) in which he removed the upper jaw without any incis-
ion  through the  cheek.  This method was adopted  by Dr. Alexander
H. Stevens, in 1823.   G. C.  B.]

      Article  VII.—Exsection op  the Larynx and  Trachea.

   Necrosis  and caries of the os hyoides, and  cartilages of the larynx
and trachea, may  also require exsection.  A sequestrum with a fistulous
opening into the air  passage, (fistule aerienne,) the origin of which J.
L. Petit (Acad de Chir., p. 185, t. II.)  ascribed to syphilis, came near
falling  into the trachea.  It became  necessary to attach a thread to it
until it came away entirely, and afterwards to have recourse to tents of
lint imbued with wax and cocoa melted.  We must  evidently attend in
good season to the means of securing a necrosis  of this  description,
which, perhaps, it would  be better to detach, and then unite by means
of suture, the portion of skin which covered it to the neighboring parts.
In  a case  mentioned  by Marchettis,  (Bonet, t. III., p. 240, Obs. 40,)
the caries was rasped, and thus perfectly destroyed.  The fistula existed
between two  of the rings of the trachea.  Having dilated  it with a
sponge, the rasp could be applied  to the  diseased  cartilages on both
sides, which could thus be conveniently scraped.  Having laid open the
ulcerous passage, I was enabled to  excise a portion of the os hyoides, 
390
NEW ELEMENTS OP OPERATIVE  SURGERY.
and to cure a fistula which  in one case had existed eight years, and iii
another three, being two adult patients whom I operated upon with M.
Pegot, in 1834, and on the other with  M. Leclerc in 1836.

                     Article VIII.—Sternum.

  The sternum being a spongy, thick  and  superficial bone, is naturally
liable to all the diseases common  to  the osseous system ; consequently
attention has been early directed to the modes  of laying it  bare and of
excising  or perforating it.  The abscesses which  form in  the anterior
separation  of the mediastinum, and  which are thus  imprisoned as it
were in the chest, might easily be cured, if an aperture should exist in
the sternum.   When this  bone is carious or necrosed, it may  become
itself  the source  of  dangerous suppurations, or accidents which almost
always ultimately have a fatal termination.   [In a case of  an old  man
aged  about 70, of broken down constitution, and vitiated by neglected
or improper treatment for syphilitic disease many years before, the mid-
dle  bone of the  sternum had been for a long time carious, and finally
changed to a true necrosis, and penetrated into the mediastinum, induc-
ing pulmonary symptoms, expectoration and hectic which in a few months
carried him off.   The autopsy, I found, confirmed my diagnosis and the
fetor emitted from the slight perforation which the  necrosis  had worked
through the bone, was remarked as peculiarly offensive.   T.]
  Whatever Leveille may say to the contrary, there  is every reason to
believe that Galen, (Teyrilhe, Histoire de la Mid.,  etc.,) had performed
exsection upon this bone, in that patient in  whom he was  clearly enabled
to see the pulsations  of  the heart.   De la  Martiniere, (Mimoirs de
VAcadim. Roy. de Chir.,) shows by the observations of Mesnier, Alarec,
Sedilier, Lecat and  Ferrand, as has been proved also by those of Labis-
iere, J. L.  Petit, Ravaton, Genouville, Cullerier, (Champion, Traiti de
la Risection,  p.  42,)  Boyer,  (Malad.  Chir., t. III., p. 526,) Jaeger,
(Gas. Mid. de  Paris, 1833, p. 645,) and Gilette, (Journ.  Hebdom., t.
II., p. 228,) that exsection or  trephining of  the  sternum  is very fre-
quently indicated.  Colombus Purmann,  (Champion, Op.  cit., p.  41,)
and Marchettis, therefore were  right  in recommending  it or in having
recourse to it.   Guillemeau, (OEuvres de  Chir., p. 651, 1649,)  had
already recommended  the trephine for extracting a ball buried in the
sternum; De La Martiniere, (Mim. de VAcad. de  Chir., t.  IV., p. 545,
in 4to,) in  a case of fracture extracted  four fragments  of  the bone by
means of the  elevator;  M.  Mosque, (Application du Tripan au  Ster-
num, p. 13, No.  439,  These de Paris,) mentions a fracture of the  ster-
num  with  depression, and complicated with  emphysema and effusion,
which were laid bare by the trephine.  An individual received the ball
of a pistol, the muzzle resting on the sternum, and the  ball was lost in
the chest.  The parts  were dilated, splinters removed, the  trephine ap-
plied, and  the wadding and  portions of the clothing extracted, which
was followed by taking half a palette  of blood.  The patient was at tho
point of death,  says Ravaton, (Chir d?Arm., p. 215—239, obs.  50;)
the ball was not extracted till the thirteenth day, but  the case notwith-
 standing got well.
   In the case related by Galen, (Opera, lib. VII., cap. 13,) and which 
             EXTRA-ARTICULAR  EXSECTIONS IN PARTICULAR.         391

occurred  in the servant of Marcellus, the disease was caused by a kick
on the breast, " abscess after four months, incision, cicatrization ; new
inflammation and abscess, cicatrization impossible ;  consultation of phy-
sicians ;  all pronounce the  disease a sphacelus  with corruption of the
chest.   Afraid to penetrate into the chest, no one dares attempt to ex-
sect the diseased  bone.   Galen promises to remove it without opening
into the chest; but without guaranteeing to  make a perfect cure of the
case !  The part being laid bare, no other portion of the sternum was
found diseased, which inspired courage and  confidence in the operative
process.   Having cut through the corrupted bone at  the place  where it
is adherent to the point of the  sheath of the  heart, and  the heart being
visible through  it, because its sheath or pericardium was rotten, Galen
and his assistants  formed a bad prognosis of the case ; nevertheless he
recovered perfectly in a short time."
  We should  not, however, decide in these cases upon exsection unless
the existence of an abscess underneath the sternum was positively indi-
cated, or unless it was evident by the fistulas or the explorations with
the  probe, that  there was a caries or necrosis in the neighborhood.  I
have once performed  this operation under these  circumstances.   It was
for a necrosis of long standing and  altogether  local; I required only
the gouge and mallet to destroy it completely, as it did not penetrate to
the mediastinum.  In some cases we  are obliged  to make use afterwards
of the hot iron to eradicate the  remains of the caries.   The  trephine
also often  becomes indispensable, not that  it is useful,  as Duverney,
(Malad. des Os, t. II., p. 448,) has strangely supposed, to leave in its
place the  boney disc  circumscribed by the trephine, after having sawed
around it; but  because it  would be difficult to penetrate the sternum
through and  through, in any other manner.   At the present day, how
ever, the concave rowels enable us to excavate the bone so extensively
and so deeply, that the trephine would no longer be required except to
penetrate directly to  the anterior separation of the mediastinum; by
means of the osteotome of M. Heine, M. Dietz, (Gaz. Mid.,  1834, p.
644,)  or  Jaeger, (Jaeger, Operat. Resect, &c, p. 17,) was enabled  to
remove a semilunar  portion of the  length of two inches. (See Tre-
phining.)
  Here, less than in  any other part of the  body, ought  the wound to
be united by  first intention ; the dressings  therefore should be  flat, and
as I have described in the preceding exsections.

                   Article  IX.—The Vertebra.

  By their nature and their functions, and especially by their deep situ-
ation, the vertebrae unfortunately  are out of the reach of the action of
surgical instruments, at least so far as regards their body and transverse
processes.  The spinous processes, however, have already been several
times successfully excised.  In operating at the Hotel Dieu on a woman
with a tumor at the nape of the neck, Dupuytren removed at the same
time the  spinous  process of the  seventh  vertebra.  M.  A. G.  Smith
{Jour, des Progres, t. XVII., p. 281, Jour. Hebd., t. V.) also  removed
the spinous processes and laminae of several of  the  dorsal vertebras in
an individual who had depressed  them in, and  was paraplegic, in con- 
392
NEW ELEMENTS OF OPERATIVE  SURGERY.
sequence of a fracture in this region.  The  operation, says the author,
was followed by perfect success, as his patient recovered the faculty of
walking.
   This excision, which was advised  also by Visraroux, (Hevin,  Cours.
de Pathol., etc., t.  II., p. 205,) and by  M. J. Cloquet, was also per-
formed twice by M. Tyrell in 1822 and 1827 ;  by Cline (Olivier, Mala-
dies de la Moelle, etc., p. 222, Jaeger, Op. Cit.)  in 1814 ;  by M. Wick-
ham in 1817, and also by another English surgeon.  M.  Heine (Gaz.
Mid.,  1834, p. 645) also aided  by his osteotome has not  feared  to un-
dertake it.   M. Roux also was obliged to have recourse to it in remov-
ing an enormous cancerous  mass from the  back in a patient  whom I
saw, and M. Holscher had done the same in 1828.
   Without  admitting with Bartholin,  (Bonet, Corps de  Mid., t. IV.,
p. 555,) who, on the testimony  of the Duke  of Lunobourg, affirms that
two of the dorsal vertebrae were carried away by a cannon-ball without
causing the  death of the patient, I will nevertheless allow that the ex-
cision or exsection of every projecting part  of the  spinous processes
or of the vertebral  laminae, does not appear to me to have anything in
it impracticable or even unreasonable.  Having therefore laid  bare the
root of these osseous projections by means of suitable incisions, I would
recommend that we  should excise the spinous  processes with the simple
cutting pliers, or if the laminae of the vertebrae were to be removed,
with the crested saw  or rowel  saws either of M. Heine,  M. Leguillou
or M. Martin.   As the spinal marrow  lies some lines in front, the in-
strument would not wound it if the surgeon took the precaution of not
going  beyond the plane of the roots of the  transverse processes.  So
long as it concerns only the spinous process, the operation cannot, prop-
erly speaking, be either very  serious  or very difficult.   If  the vertebral
plates, however, are to be penetrated, there will be real danger, less on
account of the  risk of traumatic lesions to the spinal marrow, than on
account of the inflammation which may  soon be produced in the interior
of the  arachnoid cavity, or on the surface of its appropriate membrane.
We must guard therefore in such cases against approximating the lips
of the  wound, and not fail to dress it lightly and with the aid  of small
balls of lint, in order that cicatrization may  only take place by second
intention.
   [During  the month of November, 1854, I  exsected about  one  and
three quarter inches of the upper and posterior  wall of the sacrum.
The patient, Mr. Simon Ostrander, a well  known citizen of Newburgh,
N. Y. was 44  years of age.  Four years and five months previous to
the operation he fell backwards through a hatchway in a store, and was
found in an insensible condition.   In a few hours he regained  his con-
sciousness, but motion and sensation in his lower  extremities  were en-
tirely destroyed.  Both urine and faeces were voided involuntarily. In
this miserable condition he had  dragged  his body around for the long
period above mentioned and was anxious to submit to any operation I
might  propose.  As there  was  some  irregularity at the  point  already
designated, and the patient himself a  very intelligent gentleman, seemed
to be  positive  that it was  the  seat of all his difficulties, I decided to
expose, and if appearances warranted, to remove the posterior wall of
the spinal column.  A single large flap was raised sufficient for the first 
             EXTRA-ARTICULAR EXSECTIONS IN PARTICULAR.         393

named purpose, and all present expressed their conviction that the poste-
rior wall was  depressed.   Being well satisfied of the fact I removed
the  spinous  process of the  upper bone of the sacrum, with a pair of
strong  bone nippers  aided  by a Hey's saw.   A trephine wa3 now ap-
plied and through the opening thus made the bone nippers  were intro-
duced and about one and three  quarter inches of  the posterior wall of
the sacrum removed.   Considerable hemorrhage followed the laceration
of an artery passing  from the coverings of the spinal cord to the bone.
Owing to its retraction it was found impossible to  secure it either  with
the tenaculum or forceps, and I was obliged to resort to pressure with a
sponge.  The operation was performed about 3 o'clock, P. M.  and  dur-
ing  the night for  the first time  after the accident, the patient became
conscious of the passage of his urine.   The next day he experienced
strange sensations about the rectum, and was aware of the  evacuation
of his faeces.   Instead of being of an icy coldness, his extremities be-
came warm,  and he complained  whenever a needlo was thrust into his
flesh.  About the third day  after the operation, on tickling  the sole of
either foot, his  legs would  be flexed to an acute angle with the thigh.
Five weeks have now Jan. 2. elapsed, since the operation, and strange
to say,  during the past fortnight he has gained considerable voluntary
power in moving his limbs,  as was satisfactorily demonstrated both to
Dr. Ely and myself on Christmas  night.   The wound  healed  speedily,
with the exception of a very narrow orifice through which healthy pus
is occasionally  discharged.   The operation was witnessed by numerous
physicians of Newburgh and its vicinity, several of whom have watched
the progress of the case and have expressed their astonishment at the
result.  Its  subsequent history  we  shall endeavour  hereafter to com-
municate to the profession.  In December, 1854, we operated in another
case, on the same day of the accident, but in this  the injury was in the
upper dorsal vertebrae, and proved fatal in eight days.  G. C.  B.]

                      Article  X.—The Ribs.

   Among the exsections of the  bongs of the trunk, there is one which
has  more especially  attracted the  attention  of modern  observers : I
mean exsection of the ribs, performed in other times by Galen, Levacher,
(Mercure de France, Avril,  1758,) Gooch, (Gaz. Salut., No. 28,1775,)
Sediller, Lecat, (Prix de VAcad. de  Chir., t. II., p. 34,12mo,)  Ferrand,
M. Larrey,  (communicated  by M. Jacquier  to M.  Champion, 1807,)
Beullac (Soc. Mid. de Marseilles, 1817,) &c; an operation  which it
is said the Hindoos (Indiens) also frequently  practise in tlie treatment
of Caioso, (Journal  Univers. des Sc Mid., October,  1818,) and which
they designate under a particular name.  The ancient Journal  Encyclo-
picique contains a singular case of this exsection.   Suif excised two ribs
from a man  named Botaque, in  such manner as to be  enabled to intro-
duce the fist into  the  chest.  A portion of the  diseased  lung was re-
moved, and the patient got well!   Nevertheless, it  was scarcely thought
of any  more, until in the  year 1818, when M. Richerand (Bull, de la
Fac de Mid., t. VI., p. 104) performed this operation upon an officer
of health, affected  with cancer  of the thorax.  It is known that since
then M. Cittadini (Arch. Gin. de Mid., t. XVIII.) has twice  perform-
   Vol. II.                     50 
394
NEW ELEMENTS OP OPERATIVE SURGERY.
 ed it with success  in Italy.  Percy (Diet, des  Sc Med., t. LXXII.;
 Jour, de  Med., 1820, t. LXXIIL, p. 351,) also  states that he perform-
 ed it successfully  on an officer named Muller, who had two of his ribs
 carious, caused by a gunshot wound.  The Journals  also relate that it
 has  been  made trial of also at the hospital Beaujon, by M. Blandin, at
 La Charite by M. Roux, and in  America by M. Mott.  The  case of
 M. Richerand is unquestionably the most remarkable of all.   It became
 necessary to remove the middle  portions of four ribs to the extent of
 several inches.  The pleura which  was greatly  thickened, had also to
 be removed, so that the pulsations of the heart in the pericardium were
 exposed naked to the sight.  The results of this operation at first were
 of the most satisfactory nature ;  but at the expiration of  a few months
 before the wound had  completely cicatrized, the cancer  regerminated
 and ended in death.
 ^ Operative Process.—The patient being placed upon his back, if the
 disease  is  in front, and on his belly if it is behind, and on the side in all
 other cases, is to be held securely in his position by the assistants.  A
 pillow or  cushion  is to be placed under the opposite flank, in order to
 raise up and stretch the diseased  side.   After  having  laid bare  the rib
 or ribs we propose to exsect, and prolonged the incisions in front and
 behind  beyond the extent  of the disease, we make use of a crested or
 chain saw, or a rowel-saw, either flat or of the  mushroon form, or we
 use only the kind of pliers  which is employed in  the amphitheatres, and
 known under the name of the sector.  This last  mentioned instrument,
 however,  would have to be modified if we use  it on  living man.  Its
 blades would have to be narrower and sharper, in order to take up less
 space and to  avoid wounding the  soft parts.  Its branches also should
 be longer  by one-third, in order to give the operator more power.   Con-
 structed in this manner it  has appeared to me to render  the operation
 very simple in the three cases in which I have employed it.  We com-
 mence with either extremity of the rib and finish  with the opposite one ;
it is, however, better to make the  section on the posterior part of the rib
first.   We must take  particular  care  to  avoid  wounding the pleura,
which, as  has been noticed by all  observers, is ordinarily in these cases
manifestly much thickened.  If, however, it should be found to be exten-
sively diseased, and especially if it is the seat of  a cancerous degenera-
tion, we we must not hesitate in  removing it.   Herissant, (Acad, des
 Sciences, 1643, p. 71,) who opened it by mistake, had no  reason  to re-
pent of having done so.  To escape wounding this membrane, which, ac-
 cording to Botal, Galen succeeded in avoiding, though he removed an
 entire rib, it is important  to scrape carefully each border of the bone,
 and not to incline the point of the  bistoury towards the intercostal space.
 Before  going  any  farther  we should detatch its inner surface with the
 blunt point of a curved  sound, or draw it outside and towards us by
 means of  a blunt hook.  In this manner we divide only the inferior ar-
 tery  in each rib that we take away.  The  blood  also in certain persons
 flows copiously  during the operation, and authors have done wrong in
 omitting to notice this hemorrhage.  Fortunately tamponing  properly
 applied, is almost always sufficient to put a stop to it;  for it would be a
 difficult matter to seize the  arteries  in order to twist or tie them.  The
 wound being irregular and  contused is to be dressed flat; and we should 
             EXTRA-ARTICULAR EXSECTIONS IN PARTICULAR.         395

Incur the risk of serious  dangers if we attempted to heal by first inten-
tion.
  Appreciation.—Exsection of the ribs which is recommended in gene-
ral terms by  Celsus, (De Re Med., lib. VIIL, c. 2,) by Soranus, (Cham-
pion, Traiti  de-la Risect., p. 44,) in  cases of compound fractures ; by
Arcaeus in order to dry up certain fistulous discharges; and which was
actually performed in cases of caries  and necrosis by Severin, (Cham-
pion, Traiti, ined., p. 44,) J. L. Petit,  (CEuv.  Chir., t. II., p. 25,)
Duverney, David, Lapeyronie, and Desault, (Champion, Op. cit., p. 44;
Jour, de  Chir., t. I., p. 317,) is an operation neither very dangerous nor
very difficult.  Besides the practitioners whom I have mentioned above,
MM. Anthony,  McDowell and Jaeger,  Coulon, These, Wurtzburg, 1833,)
have also performed it with success.   Aymar (Bonet, t. IV., p. 95, obs.
105, 96) in a case of scirrhus removed three inches from the fifth, sixth,
and seventh left ribs.   Moreau, (Champion, Traiti de la Resect., p. 50,)
who was obliged to remove a  portion  of  the sternum at the same time
with the fifth and sixth cartilages of the right ribs, succeeded in curing
his patient.   M. Clot,  (Jour. Hebd., 1835, t. II., p. 296, 297 ;  Compte-
rendu de VEcole d'Abouzabel, 1832, p. 50,) in removing the second rib
in a carious state in one case, the sixth in  another, and  the seventh and
eight in a third, was no less  fortunate.  M. Warren who extirpated the
seventh rib in a case of osteo-sarcoma, afterwards the sixth and seventh
affected with caries in  another patient, and M.  Textor, who in 1837 ex-
tirpated the tenth or eleventh ribs also in  a carious state, were equally
successful.   I  have myself performed  the  operation  three times, and
none of the  cases died.   This, however, is no  reason for deciding upon
the operation lightly.  The patient of M. Roux died in consequence of
the operation, so that without admitting with Lassus that caries of the
ribs is an incurable disease, I am ready to allow that it  may  exist
for a great number  of  years without impairing the general health.   The
operation, moreover, has caused the death of many other patients.
  [The  most  remarkable case of exsection  of the  ribs  which we
have  been able to  find on record is that reported by Milton Antony, of
Georgia, in   the  Philadelphia Journal of the  Medical  and Physical
Sciences, Vol.  VI. 1823,  p.  108.  The  report is accompanied with  a
plate. In this  case there was extensive caries  of the fifth and sixth ribs,
together with  a disorganization of the greater part of the right lobe of
the lungs.   The  carious ribs  were  removed, with "two thirds of the
right lobe of the  lungs"!   The operation was performed on the 3d of
March, 1821, and the patient lived until the 11th of July, of the same
year.  There are many  interesting facts connected with this case which
our limited space will  not permit us to mention.
  Another extraordinary case is related by Dr. John H. B. M'Clellan, in
the  edition of  his father's work on the  Prin. and Pract. of Surgery, p.
352.   In  this instance, the late Dr. Geo M'Clellan removed a tumor in-
volving the sixth and  seventh ribs, on the right side, and which extend-
ed from their cartilages nearly to the dorsal vertebrae, being ten inches in
its  longest diameter.  It  projected externally at leastfour inches from
tho  surface  of the ribs,  and about the same distance within them,  push-
ing behind it the  pleura, and it had nearly destroyed the functions of the
lung by its  encroachment.  The  tumor  was a genuine  spina ventosa. 
396
NEW ELEMENTS OP  OPERATIVE SURGERY.
 After  separating  the integuments, the morbid parts were removed with
 the  chain  saw and bone nippers.  There was considerable hemorrhage,
 but  it was soon arrested by the application of patent lint slightly moist-
 ened with creosote.  " The  cavity, as  then apparent, was really enor-
 mous—the largest I have  ever seen made upon the human body; with-
 out the slightest exaggeration, it would  have admitted into it with ease,
 a child's head of the ordinary size  at  birth.  It not only extended as
 before described in length, but internally  projected, both above and be-
 low, much  beyond  the two ribs  involved, and exhibited  the smooth and
 polished  surface of  the  pleura  costalis which had been separated from
 the ribs, and pressed back  upon the lung in the advancement of the dis-
 ease."  The  patient speedily recovered from  the operation, but died
 about ten weeks afterwards from remittent bilious fever, which " assum-
 ed the worst form of the congestive fever of the south-west."
  Dr.  M'Clellan operated  in a very similar case,  in 1836, and this pa-
 tient was in perfect health some ten or twelve years afterwards (op. cit.
 p.  354.)   In another case he removed the ossified cartilages and tho
 anterior  extremities  of two carious ribs, together with the lower  portion
 of the  sternum.  This  patient was living 20 years after the operation.
 (Phil.  Med. Exam. Vol. VI. 1851).  Dr. John C. Warren has had two
very interesting cases  of exsection  of  the ribs which may be found re-
ported in the Bost. Med.  Surg. Journal, Vol.  XVI., p.  201,-1837.
But  to these we  can  only refer.   M.  Jacquet, of Brussels, in excising
portions of two of  the ribs  affected with caries, wounded the pleura, yet
his patient recovered.   MM. Marchal  (de Calvi)  and  Sinoli have also
 operated in a similar case.   Prof. Gibson removed  an osteo-sarcomatous
 tumor  involving the ribs,  which  required  the  exsection  of the latter.
 The case is reported  in his Institutes of Surgery, 7th ed. Vol. 1st. p. 421.
   Some two years since, during a temporary residence in France, we were
 consulted by a provincial surgeon in  a case, not unlike the first of those
 above mentioned, in  the practice of Dr.  M'Clellan.   Prof.  Eve of Nash-
 ville afterwards saw the case with us,  and was of our  opinion, that the
 success attained by Drs. M'Clellan and Warren, was sufficient to war-
 rant an  operation.  But, from this, he was dissuaded by M. Velpeau,
 who subsequently  saw  the case, and none was performed.   The tumor
 was  rapidly  increasing and has probablv long since destroyed the pa-
 tient.  G.  C. B.]
   The excisions of  the true ribs  must always be a serious operation.
 It is true that when  the disease is situated in one  of the  three  last we
 are in no fear of wounding  the viscera of tho thorax ; but we are not to
 forget that we are  then  in the neighborhood of the peritoneum and the
 abdominal  organs.   The two floating ribs, moreover, require some special
 precautions.  As they are free at their anterior extremity, it is important
 to support them with a hook in this direction, while we  are isolating and
 dividing them posteriorly.  From their  great mobility the sector is infi-
 nitely more convenient for  making their division  than  any other instru-
 ment, and  their section anteriorly becomes unnecessary.  Adopting these
 precepts I was enabled to effect the exsection of the twelfth rib on tho
 right side in a young man  aged seventeen, without any very g$eat diffi-
 culty.                                      .
   Another circumstance not to be forgotten is this, that the caries or 
EXTRA-ARTICULAR EXSECTIONS IN PARTICULAR.         397
necrosis which we propose to remove may be only the symptom or effect
of a deep-seated disease, and may not be limited, as we might be tempt-
ed to think.   In four men who  solicited  me to perform the operation,
and  which I declined to do, the affection  of the ribs in one case originat-
ed from caries of one of the vertebrae, and in  the others from pulmona-
ry tubercles.   In conclusion, this  exsection is not to performed  unless
the disease, besides  being cirumscribed, is altogether local, or unless by
its presence it threatens to give rise to serious accidents.

                     Article XL—The Pelvis.

  Many points of the bones of the pelvis project so  much outwardly as
to have naturally suggested to the  minds  of  surgeons  the  idea  of at-
tempting their exsection.

                                 §1.

  The coccyx and point of the sacrum,  among others, have often been
removed for caries or  necrosis, whether caused  by a fall on the breech
or by any other force, or by some  internal disease.
  Bourleyre (Anc Jour, de Mid., t. XLIIL,  p. 316) gives the history
of a caries which perforated through and  through  the  sacrum.  The
bone in its middle portion was denuded to the size of a sou,  and pierced
from above downwards;  but no treatment was used but  that of bour-
donnets, (see  Vol. I.—rolls  of lint,) saturated  with mercurial water,
(proto-nitrate of mercury.)  Champeaux  (Gazette  Salutaire,  1769,
No.  31, p. 3)  mentions the case of a female aged thirty-six years, who
in consequence of falling upon a cart wheel from a height of more than
twenty  feet, had a necrosis of the sacrum.  A  longitudinal incision from
the middle part of the bone as far as the extremity of the  os coccygis,
enabled the surgeon  to ascertain with  his finger  that  the sacrum was
fractured throughout the greater portion  of its extent, and that most of
the splinters were loose.   He thus extracted  by means of the forceps
more than  twenty pieces  of bone,  and the cure was accomplished at the
expiration of two and a half months.
  The operation, moreover, in such cases is so easy  that it  scarcely re-
quires to be described.  The patient should have a pillow placed under
the belly, and ought  to lie down in that  position on  the border or foot
of the bed.  Nor would there be  any objection  to placing  him in the
same manner as for the operation of fistula in  ano or for stone.
  The sides of the breech being  then held apart, the surgeon incises
upon the median line from the neighborhood of the anus to the posterior
surface  of the  pelvis; then separating the lips of the wound as he con-
tinues to detach them, he  prepares for seizing hold of and raising up
the diseased bone.   For that purpose a good pair of  forceps will answer
if the osseous  fragment is  moveable; in the contrary case he proceeds
with a mushroon-shaped saw, if there is only a superficial  necrosis  or
caries, or with the flat rowel saw in case  of  a deep-seated lesion, to cut
through the whole  thickness of the bone, at  some lines outside of the
diseased region.  A  chisel  or spatula, or any other solid lever, inserted
into the track of the saw, would  then suffice to detach  the  bone and 
398
NEW ELEMENTS OP  OPERATIVE SURGERY.
thus complete its exsection.  Seizing it then  with an erigne, a forceps
or the fingers,  nothing  more remains, in order to extract it entirely,
than to gradually detach from it the  fibro-cellular  tissues  upon its bor-
ders and its deep-seated  (internal) surface.   The  wound  being dressed
with balls of lint, the perforated linen and a plumasseau,  (see Vol. I.,)
would require moreover the same kind of bandage as  all other wounds
of the anal region.
  M. Van Onsenort, who extirpated the os coccygis in consequence of a
fistula kept open by a caries  of this  bone, proceeded  in  the  following
manner.   With the fore-finger of the left  hand introduced into the rec-
tum he supported the rectum.  An incision was then made on its middle
part, from the base to the apex  of the bone.   By means of a transverse
incision made on a line with its  point, he was enabled to  detach  this
latter and to separate the soft parts  from the inner side of the coccyx.
The operation terminated with disarticulation, and the patient promptly
recovered without any accidents.  M. Kerst  has  seen a  case in  which
the coccyx was entirely detached from the sacrum and  expelled sponta-
neously.   The patient ultimately recovered.
  [The os coccygis has been recently extirpated by Dr. Nott, an Ameri-
can surgeon,  (See Amer.  Journ. of the Med. Sciences,) in  a lady, aged
25, for severe neuralgia—a diagnosis  of  the condition of the spine in-
dicating extreme tenderness over that bone.   The incision was made
down to the bone  two  inches  in length vertically  upwards  from the
point; the bone was then disarticulated at its  second joint, the muscular
and ligamentous attachments divided, and the two  terminating  bones
dissected out without much difficulty.  The last one was  found carious,
hollowed out to a mere shell,  and the nerves exquisitely sensitive.   The
operation, though short, was  attended with extreme suffering, and the
pain afterwards violent for  hours, coming on  every  ten or fifteen min-
utes, and accompanied with a sensation of bearing down like labor pains.
At the end of a month, all medicaments  proving of  no avail,  the pains
subsided, the wound healed, and the general health was much improved.
At the next catamenial period, she suffered severe  pains and tenderness
in the vagina, which were ultimately effectually cured by citrate of iron
in five-grain doses three  times a day.  T.]

                               §11.

  Tho tuberosity of the  ischium could without doubt, should its  dis-
eased condition require it, be exsected in the same way as the great
trochanter.   Maunoir (Questions de Chirur., Traiti des Ulceres, p.
164)  has published a case of this kind.   The  caries had  proceeded to
o-reat extent.  After the  incision two  cauteries were applied,  heated to
a white heat, and  then recourse was had to  tamponing, i. e., plugging
or tenting a wound, see Vol. I.)  Two months later, and after repeated
attempts, the surgeon succeeded in extracting a portion of the ischium
of the size  of a small pullet's egg, when a cure  was effected.   But I
have not been enabled to ascertain  that any  person since up  to the
present time has ever suggested or any other  surgeon  had  occasion to
perform this operation. 
EXTRA-ARTICULAR EXSECTIONS IN PARTICULAR.          399
                               § III.

  It is not,  however, altogether the  same  with the  spine of the ilium.
The extent and superficial position of this  border of the pelvis, expose
it to the action of external violence  of every description.  Thus is it
often the seat of fractures, contusions, and also of caries and necrosis.
Abscesses at the bottom of the gluteal  region  and in the internal iliac
fossa, have also more than once led to the  necrosis, and afterwards to
the  perforation, of the  ilium.  It is easy to conceive, therefore, that it
may be advantageous to remove a portion of it in order  to preserve  the
remainder.   It is asserted  that Leaute  (Le Dran, Obs. de Chir., t. II.,
p. 265) once exsected the spine of the  ilium  successfully.  De Lamar-
tiniere, who  recommends trephining the iliac  fossa, was imitated  by
Boucher, (Siance Pub.  de VAcad., in  4to,  Paris, 1779; Sprengel, t.
III., p. 33,) who thus gave egress to an internal  abscess in the pelvis.
Manne, (Traiti  Elim. des Maladies des Os, p.  186, 1789,) having met
with a comminuted fracture [of the ilium] had  recourse to incisions to
raise up or  extract  the displaced  fragments of bone, and applied  the
trephine to the neighboring portion in order  to raise up those  portions
which  the elevator could not adjust, and to extract the foreign substan-
ces.  A fact  noticed by Arrachard (Mim. de  Chir., p. 269, 1805) at
the hospital of La Charite, proves indeed  that  the  bones of  the ilium
may thus be nearly all removed without causing  death.  Theden (Nouv.
 Obs. et Expiriences pour enrichir la Chirurgie et la Midecine, 2e part.,
chap. III., p.  48-49) speaking of the trephine for the hip, cites a case
in which a ball was accidentally lodged  in the pelvis, and  extracted by
means of this instrument.   Weidmann, (Traiti  de la  Necrose, p. Ill)
also has seen a sequestrum in the diploe of  the ilium, enclosed  in a new
boney  encasement, without  any external opening being noticed in  its
neighborhood.  I have met with two patients  who would evidently have
derived some  advantage from exsection, if they had been willing to sub-
mit to  it.   I have seen two others, in whom,  if the  trephine  had been
applied to the bottom of an abscess in  the external  iliac fossa, the  ne-
crosed portion of the bone might have been easily removed.
  The process to be followed would be simple and  easy.  An incision,
parallel with the border of the pelvis, to be prolonged  in front and be-
hind an inch beyond the limits of the diseased portion, would ordinarily
suffice.  Separating  the lips of this  wound apart by  dissection,  we
could, if it were necessary, detach, without fear, the  lower one,  as far
down as on a line with the insertion of the gluteus minimus muscle.   In
order to avoid the anterior circumflex  artery, it would  be necessary to
graze very near the bone, while pushing to the inner side the upper lip
of the wound.  It  is easy to perceive  that, by means of the crested or
the ordinary saw, directed transversely from without inwards, while  the
abdomen was protected by a piece of pasteboard, wood, or fold of linen,
we  would  be enabled to  remove the diseased portions of the  spine of
the ilium to any extent  desirable.
  Should the affection consist only of a very circumscribed point of ne-
crosis  or caries, it  could  also  be removed with the  mushroon-shaped
rowel  saw, or by the chisel. 
400
NEW ELEMENTS OF OPERATIVE SURGERY.
   At the bottom of the iliac fossa, there could be no fixed rules for the
operation.   One or several incisions to lay the bone bare, and one or
more applications of the crown of the trephine, unless we should prefer
the  rowel  saws of M. Charriere, or  the  osteotome of M. Heine, is all
that we can indicate of the general course to be pursued.
   [These limited carious or necrosic affections are  sometimes, though
rarely, seen on the crest of the ilium, in marasmal, broken-down cases,
from improper treatment of syphilis.   The  purulent diathesis, which is
occasionally noticed  in such cases, will also, as I have seen, attack the
thin layer of superincumbent  tissues  on the antero-superior and antero-
inferior spinous processes, after which the  suppuration involves these
prominences in caries, laying  bare a  portion of the cavity of  the pelvis
upon the internal iliac fossa.  Yet I have seen a case of thi3 kind which
gave no pain, care or trouble  to  the  patient, and  where  this dark hole
into the pelvic cavern  had existed for a year, was accompanied by no
discharge, but presented, to say the least  of it, a very curious appear-
ance.  T.]

                               §  IV.

  The pubes themselves also may be submitted to exsection.   Desault
(Chopart, Maladies des Voies Urinaires) mentions a lesion of the blad-
der, caused  by a splinter  of the pelvis; the fragment  was extracted,
and a sound placed  in  the urethra, when the patient got well.  A se-
questrum of the pubis having made its way to near the groin, caused an
abscess, and afterwards an ulcer, which reopened  and closed up several
times without  effecting a definitive cure, until the splinter  of bone itself
was expelled, which was nine lines long by two in breadth, (J. L. Petit,
 CEuvres Posthum., t. II., p. 33.)  A portion of more than  two inches
of  the pubis,  which  had been fractured and become detached, was re-
moved by  Maret, (Mim  de  VAcad. de Dijon, t.  II. ;)  the  horizontal
position, with flexion and evcrsion of the thigh, in order to prevent  the
narrowing of  the pelvis, enabled this surgeon to obtain a callus which
filled up the void left by  the loss of substance of  the bone, and accom-
plished the  cure in a short time.

             Article XII.—The Thoracic Extremities.

   When the disease occupies  the limbs, we have reason  to hope  that,
by excising some portion of the  body of  the bones, we may render am-
 putation unnecessary, and  preserve certain  important organs to the pa-
 tient.  Whether it  be caries, or necrosis, or any other morbid  produc-
 tion whatever, it is easy to conceive that, in order to destroy the totality
 of the disease, it will be sufficient to remove with it the whole thickness
 of the calibre ; at other times, only a plate of the bone.   In this man-
 ner, everything above and below the disease is so much  gained to the
 organism, and the surgeon in reality destroys only the portion which it
 is  impossible  to save.   We thus avoid removing a  great extent of sound
 parts for a  small extent of diseased tissues.  Viewed under this aspect,
 exsection of the  bones in our times has made substantial acquisitions.
 Thanks  to the labors of Hey, Moreau, Champion, Joagcr, and Roux,  and 
             EXTRA-ARTICULAR EXSECTIONS IN PARTICULAR.         401

 a multitude of modern practitioners, we no longer perform amputation
 of the limbs for an isolated disease of some of the bones which enter in-
 to their composition.   Nevertheless, we  must guard ourselves  again3t
 falling into the opposite extreme or that in which surgeons had so long
 continued.  To be enabled to  substitute with advantage exsection of the
 body of the  bones for amputation, we  must  be sure of  removing  the
 whole of the disease.   But every one  knows that it is usually  exceed-
 ingly difficult to  establish the limit  of  a caries or  necrosis.  Without
 that, however, the patient incurs the risk, after having  undergone an
 operation which is generally  tedious and difficult,  of being obliged to
 submit also to amputation.
   All other  things being equal, amputation  is more prompt and easy,
 and more certain in its result,  than exsection.  The latter, which neces-
 sarily exacts a delicate dissection, and multiplied incisions, and more
 numerous  explorations, and which leaves irregular, extensive, and more
 or less contused  wounds, is, on the other  hand, accompanied with less
 danger to life, and possesses the immense  superiority of not mutilating
 the patient, and of only altering sometimes, but not abolishing the func-
 tions of the part.
   In fine, in order that exsection should have the preference, there should
 be no  doubt as to the importance  of the organs which it will enable us to
 preserve, or as to the possibility of our leaving the articulations intact,
 while  at the same time we remove the whole disease.
   Caries being ordinarily very circumscribed in extent, scarcely ever com-
 promising life and almost always becoming ultimately restricted within
 certain limitations, cannot require exsection, unless it should have exist-
 ed for a considerable  length of time.  We may, moreover, say of it, as
 of gangrene and of diffused inflammations in general, that  we should not
 think  of removing it until the constitution has put a definitive termi-
 nus to the progress of the  malady.
   As to necrosis, it is a disease so little painful, so slow in its progress,
 so little serious  in itself, and one which gives such trifling inconvenience
 to the patient, that it would be censurable to commence its treatment at
 once with surgical remedies.'  Never can  necrosis justify exsection in
 the  diaphysis  of the  bones of the limbs, until the morbid process shall
 have separated it from the living tissues.   Before thinking of the opera-
 tion, therefore, we should make ourselves  perfectly well assured that the
 sequestrum, or necrosed fragment, already possesses a certain degree of
 mobility, and that it is positively isolated  from the rest  of the bone.
 Until that takes place, the  necrosis may give rise to pain, inflammations,
 and  fistulas, and stimulate to  incessant  suppurations, and that for a
number'of years, which it  is impossible to determine  ; but this does  not
make it proper that we should  proceed to exsection.
   This species of exsection is, moreover, applicable  to the short bones,
as well as to the long and  flat bones.  In the long bones, it may  be had
recourse to, both upon  the  middle portion and the extremities; its char-
acteristic feature lies in this :  that it respects the synovial or articular
cavities.   It also interrupts, sometimes completely, sometimes only par-
tially, the continuity of the diseased bone; and what  I have said, in this
point of view, of necrosis, may be applied to all the other organic affec-
tions of the osseous system.
   Vol. II.                    51 
402
NEW ELEMENTS OP OPERATIVE SURGERY.
                      § I.—Bones of the Hand.

   The bones of the  hand are  charged with  such important functions,
 that we are always exceedingly fortunate in being enabled to preserve any
 of them.  On the other hand, they are so short that their diseases rarely
 allow our saving the articular  extremities, and of destroying only their
 middle portion.
   Supposing it were possible, in certain cases, to remove  only the body
 of the bone, we ought to ask ourselves the question whether the corres-
 ponding finger would not thereby become more inconvenient than useful
 after the operation.   Certain facts, however, authorize me in asserting
 that, in  the  phalanges, we might  remove their middle portion, should
 their articulations in reality be in a sound state.  " When the middle
 phalanx only is corrupted, [corrompue, i. e., necrosed or diseased.   T.]
says Lembert, (Comment., ou  OEuvres Chirurgical.es, p.  397,1671, in
4to.) we lay it bare by two incisions—one on each side of the finger—in
order to  avoid  the tendons employed in flexion and extension.  If the
necessities of the disease should require the section of either one or the
other set of  these tendons, we are to preserve the  flexors.^ The bones
being laid bare, we macerate \mortifierons,i. e.,'\n this antiquated phra-
seology  and  practice, favor their dissolution or decomposition.   T.]
them.  After the abscess, (i. e., the separation of the bone,) the first
phalanx  approximates to the last, and their coaptation renders  the ac-
tion and use of the finger commodious."
   With the  instruments which the  surgeon of the present times  has
at his command, the operation is neither  difficult nor  dangerous.   If
there are wounds or fistulous  passages, we  enlarge them by dilating
the tissues  in the direction of the finger.  By means of a strong pair
of forceps the  necrosed fragments are extracted, and with the rasp we
destroy the  carious portions.   If the bone  is  diseased throughout its
whole extent, and there is no  convenient opening through the skin, we
make an incision upon  the dorsal region of the finger, from one extre-
mity of  the  phalanx to the other.  We afterwards detach the tissues in
front and posteriorly, with the bistoury ; then by means of  Liston's pli-
ers, or the articulated, or the  cultellaire  saw, we make the section in
succession of the two extremities of the diseased portion of the  pha-
lanx.
   A. Phalanges.—The  finger  dressed in the  same  way as if it were
fractured, shortens,  during the  progress of  the  cure ; but a sort  of
osteo-fibrous  tissue  or bridle, ultimately unites the two ends in  a solid
manner, while the tendons in a greater or less space of time, restore to
 the ungual phalnax and  the other phalanges preserved, a certain  degree
of mobility.   This, at least, is what I have observed to take place in three
 patients, who had thus  lost, one  of  them  the middle phalanx, and the
two  others  the  metacarpal phalanx, of one of the fingers.  Viguerie,
 (Mem. de VAcad. de Toulouse, t.  III., 1788,)  cites  two similar cases,
 in one of which it was  the first phalanx, and in the other the  second.
 The same thing  took place in the thumb of one of my best friends, and
 one  of  the  first  physicians  of France.   The first phalanx of  his left
 thumb diseased for  more than a year, in consequence of a wound, ne- 
             EXTRA-ARTICULAR EXSECTIONS IN PARTICULAR.         403

 crosed throughout its whole extent and surrounded with a sheath in full
 suppuration, admitted of being extracted through an ulcerous opening,
 which required only to be a little enlarged ; the finger thus treated, par-
 tially  recovered its functions.   M.  Heine, (Gaz.  Mid.,  1834, p.
 644.) also states that he has .removed the middle portion of a first pha-
 lanx, by means of his osteotome ; and M. Sanson, ( T/dse de Concours,.
 1833,) has seen the first metacarpal bone reproduced after  having boon
 destroyed  by necrosis.
   B. Bones of the Metacarpus.—In  treating of  amputation  of the
 fingers and of the hand, I have already  spoken of some exsections of
 the bones of the matacarpus, and I shall speak of them again further on.
 I will add in this place, that if the extent of the evil permits, we ought
 to exsect' only the  body of the  bone, and do all  in our power  to save
 the  extremities.   Attacked  upon the radial  side of its dorsal surface,
 the metacarpal bone of the thumb  could be as easily excised with Lis-
 ton's pliers, or  Rambaud's  saw, as it  could be disarticulated  by the
 method which I have elsewhere spoken of, (vid. supra, under Amputa-
 tions,) or by that which I shall soon mention.  The same could  be said
 of each  of the  other bones of the  metacarpus ; all  of them might be
 laid bare separately on their dorsal surface  by a long incision,  and di-
 vided near their head with the instrument I have just mentioned.  The
 tendons  pushed to one side  or the other during  the operation, could be
 easily avoided, so as to be enabled afterwards to resume their functions.
   Besides  that this  operation, which was already recommended by M.
 Champion, in 1815,  is more easy  and infinitely less serious than disar-
 ticulation, it would have also the advantage, the osseous epiphyses being
 preserved, of rendering the  re-establishment of an osteo-form cicatrix
 less difficult, and  of presenting  many  more  chances of retaining the
 form and primitive  functions of the corresponding finger.   It would be
 an easy matter for me, were I  disposed to analyse the cases where am-
 putation  of the bones of the metacarpus with disarticulation of one or
 both their two extremities has been performed, whether the finger cor-
 responding has  been preserved or carried away at the same stroke, to
 show that it  would  have been  possible in many of these cases to have
 restricted ourselves to the simple excision of the part diseased.

                        §  II.  The Fore-arm.

  When  the body of the bones of the  fore-arm is carious, or necrosed
 or degenerated, it may seem  impossible to cure the disease without am-
putation.   I have to reproach myself with having  amputated the arm
of a man, whose fore-arm swollen  and perforated with fistulous passages
for  many years, had nevertheless, for its fundamental  lesion, no other
than fragments of necrosed bone,  which were completely isolated in the
centre of the ulna, and which it  might have been possible to have re-
moved by exsection.   The same thing  happened to me with a scirrhous
affection  which  was situated in the body of the radius, and  which at
the present day  probably I would have destroyed, while preserving to
the patient his hand.
  A.  Ulna.—Scultetus, (Arsenal  de  Chir., tabl.  28, p. 83,)  in order
to remove an invaginated necrosis of the ulna, made an incison from 
404
NEW ELEMENTS OP OPERATIVE SURGERY.
the carpus to the elbow, and Pezoldi, (Obs. Med.-Chir., p. 126,) relates
that Fr. C. D'Armbruste, had  successfully extracted  twenty portious
of this  bone from a student affected with spina  ventosa.  In a case of
caries, Roland, (Bonet, t. IV., p. 116,) succeeded by rasping  the bono
daily; and  M. Baudens, (Gaz. Mid.,  1838, p. 415,) in a case of gun-
shot wound has removed  four  inches of this  bone.   It appears also,
that the middle  portion of  the ulna had already been  exsected, during
the last century by a surgeon who was  an acquaintance of Orred, (Bull.
des  Sc  Mid. de Bologne ; Journ. des Connaiss. Mid., 1834, t. II.,
p. 201.)  A soldier  who had lost  a considerable portion of  the ulna,
and  whose  case was mentioned  by  Dupuytren to M. Champion, (These
No. 11, Paris, 1815, p. 57,) was not maimed by it; and  the  exsection
of this  bone appears also  to have  been performed by M. Withusen,
(Jaeger, Op. cit.,-p. 20,) and by M. Werr, (communicated by M. Spreng-
ler, in 1838.)
  Three conditions  may be presented  here, as in almost  all  the long
bones ; sometimes the disease is situated upon the surface of the  bone,
and  does not include its entire  thickness ;  sometimes a sequestrum has
been formed in the centre of a new  bone, as if in a sheath or long
cavern ; finally it may  happen that  the bone is diseased throughout the
whole thickness of its cylinder.
  In the first  case, we  incise all the  soft parts  upon the superficial
surface of the  bone,  above  and below, and to an extent which goes an
inch beyond the limits  of the disease.   After having properly isolated
the part to  be cut out, we make use of the crested  saw,  or that in the
shape of a mushroon, or with a flat  disc, in such manner as to preserve
as much of  the thickness  of the  bone as possible, while leaving none
of the  disease  bohind.  The gouge, mallet, and rasp  may  also be of
service in  these cases.
  In the second condition,  we must also incise  extensively.   Upon the
supposition  that ulcers penetrate to the necrosis, and  that this latter
does not appear to be very extensive, we then limit ourselves to enlarg-
ing the opening.  Then  seizing the  fragment  with a good pair of scis-
sors, we sometimes succeed in extracting it without any further difficulty.
In the contrary case, we are obliged to  remove a greater or less portion
of the osseous  sheath  which encases the sequestrum.   If this sheath
has only one  opening, we may enlarge it by  means  of the concave
rowel-saws.  If it is confined by a sort of bridge, a cut of the crested
saw on each side will enable us to extract  the  sequestrum afterwards
by a stroke of the chisel.   We could effect the same object by introduc-
ing under it, by means of a flexible and curved probe, the  chain-saw of
Aitken.   Entering by one aperture, and coming  out at the  other, this
saw would thus divide the osseous substance from within outwards, and
first on one  side and then  on the other, with the greatest degree of
facility.  The  chisel and gouge, and even the trephine,  might also hero
be of service.   But a strong pair  of forceps, and either  the  crested,
rowel, or articulated  saw, or the osteotome of M. Heine, would scarcely
permit us  to feel the want of any other  instruments.  The canal which
encloses the necrosed sequestrum, in such cases, and which is ordinarily
verv large,  when once  liberated from  the  former, contracts and heals
without difficulty.  But we should  err, in attempting to close it by im- 
            EXTRA-ARTICULAR EXSECTIONS IN PARTICULAR.         405

mediate union.   It is one of those wounds which must suppurate, which
are to be dressed from the  bottom, and  filled daily with small balls of
lint.
  I.— Olecranon.—I  have never had occasion to perform  exsection
upon the lower extremity of the ulna ;  but I have seen  many patients
whose  olecranon should have  been  excised, and  might have been so
operated upon with advantage, if the patients themselves had consented
to it, or the surgeon had  decided upon  it.   I once performed this ex-
section on a young girl, who recovered perfectly ; a necrosis accompanied
with caries existed on the projecting point of the  elbow; every  thing
had been made trial of for  the space of eighteen  months, and several
physicians had expressed an opinion that the articulation was involved.
Having made a crucial  incision upon  the soft parts, I laid bare the
entire olecranon without any difficulty, taking care to avoid  the  ulnar
nerve behind and the humero-radial articulation  in front.   Then bending
the fore-arm, I was enabled with two cuts of the saw to excise a cunei-
form fragment corresponding with  the length of the olecranon, and
thus to remove  the  whole of the  diseased portion of  bone.   After the
cure, the functions of the limb were performed as perfectly  as before
the disease.  M. Textor  (communicated by M. Sprengler) was equally
fortunate with a patient upon whom he operated in the year 1836.

                  [Exsection on the  Olecranon.

  The Exsection of the Olecranon, as  performed by Dr. G. Buck, atl
the New-York  Hospital, Oct. 29th, 1842, (Vid. The  American Journal
of Med, Science, Philadelphia, April and July, 1843,) for hypertrophy
of that process from the effects of a fall, and whereby flexion and ex-
tension of the fore-arm were abolished, though pronation and supination
remained  nearly normal,  is  reprehended in unqualified terms by  M.
Guerin (Gaz. Mid. de Paris, tome  XII., 1845, p.  291,) as an uncalled
for, and severe and dangerous operation, especially when the surgeon
must have known that anchylosis is the very result we have to apprehend
from such attempts, and  which  result  was  actually  now permanently
produced  by the ablation  in question ; i. c, a fixity of  position was
now given  to the  arm,  when before  it had  considerable  extent of
motion, aud gave no inconvenience  whatever—assuredly a dear-bought
compensation, that should have deterred  the operator from an experiment
of this kind.  It is a very  different thing where a whole anchylosed,
consolidated joint has been  exsected, as has been  frequently done  at
the knee.
  II. Body of the Bone.—When the whole thickness  of the  bone is
to be exsected, the operation becomes a little more serious.  If  the
soft parts themselves are adherent and ulcerated, we must not hesitate
to sacrifice some portions of them.  The most convenient  process here,
consists in making two  very long and  slightly curved incisions, with
their concavities facing  each other, as in  circumscribing an ellipse.
The lips of these incisions are then dissected in  front and behind  as far
as the radial border of the bone.   The section of  the  bone may then be
effected by means of the chain-saw, if it should be convenient to pass it
around  the  bone by inserting it through the inter-osseal space.  If the 
406
NEW ELEMENTS OP OPERATIVE SURGERY.
chain-saw  cannot be  used, and the ulna is somewhat voluminous where
we wish to  divide it, Liston's pliers may be of service.  Otherwise we
should  make use of the vertical saw of M. Leguillou,  the flat rowel of
M. Martin, or either the crested or hand-saw.   The soft parts will have
to be carefully protected by compresses or pieces of wood or pasteboard;
and we should  generally  commence on  the most movable part of the
bone.   An elevator, or any resisting metallic plate slipped into the track
of the  saw, will complete the separation of the fragment we wish to re-
move, when it should appear to be difficult to effect this by means of the
saw.
   The  excision  of the ulna having been accomplished,  we must now at-
tend  to the  dressing with some degree of care.  The immovable ban-
dage  with  a  long opening would in a case of this kind be particularly
advantageous, since  it would  allow  of the hand being maintained in a
suitable position, would  prevent  the two  fragments of exsected  bone
from  approximating  too near to that which has been preserved, and at
the same time enable us to dress the wound conveniently.
   B.  The radius.—What  I  have just said of  the ulna applies equally
well to the radius.   The  carpal extremity of this  bone might  be ex-
sected like the olecranon without obliging us to penetrate into the ar-
ticulation.
   I. Exsection of the middle third  of the radius has been performed by
M. Baudens (Gaz. Mid., 1838, p.  415)'in cases of gun-shot wounds.
M. Flameng (Dissert Inaug., &c, Utrecht, Juin, 1834) in Holland has
also successfully exsected  this bone  in a state  of necrosis.   He made
use of the chain-saw, which broke twice during  the operation ; a fibro-
cartilaginous tissue ultimately replaced the part of  the bone which had
been removed.   This soldier who was operated  upon in  1826  did not
die till  the year  1832 ; and the dissection  of the limb presented one of
the most remarkable cases known.   M. Saint-Hilaire (These, Montpel-
lier, 1814, p. 16) relates another remarkable example of this operation.
The process in other  respects  is the  same  as for the extirpation of the
radius itself.  "
   II.  Extirpation.—A necrosis with  fungous  degeneration of the peri-
osteum  whieh extended nearly throughout the whole length of the fore-
arm, suggested  to me in 1826 the  idea of removing the  radius which
was alone  affected, in place  of amputating the arm ;  but  the patient
preferred the latter operation.
   In  the dead we may perform this operation without any difficulty, and
without absolutely destroying  any  tendon or muscle.  The  fore-arm is
to  be  placed in semi-flexion.   An incision parallel to its axis first lays
bare  the outer  and posterior side  of the radius. The two lips of the
wound are then  held apart and separated by means of the bistoury from
its anterior and posterior surfaces, a little below  its  middle portion,
since the radius there lies  in some measure naked under  the integu-
ments.   We  then endeavor  to insert between its ulnar border and the
soft parts  a grooved sound,* which should serve as a  conductor to the

  ♦Wherever a grooved sound (sonde cannelee) is mentioned in these volumes, it corresponds
in function to the instrument which the English and American surgeons  term a director.  But
as the author sometimes speaks specifically of a director or conducleur, we  have preferred to give
the phrase sonde cannelee, whioh appears in almost every one of the operations he describes, a 
            EXTRA-ARTICULAR EXSECTIONS  IN  PARTICULAR.         407

articulated  (or chain)  saw.  With this last instrument we make the
section  of the  bone, acting from within outwards; we then extirpate
the two fragments in  succession, dissecting them carefully from their
free extremity to their articulation.   If there should be too much difficul-
ty in  pushing the integuments  outwards, or  that  they should interfere
with the introduction of the saw, there would be no impropriety in divid-
ing to the extent of  a few lines each of the borders of the first wound.
  If an osteo-sarcoma,  or  any tumefaction whatever should occupy the
bone in such manner as not to admit of our sawing at the middle part
first, we should begin,  after having completed the incision through the
soft parts, by disarticulating the upper extremity first, in order to extir-
pate the bone from above downwards.  The rest of the operation is to be
conducted upon the same  rules as for  exsection of the body of  the
radius.   This operation of extirpation of the  radius, moreover, has now
received the sanction of experience.   M.  R.  Butt (Anat. Chir., Amer-
ican translation, by M.  Sterling) of Virginia, performed it  with perfect
success on living man in 1825.

                          §  III.— The Arm.

  Exsections of portions of the humerus external  to the articulations of
the arm,  have  frequently been performed.   Moreau, (Champion, These,
<fcc., p.  53,) in this manner removed the  whole continuity  of the bone.
According to Jaeger, (Op. cit., p. 19,) Lecat did the same.  These ex-
sections, like those  of  the fore-arm are of three kinds.  That for inva-
ginated necrosis, is  the one that has been  performed the  most frequent-
ly.   This  necrosis, whether it be  situated in the superior  extremity or
in the middle or inferior portion of the bone, must nevertheless be always
attacked upon the outer side of the limb.
  At the lower portion  we may often remove it without opening into the
articulation, or  proceeding to amputation.   A young peasant, who had
his elbow fractured five years before, being exhausted by long continu-
ance of pain, was admitted into  the Hospital of La Charite  in the begin-
ning of 1838, for a necrosis, complicated with inflammation at the joint.
The whole lower extremity  of the humerus was greatly enlarged and
swollen.  I was enabled to ascertain with the probe that the centre of
the disease was situated in the interior of the outer condyle.   A crucial
incision, carried an inch longer above than in the  opposite direction, ex-
posed  the whole external  condyle of the humerus, which I then exsect-
ed  with the  cutting pliers.   A fragment of necrosis which was formed
there in a boney sheath, was extracted by means of a strong forceps.  I
then clipped off the margin and inequalities of this cavity,  by means of
the chisel,a strong scalpel  and the cutting pliers mentioned.   This young
man who had already been severely troubled for  six weeks with a wan-
dering  erysipelas  was  attacked with it again fifteen days after the ope-
ration, and died at the expiration of two months subsequently, in conse-
quence  of the  eschars  and sub-cutaneous purulent abscesses which ap-
peared throughout every region of the  body, and from a diarrhoea which

literal translation.  Its meaning is understood, and must not be confounded with the sound
used in lithotomy, &c.  The French call catheters, bougies, directors, &c, all by the general
came of sonde or sound.  T. 
408
NEW ELEMENTS OP OPERATIVE SURGERY.
nothing  could  check.   The wound of the elbow, however, was in pro-
gress ot cicatrization, and there remained nothing of the disease either
in the humerus or arm, [fore-arm,] or about the elbow.
   At the middle portion of the humerus the incisions should be made in
the  same manner  as I have described for non-consolidated fractures.
At this  part I have frequently succeeded by making an incision of only
two inches  in  length, in extracting from the centre of  this bone by  the
aid  of a strong dissecting forceps, necrosed portions from two to three
inches long, and thus  have been  enabled in the course of three weeks
or  a month, to effect cures in patients who had been from eight to ten
years the prey to inflammations, abscesses or fistulas.
  The operative process will vary here as in exsection of the bones of
the fore-arm, and is to be regulated by the same rules.
  In  its  upper third, the  humerus affected with  necrosis, can only be
reached through the deltoid muscle.  I have found an advantage in that
part cutting out a  semilunar  flap, with  its free border outwards and
backwards.  Raising up this flap as a kind of covercle, and which con-
tains within  it the fistulous passages with which  its tissues may be perfo-
rated, we are enabled to lay bare with ease all the projecting portion of
the bone.  Operating in this manner upon a youth whose arm had been
diseased for  six years, I exsected the bone by means of the saw, carried
from above downwards, and parallel to the axis of the arm, first near the
root of the  flap, and  afterwards  near the posterior lip of the wound.
These two cuts of the saw, which went to join each other at their extre-
mity, circumscribed  an operculum which  I  afterwards  detached   by
means of a chisel.  The osseous cavity being thus completely laid open,
exposed to view the necrosed cylinder, which  was seized hold of, and
extracted without difficulty.   Having cleansed it of the  fungosities and
necrosed  fragments which remained in it, I had nothing more to  do than
to allow  the semilunar  flap of soft  parts to fall down upon it, and to
treat it with  simple dressings.  No accident supervened, and the young
man got perfectly well.
  Enormous  portions of the humerus may be in this manner extracted.
The arms, in the patient Schmid, (Journ. de Mid., 1686, p. 56—58,) fur-
nish a proof of this;  Ruland gives another example, (Bonet, t. IV., p.
140;) and  Walker, (Gaz. Sal., 1776, No. 31,)  Weidmann. Amvaud,
(Abrigi des  Trans., trad, de Pinel, p. 324,) Schaack, (Mursinna, Journ.
de Chir., t. I., p. 195,) Middleton, (Trans. Philosoph., abr<'gr  par  Pi-
nel, p. 321,) M. Champion and Simonin  (communicated by M. Champi-
on,) relate analogous cases.   To the  remarkable examples of this kind
which are given in  the Memoires de V Acadimie, and to those which  oc-
curred in the practice of Dupuytren, and which I  myself saw at the Hotel
Dieu, may be added the following : A young vine-dresser, aged  fifteen
years had  in  consequence of measles a necrosis in the  humerus, for
which nothing  was done for the space of near  two years.   M. Anthe-
aume a surgeon of Tours, seizing the necrosed  fragment with an ordi-
nary forceps, extracted it, and found  that it comprised the whole upper
and middle  third of the humerus.  Notwithstanding this enormous loss
of substance, the arm gradually re-acquired  its original strength, and
enabled  the young man to occupy himself without any  inconvenience
with the laborious occupations of husbandry, (Sociite  Mid. de  Tours,
1817, 2e trim., p.  14.) 
EXTRA-ARTICULAR EXSECTIONS IN PARTICULAR.         409
                        § lY.— The  Clavicle.

  The body of the clavicle, which  is frequently affected with exostosis,
caries, and syphilitic  necrosis, is also very liable to critical and scorbu-
tic necrosis, as in the case of Angerville, (Chopart, De Necrosi Ossium,
1776,) and also to sarcomatous  degenerescence.  Its relations with the
chest and especially with the subclavian vessels, and the little  opportu-
nity it offers for instruments, had at first placed it altogether out of the
pale of surgical operations.  Even supposing that the idea of removing
the middle portion of the clavicle  had suggested itself to  the minds of
surgeons, it would have  been soon  also renounced  from the fear of de-
stroying at the same time the functions of the arm.   At the present day
these apprehensions  have  been put  to rest.  Kulm (These de Waller,
trad. Fraii9.) had already mentioned the case of a  man in whom exsec-
tion was performed upon the clavicle for an osteo-sarcoma, weighing five
pounds, and which patient got perfectly well without losing the use of his
arm.   Meyer (Rougemont, Bibl. Chir. du  Nord, t.  I.) relates  the  case
of a young person in whom the  whole continuity of the clavicle in a state
of necrosis was extracted without leaving any infirmity.   The same thing
occurred in the  patient of Otto, (Gaz. de Mid. Nation, pour  VAllem.,
1778, No. 46,) and more strikingly still in the one mentioned by Pezol-
di,  (Obs. Mid.  Chir., p. 126, 1715.)   The case of a child is also given
who in consequence of small-pox lost one of its clavicles entire, without
however impairing any of the functions of the corresponding arm [ !].
The case given of M. Gilgencrantes (Journ. des Progres,  t.  III., p.
240) in which he extracted more than three inches of the clavicle; the
facts mentioned  by M.  Coulon, (These citee, 1833, p. 29;) the  opera-
tions performed by MM. Mott,  Warren, (communicated by the author,)
and Travers, of  which I shall speak farther on, have moreover shown  that
the clavicle may be exsected or even extirpated in its totality with success.
   Operative Process.—Whether the disease be a necrosis or an osteo-
sarcoma, the body of  the clavicle  should be attacked  always upon its
antero-superior  region.  Where there is necrosis there will necessarily
be some ulcers and fistulas.  After having divided the integuments which
separate these passages, or enlarged the only one that exists,  we shall
be enabled to ascertain if it will be advisable to treat the perforations in
the new bone in the same way,  [i. e., by dilating them—see above. T.] ;
if the openings in this  latter  are not arranged  in such manner as
to admit  of the issue of the diseased fragments, we proceed to the em-
ployment of the crested or  rowel saw, and a  strong scalpel, and the
gouge and mallet, in the  manner I have already  described  in speaking
of exsections  of the  humerus.   The  species of table which constitutes
the anterior portion of the bone, may  in this manner be exsected entire,
when any necrosed parts  whatever that exist may be then readily ex-
tracted.   Upon the supposition, however, that  the  sequestrum reached
to a great extent towards  the  acromion or sternum, we  might  then be
placed under the necessity of breaking it in order afterwards to extract
the two portions successively.
  This  kind of exsection is not difficult, nor is it very dangerous;  the
continuity of the bone moreover  remains intact, and the portion left upon
  Vol. II.                   52 
410            NEW ELEMENTS OP OPERATIVE SURGERY.
 the postero-infenor region, always  suffices for the reconstruction of the
 whole.   When  on the contrary the disease is of  a  cancerous character
 and it becomes necessary to exsect the whole thickness of the clavicle'
 the operation becomes  exceedingly delicate  and  dangerous.   [Wo give
 the author's own words, because ignorant or envious persons, who gene-
 rally presume the most, have in some places endeavored to decry this ope-
 ration as  trivial—seeing that  they  do not come in for a share of the
 honors.  The author, it will be perceived,' forcibly  pourtrays the danger
 of these exsections.   T.]  It is in this operation where there is no mo-
 ment at which each stroke of  the bistoury may not incur the risk of ad-
 mitting air into the veins; where no tissue can be divided without ex-
 posing to the  danger of  wounding  enormous veins or voluminous arte-
 ries ; it is here also that suppuration may be effused into the chest with the
 greatest degree of facility, leading to consequences which may prove speed-
 ily mortal; therefore in this operation we must circumscribe an ellipse of
 greater or  less breadth upon the integuments and in front of the tumor,
 taking care to prolong the angles of this ellipse, very far in the direction
 of the acromion and sternum.   Dissecting  afterwards each lip  of the
 wound, the upper one to the neck, and the lower one to near the first rib,
 we effect the isolation of the bone upon sound parts on its inner as well
 as  outer   extremity.   This being accomplished,  I would recommend
 that we should with the aid of the  bistoury graze the inferior, and then,
 the  superior  surface  of the bone  on  the outer  side of the tumor, in
 order to introduce the  chain saw and to effect  the section in that part
 before proceeding any  farther.  The  same thing should be done on the
 sternal side, if the thickness of the tissues should not render the com-
 ing down upon the clavicle in this  direction a matter of too great  diffi-
. culty.  Then  grasping the tumor itself in  order to raise it up while
 drawing it towards us, we should dissect carefully  from below upwards,
 and from before backwards, or from without inwards, never losing sight
 of the neighborhood of the subclavian vein and even that of the inter-
 nal jugular.  As  the operation may be long, it will be necessary to  tie
 in succession all the arteries.
    The removal of the tumor being effected, I would fill up the bottom  of
 the wound with small balls of lint, after which I should bring  the bor-
 ders  of the wound slightly together, and not place them definitively into
 actual contact until after the expiration of eight  or ten days.

  No.  III.—June 17th, 1828.—An account of a  case of osteo-sarcoma
    op the left clavicle,—in which Exsection of  that Bone was success-
    fully Performed,—By Valentine Mott, M. D.  (See American Jour-
    nal of the Medical Sciences, Philadelphia, 1828, Vol. III. p. 100-108.)

    On a former occasion, the author of the  following paper laid dowu the
  principles  which ought to govern a surgeon in relation to operations gene-
  rally and gave, in illustration, an account  of a successful amputation
  at the  hip-joint, (See supra, this vol.; also Phil. Med. and Phys. Jour.
  Vol XIV. p. 101.)  Since then, he has enjoyed  the satisfaction of see-
  ing  the same views beautifully illustrated by Dr. Barton's excellent oper-
  ation for the  production of an artificial joint, (lb. p. 177,) and has him
  self presented  a further illustration in the successful ligature  of the 
             EXTRA-ARTICULAR EXSECTIONS IN PARTICULAR. •        411

common iliac artery, (See, supra, this vol.; also Jour, of Med. Sc  Vol.
1st, p.  156.)  The instance now to be adduced, is  of a character to
supply  all the  confirmation desirable to the establishment of any such
principle ; and we think it may henceforward be regarded as  an  axiom
that it is the duty of a surgeon to operate in every case which allows of
a rational hope of success, either of improving the patient's condition, or
of preserving his life.  It is almost superfluous to add, that in arriving at
this conclusion, we do not believe it proper for every man who is nom-
inally of the profession to assume such high responsibilities  ; but,  that
we regard those as surgeons and those alone, who have, by conscientious
devotion to the  study of our science, and  the  daily habitual discharge
of  its multifarious duties,  acquired  that knowledge which renders the
mind of the practitioner serene, his judgment sound, and hand skilful;
while it holds out to the patient rational hopes of amended health  and
prolonged life.
   William B. Yates, of Charleston,  S. C.,aged nineteen years, of a ple-
thoric habit, consulted me on  the 26th of  May  last, respecting a tumor
situated on the left clavicle.
   He stated, that on  or about the 1st of February, 1828, he discovered
a small tumor, as large as a pigeon's egg, very hard and immovable, in
the left clavicle ; no pain whatever attended it, and the skin  was of its
natural color.   He can assign no cause to which it could be attributed ;
he had always enjoyed good health ; he recollects,  however, having
sprained his arm a short time before he first observed the tumor, but  does
not ascribe it to that, as it might have existed  previous to the accident,
and unknown to him.  He applied immediately to a physician, who  pro-
nounced it an encysted tumor, and applied warm salt-water ;  which, not
producing any good  effect, blisters, poultices,  a seton,  and escharotics,
were resorted to, but without retarding in  the least its  growth.  These
remedies  debilitated him so much, as to prevent him from taking ordinary
exercise.   But during his passage to New  York, he regained  his, in some
degree, former energy, and has since enjoyed pretty good health.
   On examination, a conical tumor,  about  four inches in diameter at its
base, and of an incompressible hardness, was found on the anterior por-
tion of the clavicle, to which it was firmly attached ; the apex  of the
tumor was covered with luxuriant fungous granulations, the consequence
of the  above  applications, from  which profuse bleedings from time to
time took place.
'■   The  rapid increase of the disease led him to request that some opera-
tion should be  performed, preferring to submit to a new and uncertain
operation, rather than perish with the terrible disease that now  threat-
ened his  existence.  All the circumstances were candidly stated to him,
both by Dr. Barrow, who was associated with me in the case, and myself—
that the operation was without a  precedent—that it was impossible for me
to say the disease could be eradicated—if it could, it would be exceed-
ingly difficult and dangerous—that the operation would be very compli-
cated, as the parts  connected with it were of the greatest importance to
life, and  involved the most important structure.  Nevertheless he was
perfectly resigned,  and resolved to submit to a doubtful remedy.   With a
composure and fortitude which has rarely been  equalled within mv obser-
 vation, he said he had resolved to take the chance of the operation, and
 disregarded the pain and suffering to which he must be subjected. 
412
NEW ELEMENTS  OF OPERATIVE SURGERY.
  On the 17th of June, between eleven and twelve o'clock, A.  M., ho
was  placed  upon a table, with his shoulders a little elevated, inclining
to the left side.   Assisted by Dr. Barrow, Dr. Proudfoot,and Dr. A. E.
Hosack, in the presence of Drs. Hull, Storer, Leveridge, Pratt, and a
number of my pupils, the following operation was performed :—
  An incision was commenced over the articulation of the clavicle, with
the sternum, and carried in a semicircular direction, as close to the fun-
gous projections as the sound integuments would  admit of, until it ter-
minated on the top of the  shoulder, near the junction  of  the clavicle,
with the  acromion  process of the scapula.  This  incision  exposed the
fibres of the pectoralis major, which was divided  as near the tumor as
possible ; in accomplishing this,  as  well as the first incision, arteries
sprung in every direction, and required ligatures.   A number of large
branches of  veins, under this muscle, emitted blood freely, and required
to be tied.
  In conducting the incision through the pectoral  muscle, towards the
scalpular extremity of the cavicle, care was taken  to avoid the cephalic
vein, as it passes  between this and the deltoid muscle.   A small  portion
of the latter muscle was detached from the clavicle, which readily allowed
the vein to be drawn outward towards the shoulder.
  On attempting to pass the forefinger under the vein and deltoid to the
lower edge of the clavicle, it was found  impracticable,  as the hard os-
seous part of the tumor extended beyond this point, and was completely
in contact with the coracoid process of the scapula.
  Finding it impossible, from the size of  the tumor and  its proximity to
the coracoid process, to get under the  clavicle in  this direction, an in-
cision was made from the outer edge of the external jugular vein, over
the tumor, to the  top of the shoulder.  After dividing the skin, platysma
myoides, and a portion of the trapezius muscle, a sound part of the cla-
vicle was laid bare at a point nearer the  acromion than a line with the
coracoid process ; a steel director, very much curved, was now cautious-
ly passed under the bone from above ; which, from the firm  boney state
of the tumor at this part, had a considerable obliquity outwards.   Great
care was taken to keep the instrument in close contact  with the under
surface of the bone.  The  depth of the bone from  the surface, rendered
it somewhat difficult to  accomplish this safely:  an  eyed-probe, similarly
curved, conveyed along the groove  of the director a chain-saw, which,
when moved a little, showed  that nothing intervened between it  and the
bone ; the clavicle was  then readily sawed through.
  The dissection was  now  continued along the  under surface of the
tumor, below the pectoralis major;  here a number of  very large  arteries
and veins required tying. The first rib being next exposed under the ster-
nal  extremity of the  clavicle, the costo-clavicular  or rhomboid ligament
was divided, and the joint opened from the lower part.   This gave con-
 siderable mobility to the  diseased  mass, and encouraged us to believe
 that its complete removal would be  practicable.
   By means of  a double hook and elevator, with  the assistance of our
 strong and very broad spatulas, properly curved, we were enabled to
 elevate a little the sawed end of the clavicle.   After  loosening the parts
 about it, by keeping close  to the  tumor,  we wished to discover  the
 subclavius muscle, as it is  inserted in the bone about  this situation ;  but 
EXTRA-ARTICULAR EXSECTIONS IN PARTICULAR.         413
it could not be seen, as it  was incorporated with the diseased mass.
Had this muscle been found, the  separation  of the tumor would  have
been  much less difficult and tedious, as, by  keeping above it, the sub-
clavian vein is of course protected.   The origin of this muscle, from the
cartilage of the first rib, was  seen and divided, but it was almost im-
mediately obliterated in the tumor.
  Continuing the removal of the tumor at the upper and outer part, the
omo-hyoideus was found  lying under it, which we exposed  from where
it passes under the mastoid muscle, to near  its origin from the superior
costa of the scapula.  In separating  the  tumor from  the cellular and
fatty structure, between the omo-hyoid  muscle and the subclavian ves-
sels, a number of large arteries were divided, which bled freely, and
particularly a large branch from the inferior  thyroidal.
  The anterior part of the upper incision was now made  from the ster-
nal  end of the clavicle, and carried  over the tumor, until it met the
other at the external jugular vein.  After cutting through the platysma
myoides, this vein was  carefully separated from  the surrounding parts,
and  two fine  ligatures passed beneath it, and tied a short distance from
each other;  the vein  was then cut between the ligatures.
  The clavicular part of the sterno-cleido-mastoideus was next divided,
about three  inches above the clavicle in the  direction of this incision.
The deep-seated  fascia of the neck  being  now exposed,  the mastoid
muscle, and the diseased mass, were  very cautiously  separated  from it,
until the anterior  scalenus was exposed.
   The subclavian  vein, from  the edge of the scalenus anticus  to  the
coracoid process,  was so firmly adherent to the tumor, as to lead me at
one  moment  to believe that the coats  of the  vein were so intimately in-
volved in the diseased structure, as to render the  complete removal of
the morbid part utterly impracticable.  By the most cautious proceed-
ing, however, alternately with the  handle and  blade of the knife, we
finally succeeded in detaching the tumor, without the least injury to  the
vein.  This  part  of  the operation  was  attended with peculiar danger
and  difficulty.  At every cut, either an artery or vein would spring, and
deluge  the  parts  until  secured  by ligatures.   Besides several large
veins, the external jugular was so  situated  in  the midst of the boney
mass, as to require two more  ligatures in this place, near to the sub-
clavian,  and it was again divided in  the  interspace.   Near the sternal
end  of the clavicle, a large artery and vein  required  tying ;  they were
considered as branches of the inferior thyroidal artery and vein.
   From having  cut through the clavicular portion  of  the mastoideua
muscle, obliquely upwards and outwards  a  little  above  the  tumor,  we
were enabled, by turning this down and keeping close to the fascia pro-
funda, to detach the tumor from over the  situation  of the thoracic duct
and  junction of the  internal jugular and left subclavian, without  the
least injury to these  important parts.
   To reach the lower part of the tumor as it extended upon the thorax,
it was necessary  to separate  the pectoralis major in a line with  the
fourth rib,  and  to make a  transverse  incision  two inches in length
through the  integuments and muscles at about its centre.   The incision
upon the neck extended from the sterno-clavicular junction in a semi-
circular directiou, to within an inch of the thyroid  cartilage and base of 
414
NEW ELEMENTS OP  OPERATIVE SURGERY.
the lower jaw, and two inches from the lobe of the ear, and terminated
near the  junction of the clavicle and scapula.
  The fungous and bleeding character of the apex of the tumor implied
that it was freely supplied with vessels.  The discharge of blood was so
free at every step of the operation, that about forty ligatures were ap-
plied.  It was estimated that  the patient  lost from sixteen to twenty
ounces of blood.
  All  the parts now  presenting a healthy appearance, the ligatures
were cut close to the  knots, and the cavity  of  the wound filled with
lint.  Long strips of adhesive plaster were applied, to prevent the edges
of this extensive  wound  from  further  retracting; a light  compress, a
single-headed  roller  loosely applied  around the chest and shoulders,
completed the dressing.
  He was placed in bed upon his back, inclining a little to  the right
side, with the head considerably  elevated, whilst  the left shoulder and
arm were supported by a pillow.
  I requested two of my promising pupils, Messrs. Thomas G. Swain of
New York, and John W. Schmidt of Charleston, S. C, to remain with
him during the day  and following night; and  such was the interest
which his case excited in their minds, that they  remained in the room
with him night and day for the first week.   To  their  unwearied atten-
tions I am indebted for the following report of his symptoms :—
  June 11th, 1828, 7 o'clock, P. M.   Feels  comfortable, except being
nauseated by the wine and water given him during the operation, which
he says generally produces  this effect upon him.   Some reaction is in-
dicated.   Between 7  and  8, P.  M.,  took  two cups of gruel, and has
since vomited a little.   9 P. M.  Pulse  110; skin moist and cool.   He
feels tolerably comfortable, and is much gratified that the operation has
been performed.   Took  a little  mint  tea, which was  grateful to him.
12 P. M.  Has  had a short repose ;  drank some mint tea,  and feels
quite comfortable ; pulse 128 ;  thirst considerable.
  June 18th,  3 A.  M.   Has had a  comfortable sleep,  during  which
there was considerable hemorrhage from  the  wound;  pulse 120, hard
and full.   8 A. M.  Took a cup of tea, ate a piece of toast, with a few
strawberries; feels better  than  previous  to the  operation; pulse 124.
12 P. M.  Has slept during two hours, and  is  now in a  comfortable
sleep ; pulse 130; skin moist and warm.
  June 19th, 4 A. M.  Feels much refreshed ; administered the follow-
ing:—R., Sulph. magnes.  §ss.—calc. magnes.  5 j. M. dissolved in a
small quantity of water.  10 A.  M.  Another cathartic directed, which
produced an evacuation at 2 P. M., and afforded much relief.  9 P. M.
Has taken toast  and tea, and has a good appetite ; pulse 124, and much
softer ; copious discharge from the bowels ; febrile symptoms less.
  June 20th, 3 A. M.   Skin moist and cool;  appetite good; pulse 120.
9 P. M.   Pulse 106 ;  bowels free ; feels comfortable.
  June 21sl, 2 A.M.   Thirst  much  abated; skin moist and cool; has
slept well.  9 A. M.  The bandage and part of lint removed, it beino-
a little fetid; inflammation moderate, and accompanied with a slight
suppuration; bowels being somewhat torpid, the following medicine
was prescribed :—R., Pulv. rhei.—mag. calc.  aa 5iss.—sacch. alb. g j.
—aqua menth. pip. 1  iiij.—took two table-spoonfuls every hour, which
operated at half-past one copiously. 
EXTRA-ARTICULAR EXSECTIONS IN PARTICULAR.         415
   June  22d, 9  A. M.  Has had  small  evacuations from the  bowels;
 slept  well  and comfortably; pulse 108 ; the dressings were removed
 except a small  pledget of lint at the bottom of  the wound, over which
 an emollient poultice was applied.
   June 23d, 9 A. M.  Has slept comfortably ; pulse 109, soft and full;
 skin natural.   Ordered the following  cathartic:—R., Sulph.  magnes.
 § ss.—magnes. calc. 5 j«—which was repeated in the afternoon.
   9 P. M.  Medicine has operated copiously; pulse 99, softer and
 more natural; skin pleasant; tongue clean; renewed the poultice.
   June 2±th, 9 A. M.  Symptoms the same ; bowels have been opened ;
 removed some of the remaining lint;  applied a fresh poultice ; removed
 him to another bed, for  the  purpose of airing his ; no inconvenience
 from the removal; takes toast and tea, gruel, <fcc, through the course
 of the day.
   June 25th, 9 A.  M.  Pulse 98 ; tongue clean ; bowels torpid.  Or-
 dered a Seidlitz powder every hour till it operated ; he took seven.
   June 26th, 9 A. M.  Pulse 95 ;  slept well during  the night;  patient
 expressed a desire to eat;  gave him some  chicken broth, which was
 very palatable.
   June 21th, 9 A. M.  Pulse 84 ; at 10  o'clock administered an enema,
 which produced copious evacuations.
   June 28th, 9 A.  M.  Took some  strawberries, toast and tea;  takes
 §viij. of the infusion of cinchona through the day.
   June 29th, 9  A. M.  Pulse soft and  full; bowels  torpid.  9 P. M.
 An enema administered, which produced copious evacuations.
   June 30th, 9 A. M. Pulse  95, full and hard ; the wound is dressed
 every morning ; it is now nearly  half filled with healthy granulations.
 The skin much contracted;  some  ligatures  have been  removed, others
 quite loose.   He requires an enema every other evening,  to  keep his
 bowels  open.
   July  1st.   Pulse 100;  injection produced copious  evacuations  of  a
 natural appearance.
   July 2d.   Permitted him to eat meat; pulse natural;  wound con-
 tinues to fill up rapidly  with healthy granulations ; continues to take
 the cinchona Sviij. per diem.
   July 2>d.   Feels  in every respect much better; pulse natural; skin
 moist;  experienced a slight indisposition from  a cold  produced  by  a
 sudden change in the weather.  Directed  him a  dose  of the eccoprotic
 mixture.
   July Ath.   Wound has a healthy  appearance ;  cicatrization  has  com-
 menced ; seven ligatures were removed;  dressed it with lint, over which
 a compress was applied.
   July 5th.   Sets up in bed with ease ; two  ligatures removed.
   July 6th.  An apparatus applied yesterday to support the arm.  No
unfavorable  symptoms have appeared.
   July 1th.  A number of ligatures were removed to-day.
   July 8th.   Bowels require  no more  injections at present.  Wound
nearly filled, and is very florid and healthy in its appearance.
   July 9th.  The cut  end  of the  remaining  portion  of the clavicle is
perfectly sound and healthy.
   July 10th.  Continues to improve in strength; bowels still regular
 skin pleasant; tongue clean ; pulse natural. 
416            NEW ELEMENTS  OP OPERATIVE SURGERY.
  July 11th.   The slight catarrh, complained  of a few days since, has
entirely left him.
  July lWi.   The end of clavicle entirely covered* with healthy granu-
lations.
  July 14:th.   The ligatures remaining arc very few; wound contracted
astonishingly ; nearly filled with very florid  and healthy granulations.
Walked down stairs to dinner yesterday and to-day without the slight-
est inconvenience.
  July 15th.   The  patient goes  about the  house with  his arm in a
sling  and the apparatus to support the shoulder.
  July 16th.  No more  ligatures  remaining; the granulations  rising
above one part  of the  integuments,  require  pressure.  Continues the
infusion of bark.
  He continued  to improve in general health,  and the wound gradually
filled  up, until the middle of August, when he left the city on an excur-
sion of pleasure  to the Springs  at  Saratoga.  He returned in Septem-
ber, in better health  than he had ever enjoyed.
  The tumor is  about the  size of a man's doubled  fists, or of a circum-
ference just to allow me to grasp it with my fingers fully extended.   It
consists of a boney cup, incompressibly hard  at all parts, except supe-
riorly and inferiorly  to a small extent.   From an opening of  an ellip-
tical shape at the upper part,  protruded a bloeding fungus, of the size
and shape of half a hen's egg.   At the under surface, as it lay  upon the
great subclavian vessels, the  boney character is  less manifest; the
structure about the centre particularly appearing to be cartilaginous  or
semi-osseous.  This  boney enlargement  occupies the clavicle  from the
sternal articulation to within half an  inch  perhaps of the  acromial ex-
tremity.  From  the motion which can be  given to each end of the cla-
vicle, the natural structure of the bone seems to be entirely destroyed.
  This operation far surpassed in tediousness, difficulty, and  danger,
any thing which I have ever witnessed or performed.  It is impossible
for any description which  we are capable of giving, to convey  an accu-
rate idea of its formidable nature.   The attachment of the morbid mass
to the important structure of the neck and shoulder of the left side, and
to so great an extent, is  sufficient to indicate  its magnitude and  diffi-
culty.
  The extensive nature of this  operation, led  us to take  the precaution
»f securing the external jugular with  a double ligature, and dividing it
between them.   Though in operating upon the  neck we  have several
times cut these veins without any unpleasant consequences, we  however
think we have witnessed almost fatal effects from the division of a large
vein, and the admission of air into the circulation.
  The case of  Baron Dupuytren's in which a young woman  suddenly
died under an operation, from  the division of a large vein in the neck,
whilst he was engaged in removing a tumor, contributed, with my own
experience, to make  me take the precaution of previously tying  the vein
in this operation.
  In an attempt which I made  to  remove  the parotid gland in an en-
larged and scirrhous state, the facial vein, where it passes over  the base
of the lower jaw, was opened in dissecting the integumeuts from the
tumor, in  the early stage  of the operation, before a  single artery was 
              EXTRA-ARTICULAR EXSECTIONS IN PARTICULAR.         417

  tied.  At the instant this vessel was opened, the attention of all present
  was arrested by the gurgling noise of air passing into some small open-
  ing.  The breathing of the patient immediately  became  difficult and
  laborious, the  heart beat violently  and  irregularly, his  features were
  distorted, and  convulsions of the whole body soon followed, to so great
  an extent as to make it impossible to  keep  him on the table.  He lay
  upon the floor in this condition for near half  an hour, as all supposed in
  articulo mortis.  As the convulsions gradually left him, his mouth was
  permanently distorted, and complete hemiplegia was  found to have en
  sued.   An hour and more elapsed before he could articulate, and it was
  nearly a whole  day before he recovered  the use of  his arm and  leg.
  From a belief that these effects arose from the admission of air into tho
  blood-vessels, which was  not doubted by any person present, I instantly
  called to mind a set of experiments, which I made some twenty years
  since upon  dogs, by blowing  air into the  circulation, by inserting a
  blow-pipe into a large superficial vein upon the thigh, and  was forcibly
  struck with  the similarity of result.
    To the extraordinary composure of mind which our patient manifest-
  ed, is to be attributed in a great measure his undisturbed and  speedy
  recovery.   No  adverse  symptoms, of a general or local  nature, took
  place to interrupt the process of granulation in the wound.   The im-
  mense chasm which was  left, and  such important parts as  have  been
  described, being only covered with lint, necessarily occasioned me great
  solicitude, until I saw suppuration fully established, and the great ves- v
 sels covered by granulations.
    No difficulty attended  keeping  his shoulder in a proper position, by ,
 the use of the common apparatus for fractured clavicle.  With this he -
 walked about without any inconvenience, after four weeks had elapsed ;. '
 and  two months  from the time of the operation, he was able to discon-
 tinue the sling,  and by means of an apparatus contrived by Mr. James
 Kent, a  most ingenious and inventive artist, to supply  the want of clavi-
 cle, he was so fitted  as to have his shoulder in  its proper position, at
 the same time that the full motion of his arm was preserved.

   Professor  Motfs case of Exsection of  the Clavicle.  (Extract  of a
 letter from Dr. A. F. Vache, of New York, to Dr. Hays.   See Phila.
 Amer. Jour,  of the Med. Sc, vol.  VII., p. 271, year  1830.)  You ex-
 press a desire for a continuation of the  case  of exsection of the clavi-
 cle, or rather for a report  of its result.  It gives me much pleasure to
 state its  successful termination, and the perfect health  of the gentleman
 upon whom it was performed.  About two months ago, while on an ex-
 cursion of pleasure to New York, he  called at Dr. Mott's, and I exam-
 ined his shoulder.  He remarked that he continued to wear the mechan- k
ical contrivance until  the anniversary of the performance of the opera-
tion, when he laid it aside, not finding it any longer necessary.   On ex-
amination, I found that the small acromial portion of the clavicle, which
had not been removed by  the operation, had  formed permanent  adhe-
sions with the surrounding parts, and maintained  the shoulder in its
natural position.   He had  perfect use of  the arm  in  all  its  motions,
and the cicatrix  was all that appeared  to  indicate  any  operation ever
having been performed.
  Vol. II.                   53 
418
NEW ELEMENTS OP OPERATIVE SURGERY.
                    [Exsection op the Clavicle.

   Mr. Liston, of London, (See his Surgical Lectures—London Laucet,
Dec.  21, 1844, p. 361,) would  appear to make rather light of the idea
of any  thing  very  formidable  being attached to the exsection even of
the entire clavicle.  It is to be  noted, however, that Dr. Mott, in his
lectures teaches, and has ever taught, that this operation, which is another
of those in surgery first performed by him, that he deems it, so far as
the manual is  concerned, one of the most dangerous and  difficult, if not
the most so, of any to which the  human body has ever been subjected,
not excepting that  of the ligature upon the arteria innominata; an un-
wavering adherence to  which opinion, deliberately  formed, Dr.  Mott
would, with all due deference to the judgment of others, take occasion
to reiterate in this work.
   It is unnecessary to recapitulate what is familiar to all, the extent of
vital  parts immediately interested with or actually attached, it may be
said,  to this bone throughout its whole length.
   What facilities Mr. Liston may derive from a species  of screw-lever
to be inserted into  the bone after disarticulating or making the section
of one extremity, to hold up the diseased mass, Dr. Mott never  having
used it, cannot say ; but no doubt it may be serviceable, as well as the
small copper  spatulas to hold the parts well  asunder while dissecting
the bone, and  which Mr. Liston says he has found immensely useful.
   But nothing, as it appears to us, can justify (if his lectures be cor-
rectly reported,) the degagee  manner in which he speaks of this opera-
tion when he  says, (lb., Loc cit., p. 361.)  "It  (i. e. the  operation
of removing  the clavicle for what he calls  fibro-cartilaginous tumors,)
is attended  with some little  difficulty; there are very important parts
under it; but  by dissecting close upon the  bone and tumor, you avoid
the nerves and vessels" !
   We trust  no young  surgeon will be induced by the cheapness which
the London professor's language would seem to attach to  this operation,
and which to him  perhaps may  not be  formidable, to undertake  hap-
hazard  or thoughtlessly to carry  his knife  into such a region without
some little surgical experience and anatomical knowledge at least, though
aided by ever  so powerful an array of adjunct mechanical implements.
   Mr. Liston  considers that in osteo-sarcomatous  and soft tumors  of
the clavicle, especially if the glands are affected in the  latter, the ex-
section  of the  bone is not to be meddled with.  In fibro-cartilaginous
tumors he would remove it, and has removed it as he informs us.   T.]

                         § V.— The scapula.

   The scapula may, like  the clavicle, be affected with necrosis and sar-
comatous degenerescence : but it is surrounded by such  thick muscles
that its exsection would  seem at first to be a difficult matter.  Certain
facts, however, prove that this operation is not impossible.   M. Janson,
for example, effected the removal of a great portion of the scapula with-
out touching either  the shoulder or the chest;  so also did M. Luke.  It
is also  said that Ja3ger (Coulomb, Op. cit., p. 29—30,) who himself 
             EXTRA-ARTICULAR EXSECTIONS IN PARTICULAR.         419

 ascribes operations of this kind  to MM. Liston, Haymann and  Syme,
 (Jaager,  Opirat. Risect., etc., p. 16,) has successfully exsected the
 spine  and almost the entire body of the scapula, in a young girl, upon
 whom M. Textor had previously performed amputation of the arm.
   A.  Exsection here also presents a number of modifications : we may
 have to remove only  one of the angles or the spine of the scapula, or it
 may become necessary to exsect the greater portion of this bone.  To
 cut down upon the inferior angle,  as Sommeiller did it, in 1796, (Cham-
 pion,  These, etc., p. 47,) the  better plan would be  to incise  liberally
 through the corresponding region  of  the integuments  and latissimus
 dorsi muscle.  Being properly denuded, the bone could then be readily
 excised with the common, or crested or chain saw, or M. Liston's cut-
 ting pliers.
   B.  The superior  angle  would also  require a  transverse  incision,
 which would involve  a portion of  the trapezius and levator anguli scap-
 ulas muscles ; the same instruments  would also be  required for the sec-
 tion of the bone.  As to the spine itself of the scapula, the inner half
 of which was exsected by M. Champion, we should in order to cut down
 to it, begin with an incision which  should  follow the entire length of
 the  spine and enable  us to isolate  the supra-spinatus  muscle above, and
 the  infra-spinatus  below.  M. Liston's  cutting pliers, or the ordinary
 cutting forceps, or the concave rowel saw, would then be more suitable
 than any other instruments.
   C. If the body of the scapula should be diseased as in the case of M.
 Jaeger, or  that  of  M. Castara  (Com.  by  the author, Dec. 1838,) we
 should obtain some facility in  exsecting it, in laying it bare by means of
 three  principal incisions, one over  the  whole  length of the spine, and
 the two others setting out from the anterior extremity of this prominence,
 to be prolonged to the root of the neck in one direction, and to the hol-
 low of the axilla in the other. The soft parts which cover the supra-spina-
 tous and infra-spinatous fossae, should afterwards be  turned back above
 and below, under the form of a triangular flap for each.  After having
 sawed through the root  of the acromion, and  detached the whole cir-
 cumference anteriorly and  posteriorly,  and then reversed  from within
 outwards the body of the scapula, we could in turn, make the exsection
 of this latter near the glenoid cavity, either by means of  the chain-saw
 glided underneath, or by the small hand-saw.  We  should in such a
 case be obliged to divide the common scapulary and supra- scapulary ar-
 teries.  The  sac formed  by the wound  would  be  easily diminished by
 the approximation of  the flaps, but we ought not  to attempt the complete
 closure of the wound  until after the expiration of eight or ten days.

                 § VI.—Exsection of the  Scapula.

  The operation  of exsection of the body of the  scapula, also, would
vary still more than that for the clavicle.
  M. Janson, (Arch.  Gin. de  Med., t. XII., p. 414,) who has perform-
ed it, commenced by circumscribing  the  tumor by means  of two  semi-
elliptical incisions,  while  preserving as  much of the  skin as possible ;
he then dissected and reversed upon their external  surface the two lips
 of the wound; and detached the morbid mass in every direction  down 
  120            NEW ELEMENTS OP OPERATIVE  SURGERY.

  to the fossa  sub-scapularis ;  but while he was raising it up in order to
  bring it forwards, it broke at its middle, and compelled him to separate
  at first only its outer half.   After  having  divided the attachments of
  the trapezius, supra-spinatus and infra-spinatus muscles, the operator,
  discovering that the portion of the scapula situated above its spine was
  sound, separated, by means of the saw, the whole of the diseased bone,
  and thus preserved the articulation of the arm.  By means of a last
  incision directed obliquely from below upwards, from behind forwards,
  and from without inwards, he laid bare the rest of the tumor ; dissected
  it with care; drew  it cautiously upwards ; felt the cellular  tissue which
  had attached it to the arm giving way,  and finally detached  the mass
  completely.   All the vessels  were tied.   The  bottom of the axilla  was
  tamponed, and the  lips of the wound, which was six inches in its trans-
  verse diameter and nine inches from above downwards, were brought
  together by  means of adhesive plasters.   The  motions of the arm upon
  the glenoid  cavity were  preserved.   The tumor weighed eight pounds
  and a half, was easily torn, and in its interior resembled a pomegranate.
   Faure, (Mem. de VAcad. de Chir., t.  VI., p. 114,) after amputating
  the arm, exsected the acromion on account of some irregular asperities
  upon  it, and Frater, (S. Cooper, Diet.  Chir., t. I., p.  92, col.  1, also
  advises this operation, which  is disapproved of by M. S. Cooper, (Ibid.)
  Laisne, (Journ.  Gin. de  Mid., t. VIII., p.  401,) removed  in this man-
  ner a sequestrum from the glenoid angle, on the seventy-first day after
  the wound.   In a case mentioned by Despelettes, (Mim. de VAcad. de
  Chir., t.  II., p. 552, in 4to, et edit, in 12mo, t. VI., p. 247,) and  where
  the shoulder had been carried away by a gun-shot wound, there remained
  nothing but the anterior angle, yet the patient recovered.  In the  patient
  of Halliday, (S. Cooper,  Diet, de Chir., t. II., p. 292,) which was seen
~by M.15. Cooper, though the  shoulder was in great part destroyed, and
  the lung and pericardium exposed, the patient recovered notwithstanding.
  In the case of Borel, (Bonet, Corps, de Mid., t. IV., p. 84, obs. 49,)
  the two  shoulder-blades  had been  carried  away by  a musket-shot.
  Bond, (Mid. and Phys. Journal, Aug., 1821,  Vol. LXVL, No.  270,)
  having seen a suspected case of osteo-sarcoma in the  scapula, asks  the
 question, if the  patient's life  could not have been saved by the removal
  of the  bone ?  Mareschal, (Mem. de VAcad, de  Chir., t. II., p.  60, in
 4to,) applied the trephine to the scapula, in a case of abscess between
 that bone and the ribs.  A ball  was buried in the middle of the infra-
  spinous fossa; M. Champion placed the trephine by the side of the ball,
  and succeeded.  Else, (Sprengel, Hist, de la Mid., t. VII., p. 33,) tre-
  phined the  shoulder in a case of caries.   Exsection of the lower  angle
  of the scapula, was  performed also by MM. Sommeiller and Champion,
  (Champion,  These de VEcole  de Paris, No. 11, 1815,) which latter, in
  another case, excised  the inner half of the spine  of the  same  bone.
  Haymann, removed  the greater  part of the bone for an osteo-sarcoma ;
 but the  disease  returned at the  end of a year, and  ended  fatally.  In
 the case of  Luke, as well as that of  M. Castara, (communicated by the
 author, Dec. 1,1838,) the greater part of the shoulder had  been invad-
 ed by a medullary fungus.
   Ravaton  (Chir. d'Armie, p. 249, obs. 52,1768) speaks of the two
 lower thirds of the  scapula, together with its acromion and  spine, frac- 
              EXTRAARTICULAR EXSECTIONS IN PARTICULAR.         421

 tured by a gun-shot wound, and which had separated successively.  Both
 in the  case  of Riolan (Manuel Anat., et Collect. Acad., part. Etrang.,
 p. X.,) and  in tfrat of Chopart, (De Necrosi  Ossium, p. 7, 1776,) a
 reproduction took place after a sequestrum in the scapula was removed.
 After a comminuted fracture of the scapula and clavicle, from gun-shot
 wound, mentioned by Monbalon, (Gazette  Salutaire, 1764, No. 50, p. 2
 col.  2,) it became necessary  to extract  four fragments of the first-
 mentioned bone, one of which fragments,  and which was of considerable
 size, belonged to its spine.   The fifth and  largest fragment could  not
 be taken away until the fifteenth day.  Two large pieces of the clavicle
 had to be removed at a little later period, and the patient recovered.
    [In 1837, Professor Reuben  D. Mussey, now of Cincinnati, removed
 both the clavicle and scapula throughout their entire extent.   The dis-
 ease was osteo-sarcoma.   The immense wound became consolidated
 without the formation of a tea-spoonful of pus..- In the summer of 1852,
 Prof. M. heard that his patient was  perfectly  well.   In a letter from
 this distinguished surgeon dated May 13th, 1854, he informs us that in
 July, 1845, he removed  the  arm, entire  scapula, and  one half of  the
 clavicle, in another  patient  affected with osteo-sarcoma.  He had  re-
 cently heard from this patient, and he was in perfect health.
   In 1838, the late  Dr. Geo. M'Clellan removed the entire scapula and
 clavicle for osteo-sarcoma.   The boy died from a return of the disease
 in the course of six months.
   The following interesting case of excision of the scapula, is  reported
 by Prof. Gross in the American Journal Med.  Science, April, 1853.
   The disease in this case was an  osteo-sarcomatous  mass, measuring
 fifteen inches in all directions, implicating  the  whole of the  scapula,
 growing rapidly, and wearing down the strength  of tho patient by  the
 pain it occasioned.  The patient was a slim and delicate man, aged 40.
 "A full dose of chloroform having been administered, an  incision, six-
 teen inches in length, was made from the  superior  angle of the scapula
 to the inferior extremity of the tumor, its direction being obliquely down-
 wards and inwards.   Another,  beginning about five inches below the up-
 per end of the first, and  terminating about  the same distance  from  its
 lower end, was then carried, in a curvilinear direction, so as to include
 the  small oval flap  of skin with the tubercle, previously alluded to, in
 its  centre.  The integuments, which were  exceedingly  dense and thick,
 especially at  the  superior part  of the  tumor, were then dissected off
 from the surface of the morbid growth, first towards the  spine, and then
 towards  the axilla.  Having detached the  elevator and trapezius mus-
 cles, I sawed through the acromion  process of the scapula just behind
 the clavicle, and then divided the broad  dorsal  and anterior serrated
muscles.  Carrying my fingers  next underneath the tumor, and  raising
it up, I severed its connections  with the ribs, cut  the deltoid and other
muscles of the arm,  sawed the  neck of the scapula, and thus removed
the entire mass with comparatively little difficulty.
  Several vessels were  divided in the early stage of  the operation, at
the posterior  and  middle  part of the tumor; but these were easily con-
 trolled by the fingers of  my assistants.   Several arteries near the neck
 of the bone bled  so freely as to demand the ligature after the removal
 of the morbid growth.   About  twenty-four ounces of blood wore lost. 
 422            NEW ELEMENTS OF  OPERATIVE SURGERY.

 The  patient became very faint towards  the close of the operation, and
 cordials were necessary to revive him.  The immense wound  thus pro-
 duced was dressed with  three interrupted sutures and adhesive straps,
 and supported by a compress and a broad body bandage.  The patient
 was  placed  in bed, and immediately took one  grain of morphia.   At
 four o'clock  in the afternoon there was a slight oozing of blood  from
 the wound, and the patient complained of the tightness of the dressings,
 which however, were found to be sufficiently loose.  He had taken half
 a grain more of morphia, had slept  somewhat, and was free from pain ;
 the pulse was 76, and of good volume ;  and there was no nausea, urgent
 thirst, or restlessness.   On  the  following evening, September  27, the
 patient having slight traumatic fever, was ordered ten grains of calomel,
 with  one of opium and one  of ipecacuanha, to be followed in the morn-
 ing by castor oil.
  No untoward  symptoms  of any kind occurred after the  operation;
 nearly the  whole wound healed by the first intention;  and at the end of
 three weeks, my  patient went home with  every prospect of a long and
 prosperous life.   In descending  the Ohio River, however, which was at
 that time exceedingly low, and which caused his detention upon the way
 for nearly a fortnight, he took a severe cold, from the effects of which
 he  never completely recovered.  A harrassing cough followed,  with
 symptoms of pleuro-pneumonia, and he died three months after the op-
 eration."
  Mr. Liston encountered frightful  hemorrhage  during his operation in
 1819, for the removal of a  vascular  growth  situated  chiefly  below the
 transverse  spine of the scapula.  With this he also removed about three-
 fourths of the bone.  In February,  1847,  we witnessed  the removal  of
 the scapula with about two inches of the  clavicle.  The operation was
 performed  by that accomplished  surgeon Mr. Fergusson, at King's Col-
 lege hospital, London.   Full  details of  this case are given in his Prac-
 tical  Surgery, 3d.  Lond.  Ed.  pp. 309, 311, together with an illustration
 of the parts removed, and of the wound after it was healed.   In 1828,
 Mr. Luke of  the London Hospital,  removed the scapula  involved  in a
 medullary  tumor.   The hemorrhage was  free, some 20 or 30 arteries
 requiring the  ligature.  " Eleven months  after the operation, the mo-
 tions  of the arm forward and  backward were perfect, and in fact, more
 than ordinary, the  limb moving with more than usual  pliancy, but yet
 there  was considerable power. She  can also perforin the actions of ro-
 tation outwards and  inwards.  The  elevation of the arm  from the side
 cannot be  easily  accomplished, and requires the  aid  of the  opposite
 hand  to raise it to a horizontal level.   She can  lift with ease, moder-
 ately  heavy substances."  (Lond. Med. Gazette, vol. V., 1830).
  Sometimes in cases of large tumors covering the scapula, it is impossi-
ble to dscide  previous  to an  operation, whether  the bone is  or is not
involved.   Very recently, we prepared to remove the entire scapula,
which was  completely buried beneath  a very  hard fibro-cartilaginous
tumor, measuring 24 inches in circumference  at  its base.  This, how-
ever, was readily detached from the scapula, which was perfectly sound.
Lisfranc in  his Precis, de Med. Oper., relates a  case in which he was
 perplexed in ascertaining the  connections of the tumor, but in which he
 was at length able  to save the bone.   G. C. B.] 
EXTRA-ARTICULAR EXSECTIONS IN PARTICULAR.         423
                           CHAPTER II.

                       ABDOMINAL EXTREMITIES.

   Though it may be difficult at the present day to question  the  advan-
 tages of exsection as applied to the thoracic extremities, it  is not alto-
 gether the same in respect to the pelvic limbs.  Here the artificial limb
 fulfils almost all the  functions of that  which  has been amputated.   In
 the upper extremities, on the contrary, no apparatus can be so adapted
 as to render any real service to the  patient;  [See an exception to this
 remark in our notes  on  artificial arms, supra.  T.] however deformed
 the rest of the arm may be, in whatever state the hand may be, so long
 as they are saved, it is always possible to derive advantage  from them,
 in a variety of circumstances.   Nevertheless, exsection has been advised
 and often performed for all the articulations of the lower limb, as well
 as for those of the upper.

              Article XIII.—The Pelvic Extremities.

                          § 1.—The Foot

   Exsection of the body of the bones, is felt to be much less necessary for
 the foot than for the hand ; it is for example useless to think of it  for the
 phalanges of the toes ; on the bones of the metatarsus, however, it might
 be performed with advantage, if their middle portion alone should be af-
 fected ; also in such cases where at the present day disarticulation would
 be performed.  Having elsewhere stated what has been done for the meta-
 carpal bone of the great  toe,  I shall not return to that subject  at present;
 I  will only add that  Heiste, (Institut.  de Chir., liv.  V., chap. 9,) had
 already excised its middle portion, and that the four other metatarsal
 bones could readily be exsected in the same manner.  A longitudinal in-
 cision either of simple or elliptical form, would enable us to isolate their
 dorsal surface and two sides in such a manner, as to admit of their exsec-
 tion at a single stroke first in  front, and then behind by means  of M.
 Liston's pliers, or one of the small flat rowel saws of M. Martin, or the os-
 teotome, of M. Heine, though the chain saw would  enable  us to do it
 equally well.
   As it is next to impossible  to exsect the cuboid, scaphoid, or cuneiform
 bones, without implicating the articulations, I will refer to the article on
 Partial Amputations of the Foot, or the Exsection of the Joints, [vid.
both supra,] for what relates to exsection of the body of the bones of
the tarsus.  .
   [In the Appendix by our author attached to  the last edition of this
work, he states that in one case he  exsected the posterior extremity of
the two last metacarpal bones, with the unciform bone ; and in another,
the cuneiform bone alone.  One of  the patients died ; the other remain-
ed a long time in the hospital.  G.  C. B.]

                         § II.— Os  Calcis.

   There is in the foot, however, a bone  which under this point  of  view, 
424
NEW ELEMENTS OP  OPERATIVE SURGERY.
 constitutes an exception ; I mean the os calcivS.   This bono which is very
 liable to caries and necrosis, and which makes a projection beyond and
 in a manner altogether distinct from the others, in the form of  a posterior
 appendage, is  as favorably  situated for exsection as the long bones.
 Whether the heel therefore  be  affected with caries, necrosis, or osteo-
 sarcomatous degenerescencc, provided the disease be altogether local, the
 surgeon  ought not to think either of  amputation of the leg, nor even of
 removal  of the foot; exsection of the os calcis alone will be sufficient  to
 cure the  patient.
   Science possesses numerous and various examples of this.  Formey,
 (Riviere, Obs.  communiqui.es, Obs. 3, p. 626, in 8vo.) or Formio (Sam-
 uel,)  says that  a  ball existed for  seven years  in the os calcis where it
 was deeply embedded, and that he succeeded in extracting it by means
 of the trephine.   In a  similar case  Morand (Opuscules de  Chirurgie,
partie 2, p.  248,) could not extract the ball, except  by  embracing it  in
 the circle of the  crown of the  instrument.   Moublet, (Anc. Journ. de
 Mid., t.  XV., p.  548,) having made  extensive incisions, in order to lay
 bare the  bone of  the heel, removed by moans of  the  chisel every thing
 which appeared to be rotten, and afterwards applied the actual  cautery
 three times.  The cure succeeded  to the exfoliation.  Hey,  (Practical
 Observations on  Surgery, p.  37,) removed a considerable portion of this
 bone without wounding the  tendo Achillis : the patient after the cure
 could walk with the same  facility as before.  Hey, (Ibid., Ibid.,) adds
 that the same treatment had  been  pursued in many cases  admitted into
 the Hospital of Leeds.  This author mentions another fact which ought
 to be  noticed.   In a case which  he attended, the wound had been sta-
 tionary for many years.  Suspecting that this condition of things depend-
 ed upon some disease of the bone, though he could perceive no evidence
 of degeneration in the soft parts, he  detached the integuments from the
 subjacent bone,  and removed  by means of the chisel a very thin osseous
lamina, though  this also presented no appearance of degeneration, after
 which the patient got completely well.
  Briot (Hist.  Milit.  Chir., p. 187, 1818) saw more than  two-thirds of
 the os calcis removed in a soldier, who, in order to walk with ease, re-
 quired nothing afterwards  but a  high heel to his boot; and Dupuytren
 announced, in one of his lectures in 1816, that he had seen the os calcis
 in an  infant reproduced  entire.   M. Champion  (communicated  by the
 Author, 1838) removed  from a child, aged  eight years, an internal se-
 questrum from the os calcis, of the size of the little phalanx of the thumb
 of an adult.
   I myself have performed this operation six times, without ever having
 seen it give rise to any  serious consequences.    In the same way as for
 the humerus, I lay bare the bone by cutting a large semi-lunar flap  from
 the soft  parts,  in such a  manner that the convex border of this flap is
 turned towards the  front, or behind, or above,  or below, according as
 the disease  requires that  we should cut down to it in one direction ra-
 ther than another.  This flap being raised up and folded back upon its
 root,  enables us to apply upon the bone either the crested or the small
 common  saw, or the flat or concave rowel saw, the gouge, mallet, sickle-
 shaped  scalpel, or even the actual cautery or trephine.  The  operation
 being terminated, the flap  naturally falls of itself upon the wound, and 
EXTRA-ARTICULAR EXSECTIONS IN PARTICULAR.
425
is generally more favorable to regular cicatrization than the crucial inci-
sion.
   In two patients, who had on the under surface of the os  calcis a necro-
sis the size of a nut, I placed the free border of the flap backwards, and
found  it easy to  remove  the  entire projecting  portion  of  bone by
means of the small  common saw, directed from above downwards and
from behind forwards.  In another case, I deemed it proper to place the
border of the flap  forwards, and directed the saw from below upwards
and from before  backwards, because the necrosis was situated immedi-
ately under the insertion of the tendo Achillis.  In a woman, upon whom
I operated at the hospital of La Pitie in 1833, the necrosis occupied the
outer side of the os calcis, near its under surface; I raised the flap from
below  upwards  and from within outwards.   Being obliged, on the con-
trary, to destroy  a  similar  disease on the inner border of the os calcis
in a child aged six  years, upon whom I operated at La Charite in 1838,
I turned the convex border of the  flap forwards and  upwards, in order
to be enabled  to avoid with certainty  the  fibro-synovial sheaths which
lie behind the internal malleolus.   I adopted the same course, in Octo-
ber, 1838, in a patient of M. Barbette, in whom it became necessary to
remove the outer half of the right os calcis, which had been a long time
carious.
   If, however, the whole of the  os calcis is to be removed, the crucial
incision  may be  adopted.   It is rare, however, that  any other than de-
generations of a  bad character  require this kind of exsection ; the ne-
crosis  presenting itself almost  always under the form of a fragment or
nodule, imprisoned, in the centre of a fistulous cavity,  requires only that
we should make an opening of sufficient size to extract it, and thus place
the system in a situation to dry up  the  purulent  discharge.  The exci-
sion of  the  os calcis, which  has been performed  at  Wurtzburg by M.
Heine, (Gaz.  Mid., 1834, Memoire citie, p. 644;) at  Paris by M. Roux
(Lancette  Franc,  t. II., p. 215) and by  Dupuytren, (communicated
by M. Champion, 183S,) who, in 1833, related four cases  of this  kind
to M. Champion,  has furnished every where favorable  results.
   The patients thus operated upon, have a heel  which has a great ten-
dency to become ulcerated and excoriated ; but in other respects the
functions of the foot are not disturbed.
   [Exsection  of  the Os  Calcis.—In cases  where  the  tuberosity of the
os calcis alone is  affected, excision, says Mr. Syme, (Cormack's Lond.
Sf. Edinb.  Month.  Journ., &c, Feb., 1843,  p. 95,)  may  be  executed
completely and certainly ; and it is sometimes, though rarely, possible
to extirpate the disease, even when it extends to the articulation, either
directly  by gouging out the  carious part, or by making a perforation
through it across  the foot, and passing a seton, which may be made the
vehicle of suitable  applications, such as the red oxyde of mercury, the
mineral acids, or  a saturated solution of the nitrate of mercury.
   Exsection  of the Astragalus.—M. Rognetta  successfully extirpated
the astragalus in a man who, in the terrific  accident  on the Versailles
railway in May, 1842, had received a compound  dislocation and frac-
ture of this bone.  What was remarkable, the limb, after recovery, re-
tained  its normal length,  (Cormack, Lond. 8c Ed.  Month. Journ. of
Med. Sc, Aug., 1843, p. 745.)  T.]
   Vol. II.                   54 
426
NEW ELEMENTS OP  OPERATIVE SURGERY.
   [The cases related by our author must have escaped the attention of
Mr. Guthrie, who has given to Mr. Hancock the credit of being the first
to remove the os calcis for disease of its  substance.  (Comm. in  Sur-
gery, p. 100.)   Among the British surgeons who  have lately repeated
this operation may be named, Messrs. Page, of Carlisle, Gay, Greenhow,
Fergusson, Hancock and Wakeley, the  latter, indeed, having removed
both  the astragalus and  os calcis, an  operation, pronounced  by Mr.
Guthrie to  be worthy of imitation in similar cases.   The particulars of
this case may be found in the London Lancet, July, 1848.  The astra-
galus has been successfully removed after compound luxations, by Dr.
A. H. Stevens of this city, and  Dr. Gillespie of Virginia.   A similar
operation was unsuccessful in the hands  of Dr. Norris; in this case am-
putation  was performed,  and the patient died.   In the Brit. Sc For.
Med. Chir.  Rev. July, 1853, Mr. Greenhow has given  the  particulars
of twelve cases  in which  the os calcis was removed.   In four of these
Mr. Greenhow was  the operator.  In ten, the operation was successful.
In the remaining two, the limb had, subsequently, to be amputated.  In
the successful cases  the patients were  able  to walk with only a very
slight halt, and the  shape of the foot was not materially disfigured.  G.
C. B.]

                          § III.— The  Leg.

  Next to the humerus, the bones of the leg present themselves for ex-
section ;  but it is rare that we ever operate upon more than one of these
bones at  once.
   A..  Exsection of the Tibia.—Up to the present time, exsection of the
tibia has  rarely been performed, except for necrosis or caries.  In cases
of osteo-sarcoma, or of  spina ventosa, amputation would generally be
preferable.   Necrosis and caries of the tibia, moreover, are situated
sometimes on the middle portion and sometimes on one of the extremi-
ties of this bone.
  I.  The body of the tibia, when its outer laminaa are in a state  of ne-
crosis, might easily be laid bare and excised with the crested or the rowel
saws.  The  gouge and mallet, rasp, and chisel may  also be employed
here  without any danger.   For this operation, I am in the  habit of
making the incision  into the soft parts, in such manner that  the wound
represents the arc of a great circle, with its convexity inwards, and then
to dissect the flap from  behind  forwards, in order to turn it outwards.
By this means we have full liberty to manipulate, with the saw or other in-
struments, from the  inner  towards the  outer surface  of  the bone.   The
tegumentary flap thus cut out, may afterwards be easily brought down
over the loss of substance.   M. Heine says that his instrument has been
employed in  Germany six times in cases of this description, and M. Textor
also used it in the years 1837 and 1838,  on two patients  who recovered.
M. A. Severin (De Recondita Absessum Nat., etc.) rasped the bone of the
tibia at its middle portion for an abscess, and Scultetus (Arsenal de chir.,
Obs. 98,  p. 130) cites a similar case, in which he had to  make an in-
cision into the parts, throughout the whole extent  of the leg.   A  girl,
in whom Benivenius (Bonet, t. IV., p. 600, Obs.  88) excised a great
portion of the tibia,  got perfectly well.   Lecat, (Planq., Bibl., t. XXIX., 
             EXTRA-ARTICULAR EXSECTIONS IN PARTICULAR.         427

p. 129, in 12mo,) in the  same manner, removed  an enormous portion of
the tibia  in a putrid state, and covered with exostoses.  J. L. Petit,
(Malad. des Os, t.  IL,p. 229,) Bromfield, and Vigaroux (CEuvr. Chir.,
1802, p.  102, 398) have also reported analogous  cases.  M. Ducasse
(Journ. Gin.  de  Mid.,  t. LIIL,  p.  149)  saw  M. Vives extract,  with
success, a long sequestrum from the tibia ;  and  M.  Wathely (Practical
Observations on  Necrosis,  &c., 1815) was not lesa  fortunate than M.
Vives.  Cartier, (Precis d'Obs. de Chir., p. 213,) who in this manner
removed almost the entire tibia, found the new bone so soft  that he was
obliged to place it in a fracture apparatus.
  David,  (Obs. sur la  Necrosis, 1782,) Viguerie, (Acad de Toulouse,
1788, t. III., Obs.  1, 2, 5,) Dussaussoy, (Gaz.  Salut.,  1786, No.  28,)
Laumonier, (Medec Eclairie par les Sciences Phys., t. III.,  p. 155,)
and Hall, (Gaz. Salut., 1776, No. 37,) have also taken out very large
portions of the tibia, in  a state of necrosis or caries.  A sequestrum im-
prisoned in an ancient callus, was removed  successfully in one case by
M. Champion (communicated by the author) and  in another by M. Sauter,
(Instruct, sur les Fract., p.  72, pi. 3.)  M.  Champion succeeded also in
the same  manner in two other patients in whom there existed an im-
bedded necrosis, and similiar  facts are related  by J. L. Petit, ( QSuvr.
Chir., t. II., p. 31, 32,) Verguin,  (Journ. de Home, t. VII., p. 395,)
and Cullerier.
  Hey, (Practs.  Obs. in  Surg.,  p.  26, 32, 34,) who  operated on this
bone the first and second time in 1792, and the third time in 1804, taking
for his guide the caries,  excised only the external laminae of the tibia.
The same course was  pursued by M.  Champion, (These, 1811, Cham-
pion, These p. 90,)* and Percy, and by MM. Graefe and Liston, (Jaeger,
Opir. cit., p. 20.)  Moreau, whose remarkable cases were  collected
and  published  by M. Champion, (These, etc.,  p. 77, 79, 80, 82, 84,)
performed partial excisions of the tibia six times, at different degrees of
depth.  Exsection  through the whole  thickness of the tibia in an old
man, and afterwards upon a young man who lost in this manner an ex-
tent of four inches  of the bone, was also successfully performed by this
practitioner, (Champion, These, p. 85, 86,) as it already had been also
by Smith  and Noble, in a man who died of small-pox six weeks after-
wards.   MM. A. Cooper, Siebold and Wickham,  (Jgeger,  Op.  cit., p.
20,) also  severally  succeeded with partial  excisions upon  this bone in
destroying an exostosis,  spina ventosa and hydatids.
  In cases of invaginated necrosis the entire body  of the  bone may be
dead.   There  are  numerous examples of the kind  on  record,  and in
which nearly the whole of the diaphysis of the tibia had to be extracted.
Without referring to the observations mentioned farther back, or to those
related by Weidmann, Bousselin (Observ. sur la Nicrose, Acad.  Royale
de Mid.,  Janvier, 1782,) Chopart, (De Necrose Ossium, 1116,) and M.
Champion, (These, etc.,Obs. 22,  p. 90.) I will  cite the case of a young
girl, who, after a putrid fever, had the whole body of the tibia necrosed
from one  epiphysis  to the other.  The dead cylinder  was removed, and

  *[This fact (says our author in a note) is one of the most curious;  the patient, Nicolas Gre'-
goire, whom M. Neve again saw in 1829, having overheard MM. Breton, Hennequin and Oulied,
discussing the nature of his disease, undertook to operate upon himself in 1803. He was three
days occupied in this manner with the saw, chisel and hammer !] 
 42S            NEW  ELEMENTS OP  OPERATIVE SURGERY.

 M. Antheaume, the surgeon, showed it afterwards to M.  Herpin, (Con-
 stitution Mid.  de  Tours, 1817, 2e  trim., p.  14,) who relates the  case
 and who states that this young lady was perfectly cured, so that she could
 dance and use  all sorts of exercises as though she never had had any
 disease in the leg.  M. Herpin mentions also the  case of a soldier who,
 in consequence of a sabre-cut on the middle  portion of the right tibia,
 was ultimately  restored in the same way.  The surgeon having  divided
 the sequestrum  into two portions, was thus enabled  to extract them  without
 difficulty, and cured  his patient so perfectly that the latter no longer
 thought it necessary to ask for his retreat.
   [Mr. Stanley (On the Bones, Am. Ed. p. 120) relates a case of ne-
 crosis of  the entire shaft of the tibia which  was under the care of Mr.
 Lawrence at St Bartholomew's Hospital.  Mr.  L. removed the dead bone,
 which " comprised the whole thickness and nearly  the whole length of the
 shaft of the tibia."   A new bone formed " giving to  the leg firmness,
 together with its natural size and shape.
   Through the  politeness of Dr. Fuller, of Schenectady, we have recently
 had an opportunity of examining a boy some 15 years  of age from
 whom about  six years since he removed at least nine tenths of the shaft
 of the tibia  in  a  state of  necrosis.  After the lapse of a year  the boy
 gradually regained the use of his leg, the vacant space having been en-
 tirely replaced  by  new bone.
   Mr. Adams  of  the London  Hospital, has  recently  reported  a  case
 in which  the whole  shaft   of the   tibia, in  a state  of necrosis,  was
 removed by  him.   He considers it  a matter of importance to give suffi-
 cient time, in such cases, for the formation of a firm, bony case, before
 the operation of removing the sequestrum is undertaken.  Although this
 may increase the difficulty in its performance, by it the security of the
 limb  will be promoted.  The  strength  of the patient also should be
 brought to the hightest standard possible, before any operation is under-
 taken (Rank's Abstract, No. 18.)   Mr. Curling, of the London Hospi-
 tal, in a clinical lecture on necrosis of the tibia, has reported some cases
 in which, after the  removal of the dead bono by  operation, there
 was  failure  in  ossific reproduction, and amputation became necessary.
 This  is of rare occurrence, and Mr. Stanley cites the particulars of one
case only.  The remarks of Mr.  Curling in  his  interesting lecture are
worthy  of perusal, and mav be found in the London Lancet, Am. Ed.
 June, 1852, p. 439.   G. C.B.]
  This  bone  also is often diseased  only in tne centre, and in such man-
ner  as to present the necrosed fragments only under the form of splint-
 ers, or irregular sequestra.  In the first case the probe strikes upon a
 sonorous, movable body, and apparently of considerable volume.   In the
 second case the instrument indicates rugosities and fungous or anfractu-
ous  surfaces, but nothing irregular.   In either case it becomes necessa-
ry to lay bare the swollen region of the tibia in its whole extent.   If the
hyperostosis  should be  found  to be not over three inches in  length, we
 should, after  having  laid it bare, by  raising up a semilunar flap'of the
integuments, remove its vault with the  trephine or the concave  rowel-
saw.  By this means  we make a large  opening into the cavern of the
tibia, which is to be then freed of the fragments  and fungosities it con-
tains, or even cauterized with the red-hot iron should its interior bo af-
fected with caries. 
              EXTRA-ARTICULAR EXSECTIONS IN PARTICULAR.         429

    When  the  necrosis is actually invaginated, the tumefaction of the
 bone is usually very extensive.  The  great flap which I have spoken of
 being reversed from  within outwards, places the whole anterior surface
 of the tibia under the eyes of the surgeon.  We then make use of the
 crested, the small chain or concave rowel saws, after which strokes upon
 the chisel, to evulse the osseous  bridles and bridges which go from one
 fistula to  another, and which  obstruct  the egress of the sequestrum to
 be removed.
   This sequestrum  being once brought into view, is easily removed if
 either of its extremities is free on a level with any part whatever of the
 breach we have made.  In those cases where the two extremities to-
 wards the epiphyses, by being  fastened  there, do not admit of our loos-
 ening or  extracting them, we should, after the manner of  M. Herpin,
 break the sequestrum in its  middle,  in order to remove its two halves
 separately, by making tractions downwards upon  the portion above,
 and upwards upon that below.   To  accomplish this, nothing more hardly
 is ever required then  to insert the extremity of a spatula or a chisel or
 any solid  lever whatever under the middle portion of  the sequestrum,
 which latter is then to be raised up with some force by securing a point
 d'appui  on the most  solid part of the new bone.  Dupuytren, however,
 found this in some cases so difficult that he got the manufacturer Char-
 riere to construct a particular instrument  for the purpose called otseo-
 triteur (or bone-crusher) a kind of exfoliating trephine, which however
 is in other respects sufficiently  complicated.   The  necrosis being re-
 moved, we  smooth down  the borders  of the cavity which contained  it,
 fill it with boulettes of lint, and gently bring in front of it the raised-up
 flap of the integuments.
   II.  The Lower Extremity [of the tibia.]—Up to a late period, caries
 and necrosis  of the internal   malleolus, were treated only by exsection
 or  amputation of the  articular extremity  of the tibia.  A practitioner
 mentioned by  Theden, (Neue Bemerkungen und Erfahrung., etc.,t. I.,
 p.  73, ou  t. II., 2e part.,)  let  one of  his patients die from having ven-
 tured to operate upon him in a different manner.   Theden also gives
 two other  examples of the same kind.  In this point of view, practice
 has made  considerable advances.  If the disease is situated external
 to the articulation, the concave rowel-saw of M. Martin enables us  to
 remove it  without destroying the continuity of the bone, and  without
 opening into the neighboring synovial cavity, so that we substitute a sim-
 ple operation, which is attended with  but little danger, and which ex-
 poses the functions  of  the foot  to no inconvenience, to one which is of a
 serious  nature and  one of the  most delicate in surgery.
  To perform this operation, I cut a semilunar flap, having its free bor-
der anteriorly, and which I reverse from before backwards, upon its pos-
terior border, and upon the apex of the malleolus internus.   This being
done, I carefully denude the bone of its periosteum and of the lardaceous
tissues which  surround it.  While  an assistant holds the tegumentary
flap, turned back towards the  heel  by  means of a roll of linen, the sur-
geon adjusts and guides the cutting  edge of the mushroon-shaped saw
from the anterior  to  the  posterior  part of the malleolus, while at the
same time  a skilful assistant turns the  shaft of the instrument.  Remov-
ing in this manner  the bone layer  by  layer, we may excavate it deeply 
430
NEW ELEMENTS OP  OPERATIVE SURGERY.
 without  danger, provided we avoid the articulation below and the fibro
 synovial sheaths of the tendons behind.   It  is  time  to stop, however,
 as soon as the whole traumatic surface under the action of the saw pre-
 sents a  reddish  tint and granular appearance, with bloody points.  If
 some portions of this surface should continue yellow, and actually dis-
 eased to too great a depth, we should lay aside the rowel to attack them
 separately either  with the trephine or chisel.   I have performed this
 operation on  the inner ankle only once; it was  attended with no diffi-
 culty, and  was  followed by no serious accident;  but the young man,
 though  cured at first, was  re-attacked some months  afterwards, with
 caries of the  radius, then of the  pelvis, afterwards in the knee and same
 foot, and  in  this state returned to his home in the country.  It would
 appear  also  that this operation has been performed  once successfully
 with M. Heine's saw, (Gaz. Mid. de Paris, 1834, p. 644.)
  III.   The   Upper Extremity  [of  the tibia]—The upper portion  of
 this bone  being spongy, thick, and very vascular, is frequently attacked
 with a complication of caries and necrosis, either in its center or on its
 surface.  In a woman admitted into the hospital of St. Antoine, in 1828,
 for treatment  of an enormous sub-patellar  abscess, all that was found
 requisite was to cut  down upon the integuments to the extent of  three
 inches, in  order to  lay bare and remove a large necrosed lamina of the
 tibia.  A young man who had had numerous abscesses in the upper part
 of his leg, had a necrosis there, situated so deep, that  I was obliged in
 introducing the trephine, and afterwards the gouge, on a line with the spine
 of the tibia, to go  from below upwards, and from before backwards, to
within  some  lines of the articular cartilage, before  I could  thoroughly,
destroy it.  In another  patient, whom I operated upon, at the hospital
of La Charite, in 1836, I  was under the  necessity of destroying,  by
means of the  concave rowel-saw, a great portion of the inner surface of
the tibia, and  afterwards of  excavating into this  bone  by means of the
gouge to the  extent of several inches, making thereby a cavity large
enough  to  hold more than one half the first.   None  of these patients
 died, but they were a very long time in getting well; the last mentioned,
who was admitted  into Bicetre, was amputated three years afterwards
 by M. P. Guersant.
  The  operative process, moreover, in these cases, is entirely subordi-
nate  to the degree,  actual situation  and form of the disease ; so that
 we have sometimes  occasion for the crucial  incision, or the elliptical or
 simple incision, and also for every variety of saws and  osteotomes.
  [The following interesting case of exsection  of the tibia, was per-
formed  by  Dr. Mayer of the Orthopaedic Hospital  at  Wiirzburg.  Its
 object was to remove the deformity known as knock knees, and as will  be
 seen, it completely succeeded.
  John H----, a strong and healthy-looking  boy of fifteen, son  of a
baker, and employed in  his father's business, was found, on admission
into the Orthopaedic Hospital at Wiirzburg,  to have the  right leg diverg-
 ing about seven inches, and the left about eight, from  the direction of
 the corresponding thigh, as  seen in the first figure of the accompanying
 sketch.
  On the 14th of August, 1851,  the  lad having been put under the in-
fluence of chloroform, Dr. Mayer  made an incision beginning three-quar- 
             EXTRA-ARTICULAR EXSECTIONS IN PARTICULAR.        431

ters of an inch below the insertion ofthe ligamentum patellae, and curv-
ing downwards so as nearly to surround the front and inner (or mesial)
side of the head  of the tibia.  He then turned the flap upwards, and
divided the periosteum in the line of the first incision, and  afterwards
with Heine's cutting-needle separated the periosteum from the outer and
posterior  surface of the  tibia, so as to  prepare for the use of the saw.
To protect the soft  parts in that situation during the sawing, a strip of
watch-spring, about half an inch wide, was introduced between the de-
nuded bone and the periosteum.   Dr. Mayer then, with a round saw,
made*two incisions converging towards  the posterior part of the tibia,
and meeting about a line and a half from the surface, without therefore
quite cutting the bone in two.   The wedge thus excised was about five
lines thick at  its base, and  was easily removed by the  forceps.  The
wound was cleared  of bone-dust by  forcible  injections of cold  water,
after which, through the flexibility of the remaining isthmus of the tibia
and  the mobility of the fibula, no  difficulty was found in bringing the
cut surfaces of bone into close apposition.  The outer wound was brought
together with  the greatest accuracy by needles and  ligatures  (as for
hare-lip), the hemorrhage being quite inconsiderable.  The leg was then
put into one of Boyer's hollow splints, used for fracture of the patella.
   Half an hour after the operation, as through the perfect apposition of
the divided parts no discharge of  any kind was visible, the wound was
covered with a thick layer of collodion, and upon  this drying the liga-
tures and needles  were removed.   The traumatic  reaction was very
slight, and on  the fourth day  the external wound (five inches long) had
perfectly united.  The leg was now  left quiet in the splint for twenty
three days, when Dr. Mayer had the pleasure of finding that the  incised
surfaces of bone had united also.  The next day the patient was allow-
ed to walk in  his room with  crutches, and a few days afterwards in the
garden without any artificial  support whatever.
   On the 3rd  of October  the other leg was operated on in the same
manner and with  the same success.   He left the hospital, free from de-
formity, and with a firm and  natural gait, on the 19th of November.—
Lancet, June 18, 1853, p. 557.  G.  C.  B.]
   B.  The Fibula.—-The body  of  the fibula, as it would  seem,_may be
destroyed without any serious  inconvenience  to the functions either of 
432
NEW ELEMENTS OP  OPERATIVE SURGERY.
the leg or foot.  Desault, (Jour, de Chir., t. IV., p. 254,) who propos-
ed to excise in this manner an osteo-sarcoma, saw, it is said, a case, in
which the loss of a great portion of this bone caused scarcely the slight-
est inconvenience in walking or standing.
  Bourienne  (Journal de  Midicine de  Dehorne, t. I., p. 215) speaks
of a case, in which three fingers' breadth of the fibula was destroyed by
a bullet, but which nevertheless recovered.  The same result took place
in a case cited  by Gavard, (Anc Jour, de Mid., t. LXXIIL, 1787,)
in which a sixth part of the body of this bone was extracted, in conse-
quence of fracture from a ball.   Boyer  (Boyer, Malad.  Chir., t. I.,
p. 241) also mentions a case of removal of the fibula by  a ball in Gen-
eral Duch . . . .  , who however recovered.
  I have  elsewhere  stated that Logan  had exsected a portion  of the
fibula, in order to tie the posterior tibial artery.   I will  add  also that
Croxall,  (Annul, de Litter. Mid.  Etrang., t. III., p. 375,) and  Briot
Essai sur les  Turn. Artir., p.  135) imitated Logan or  Gooch  for other
hemorrhages of the leg.  Three inches of carious fistula  were removed
by Theden  (Pragr. Ulter., etc., p. 157) in a patient, who  died some
time after without being  cured.   The  one, however,  from whom M.
Ouvrard  (Miditat., etc., p. 157) excised only an inch, got well.
   [In cases where from loss of substance in the tibia the divided ends
of the  bones cannot be brought into apposition, Mr. Luke has  proposed
the excision of the fibula to an extent sufficient to admit of the  object
proposed.  Vid. London Lancet, Am. Ed. June, 1852. p. 442.   G.  C. B.]
   " We have," say Percy and Laurent,  (Diet, des Sc.  Mid., etc.,*) " a
fibula entire, which we disarticulated above and below, in order to put
a stop to an ulcerative state which occupied the whole  outer surface of
the left leg, and which had been  produced and kept  up by the almost
general carious condition  of  this bone."   We should state, however,
that in a patient mentioned by M. Barbier du Bocage, this  destruction
of the  fibula, though partial,  was  followed by a manifest inversion of
the foot inwards.  It is, however, satisfactorily established, at the pres-
ent day, that the body of the  fibula may be excised through  its entire
thickness, and in the greater extent of its length,  without the  foot
thereby necessarily suffering any inconvenience.   We  shall  see further
on what  Beclard, M.  Roux, and M. Seutin have  obtained  from  this
operation.
   To remove in this manner the body of the fibula, a simple incision is
required where there is only necrosis upon its periphery,  or an elliptical
incision, in case of swelling  or tumor, which incision should be made
in such manner, as to admit of our laying bare the bone  throughout the
whole  length of its  antero-external region.   After  having  detached
from its  anterior and posterior surfaces the peroneus  longus, peroneus
brevis, extensor longus digitorum pedis, and soleus muscles, we  should
have to divide it at the malleolus below, and at its small head  above,
either with the small chain-saw, the crested saw, directed very obliquely,
or the flat rowel-saw.   The separation of the  rest of the mass could be
made with promptitude, and without any farther difficulty.   The pero-
neal artery  alone, which is the only  one that might be wounded, could
 most generally be avoided.  But the dressing would  require some pre-
 cautions.  It would be necessary that the immovable dressing  should 
EXTRA-ARTICULAR EXSECTIONS IN PARTICULAR.         433
cover the entire inner side of the leg, so as to fix the foot and knee se-
curely upon this side, without interfering with the daily  dressing of the
wound.   A patient, in whom M. P. Guersant (Jour, des Connaiss. Mid.-
Chir., 1838, p. 189) excised  a portion of the whole thickness of tho
fibula for ancient fungosities, recovered perfectly.
  [In February, 1847, we saw a patient at  the  Hotel  Dieu, on whom
Blandin  had  successfully performed this operation.   Mr.  Elliot, of
Carlisle, has removed some eight inches of  the  fibula, with benefit to
his patient.  G. C. B.]
  If the disease of the fibula was only an invaginated necrosis, it could
be operated upon in the same manner  as for that of the tibia.   In a
young man upon whom I operated in this manner, I made a long curved
incision from the upper attachment of the peroneus longus muscle down
to the root of the external malleolus, so as to circumscribe a long flap
which was  semilunar and convex posteriorly, and which I dissected  from
the outer border of the  leg to the anterior  inter-osseal fossa.  To lay
bare the  cavity, I used the crested saw, and  afterwards  the  gouge and
mallet;  but as a solid (pleine) portion of bone separated the two frag-
ments of the necrosis, I was obliged to avoid  this middle portion of it,
and to extract these fragments, the one from  above  and the other  from
below.  The narrowness of the canal, and the great distance between
the osseous fistulas in this case, suggested to M. H. Larrey, who assisted
me, the  idea of a small, fine saw, bent to an  angle near  its handle, and
with which it would be easy to saw through the vault or covercle of the
necrosis, from the interior to  the exterior, upon the supposition  that
a long, flexible probe would not allow of conducting the  chain-saw  from
one fistula  to the other,  as under the arch of a bridge.   Be that  as  it
may,  this young man who was  attacked with  an angioleucitis of quite a
serious character, and afterwards with  small-pox, ultimately  got  well,.
without having any actual weakness in his leg.
  II.  The  Inferior Extremity (of the  fibula.)—The external malleo-
lus, like the internal, and in truth much more than  that, is liable to caries*
and necrosis.  So long as the  disease  does  not  penetrate through its
whole thickness, and has not invaded the synovial cavity, it may be at-
tacked like the preceding with  the trephine, rowel  saw, gouge and mallet.
One  of  the patients operated upon  by  Theden  (Neue  Bemerkungen,.
etc., trad. Franc,., p. 98, 99) died, but the other recovered.   In perform-
ing this  operation  upon a man who  had had a caries  in the external
malleolus for two years, I found it exceedingly easy.  A semilunar flap,
reversed from before backwards to the outer side of the heel with the
precaution, unless the extent  of the  necrosis should require it, of not
opening into  the synovial sheath  of the peroneal  muscles, constitutes
the first stage of  the operation.  We have then laid bare before us the
whole extent of the external malleolus.   With the concave rowel saw,
directed by the surgeon, and the  shaft turned by an assistant, we then
remove successively from above downwards, and from before backwards,
all the diseased laminae of the bone, which may in this manner be scooped
out in form of a small  cup or  saucer.   There is  no  artery of any size
to avoid, and the attention of the surgeon has only to  be  directed to
the tibio-tarsal articulation, or the fibrous sheaths of the peronei muscles.
In another  case, I found a simple incision quite sufficient to  enable me
   Vol.  II.                    55 
434
NEW ELEMENTS OF OPERATIVE SURGERY.
 to  remove with the forceps an isolated  sequestrum from  a necrosed
 malleolus.

                         § IV.— The Femur.

  A nobleman, of Verona, had  on  his thigh an enormous ulcer, which
 had affected the bone with caries to such extent that the medullary sub-
 stance ran through the opening.   The application of caustics and sarco-
 tics, had  been had  recourse to  repeatedly.   By means of a rasp I re-
 moved, (says Marchettis,) every portion of the bone in a carious state,
 until  the blood oozed from the scraped surfaces.   I then covered them
 with dry lint and applied sarcotics to the neighboring soft parts.  In a
 few days after the bone was covered with granulations, which sprouted
 from the neighboring parts  or from the bone itself; and this was shortly
 followed  by  the  cicatrix.   (Marchettis, Observ. Medico-Chirurg. rar.
 Syllog., p. 130, obs. 57, 1665.)
  In November, 1781,  David,  (Observ. sur la Nicrose, p. 13,) extract
 ed a portion of the  femur seven inches in length, and which was com-
 pletely encased in an osseous  cylinder almost as hard as the primitive
 bone, and the walls of  which had already acquired a thickness of 7 or 8
 lines,  though the disease had existed only 2 years.  He detached for
 that purpose to the extent of  about  10 inches in  length by 4 to 5 in
 breadth, integuments, aponeuroses and muscles, in  such  manner as to
 lay bare the new cylinder, and to be enabled by means of the gouge and
 mallet to make an opening of sufficient size  to extract the dead bone.
 The fever lasted but twenty-four hours; no  accidents  ensued, and the
cure was almost completed  at the time David  wrote.
  " A  child, aged fourteen years, says  Viguerie, (Mimoire de VAcad.
de  Toulouse, t. III.,  an 1788,) was  admitted  into the  Hotel Dieu, with
the lower part of the right thigh  double the size of the left; it was easily
 perceived that the tumefaction was osseous.   At the lower part of this
swelling there was an ulcer, through which the sound  reached the dead
 bone at the depth of  two inches.   I  laid it bare by means of caustic, and
with the aid of the  forceps  extracted a cylindrical sequestrum of five
inches in  length.   The osseous cavity from which I had removed it was
 still some days after  sufficiently capacious to allow of its being replaced.
 M.  Gardeil came to examine it.  I was desirous in his presence of re-
 placing the dead bone  in the  new  one;  he  begged me to desist.  The
inspection of it, said  he, is sufficient  for me.  He contemplated this pro-
 cess of nature with  the satisfaction which a man of talent  experiences
 when  beholding such marvellous  results."
  No  one certainly  would venture  to remove the  body of the femur
 affected with cancer  or degeneration of a bad character.  But like the
 tibia and humerus, this bone is frequently liable to different kinds of ne-
 crosis.  Castel, (Champion, These No. 11, Paris, 1815,) in  the  case of
 a soldier, adopted with  success  the plan of Marchettis.  Bousselin, ( Obs.
 sur la  Nicrose, obs. 4 and 8,) has seen a case in which almost the whole
 of the diaphisis of the femur  was  extracted without the patient being
 thereby rendered infirm.   M. Champion, also, speaks of a  man who it
 is said had lost  a  fragment of  the  femur four inches in leno-th whose
 thigh  became shortened to the  same  extent, but who was ultimately ena- 
EXTRA-ARTICULAR EXSECTIONS IN PARTICULAR.         435
bled to walk.   In the femur in fact as in every other bone, the seques-
trum is not formed without a kind of new bone being developed in place
of it as its substitute.  Under this point of view we may extract with-
out danger the largest description of necrosed portions  of the thigh.
The delicate  part of this  matter is that which  relates to the operation.
No part of the body of the  femur is exposed and  superficial like  the tibia,
or even like the humerus.  Moreover, it is almost always upon the inside
or posterior part of the thigh that abscesses and fistulas caused by the
necrosis, find their exit; in  which regions the number of the muscles,
and the size and importance of the vessels and nerves, are naturally cal-
culated to create in the mind of the surgeon the greatest degree of cir-
cumspection.
   There  are two modes of reaching  these  necroses in the thigh bone;
one by election represented by the antero-external  region of  the  limb,
and the  other that of necessity, indicated by  the seat  of the disease.
However  few openings, therefore, or however  little attenuation of the
laminae  there  may  be  on  the convex  portion  of the femur, it is  there
nevertheless that we must endeavor to lay it bare to attack the disease.
The curved incision and  the semilunar flap of which I have already
spoken would  be of great advantage here.  Raised up from without  in-
wards and from behind forwards, they  would allow of our laying  bare
the bone to a great extent.  We are  then to  make  use  of the different
kinds of saws and scissors we have  described  in speaking of  the  tibia.
The wound also is to be closed and dressed in the same manner.  When
the fistulas are immediately behind, the opperation would be too danger-
ous and difficult to  be  undertaken, unless the  sequestrum  should, as it
were, present itself of its own accord  to the instruments.  Suppose  the
disease should be outside of the  sharp line of the femur, we might  come
down to  it  between  the vastus  externus  and  the  biceps  muscles.
Provided there should  be a chance of finding the diseased point upon  the
inner part of the thigh, we might also hazard the attempt of laying that
part bare by cutting down upon the  posterior insertion of the  vastus  in-
ternus muscle.
   A young girl who was afflicted for many years with a necrosis in  the
lower part of the femur, and who had had a great number of abscesses in
this region, was received into the Hospital of La Charite  in the month
of July, 1838.  Having ascertained  that a voluminous sequestrum  ex-
isted in the centre of the thigh bone, which was otherwise considerably
hypertrophied, I made, at the  distance  of five fingers' breadth above
the knee, an incision of four inches' length, which, in crossing the  fibres
of the vastus  internus  muscle, penetrated nearly down  to the  bone.   A
strong sickle-shaped scalpel, and a  few  strokes  upon the chisel which
was directed so as to act as a lever, enabled me to enlarge to sufficient
extent the principal osseous fistula.  Then  seizing hold of the seques-
trum with a strong  pair of forceps, I ultimately succeeded  in  loosening
it and extracting it entire, though it was nearly four  inches  long, and
included nearly the whole thickness of the cylinder  of the thigh at  its
lower extremity.    One single ligature only was required, and simple
dressings.  The young girl had no accidents, and perfectly recovered.
   II. The Great Trochanter.—The  great trochanter, being  separated
from the common integuments externally by a bursa mucosa, and having 
436           NEW ELEMENTS OP OPERATIVE SURGERY.

on its posterior part between the tendon of the gluteus maximus and
the nock of the femur, a  small  synovial sac,  and being  also  the com-
mon point of  insertion for most of the muscles  of the pelvis  or hip, is
consequently exposed  to the  action of numerous causes of disease.
from whence it happens  that it frequently becomes the  seat of caries
and necrosis, and the source  of abscesses and  serious  accident3.   An
adult man was attacked with pains, afterwards an enormous abscess and
fistulas  formed below the breech;  three years of his life were dragged
out in this manner, and he appeared to be on the point  of sinking under
the exhaustion produced'.  The thigh was taken off at the joint, when
the great trochanter alone was  found in a state  of caries.   A boy, fif-
teen years of age, had  between the breech  and the  postero-external
region of the thigh an enormous abscess, which was ascribed to disease
in the bones of the pelvis or'spine.   The examination  of the dead body
proved that  the evil originated  in the great trochanter.  The case of
another young man, an individual  aged 40 years, a boy aged 13, and a
woman  who  died after lying in, together with 3 or 4 other patients
whose bodies I have been enabled to examine  after death, exhibited the
same kind of lesions, and have  proved to me  that the great trochanter
alone is often affected in such manner as to admit of its  extirpation, in
cases which  would appear to indicate disarticulation of the thigh or ab-
scesses by congestion.  The  consideration of these facts, and the cases
of destruction  of the  great  trochanter  related by Gelee, (Journ.  de
Mid. Milit., t.  IV.,  p.  230,) Le  Dran, (Obs.  Chir.,  t. II.,  p.  286,)
M. Knox, (S. Cooper, Dictionnaire  de  Chir., t. II.,  p.  156,) and  Ca-
dran, (Bagieu,  Examen  de  plusieurs Quest,  de  Chir., t. II.,  p.  493,)
soon suggested to me the idea of an exsection of this part, which Tenon,
(Mini, de VInstitut, an VI., t. I., p.  208,) had broached, and M. Cham-
pion, (These, etc., p. 67,) formally recommended, and which M. Kluge
and M. Jaeger, it  is said, had also  suggested.   I made trial of it on the
dead body in 1832;  and this operation  was performed by me for the
first time, at the  Hospital of La Charite  in  the  month  of November,
1835.  I have since performed  it  again upon a student of medicine in
the year 1836.
  The first case was that of  a  woman, aged forty years,  the external
and upper portion of whose thigh had been in a state of disease for ten
years, and perforated  with  fistulous openings.    Having satisfactorily
ascertained, and with the concurrence also  of the opinion  of  M.  Mott,
who was then at Paris, that the great trochanter was  in  a  carious con-
dition, I laid bare this process by means  of  a T incision, the stem of
which, directed transversely, extended from the anterior border of the
great trochanter to two inches behind it, towards the  tuberosity of the
ischium.   I had thus two triangular flaps, which I dissected and re-
versed upon their base, the one  above and the other below.   While one
assistant held them  down and another  drew the anterior lip of the
wound towards the groin, I removed lamina by lamina, by means of the
concave rowel saw, directed  from before  backwards, almost the entire
substance of the  great  trochanter.   No serious  accidents  supervened,
and  many months were required to complete the cicatrization  of the
wound; but the patient ultimately  left the hospital perfectly cured.
   The young man mentioned, had had  from his  infancy, and  in couse- 
             EXTRA-ARTICULAR EXSECTIONS IN PARTICULAR.         437

 quence of an enormous abscess,  a sinuous ulcer, opposite the great tro-
 chanter, which from time to time brought on attacks of erysipelas and
 a renewal of the suppuration.   Believing that the sub-cutaneous mucous
 bursa was  its point of  departure, I had, two years before, completely
 excised this  pouch.  As the ulcer was not thereby closed, and  as the
 same accidents were  reproduced,  I  was convinced  that  the great tro-
 chanter itself was actually diseased.   The courage,  moreover,  and firm
 resolution  of M. D----, emboldened  me  to undertake upon  him the
 operation which had succeeded so well in the woman whose case I have
 just described.
   I adopted the same  course in respect  to the incision and  the dis-
 section of the integuments.  I also removed, by the same process, with
 the  concave rowel  saw, a  portion  of the  laminae  of  the osseous
 projection; but having  ascertained  that  the  caries  and  necrosis in
 some measure  perforated, but in a very circumscribed space,  through
 the whole  thickness of the great trochanter, I concluded  to substitute
 for the  saw, first the trephine, and  then the gouge and mallet.   The
 operation was thus rendered longer and more painful;  nevertheless, the
 totality of the  disease was removed; the  accidents were  of  a trifling
 character, and  the cure has continued complete up to the  present mo-
 ment,  (Jan., 1839.)  Even before the expiration of two months  after
 the exsection, M. D.  was enabled to  go out, and to resume in  part his
 usual occupations.
   [Mr. Fergusson states that he has known several instances where the
 trochanter major was cut down upon and removed with a saw, in conse-
 quence of caries, and that he has seen others where such practice might
 have been of service.  He has twice removed the entire trochanter.  In
 one case, the wound was attacked with violent erysipelas, which extend-
 ed over the thigh and carried off the patient within a week ; in the oth-
 er, the result was a satisfactory cure.   (Pract. Surg. 3d Lond. Ed. pp.
 467, 474.)   This operation has  been successfully performed  by  Prof.
 Parkei*of this city.   G. C. B.]
   These facts  decide the question  beyond dispute, that  the excision or
 exsection of the great trochanter may  be  successfully performed  upon
•living  man.  It is easy  to perceive, also, that  the process to be adopted
 cannot be  the same for all the cases.   To lay bare the bone and remove
 it, by one mode or another, is the principal object in view.  The opera-
 tion is  constituted of two portions:  one the division of the soft parts,
 the  other the  excision  of  the osseous tissues.  If the integuments are
 not degenerated  to great  depth, nor  strongly adherent to  the femur, a
 semilunar flap, having its base behind the great trochanter and its con-
 vex border in front, is preferable to any other kind of incision.   Laying
 bare the whole bone on its external face and anterior border, it enables
 us to detach from it  afterwards  its posterior border and apex, without
 the necessity of changing  the primitive  form of the wound. Upon the
 supposition, on the contrary, that  numerous and large cicatrices, and
 fistulas, and ulcers, had totally changed the nature of the parts, we must
 be guided by them in our construction  of the flaps.
   The great trochanter, after being laid bare, may be exsected by means
 of the hand-saw or crested saw, directed from before backwards, from
 without inwards, and slightly from below upwards.  These instruments 
438
NEW ELEMENTS  OP OPERATIVE SURGERY.
even would be preferable to all others, if it became necessary to remove
the whole of this process from the  femur.   In cases, on the contrary,
where the caries or necrosis has more breadth  than  depth, it would be
better to make  use of the concave rowel or a large flat rowel, seeing
that this kind of saw enables us to avoid the insertion of the three glu-
tei muscles, and dispenses with the necessity of proceeding as far as the
synovial cavity, situated upon the posterior part of  the neck of the fe-
mur.  If, as in the  case of the student of medicine  which I have just
given,  the caries,  though deep,  occupied but a very  limited  space, it
would  be better to embrace  it within  the  crown of a trephine, and to
make use  afterwards of the gouge and mallet, rather than to have re-
course to the instruments  of which I have been speaking.   We are ena-
bled, also, by this means,  to avoid the same tendons  just spoken of, and
to destroy every thing  which is diseased, without necessarily exsecting
through the whole thickness of the great trochanter.
  If, however, the crown  of the trephine  has to be carried  to the point
of penetrating through and  through the whole extent of the great tro-
chanter, there would then be less  danger, I think, in  removing the entire
process  by means of the ordinary saw, than by boring it in the manner
described.   The tissues are too relaxed, and  purulent collections  take
place too readily and are too dangerous behind the coxo-femoral articu-
lation, not to induce us to endeavor, by every means in our power, to
respect the parts in question and  to avoid entangling them at least with
any species of  constriction in the direction towards  the surface.
   The vessels to be avoided  in this operation are generally of inconsid-
erable size.  The  posterior  circumflex  artery, when  we arc obliged to
penetrate to a great distance behind, and the anterior circumflex if the
incisions are much prolonged above  and in front,  are  in fact the only
arteries which require our attention, or may have need of being tied.
   During  the whole time of the  operation, the  patient  should be kept
upon his sound side, with the thigh in a state of  semi-flexion during the
incisions upon the skin—to  be placed  in complete  flexion, with^adduc-
tion and rotation inwards, at the  moment of  performing  the excision or
exsection of the bone.  By this position, the trochanter is naturally lib-
erated  from between the muscles  and the lips of the wound.   Adopting*
this course also, we find, when we afterwards  straighten the limb, that
the wound, in great part, closes of itself, and the denuded surface of the
bone is made to conceal itself underneath the integuments of the thi°-h.
   If we should go too far and  too deeply in  the posterior region, we
 might possibly wound  the great  sciatic nerve, or the descending branch
 of the  ischiatic  artery.   The gluteus  minimus, and medius  muscles,
 which  are attached to the upper border and to the  front part  of the
 great trochanter, need not  be implicated, unless we are obliged to re-
 move the entire process.   In this last case it is still  advisable if we can,
 and if  the extent of the caries permits, to save the  gemelli muscles and.
 tlie pyriformis and obturator externus;  but there is no way of avoiding
 the quadratus  femoris muscle,  except by restricting the  excision  as
 much as possible to the outer surface and middle portion  of  the  great
 trochanter,  whether we use the concave rowel saw,  the trephine, gouo-e
 or chisel.
    It will be exceedingly rare that we can ever  dress the  parts in such 
EXTRA-ARTICULAR EXSECTIONS IN PARTICULAR.         439
  manner as to undertake immediate reunion.   The tissues in these casos
  are endowed with too unequal degrees of vitality;  the wound presents
  layers that are too dissimilar and too much altered to admit of our at-
  tempting primitive agglutination.  I would  therefore recommend that
  we should apply naked upon the wound small balls of lint over all the
  anfractuosities of the  traumatic  surface, that we should  gently  arrange
  the flap over these boulettes, by  means of a few strips of  adhesive plas-
  ter, and then cover the whole with  the  perforated linen, spread  with
  cerate, succeeded by a large gateau of lint, a few compresses, and the
  square bandage, or  the pelvic spica lightly put on.   [See Vol. I. for a
  description of Dressings.']
    The patient being carried back, or having returned to his bed, should
  be kept there, either on his back or partly on his side, with the leg and
  thigh very moderately flexed and supported upon a cushion.
    As after  all exsections or excisions in the continuity of the bones,
  we must not in these  cases, proceed to the second dressing until after
  the second or third day, unless there should be particular indications to
  the contrary.  The dressing is then to be repeated daily-with the same
  articles as used in the first, and  until the whole interior of the wound
  shall have acquired a healthy aspect, assumed a rosy  tint, and  become
  covered  with uniform  cellular  granulations.  It is then  only that we
  can dispense with the boulettes of lint without inconvenience, or think
  of contracting  the wound ; in this matter, however, we should  still err
 ■in being in too great haste.  We had better  delay a week than go for-
  ward too  fast.   In  leaving the solution  of  continuity to close  up by
  second intention, we are almost certain to escape the danger of inflam-
  mation  and  purulent  collections in  the neighborhood of the external
  iliac fossa, or the coxo-femoral articulation, besides having  much less
  to fear from  the denudation and suppuration of the periosteum.
    There is no impropriety, moreover, if every thing goes on regularly,
  in permitting the patient to get up and walk about even after the second
  or  third week.  In conclusion, the  exsection of the  great  trochanter
  appears  to me  to be an operation susceptible of frequent  application,
  and of a nature  calculated to prevent in some instances  the  necessity
  of disarticulation of the thigh.   I will not terminate this subject with-
  out adding that the free border of the  semilunar flap, of which I have
  spoken, may, instead  of being brought in front, be placed  almost with
  the same advantages behind, below, or even above, should the diseased
  condition of  the integuments seem to render it necessary.

                     [Exsection op the  Femur.

    M. Ollagnier, a military  surgeon, doubts the  propriety  (See  Gaz.
{(Mid. de Paris, 1841$. and Jour, des  Connaiss., SfC, de Paris, Mars,
 1843, p.  113—114) or rigidly adopting in every instance  the law in
 surgery of amputating  the  thigh in comminuted fracture of that  bone
 from  gun-shot  wounds, where the  fragments cannot be removed ; but
 proposes as a substitute, where  the  fracture is in the  upper  fourth of
 the femur,  and  where the soft parts are not so lacerated as  to threaten
 gangrene, nor the principal nerves and  vessels injured, that we should
 exsect the bone  under the great trochanter.   For this purpose, he adopts 
 440           NEW elements op operative surgery.

 the simple incision, as directed in exsections of this bone, in the text
 of our author, M. Velpeau, (above,)  with a slight  modification.  His
 process is as follows :—An incision  from the middle of  the space com-
 prised between the anterior  superior spinous  process of the ilium and
 the great trochanter, made in such manner as not to wound  the capsule,
 but to enable us to explore with  ease the neck of  the femur, and  to
 appreciate  the extent of the  disease.   If exsection is intended, the in-
 cision should extend to four fingers' breadth below the great trochanter,
 and if it should become necessary to remove the neck of the  bone, the
 capsule will have to be opened.  The surgeon should take care, at first,
 to extend the incision no farther down than to the  great  trochanter;
 for if the lesion should indicate disarticulation of the femur, the wound
 will be quite sufficient,  and the operation may be performed  in the man-
 ner recommended by M. Baudens.  If, however, the  upper part of the
 thigh can be preserved, this  wound  would  be  a complication  of little
 consequence, and amputation could be  made in the continuity of the
 bone, which operation, M. Ollagnier  states, has been  attended  with
 much more success in the late campaigns of the  French army in Africa,
 as well as everywhere else, than disarticulation. 'It  is thus perceived,
that  M. Ollagnier says nothing of the  proposed  law of M. Syme, of
Edinburgh, (see above,) never, when  disarticulation is  not necessary,
to amputate elsewhere than at the great trochanter or the condyles.   T.]
                         PART SECOND.

            exsection or excision of the articulations.

   Though  there may be no articulation in the limbs at the present  day,
upon which exsection  has not been made trial of, there are some upon
which this  operation  has been much more  frequently  employed  than
upon others.  As a general rule, exsection is much  better adapted  to
the thoracic than to the pelvic extremities ; and there so much the more
so, as the articulation is less approximated to the trunk.   Though appa-
rently of modern origin, exsection of the articular  extremities of the
bones was not unknown to the ancients.  Hippocrates alludes in vague
terms to that  of the foot and hand ;—et in tibia ad  malleolos et
in cubito ad  juncturam MAxus.  It is very natural indeed, that igno-
rant as they were of all hemostatic means, they  should  have  preferred
all operations that would enable them to avoid amputation of the limbs.
None of  them however furnish us with the details of the processes they
followed.  It is from  the time of White, only,  that exsection  of the
joints became recognized as a distinct operation in surgery ; and it was
about the middle of the last century that we have in England  the  first
formal recommendation to exsect the  articular extremities of bones that
had become dislocated  and had perforated through the tissues.   It was
Gooch,  (Cases  and Practical Remarks  in  Surgery, p. 323,  1737 )
Cooper, of Bungay, (Gooch, Opir. cit.,)  Kirkland, (Thoughts on Am- 
            exsection or excision op the  articulations.        441

putation, Sec, Sec, 1780,) the surgeons of the hospital  of Liverpool,
(Park, Cases of the Excision of Carious Joints,-p. 73,1806,) (of whom
Park was one,) and Lerr, Hey, and B. Bell, who regularly established
this operation in that country.
   In 1776,  the same  doctrine was promulgated in France by Bourbier,
(Dissertat.  Med. Chirurg., De  Necessitate et Utilitate,  &c, § XXL,
1776:)   In luxations, says he, where the bone  protruded out of the
articulation, presents considerable length and resists reduction, the only
means of safety  left at the disposal of the surgeon, is to exsect the pro-
jecting bone ; but the operation continued at first to remain there com-
pletely unknown.  Lassus, (Nouv. Mith. de traiter les Malad. qui at-
taquent VArticul. du Coude et du Genou, par Park, p. 6, 1784,) who,
in 1784, alludes to the recommendation of Gooch, and his practice, and
that  of  Cooper,  of Bungay, is silent  upon  this subject, in his notes to
the  Treatise of Fractures by Pott, in 1788.   So that it is not until the
year 1789, that we meet with the recommendation of exsection of luxat-
ed bones, in our classical words.   Manne it was, who was the first among
us to propose it, ( Traiti Elim. des Mai. des Os, p. 266,1789.)  As Park,
Nouv. Mith., Sec, trad,  par  Lassus, 1784,) who in the beginning was
desirous  of extending exsection  to all the joints, ultimately attached
much less importance  to it, it was  Moreau, (Obs.  Prat., etc., 1803 ;
Risec des  Os, etc., 1816,) in  fact, who  was  the  first to demonstrate
its advantages to the surgeons of Europe.  The dissertation of Wachter,
(De Art. Extirpan., Gron.,1810,) published in 1809, being much more
theoretical  than practical, would have remained in oblivion, like that of
Chaussier, (Soc. Med. d'Emulation, t. III., p. 397, but for M. Cham-
pion, (These de Paris, 1815,) who, by  new facts, dispelled  the  last
doubts on this  subject that lingered in the  minds of the  Parisian sur-
geons.   The observations of MM. Roux, (De la  Resec, 8cc, 1812,)
Jeffray,  (Excision of Carious  Joints, Sec, 1806,) Crampton, (Arch.
 Gen. de  Med., ler  serie ;  Dublin Hospital  Reports, Vol. IV.,)  and
Syme (Excision of Diseased Joints, 1831) have  finally succeeded  in
fixing public attention upon this subject.
   Exsection of diseased  articulations, however, is not yet approved of
at the present  time by all practitioners.   Compared with amputations,
in fact, its advantages and disadvantages are so balanced, that it is allow-
able to hesitate before according  to it any absolute utility.  Its manual
process, which is delicate, painful and ordinarily very long, presents under
some circumstances numerous difficulties, and necessarily  involves acute
suffering : also  it may  incur the  risk of not removing all the mischief.
   As it removes the bones only,'it necessarily leaves behind the greater
part  of the  other degenerated tissues.   The wounds which are produced
by it being  extensive  and irregular, almost always become the seat  or
the  source  of an abundant  suppuration.  The cure, too, even  when  it
does take place, is not effected until after the expiration of many months,
sometimes not until  after several years.   The limb being more or less
shortened, often  immovable, and  generally  drawn  by the muscles into
one  direction or another, remains moreover sufficiently deformed to be
 rendered incapable of performing more then a limited part of its func-
 tions.
   Amputation  being generally  easy  and prompt, and consequently less
   Vol. II.                   56 
442           new elements op operative surgery.

painful, immediately disembarrasses  the patient  both of the bones and
all  the soft parts that are diseased.  Acting upon sound tissues, it leaves
a smooth wound, one easy of union, less extended, less disposed to suppu-
rate, and less favorable  to the development of phlebitis and metastases.
  The cure which is more probable  and more speedy, is also more free
and more complete.
  To these objections,  however, which are not wanting in force, it  may
be  replied, that it is for the  skilful  surgeon to know how to surmount
the difficultiss  of the manipulation in  exsections, and  to abridge their
duration, and  determine whether  he  can or cannot remove all the  mis-
chief.  The bones being once removed, the surrounding tissues, however
changed  they  may be, return most usually  to their natural condition.
The fungous or lardaceous degenerescence of the  synovial capsule, liga-
ments, cellular  tissue  and  skin, is not  always an obstacle to the cure.
The principal  arteries,  veins and  nerves being avoided, the operation
ought in reality  to produce less  shock upon the rest of the organism
than amputation properly so called.  Certain  patients moreover get  well
with great rapidity, as M. Syme mentions cases in which they were  ena-
bled to make use of their limb at the expiration  of a few weeks.   The
new substance  which is formed in the  place of the osseous extremities
excised, acquires  a sufficient  degree  of solidity,  to replace to a certain
extent the articulation and to admit of voluntary movements.   By means
of splints and skilful dressing, we may counteract every abnormal devia-
tion of the  limb, and prevent its anchylosis by habituating it in time to
proper movements.  In fine, however deformed we may consider it, this
limb will always  be adapted to a greater or  less number of uses which
the patient would regret to be deprived of.   In the aggregate the num-
ber of advantages in exsection is greater than  its inconveniences.  It
is therefore an operation, which rigidly examined, deserves to be reckon-
ed among the efficacious resources  of  surgery.
  The preparatives for the operation,  are composed:  1, of the same ob-
jects  as  those  for amputation, in order that  if unexpected accidents or
circumstances  should arise, at the moment of the operation, we may be
enabled  to  proceed immediately to the removal of the limb, in place of
restricting ourselves simply to exsection; 2, of some  particular articles,
as for example, strong spatulas, gouges, a leaden hammer, chisel; hand,
crested, rondache, semicircular, or chain saws, and that of Machell, and
the flexible saw, as frequently  used  by the  English and American sur-
geons ; M. Heine's saw, the rowel  saws, that of M. Thall, the osteotomes
of  M. Zeiss, and the cutting pliers  of M. Liston ;  3, finally of one or
more thin pieces of pliable lightwood, pasteboard,  sheet-lead, or any
other  metal, or merely narrow compresses, folded several times double,
and suitable for slipping in between the bones and soft parts.  We must
have,  moreover,  for the dressing, one of the bandages of Scultetus,
cushions, and splints, or what is better the starched bandage. 
exsection or excision of the articulations.        443
                           CHAPTER I.

                     the thoracic extremity.

                      Article I.—The Hand.

  If the anterior third, or the posterior third, of 1  of the 4 last bones
of the metacarpus, or of  any phalanx, was alone diseased it might be
removed without requiring the removal of the finger.  Many surgeons
have undoubtedly thought of, and some have  performed  this operation,
as is shown by several theses, supported at the beginning of this century.
It is to Troccon, however, to whom we are indebted for having proposed
to subject this operation to certain fixed  rules.  M. Wardrop, (Trans.
Mid.  d'Edinburgh, 1819,) who removed in this manner the head of the
second metacarpal bone, is far from being the first who performed it on liv-
ing man.  Galen, (Operaapud Juntas, 1.1.,lib. 3, cap. I.,p. 72 bis)relates
that a surgeon of much repute, by dividing a bone of the  wrist, which
was sphacelated, rendered the whole palm of  the hand sensitive by the
manner in which he operated, for want of sufficient anatomical instruction.
Bilguer,  (Diss, sur Vlnut. de VAmp. des Membres, p. 70,) says that in
wounds from fire-arms, he has detached and removed the  bones  of the
hands entire, either where  they were  fractured and shattered or not.
M. Textor has removed the  os magnum in a carious state, Jaeger, (Euvr.
cite, p. 23, No. I.,)  together with the  posterior extremity of the third
bone of the metacarpus.  In a case  of M. Champion, (Risect. dans la
Continuiti, p. 59,1815,) after the exsection of the anterior half of the fifth
bone of the metacarpus, the movements of the finger were re-established,
although it was an  inch  shortened.  Vigarous,  (OEuvres Chir. prat.,
p. 435,) by means of an  incision on one side of the index finger, extracted
the second phalanx in a state of necrosis, and also  its epiphysis, which
had separated from the body of the bone.   A perfect cure was  effected
in thirty-three days, and the patient could afterwards use his finger with
the greatest advantage.

                                §1.

  The luxated and irreducible head of the first phalanx of the thumb
was exsected in this manner successfully at the time of Cooper, (Prac-
tical Treatment of  Wounds, &c., 1767,) or Gooch, and Lassus, (Trad.
de Park, p. 7,1784,) and afterwards at the  beginning of this century,
by M. Bobe,  (Journ. Gin. de Mid., t. XXVL, p. 163 ; t. XXVII.) M.
Evans, (S. Cooper, Diet., &c.,) effected two similar cures, and M. Roux,
and M. Textor, (Colon, These, Wurtzburg, 1833, p. 46,)  have been no
less fortunate on other metacarpal bones.
  In these cases, moreover, exsection forms but a stage of  the operation
of extraction, properly so called, of the same pieces of bono.   After
having divided the  integuments, separated the extensor  tendons, and
grazed the bone on each side in order to detach from it the inter-osseous
muscles, and after having disarticulated the extremity, correctly ascer- 
444
NEW ELEMENTS OF OPERATIVE  SURGERY.
tained, of that which we wish to remove, there is no more to be done than
to glide a piece of wood, pasteboard, &c, underneath its anterior sur-
face, then to make its section slantingly, (i. c, bevelled,) or perpendic-
ularly, by means of a small saw, such as the  chain saw of M.  Jeffray,
or that of M. Rambaud.
  The surgeon of the present day having at his command  instruments
better adapted to the operation, would not be under the necessity of at-
tending even to so many precautions.  The incision of the  integuments
being made, he would divide the bone with Liston's cutting pliers or
the flat rowel-saw, and then terminate with  the disarticulation.   The
corresponding extremity of the phalanx would be extracted in the same
way, if  it participated in the disease.   M. Fricke (Grcnet,  Arch.  Gin.,
1888, t. II., p. 87.   This name is written Guernet, in the Diet, de Mid.,
art. Main ; and Gernet, Gaz. Mid., 1837, p. 555,) who confined him-
self to the excision of the third metacarpal bone in one case, exsected
the entire metacarpo-phalangeal articulation of the thumb in three other
patients.  As the tendons  are not  destroyed in  this kind of operation,
the fingers which are saved are enabled to resume a part of their func-
tions.
  " The first, second and fifth bone of the metacarpus," says M. Cham-
pion,  (De la Risection des  Os, Thhe de Paris, No.  11, 1815,) " may
be excised in  part without involving the loss of movement in  the fin-
gers, inasmuch as the incisions are  made laterally, and the extensor and
flexor tendons  thus avoided ; the  consolidation even is not an  obstacle
to the success of this operation."

       § II.—Extraction of the First Bone of the Metacarpus.

  It may be conceived that this bone may be in a state of necrosis, ca-
ries, or degenerescence, without the thumb and carpus being implicated
in the disease, in which case it would be important to  be enabled to re-
mc ve  it while preserving all the other parts. Troccon (Amp. Part, de la
Main. etc. 1816,) in 1816, maintained the practicability of making this
extraction.  Nevertheless M. Roux (Bull, de la Fac de Mid. t. VI., p.
156) appears to have been  the first who made  a practical application
of this suggestion upon living  man.  The thumb, in his patient, which
at first could not be put to any use, gradually acquired its natural func-
tions,  so as to be enabled to execute very considerable movements.  The
same practitioner  has since been equally fortunate in two  other cases.
I am acquainted with a person, who, after the first phalanx in a  state of
necrosis had been- extracted by piecemeal, preserves nevertheless all the
movements of his  thumb.   I was not aware, in  1825, that  M. Troccon
had spoken of it, and as M. Roux had  no where given a description of
his operation, I deemed it proper  to enter into some details as to  the
best method to be adopted (Anat.  des  Rigions, t. I., p.  458, 1825.)
The operation having been  performed again in  1827 by M. Blandin,
(Nouv.  Bibl. Med. 1828,1.1.,) we may look upon it at the present time
as one which is regularly established in surgery.
  [Professor Syme has excised the head of the  metacarpal  bone of the
thumb, dislocated  into tho  palm  of the hand.   The thumb was bent 
            EXSECTION OR  EXCISION OF THE ARTICULATIONS.        445

back, so as to be unable  to  co-operate with  the  fingers,  and had re-
mained in this position  for eighteen years.   After  the removal of the
head-of the bone, the thumb was readily placed in its  natural position,
and  gradually  regained its  mobilitv.  (Supplement to the Principles
of Surgery, Ed. 1851,  p.  29.)   G.'C. B.]
  First Process.—We commence  with an  incision upon the radial bor-
der of the bone, which it is important to prolong  at  least half an inch
posteriorly and  anteriorly [beyond  the  part  diseased ? T.]   We then
cautiously detach from its dorsal surface the  integuments  and the ten-
don of the extensor  secundi  internodii pollicis; we  then  do  the same
with the opposite muscle  and the  tendon  of  the  flexor longus pollicis
manus, which cover  its palmar surface.  While an assistant keeps apart
the two lips of the wound, the surgeon directs the point of his bistoury
upon the outer side of the carpal articulation, divides the tendon of the
extensor ossis metacarpi  pollicis, or  even that  of the extensor primi
internodii pollicis, while carefully avoiding the extensor secundi inter-
nodii pollicis ; then  destroys all the ligaments and all  the fibrous parts
which unite  the  metacarpal  bone to the trapezium,  and  endeavors to
luxate this bone outwardly, either by a simple pendular  movement or
by drawing upon it in that direction with the  forceps ;  he then seizes it
with two of his fingers, glides the  bistoury along  its  ulnar side in order
to separate the tissues from  it,  and disarticulates it while dividing in
succession the internal lateral ligament, the external lateral ligament,
then the anterior  fibrous layers which unite it  to  the thumb,  which
latter is th-*s left still invested with its tendons of the  extensor secundi
internodii pollicis, the flexor longus pollicis manus, the  abductor pollicis
manus, the flexor brevis pollicis, and the abductor pollicis, while  at the
same time we  preserve  the whole thenar eminence  entire.   Nor is  it
necessary to divide any artery of  any considerable size.   Consequently
it is rare that we have occasion  to leave the threads in the wound, the
two lips of which latter are  brought together from  before backwards,
and maintained  in this state by means of small graduated compresses or
by lint, and then strips  of adhesive plaster or a few points  of suture.
The palm of the hand is then padded in a proper manner,  in  order that
the thumb may be  kept by means of a bandage in  its  natural position.
   Second Process.—Performed  in this manner, however, the operation
is long and difficult.  I have since found that  it is rendered incompara-
bly more prompt, by making use of M. Liston's cutting pliers to divide
the bone near its extremities, after having  isolated the soft  parts  from
them.   If one of the articular heads itself is diseased, the same  pliers
used upon its sound portion renders its extraction more easy.  In fine,
excision is preferable here to disarticulation.  [It will be seen by our
abrege below, of M. Chassaignac's  processes of  exsection  throughout
the body, that M. Velpeau herein virtually gives  the preference to the
leading or ruling principle of those  processes, to wit,  that of excision
always before disarticulating.  T.]

     § III.—Extraction of the Middle Bones of the Metacarpus.

  Troccon did not limit himself tp recommending the extraction of the
metacarpal bone of the  thumb alone.  He is of  opinion  that we may 
446           NEW ELEMENTS OP OPERATIVE SURGERY.

perform the same operation upon the others.  I have often practised it
upon the dead body, and am bound to say, that with an accurate know-
ledge of the articulations, we may perform it without any very great de-
gree of difficulty.  M. Dietz (Coulon, These, Wurtzburg, 1833,) by op-
erating in this manner, was enabled to  preserve the  fore-finger of his
patient.   We make an incision  which is to reach  from the carpal ex-
tremity of the fore-arm to half an .inch in  front  of the phalangeal ar-
ticulation, while taking care to avoid  the  extensor  tendon.  Then  in
.firdeffo disarticulate  the bone posteriorly, we proceed as  above di-
rected.  When it is luxated we seize it with two fingers of the  forceps,
while with the point of the bistoury we proceed to  divide  the posterior
part of the capsule, the lateral ligaments and anterior  ligament of the
other articulation, always carefully avoiding the  extensor and flexor
tendons of the corresponding finger.
   In place of commencing  posteriorly as Troccon recommends, I think
with M. Blandin, who re-introduced this  subject  in 1828, that  it is
better to disarticulate the phalangeal extremity first, and terminate with
the section of the ligaments of the carpus ;  but it is  probable that this
operation will continue to be for a long time, with  the greater  part of
practitioners, nothing more than one that  has been  merely projected.
Exsection of the diseased  bone appears to  me to be an operation cal-
culated to be advantageously substituted for it on almost all occasions.
   M. Textor (Coulon, p. 35, These, Wurtzburg, 1833) was enabled, to
remove the articular extremity only  of the third metacarpal bone, and
yet preserve the finger.  When once laid bare upon  its dorsal surface,
each bone of the metacarpus could be  divided either posteriorly or an-
teriorly very near its articulation, by means of M.  Liston's pliers, and
removed without any great effort.  Examined in this  point  of view, the
operation is one of very great simplicity, and cannot be assimilated in
any respect to the exarticulation of Troccon.
   In one case I exsected  the  posterior extremity of the two last meta-
carpal bones, with  the unciform bone ; in  another, the  cuneiform bone
alone ;  and in a young man, the phalangeal extremity of the third me-
tacarpal.   One of the patients died ;  the others remained a long time in
the hospital.

       § IV.— Extraction of the Fifth Bone of the Metacarpus.

   From its having been found practicable to remove the first metacarpal
bone and  at the same time  to  save  the phalanges, the same operation
has been suggested for the metacarpal bone of the little finger.   It  is an
operation which is no doubt possible, and  even  sufficiently easy, but it
is of less  importance than at the thumb ;  so that  the preference will
always probably be given in  these cases to simple  disarticulation  with
the simultaneous removal of the finger.  If, however, extirpation should
be decided upon, this is the manner in which we  should  proceed.  A
dorsal incision extended from the head of the ulna to  the middle of the
jlnar border of the first phalanx of the little finger, would enable us to
detach the bone from the tendons and  other soft parts which cover its
dorsal and palmar surfaces.  An assistant  should  be charged  with  se-
parating the lips of the wound apart, while drawing them  at the  same 
           EXSECTION OR EXCISION OF THE  ARTICULATIONS.        447

time towards the radial  side; the surgeon  would then divide with the
point of the bistoury the tendon of the  extensor carpi ulnaris, and af-
terwards the various fibrous bundles of the articulation ; he would then
move the bone backwards and forwards in order to luxate it; glide the
bistoury flatwise upon its radial surface, then isolate  it to near the an-
terior articulation, and separate it from  the  first  phalanx of the little
finger while carefully avoiding the extensor and flexor  tendons of this
last mentioned appendage.  Liston's pliers  should also be used here as
^ith the first metacamai bone.

                               § V.

  The dangers of the operation, also, in whatever way it may be per-
formed, are the same as  those from  amputation, and M. Fleury (Journ.
des Conn. Mid-Chir., 1838, p. 249) mentions a case which, after he had
exsected the anterior half of the  second metacarpal bone, terminated
fatally by ourulent infection.

                     Article II.—The Wrist.

  Others besides Moreau, M. Roux, and M. Hublier (Bull, de  Ferussac,
t. XVII., p. 400) have  excised the  carpal  extremity of  the fore-arm.
According to M. Bobe, this operation was performed with perfect success
about the year 1800, by M. Clemot of Rochefort, or rather by M.  Saint-
Hilaire, (Os de VAvant-Bras, These, Montpellier, 1814,  p. 10,)  on a
patient in whom the radius and  ulna having been luxated,  protruded
to considerable extent through the lacerated soft parts.  Cooper (Lassus,
trad, de Park, p. 7) had been  no less fortunate  half a century before.
The attempt of M. Hublier also succeeded completely, and it  to be enu-
merated under the same head.  There was  in this case dislocation of
the hand,  laceration of the integuments, and protrusion of  the  bones
externally.   The extensor and flexor tendons, not being  wounded, the
surgeon resolved to remove the exposed portions of the radius and ulna,
after having properly isolated them ;  the hand and fore-arm were then
replaced in their natural position, and after the cure, which was attended
with no untoward accident, the movements of the fingers could be ex-
ecuted with almost as much facility as before.
  We  undoubtedly  ought not to hesitate in  such  cases, should the re-
duction of the bones be impossible, or be attended with too much difficul-
ty ; but there is another kind of exsection whose utility is not so well
demonstrated; I mean that, for example, which relates to organic lesions,
more or less ancient, caries, necrosis, or osteo-sarcoma.  These diseases,
in fact, are rarely sufficiently serious at the wrist as to require an ope-
ration  of this kind, without there being present also at the same time,
a profound alteration of the bones of the carpus and  of the  soft parts
which  surround them.  How then can the operative process be submit-
ted to  rules that are in any respect precise ?
  Nevertheless it is an operation which many surgeons have made trial
of.   M. Malagodi (Journ. des Conn. Med., t. II., p. 201) who ascribes
cases of this kind to MM.  Withusen, Cittadini, Warmuth, and Holscher,
appears in this matter to have  mistaken one  articulation for another. 
448
NEW ELEMENTS OF OPERATIVE  SURGERY.
As to what regards himself, he has in this manner removed the  ulna,
the styloid process included, as high up nearly as the  coronoid  process,
and his patient who recovered could afterwards use his hand  as well
as he could before the disease  existed.   The  lower extremity of the
ulna also appears to have been exsected successfully by  M. Jaeger,
(Heine, Gaz. Mid., 1834,  p. 645.)
   "The coude  or ulna, says M. A.  Severin,  (31id. Efiicace, § 954.
This case, says M. Velpeau, could be claimed as well almost for a frac-
ture as for a luxation,) which was  dislocated inwards  from the wrist,
and  which was fractured,  not yelding  to reduction,  in spite of the
strength of three robust men, Master Blaise and myself sawed  the ends
of the bone which protruded, and the  patient got well."   M. Breschet
(Mem.  sur  les Luxat.  du Poignet, &c., par Malgaigne, p. 39, 1833)
also appears to have exsected  an inch  and a half of  the  ulna, which
had been luxated inwards and protruded through the integuments.  The
carpal  extremity of the  radius was denuded, black, and dry, and had
been luxated for six months in consequence of an abscess.   The  father
of the child  dividing the bone on aline with the soft parts, by means of
the chisel and mallet, took  off three inches of it, and two  hours  after
detached two inches more, which constituted a part of the first  portion.
The patient can use a great portion of this hand, though its movements
are feeble, (Champion, Traite de la Risection des Os Caries dans leur
Continuite, etc., p. 57; but  the  details of the extent  of the necrosis,
says M. Velpeau, are  not  given.)   Orred (Trans. Phil., t. LIX., part.
lere, art. 2, 1779) speaks of a surgeon who exsected three inches of a
carious  ulna, (probably necrosed, says M. Velpeau.)  The  patient was
so well cured by the reproduction of the removed bone, that he continued
to pursue  his  customary labors in the  country.   In a case  cited by
Bagieu, (Examen deplus Part, de la Chir., t. II., p. 443, 440,  obs. 7,)
the head of the two bones was fractured by a ball; the splinters  were
immediately extracted ; a shortening of more than  an inch  took place ;
the radio-carpal  union  became  anch.ylosed ; nevertheless  a sufficient
degree of flexibility was preserved to the  fingers  to write  and design
almost as well as  before the wound.  This operation was  performed by
Moreau the  father, in July, 1794, for a  necrosis caused by an  acute
inflammation, on J. P. Husson, a notary seventy-one years of age, who
had already lost his left hand, and  who died on  the  29th of the  same
month, from exhaustion consequent upon the intensity of the  primitive
inflammation.   Another  patient of Moreau recovered  perfectly.  One
of the  two operated upon  by M.  Roux  died, the radius only haviug
becu exsected.
   [Mr.  Fergusson has described in  the  last edition of  his Practical
Surgery (1842) a case in which he performed the excision of the whole
of the carpus with the contiguous articulations.   Longitudinal  incisions
were made along the radial and ulnar sides of  the wrist, by which he
was enabled to remove about half an inch of the radius,  the same extent
of the ulna, and  the two rows of the carpal bones.  The upper ends of
the metacarpal bones, were also removed, with the exception of that of
the thumb, which was sound throughout.   All  the extensor  and flexor
tendons of the fingers were preserved as were the radial and ulnar arte-
ries, with the median and ulnar nerves.   Some three or four months af- 
EXSECTION OR EXCISION OF THE ARTICULATIONS.        449
terwards, the original strumous openings had not healed, there was con-
siderable swelling and the hand and forearm were as useless as before
the operation.  "Judging from this case," he  remarks, " I should not
be disposed to speak favourably of such a proceeding, but it is probably
too early to give an opinion, and it must be  borne in mind that in the
elbow-joint, and some other instances, where resection has been remark-
ably successful, a much longer time has elapsed, ere all the external
orifices have been closed.—A hand with a stiff wrist is decidedly better
than no  hand  at all.  On this point  we have ample experience in the
instances of anchylosis in this  locality, which often come under our no-
tice, and also in those cases where artificial  substitutes are used in lieu
of the hand which has been amputated." (p.  298).
   In December, 1853, we witnessed at the Bellevue Hospital, a partial
exsection of the carpus, by Dr. Sayre.   Dr.  S. proposed to remove both
row of bones, but was dissuaded by the other surgeons of the institution,
and to this circumstance he attributes his failure, amputation having been
at length required.  In the Lond. Med.  Times and Gazette, Nov. 1853,
it is stated that Mr. Fergusson in October repeated  this operation, audi
that it has likewise been performed  by Mr. Erichsen, of University Col-
lege Hospital.  In the same Journal for February, 1854, it is  mentioned!
that both of these patients had been discharged, with the wounds nearly-
healed, but sufficient time had not elapsed to judge of the utility remain-
ing to the limb.   Mr. Simon, of St. Thomas' Hospital, operated in Oct.
1852, but the wound  had not cicatrized at the end of a year, when the-
patient was seized with fever and died. For the details of these cases,
see N. Y. Journ. of Medicine, May, 1854.  p.  443.  The wrist has also
been excised by  M.  Maisonneuve, of  Paris, and by Dr. Carnochan.
Prof. Pancoast has removed the upper  row of bones.  G. C. B.
   Upon the supposition that  exsection of the wrist  may become neces-
sary, there are two or three methods which might be adopted, and which
have been made trial  of.

                    § I.—Process  of the Author.

   An incision on each border of the fore-arm, one from the root of the
thumb, the other from the last metacarpal bone, to extend to two inches
above the styloid processes of the radius and ulna, and to be united by
a transverse incision on the posterior surface of the fore-arm, would en-
able us to  reverse from  above downwards a flap upon the back of the-
hand, whereby the entire dorsal  surface of the  articulation would  be-
laid bare.   I then proceed  immediately  to the  disarticulation.  The
tissues on the anterior surface are  then detached  from the  bones, and
protected by a thin  piece of flexible wood, sheet-lead, or pasteboard.
This being done, we  divide, with the same cut of the saw, both the  radi-
us and ulna, above the seat of the disease.   The flap  preserved is united
to the opposite  lips of the wound by a few  points of suture.   A gentle
pressure approximates its anterior surface to the  bottom of  the wound,
and it is not impossible that the  extensor tendons  may ultimately re-
acquire their action upon the fingers.
   By this process, the operation is  performed with  great ease upon the
dead body, and we may avoid, without  difficulty,  the radial  and ulnar
    Vol.  II.                     57 
450            NEW ELEMENTS OF OPERATIVE SURGERY.

arteries, while  detaching the tissues  from the anterior surface of the
wrist.

                    11.—Process or  M. Dubled.

   M. Dubled,  having made his  first  incision on the inside, after the
manner of Jeffray, dissects  the  lips of the wound  from the posterior
surface, and then from the anterior surface of the ulna ;  causes them to
be drawn to the outside ;  divides  the  lateral  ligament, places the hand
in the position of  abduction ; completely isolates the head of the bone ;
makes it project as much  as possible outwardly ; detaches  it from the
radius ;  passes between it and the latter a piece of  sheet-lead or wood ;
and  then with the saw, cuts above the seat  of the disease, through the
whole thickness of the affected bone.   The same process is then applied
to the  outer  border of the articulation;  and as  the ulna has already
been exsected, it  is then  more easy to turn  the hand  inwards and to
throw the radius outwards, and thus effect its excision.  By this process,
all the tendons would be saved, and  the consequences of the operation
evidently more simple.   In repeating it on the dead body, I have found
it of very easy execution; but it is not probable that it would be equally
so on living man,  and on a deformed hand.

                    § III.—Process of Moreau.

   The  operative  manual adopted by MM.  Moreau, Roux, and Syme,
while it is not much more complicated than that of M. Dubled, has how-
ever the advantage of rendering the excision of the articular heads infi-
nitely more easy.   A transverse  incision, which commences at  the car-
pal extremity of each lateral incision, and which is prolonged from eight
to twelve  lines upon the dorsal surface of the wrist, circumscribes two
little flaps, in form of an L, on the posterior  region  of  the radius and
ulna.  These are  dissected  and raised up, one after the other, commenc-
ing with, that of  the ulna.   After having pushod  aside, detached, and
isolated the tendons, we endeavor, by  means of a spatula, to insinuate a
protecting compress between the  two  bones, and which is to be brought
out  from the inter-osseal space, so as to come between  the palmar sur-
face  of  the ulna and the soft parts.  An assistant immediately seizes it,
and  draws its two extremities towards the radius, in order that the tis-
sues may  be also  thus drawn in  the same direction.  With one cut of
the saw, the  surgeon then effects the section of the bone, which he after-
wards detaches, by means of the  bistoury, from  the carpus and  radius.
He then immediately proceeds to  the dissection of the second  flap, also
to that  of the great number of tendons on this side, and the radial ar-
 tery.  To  terminate, he  has only to  repeat on  the radius what he has
 just done on the ulna.   The patient thus  operated  upon by Moreau re-
covered.   The case, however, has not been  given with sufficient details
 to determine the precise value of  the  fact  to which it relates.   The pa-
 tient of M. Roux (Dubourg, Journ. Univers. Hebd., t. II., p. 358) was
 doing admirably well on the fifteenth day after the operation;  but was
 afterwards obliged, it is said, to undergo amputation.
   If only one of the bones should be diseased, we should, it  may be 
            EXSECTION OR EXCISION OP THE ARTICULATIONS.        451

 readily understood, confine ourselves to a single flap and  single wound.
 If the head of the ulna only was  to  be exsected, the simple incision of
 M. Dubled and M. Liston's sector (secateur) would be sufficient.  The
 process, however, indicated under the head of Exsection of the Body of
 the Bones, would become indispensable, if, as in the case of M. Malago-
 di, the diseased portion of the ulna or  radius extended very high up.
 The  vertical rowel  saws, moreover, and  the  osteotome of M.  Heine,
 would, at the present day, render  the operation more easy, by enabling
 us more conveniently to avoid the soft parts.  By means of the concave
 rowel saw, as has been mentioned above in  speaking of the malleoli, we
 might in  fact, and indeed should, where a portion of the head of the ra-
 dius only is diseased, exsect  it without  opening into  the  joint.  Tho
 process, however, which I have described  in the beginning, is the  easiest
 of all; this of itself would enable us to  excise, at the same stroke, the
 head of the bones of the carpus, if that was diseased.   The facts stated
 under  the  chapter on Deformities, (see Vol.  I.,) authorize us,  at the
 present day, to indulge in the belief that the transverse incision of which
 I have spoken would not destroy the action of the extensor  tendons of
 the fingers.

                     Article  III.—The Elbow.

   Exsection of the elbow joint, first successfully performed by  Wain
 man, (Jeffray, Opir.  cit., p. 10,) who, however, removed only the troch-
 lea of the humerus for a luxation of the  elbow ;  suggested, in 1781, by
 Park, with the view  of applying it to chronic  diseases; performed on
 living man, in 1782,  by Moreau, and a little later by  Percy (Moreau,
 Risect. des  Os, p. 57,) and many other military  surgeons; has been
 made trial of six times by  M. Roux, twice by  M. Crampton, fourteen
 times by M. Syme, and  once  by M. Spence.   Since these  first  essays
 MM.  Moreau, father and son, MM.  Champion, (Ibid., p. 57 ;  Journal de
 Corvisart, Mars, 1813 ; Bull, de la  Fac t. III., p. 20,) Mazzoza, (Journ.
 des  Conn. Med., t. II.,  p. 201,) Jaeger,  Textor, Moisisowitz, (Heine,
 Gaz. Med., 1834, p. 465,) Delpech,  Dietz, Kern, Sanson, (Coulon,
 Op. Cit., p. 45,) and others, have related new and sufficiently numerous
 examples  of it.

                       § I.—Process of Park.

  Park thought it sufficient to restrict  himself to an incision  parallel to
 the axis of the  limb,  and extended to two inches above and below the
 olecranon.   The two  lips of this wound being held apart, he  endeavored
 to divide the lateral ligaments and the tendon of the triceps muscle, and
to luxate the extremity of the humerus backwards ;  but experiencing
too  great difficulty, he first  exsected the olecranon, and then attained
his object with greater facility.  This first stage of the operation being
finished, Park effected the excision of the humerus about two inches
above the articulation, on a piece of wood or metallic plate inserted be-
tween the  anterior surface of the bone and the tissues.   The lips of the
wound were approximated  in such a manner as to be kept in contact by
means of strips of adhesive plaster. 
 452            NEW  ELEMENTS OF OPERATIVE SURGERY.

   In his letter to Pott, this  surgeon  admits that  this process probably
 would not answer for a diseased and tumefied articulation ;  that in that
 case it would be necessary, 1st, to make a  transverse incision, which
 should be placed immediately above the joint; 2, to dissect the four flaps
 which should be performed by it; 3,  to lay bare in this manner the whole
 posterior surface of the bone*; 4, then to remove  in succession with the
 saw the inferior extremity of the  humerus,  and the upper portion of the
 bones of the" fore-arm.  Such a method cannot be strictly applicable to
 any case, any more in its  primitive simplicity than associated with the
 crucial incision, though  something analogous  was in one case employed
 with success  by M. Syme.

                     §  II.—Process of  Moreau.

   In place of dividing upon the median line, Moreau commences by set-
 ting out from the condyles, and making his incisions  on the borders of
 the humerus, dividing from  below upwards the whole thickness of tho
 tissues, to the extent of  two or three inches.   A  third  incision  placed
 transversely,  unites the two first immediately above the olecranon, which
 thus enables us to form a quadrilateral flap, which  is dissected and raised
 up on the posterior surface of  the arm.   The bistoury inserted flat-wise
 upon  the anterior surface of the humerus, is then made to detach the
 tissues carefully from this  part.   A flat piece of flexible wood is then
 immediately after introduced in tho place of the instrument, and the re-
 mainder of the operation  performed  as in the  process of Park.   If the
 extremity of  the ulna and radius are  to bo removed, all that is requisite
 is  to prolong the lateral  incisions a little  lower  down, and to form, in
 this manner, a small lower flap, which being dissected, renders the sec-
tion of the bones which  it covered a very easy matter.

                   § III.—Process of Dupuytren.

   The process  of Moreau is the one that should be adopted, and which
MM. Roux and Syme  at least have followed in most of their  cases.  It
has been deemed necessary, however, to modify  their process in  some
respects.   Thus Dupuytren  has shown that the ulnar nerve, which they
almost unavoidably sacrifice, may  and ought to be saved.  After havino"
cut out a quadrilateral flap, and laid  bare the  upper  extremity of the
ulna in the manner of Park, Dupuytren begins  by excising the olecranon
and then  cautiously divides the sheath which contains the ulnar nerve
behind the inner condyle, then  pushes this  cord inwards, and causes it
to pass in front of the  articulation,  where an assistant retains  it  by
 means of a curved sound, the handle  of a scalpel or even the finder  un-
 til the lower extremity of the humerus is removed.

                     § IV.—Process of Jeffray.

   Jeffray (Oper. cit., p. 174) having devised  his  chain-saw, supposed
 that two  lateral incisions  would be sufficient,  and that the crucial  inci-
 sion of Park, and the transverse incision of Moreau, were useless.  Hia
 chain-saw requiring only a slit on  each side in order to be passed around 
           EXSECTION OR EXCISION OF THE ARTICULATIONS.         453

the bone, enabled him thus to preserve the continuity of the muscles and
tendons uninterrupted, and to save the ulnar nerve, a crowning perfec
tion being thus given to the operation which bore off the  honors from
Dupuytren.
                               § V.

  Process of Manne, (Traiti Elim. des Malad. des Os,p. 50,1789.)—
A semicicular incision was first made  at the postero-inferior part of the
arm;  a similar one at the postero-superior part of the fore-arm; then
two longitudinal incisions were made, which extended from the extrem
ities of the superior semicircular incision to those of the inferior ; the
flap comprised  between these incisions was then removed, [i. c, detach-
ed.  T.] ; the tissues were then carefully detached from the anterior and
inner surface of the articulation ; the periosteum was divided circularly
around the bones ; the tissues were then held aside with a bandage, and
the bones sawed above and below the articulation ; the lips of the wound
were  brought together, covered with  lint, and  the whole supported by
an  eighteen-tailed  bandage, the arm  and  fore-arm  being  placed in a
gutter or in fanons, (see Vol. I,) upon a pillow.
  M.  Sedillot, adhering to the two semilunar incisions, eulogizes the pro-
cess of Manne, as the one which is still the best.

                   § VI.—Process of the  Author.

  A.  The patient is to be placed upon his  belly or upon his sound side
An assistant compresses the brachial artery, and supports the soft  parts
of the arm.   Another holds the fore-arm.  The  surgeon placed out-
side, with a  straight bistoury, makes his  first incision two inches long
on  the outer border  of the humerus, beginning or terminating it at the
outer condyle, and prolonging it upwards in such manner as to separate
the brachialis internus muscle from the outer portion of the triceps.   A
second incision  is then made on the  inner border of the  arm, in such
manner that, in order to avoid touching the ulnar nerve, its lower extre-
mity may fall rather upon the side of the olecranon than upon the  inner
condyle.  After having united these two  first wounds by a transverse
incision, which divides at the  same time the tendon of the triceps, the
flap is dissected and  raised up with facility.   An assisant then seizes
hold of it, and  if the extremity of the bones  of the fore-arm appears
sound, we proceed immediately to the exsection of the humerus.  In the
contrary case, we must prolong the lateral incisions downwards, and form
a lower flap similar to the first.
  B.  Second  Stage.—As  soon as the cubital nerve is laid  bare, we iso-
late it from the bridles which hold it down between the internal codyle
and the  olecranon, and then while the fore-arm is placed in as strong
extension as possible, we slip it, as has been  just said, over  the  inner
tuberosity of the humerus.  Then  the operator draws forward the un-
divided tissues, and slightly flexes the limb; detaches with  the point of
the bistoury the muscular  tissues from the anterior surface of the  bone,
passes in front  of the humerus the plate of wood, puts the saw in mo-
tion, embraces the  upper extremity of the fragment of bone,  which he
wishes to remove, separates  all the tissues from it, in proportion  as he 
454
NEW ELEMENTS OP  OPERATIVE SURGERY.
reverses it from before backwards, and from above downwards, and then
divides the anterior, external lateral, and posterior ligaments.
  C.  Third Stage.—If the ulna and radius are to be exsected, the surgeon
detaches to a point below the disease the insertion of the brachialis inter-
nus  muscle, as well as that of the biceps, and terminates by dividing
the bones with the saw, directed from before backwards, or from  behind
forwards, according as  the  state  of the parts may seem to require or
render  more convenient.  In this case it is better also not to disarticu-
late  the humerus, and proceed afterwards to the section of radius and
ulna.  If the bones of the fore-arm are perfectly sound, it is difficult to
conceive that the excision of the olecranon can be of any service.   When
they  are  diseased,  the operation is necessarily longer and  more serious,
and  as  it  appears  to me would present  but slight chances of success,
should  it become necessary to make  the  exsection below the bicipital
tuberosity of the  radius, since we should then destroy the attachment of
the two principal flexor muscles of the  limb.  The brachial artery being
separated from the  humerus by a thick muscle, is never difficult to be
avoided.  It would incur much more risk, if we were obliged to descend
upon  the fore-arm as far down as on a line with its bifurcation.   It is
a matter of great importance that we  should make  the section of the
ulna  and radius  above  the  insertion of the brachialis internus muscle,
and especially that of the biceps.   M. Syme, however, as it  appears,
performed  exsection below  the tendon of these muscles, in some of his
patients, who nevertheless preserved the functions of their  hand.
  D.  Fourth Stage.—After having removed the bones, tied the vessels,
cleansed and adjusted the wound, and ascertained that we have  left no
portion  of disease behind, the fore-arm is to be brought  into extension;
the two flaps are to be brought together, united by two or three points
of suture, and to be  adjusted  in the same manner at their edges to the
anterior soft parts.   [At present all tension of this kind by sutures, ad-
hesive straps  or even loose bandaging, or any pressure whatever, are,
it  would appear, by general consent to be rigidly proscribed.  See note
supra, under Amputations.   The starch bandage  would be particularly
objectionable.   T.]  Gateaux of lint, a few graduated compresses, the
bandage of Scultetus, cushions  and two thin splints, or  the starch ban-
dage, [appareil inamovible—see note, a few  lines above,  T.]  would
maintain the surfaces in  contact, and the totality  of the limb in  a com-
plete  state of immobility.  [This practice of immovability or immobility
of the limb must be surrendered also with its accompaniments or  conge-
ners, (vid. notes above,) as it is  all at war with the present most ap-
proved  principles of treating wounds of joints, where  the joints are ex-
posed, whether such wounds  are  traumatic or surgical.  The favorite
starch  bandage of our  author, with every  deference  to him, must, we
think, be confined to simple fractures, and then, only  to be used where
there is no inflammation, or  where it has entirely subsided.  The  articu-
lations, when  laid bare and lacerated, or fractured or  luxated, or after-
wards  exsected,  or where all  these conditions exist  together, must,  it
is now  ascertained, be treated in the most gentle manner with light, soft
dressings, and  their flaps merely brought  together;  besides  which, a
slight  degree  of motion  must in some  way  be  kept up from the first.
See our note supra. T.] 
EXSECTION OR EXCISION OF THE ARTICULATIONS.        455
                       § VII.—Appreciation.

  The exsection of the elbow-joint, is a tedious, long and painful opera-
tion.   It is rare that it is followed  by perfect,  immediate union.   An
abundant  suppuration is  frequently the result.  One of M. Roux's pa-
tients was not  perfectly  cured until at the expiration of nearly a year.
It cannot be had recourse to except in cases where the skin and a part
of the muscles retain their natural state, or for a caries or simple necro-
sis, or  a comminuted fracture of the articulation.  All these circumstan-
ces have been calculated to intimidate  practitioners, and have rendered
the operation we are treating of more rare than would have been at first
supposed.  Nevertheless, it has constantly succeeded with the surgeons
of Bar, M. Roux, also, has had three fortunate results.   His first patient,
operated upon in 1819, recovered from the operation, but died of phthisis
five months after.   The  second, became a knife-grinder, on one of the
bridges of Paris.  The third patient,  and whom I saw operated upon,
resumed her  profession of seamstress, and afterwards that of  chamber-
maid.  A fourth case, in whom a sudden hemorrhage rendered it neces-
sary to proceed to immediate amputation of the arm, died three days af-
ter.  Two others succumbed to the consequences of the operation.  The
patient of M.  Mazzoza,  recovered.  That of M. Crampton,  operated
upon January  2d, 1823, himself signed his discharge on the  29th of
November  following.  Out of the  fourteen operated upon by M. Syme,
from October the  1st, 1828, to October the 1st, 1830, two have died.
A third, had afterwards to undergo amputation of the arm.  Eleven re-
covered perfectly, some by almost immediate union, others after a greater
or less length of time, and all have preserved,  in great part, the uses of
their limb.  M. Syme, (Coulon, Op. cit., p. 45,) was less fortunate in
another case in 1831; but  that of  M. Spence, operated upon in 1830,
also recovered  perfectly.
  [At  a meeting of the Pathological Society  of London, May 2, 1854,
Mr. Fergusson  stated that death had occurred twice in his practice, from
the shock  following excision of the elbow-joint.   G. C.  B.]
  In uniting to these facts, the two successful cases  which belong to
Wainman and  Park, (Jeffray, Op. cit., p. 68,) that  of Justamond,
(Ibid., p.  55,)  who removed the olecranon and two inches of the ulna,
that of M. Harris, (Gaz. Mid., 1837, p. 585,) whose patient recovered
the use of his elbow-joint, that of M. Warren, (communicated  by the
author, 1837,)  which ended in death, the successful case of M. David-
son, (Edinburgh Periodical and Surgical Journal, Vol. LVIIL, Expir.,
t. II., p. 104,)  then  the four cases of  M. Fricke, (Godin, Arch.  Gin.,
1837, t. XV.,  p.  187, 191,) and  those which were  collected  by M.
Sprengler, in 1836,1837 and 1838, from the practice of M.  Textor, we
have, in admitting all those also mentioned by M. Coulon, (Op. cit., p.
45,) an aggregate of about sixty cases of exsection  of  the elbow-joint,
yielding more thm forty cures, arranged  as follows:— 
456
NEW ELEMENTS OF OPERATIVE SURGERY.
In the cases complicated with Luxations or Fractures.
iVainman,           1.
Goorke,             1.
Percy,—several.
Dinus and Mazzoza,  1.
Hey,                2.
Evans,              1.
Textor,             1.
Warmuth,           1.
> Resulting fortunately.
          Doubtful.


In the cases  of Caries.
Justamond,	1.		Jaeger,	2.
Moreau, the father,	4.		Dietz,	1.
Moreau, the son,	1.		Kern,	1.
Champion, Dupuytren, Park,	1. 2. 1.		Moisisowitz, Sanson, Harris,	1. 1. 1.
Crampton, Delpech, Roux,	2. 1. 6.-	-4 dead.	Warren, Davidson, Fricke,	l.-dead. 1. 5.-1 dead
Syme,	15.-	-5 dead.	Textor,	7.-4 dead
  [In the discussion  which followed the reading of a paper by Mr.
Mackenzie, before the Edinburgh Medico-Chirurgical Society, on excis-
ions of the knee-joint, Mr. Syme remarked that he had  performed the
operation of excising the elbow-joint in nearly a hundred instances, and
that his experience had shown that " many months, or years, or even a
whole life time, might elapse before the wound was so completely con-
solidated as not to suffer  occasionally from small collections of matter
in and  about the  cicatrix, which interfered little with  the patient's
comfort, as they did not affect the usefulness of the hand or the strength
of the arm, but would entirely unfit the  inferior  extremity from being
employed as a support of the body."   (Month. Journal, July, 1853, or
Braithwaite's Retrospect,  Part XXVIII. p. 153.)  Mr. Erichsen states
(Science and Art of  Surgery, p.  614,) that  a coachman,  whose elbow-
joint he excised, was afterwards able to drive, to lift a pail  of water
and to do all the duties  of  his employment nearly as well  as if the arm
had been left in its normal condition.  In another case in which he per
formed  this operation, the  patient died of pycemia,and after  death  the
interior of the humerus was found to be filled  with pus,  and the axillary
vein in a state of suppuration.  (Op. cit. p. 571.)  Mr. Fergusson  has
also had some very successful cases of this operation as may be seen by
the illustrations in his Practical Surgery.  Dr. Thomas Harris was the
first to perform it in this country,  and  it has  since been  frequently re-
peated by Drs. Buck,  Pancoast, Warren and Mutter.   G. C.  B.]
  So that it is impossible not to admit this operation at  the present day
as among the number  of the most  valuable acquisitions of surgery, not^
withstanding the contrary  opinion of M. Larrey and my ancient precep- 
           EXSECTION  OR EXCISION OF THE ARTICULATIONS.        457

tor M. Gouraud, who adopt  it only in cases of fracture  or comminuted
luxation, with division of the integuments and protrusion, of the bones.
It is true that the destroyed parts do not seem capable of reproduction,
as some persons in the beginning flattered themselves was the fact, and
it is  also true that the  articulation at the elbow  is almost always want-
ing.   But there is, nevertheless, formed in their place, a substance suffi-
ciently  solid to serve as a point d'appui for the muscles, and to enable
the fore-arm to make flexion and extension.   The patients once cured,
have always  been enabled  to make use of their hand, and have, as we
have seen, deemed themselves exceedingly fortunate in not being obliged
to undergo amputation of the arm, the only resource which would have
been left them if exsection should not or could not have been attempted.
The loss of substance also may be made to a great extent.  Brun (Mim.
de VAcad.  des Sc.  de Toulouse, t. II., p. 38, 1784,) mentions a gun-
shot wound at the articulation of the elbow, which carried away the low-
er half of the humerus and the upper half of the two bones of the fore-
arm  to the extent of fourteen inches and a quarter in the whole extent.
The  patient, who recovered with an interval of fifteen lines between the
fragments, can make use, says  the author, of his  wrist, with  which he
raises a weight of forty  pounds ;  but  he cannot  raise  his hand to his
head, except by sudden jerks, and by means of  a vigorous contraction
of the muscles which cover the  shoulder: when  the lower part of the
arm has been carried up  in this manner, his fingers act voluntarily.
   [Professor  Syme  states (Supplement to his Principles of Surgery,
Edinburgh, 1851, p. 29) that he has extended excision of the elbow-joint
to the remedying of anchylosis.  If the Edinburgh professor will but
turn to the North American Medical and Surgical Journal,  for  April
1827, he will find that Dr. J. Rhea Barton had  anticipated him  in this
matter and had given  the  following diagrams illustrating the method
to be adopted according  as the  arm is in the flexed or straight position.

          Fig. 1.                                    Fig. 2.

  The line in Fig. 1. represents  the  direction in which the bones might
be divided, by a long and narrow saw, in cases where  the elbow joint
is anchylosed at a right angle.   The line in Fig. 2. the direction of the
section, when in a straight  position.   Prof. Syme remarks that the ope-
ration in these  cases is much more difficult  than  when  performed for
caries, and requires a very free ablation of the bone.  When properly
executed, he  asserts, it renders  the  limb nearly perfect, in  regard to
motion and strength.
  Dr. Barton, also,  suggested the extension of this principle  to  the
  Vol. II.                  58 
458            NEW ELEMENTS OP OPERATIVE SURGERY.

formation of new joints in other parts of the body where natural motion
has been lost, for anchylosis, the muscles being in a sound state.
                                                      G. C. B. ]

       Article IV.—Partial Exsection of the Elbow-joint

                              §1.

  If one of the  condyles only or  the  olecranon  was  the  seat of the
disease, we should pursue the same plan which Moreau did on one occasion
with success; that is, to make one of the lateral  incisions  above des-
cribed ; then to make from the lower  extremity of the  last  mentioned,
another incision transversely, which is to terminate above the olecranon
about the middle of the breadth of the arm ; to  dissect and reverse
from below upwards, to the median line of the limb, the triangular flap
thus circumscribed; then by means of the chisel or gouge  to destroy
every portion of the bone which is diseased, and afterwards to adjust
the flap in its place to unite by first  intention.  This  partial excision
which has been performed also by M. Fricke, and  which I have  made
trial of on one occasion, would now require  that we should  detach the
bone by means of the concave rowel  saws, the osteotome of M. Heine,
or the cutting pliers, should seem possible to respect the articulation, as
in my case related a little farther back,  (in this volume  II.)

                              Mi-

  The Radius only.  A gun-shot wound which  happened in the year
1777, fractured the  upper part of the radius ; at  the  expiration of five
weeks, inflammatory accidents supervened;  the  fractured portion is
considered as a foreign body; an  erysipelatous state of the limb, and
acute pains about the fracture, Sec, lead to the proposition of amputation.
Salmon and LaFlize, (Salmon, De Artium Amputat. rarius admittenda,
§ VIII.,  Nanceii, 1777,) oppose it, and the first named of these sur-
geons, detaches and  removes the isolated portion of the  radius,  which
was two inches in length.  A cure was effected.
  In  1796, says M. Champion, (Unpublished—Communicated by M.
Champion,)  I  saw  a surgeon of  the most  ordinary  kind,  remove an
inch and a half from the humeral  extremity of the radius, which  had
been  wounded, and laid bare by a sabre cut, without  implicating the
articulation.   The  patient  preserved  the  movements of flexion  and
extension, but rotation  was imperfect; he was enabled  however to con-
tinue his profession of gendarme.

                              § III.

  The  Ulna  alone.  A sequestrum  of  the  olecranon  was removed  by
means of the fingers by Le Dran, (Obs. de Chir.,t. L, p. 356 ;  Obs. 51,
1731,) without the articulation  being thereby injured.  But a case in
which Alanson, (Park, Nouv. Melh. de trailer  les Maladies, p. 54,)
removed a similar fragment, including the inner tuberosity, and a lamina
of the body of the humerus, was followed by anchylosis.   Jalabert, (Jour- 
EXSECTION OR EXCISION  OF THE ARTICULATIONS.        459
nal sur toutes les  Parties de VArt. de Guirir, Sec, p. 91, 1792,) has
seen a case in which *destruction  of this eminence by caries was not
followed by  any inconveniences.   In  a  patient  of Ravaton, (Chir.
d'Armee, Obs., 66, p. 294,) the olecranon was carried away by a gun-
shot wound.   In that of Planque, (Mini, de VAcad.  de Chir., t. II.,
p. 528, in 4to, t. VI., p. 241, in 12mo,) a  portion of the  external con-
dyle of the humerus was carried  away at  the same time.   Although in
the case of De la Touche, (Dissert, sur VAmput., p. 56 ; Obs. 15,1814,)
there had been a simultaneous fracture of the  two bones of the fore-arm,
pronation and  supination continued unimpaired, in spite of anchylosis
of the elbow.  In another case, the upper half of the olecranon  was
carried away by a  sabre  cut, and  M. Larrey, (Siance de la Sect,  de
Chir. de VAcad. de  Mid., 30th Sept.  1824,) as well  as M. Baudens,
( Clinique des Plaies d'Armes-d-feu, p. 452,) speak of  olecranons frac-
tured, and extracted without being followed by anchylosis.
  The olecranon was exsected in a case of luxation of the elbow-joint
backwards, rendered irreducible by the protrusion of this process through
the skin.  B. Bell,  (Cours Complet de  Chirurgie, t. VI., p. 141,) who
was witness  of the operation, is  of opinion, that  if the  fore-arm  had
been  flexed instead of being extended  during the efforts at reduction,
that the displacement could have been reduced, and the  operation avoid-
ed.  In a case  of gun-shot wound, Bilguer,  (Dissert, sur Vlnutiliti  de
VAmput. des Membres, § 36, p. 122,) extracted splinters, and exsected
the ulna tcv the extent of four fingers' breadth, removing  at the same
time pieces of iron which were buried in the parts, and cured his patient.
[An interesting case of this kind occurred near this city,  a few years
since.   A gentleman  while out shooting, had his  gun burst, and the
fragments produced a lacerated wound near the bend of the arm*  The
country physician continued  for months, in fact for near a year, to ex-
tract from the wound  fragments of every  description,  bits of the coat
sleeve, pieces of the wooden stock,  barrel, <fec; never attempting to di-
late the wound and look into the real condition of the mischief.  The
arm meanwhile was comparatively useless and rapidly withered.  The
patient came  to town.   Dr.  Cheesman, a good operator, but one   of
those who rarely condescends to inform the world of the fruits of  his
experience, nevertheless did well  here so far  as regards the treatment.
He cut down and  freely dilated  the  wound, and  discovered  two  or
three inches  of a fragment of  the  gun barrel,  which  completely  em-
braced the round anterior portion of the radius, we believe, fastened
upon it like an outward semi-cylindrical encasement.  This  being de-
tached, the patient recovered perfectly.  T.]   According to M. Jaeger,
(Jaeger, Op.  cit., p. 6, No.  36.)    Gorko, exsected the olecranon  and
four inches of the ulna in the  year 1793.   In the case of Justamond,
(Ancien Journ. de  Mid., t.  LXXXIV., p.  402,  1790.   Jaeger, says,
M. Velpeau, in stating that Justamond had removed the  upper portion
of the radius, is evidently mistaken.  The same case is mentioned  in
Park, edit, of Jeffray, p.  55, 56,) the body of the humerus not having
been implicated, the articulation was not exsected, but only the extre-
mity of one of the bones of which it is composed  ; extension and flexion
were nearly destroyed, but rotation continued unimpaired. 
460            NEW ELEMENTS OF OPERATIVE SURGERY.
   [On the 18th of April, 1852, Dr. Compton, of the Charity Hospital,
New Orleans, removed the entire ulna, and all but a portion of the lower
end of the radius.  The  following report of the case, was made by A.
Thibaut, a student in the Charity  Hospital, and was published in the
New  Orleans Monthly  Medical Register, November 1st., 18o2, p. 16.

                                 Charity Hospital, Oct. 22d, 1852.
   "Thomas Harris, a3t. 15, admitted during the month of February, for
a lacerated wound of scalp and ear; fracture of inferior maxillary and
humerus ; compound comminuted  fracture of  radius and ulna.  These
injuries were received  on board  the English ship, Manchester.  It ap-
pears that the boy was  sleeping on the anchor chain ; and  that the an-
chor was suddenly let down ;  in  its progress, the chain  caught the arm
and produced thcinjuries above mentioned.  When the boy was admit-
ted, the wounds  had been dressed  for several days, and from want of
proper attendance and  care, were  in a very filthy condition.   The arm
especially, was in a sloughing state, and both radius and ulna were ac-
tually shattered to pieces, and protruding several inches out of the mass
of muscles.  By the 18th of April, the boy being well of all  the other
injuries, Dr. Crompton  determined to remove both the radius and ulna.
He made a straight incision the whole length of the inner side  of the ra-
dius, and a counter-opening opposite the olecranon  process.  Having
dissected out both bones carefully and disarticulated them at the elbow,
he removed  them entire with the exception of a portion of the  lower
end of the radius.   A great portion of  the  periosteum  was  detached
from the bones, and left  in the wound.   The usual  treatment for such
operations was then followed  and  the patient improved rapidly, and the
wound- had  nearly healed, when several  abscesses were formed on the
fore-arm.  These abscesses were, according to Dr. C's. opinion,  pro-
duced by pieces of bones which had been  left in the arm.  His opinion
was well grounded, for several spicula of bones came out of  the wound
and the arm immediately assumed a healthy condition, and is  now well.
The arm is about two or three inches shorter than the other, and is per-
fectly firm.   It remains at a right angle to the humerus, and can be flex-
ed and extended so that  the hand  moves through 8 or 10 degrees of an
arc of a circle.   He has entire use of the hand, he can  both  open and
shut it, and  he grasps objects quite firmly.  The pulse in that arm can
be felt as well  as in the other.  This patient can  be seen in ward No. 8,
and bed No. 116, Charity Hospital."
   We have been thus particular in transcribing  the details of this case,
on account of its bearings upon the question of priority in removing the
entire ulna, which as will  soon appear, has recently been claimed  by a
surgeon of  this city.  Besides the case of Dr. Compton, we find  in tho
Phil. Journ. Med., and Phys. Science, vol. 1st.  N. S. p. 115, 1825, that
Dr. Butt, of Virginia, removed the lower two thirds of the ulna, and not
of the radius, as is so frequently misstated by surgical writers.   In three
months the patient was enabled to pursue his usual avocation as a car-
penter ; flexion,  extension, and  rotation of the wrist being as free and
uninterrupted as ever.  He afterwards declared that he had as much
strength in this hand (the left) as most people have  in the right.
   Dr.  Carnochan has  reported  in the "American  Medical Monthly " 
            EXSECTION OR EXCISION OF THE ARTICULATIONS.       461

March, 1854, a case of removal of the entire ulna.   Dr. C. erroneously
supposes that his is the  first operation of the kind.   The affection was
" ostitis, caries and necrosis."  The operation was performed in Janua-
ry, 1854 ;  and the following is his account of the proceeding adopted,
with that of the appearances presented by the removed bone:  " I made
an incision along the posterior and inner aspect of the ulna, commenc-
ing at the lower part of  its  superior third and extending downwards to
a point over the extremity of the  styloid process.   This divided the
tegumentary layers and fascia, which  were found dense, matted, and in-
filtrated.   The  tendon of the extensor carpi ulnaris was  pulled back,
and the bone  exposed.   This was found  rough, enormously enlarged,
and presenting numerous oval foramina and several cloacse, which com-
municated  externally  through the  integuments.  It was now apparent
that the bone must be disarticulated.  To effect  this at the carpo-ulnar
articulation, a transverse incision, about an inch  long, parting from the
lower extremity of  the first incision, was made across the back of the
wrist.   The superficial  tissues were here reflected, and the  tendon of
the extensor carpi ulnaris  was carefully detached from its  groove on
the lower part of the ulna.   The dissection was now carried along the
anterior surface of the  lower portion of the ulna, and the soft  parts
were  detached from the  bone as far  as  the  interosseous ligament, the
•ulnar  artery and nerve  being carefully avoided. The soft parts were
now detached from the posterior surface of the  ulna, avoiding injury to
the extensor tendons.  An attempt was then made to  pass a chain-saw
around the ulna through the interosseous space opposite the lower part
of the middle third.  This was found impossible, on account of  the ap-
proximation of the enlarged ulna to the radius, and the almost complete
obliteration of the interosseous space.  To divide the bone  at this point,
a small convex-edged saw was used.   The bone thus divided, the inter-
osseous ligament was detached  downwards, and the lower fragment of
the ulna was disarticulated  from its  inferior attachments to the radius,
libro-cartilage and the carpus.
   It now remained  to isolate and detach the upper fragment.   The first
incision was now prolonged upwards along the  posterior surface of the
ulna, so as to end at  the upper part of the olecranon,  opposite  its outer
edge.   To  this a terminal  incision was joined,  which  extended trans-
versely across the back of the elbow-joint as far as the inner margin of
the ulna.   The soft  tissues  were now dissected  from the bone upon its
posterior and anterior aspects, as far as  the interosseous  ligament and
as high up as the insertion of the brachialis internus muscle.  The bone
was next seized and pulled from the radius, and  a knife, curved flatwise,
was passed close upon its interosseal margin, and grazing  the bone, the
interosseal  membrane was divided upwards, the soft  parts being held
apart, and  the interosseal and ulnar arteries protected.
   The elbow-joint was now flexed, and  opened  behind by entering the
bistoury close to the  inner  edge of the olecranon, and  the attachment
of the triceps extensor was  next  divided  by cutting directly outwards.
The ulnar nerve was now found, and  hooked aside until farther dissec-
tion of the soft  tissues was  effected  from the inner aspect of the joint
and the upper part of the bone.  The lateral ligament was next divid-
ed.  The bono  still remained firmly attached, chiefly by the coronary 
462
NEW ELEMENTS OP OPERATIVE SURGERY.
ligament  and the insertion of the brachialis  anticus.  The ulna was
carried backwards so as to make this muscle  tense, and by  carefully
grazing the coronoid process with the knife  the tendon was detached.
Some difficulty was here presented in avoiding the humeral artery, which
lay in close proximity to the enlarged coronoid  process.   The bistoury
was now passed between the ulna and radius, and the coronary ligament
divided.   A few remaining fibres were divided,  and the bone was com-
pletely detached.
  During the operation there was a considerable flow of venous hemor-
rhage, which  soon ceased  upon removal of compression from the upper
arm.  The arterial  bleeding was arrested  by torsion of a few arteries
around the elbow-joint.
  Progress of Union.—After the operation, the patient recovered slowly
from the influence of the chloroform, the  pulse  remaining below 50 for
some  hours;  anodyne ordered at bed-time.   Next day, Jan. 15th, the
pulse 100—full and regular ; oozing of blood has occurred to some ex-
tent ; during  the night, patient has been restless, and has suffered much
pain in the arm.   Sol. sulph. morph. at bed-time.
  Jan. 16th.   Pulse 100—not so full  or strong ; no more oozing of
blood has  occurred, and the patient feels more comfortable, having slept,
and suffered but little during the night.   The first dressing removed in
the  afternoon : for four  inches above the wrist joint, the wound seems
to be uniting by first intention.
  Jan. 17th.   Pulse 83—regular; general condition good.  01. ricini
ordered.   The wound dressed ;  suppuration profuse.  The lips of the
wound have an unhealthy aspect; four of  the sutures come away.   Ano-
dyne in the evening.  The patient is ordered to commence in the morn-
ing with solution of sulphate of quinia.
  Jan. 18th.   Patient has  slept badly, having suffered much pain, during
the night, along the arm  ; pulse 80.   Dressed  the wound, which has
assumed  a better  appearance;  suppuration less,  but little adhesion.
Beef-tea ordered.
  Jan. 19th.  Pulse  90 ;  patient has slept tolerably  well.   Wound
dressed :  discharge of pus  decreasing, and  union progressing  from the
wrist upwards;  free  discharge of synovial fluid from the elbow joint,
upon removal of the dressing.
  Jan. 20th.   Pulse 84.   Wound  dressed ; favorable progress.   Full
diet allowed.  Quinine  continued.  No  undue  inflammatory action  at
either articulation.  Arm still kept in the same position.
  21st.   Patient  has suffered much pain at tho elbow joint during the
night. In the afternoon, wound dressed ;  doing well; there is free mo-
tion at both elbow and wrist joints; discharge of synovia still coming
from the elbow joint.
  Jan. 22d.  Everything  going  on  well.  Wound  dressed; but lithe
discharge, except at the several tegumentary orifices which existed be-
tween the wrist and  elbow before the  removal of the bone ; but little
synovial fluid coming from the joint.
  Jan. 25th.   General condition of the patient excellent; pulse 80, and
natural.   Appetite good.   Only slight oozing of synovia from the elbow ;
no  pain.    Splint upon which the  arm rested in a  state of pronation, dis-
pensed with ;  forearm now bent at a right angle, and held in a position 
EXSECTION  OR EXCISION OF THE ARTICULATIONS.        463
 between supination and pronation, while a light, well-padded splint, ex-
 tending from  the elbow to the extremity of the fingers, is placed  and
 bandaged  along the front  thereof, to support the radius ;  limb, thus ad-
 justed, supported by a sling passed around the neck.  Patient allowed
 to sit up.
   Jan. 29th.   First splint removed, and the arm, which had been main-
 tained  fixed for the last  four  days, adjusted, and  bandaged to another
 splint, jointed  and formed of two pieces, one for the upper arm,  and
 another for the forearm ; the joint being opposite the elbow, in front:
 by this arrangement the forearm still kept in semi-pronation, and radius
 supported, while, by regulating the angle of the splint, by a mechanism
 for that purpose, the forearm can be gently and gradually extended.
   Feb. 5th.  During the use of both splints, dressings carefully attend-
 ed to, by removal and re-adjustment at suitable  intervals.  To-day, upon
 removal of the splints  and dressing, healing process of the wound found
 to be entirely completed ;  the  tissues about the wrists and elbow  joints
 being entirely  consolidated, and free motion at both articulations  possi-
 ble by the patient himself, without any assistance.
  •Feb. 10th.   Limb still supported by a light  bandage, and by the  last
 splint, for the purpose  of allowing the tissues along the  line of the inner
 aspect  of the  forearm to become further  consolidated.   Health of the
 patient is now  good ;  he  walks  about like a well  person,  He is still
 upon tonic treatment, and is allowed generous diet.
   Feb. 15th.   Removed the splint;  patient allowed to  use his arm.
 General health entirely restored.
   Feb. 18th.   Five weeks after the operation discharged from the Hos-
 pital cured.

   Appearance  of the  Arm; and its  Functions.—With the exception
 of a depression, and the cicatrix along the ulnar aspect of the forearm,
 there is no deformity of the limb.
   The  functions of the arm are preserved in a remarkable degree of
 perfection.  The power of prehension is unimpaired ; and  flexion and
 extension at both the elbow joint and at the wrist joint can be performed
 with  facility—supination and pronation can also be effected—abduction
 and  adduction  at the wrist joint can be performed  ; as also flexion and
 extension of the fingers, as before the operation ; sensation and nutri-
 tion  are as perfect as on the arm and hand of the opposite side.
  None of the  large nerves or arteries were injured during the-exsec-
 tion  of  the bone, and the muscular tissue was carefully  preserved from
 the action of the bistoury, with the exception of the cubital origin and
insertion of those  muscles  which are attached to the upper portion of
the ulna.   These had to be divided  during the  detachment of this por-
tion of the ulna.
  Flexion at the elbow  joint is chiefly effected by the biceps flexor, which
is inserted into  the tubercle of  the radius ; but the humeral origin of
the other flexor muscles—such as the flexor sublimis digitorum communis,
the flexor carpi ulnaris, the palmaris longus, the flexor carpi  radialis,
and the pronator radii  teres—remaining uninjured, they  also serve as
auxiliaries in this function.
  The triceps extensor and anconeus were, necessarily, entirely detached 
464
NEW ELEMENTS OF OPERATIVE SURGERY.
 during the operation ;  but extension of the  forearm is sufficiently per
 formed by the action of the extensores  carpi  radialis longus et brevis;
 by the extensor communis  digitorum, the extensor minimi digiti, aud
 by the  extensor  carpi ulnaris;  all of  which muscles pass from the
 external condyle of the humerus, to be inserted on the posterior surface
 of different metacarpal and phalangeal bones of the hand.
   Flexion of the wrist joint is effected by flexor carpi radialis, palmaris
 longus, flexor carpi ulnaris ; extension, by the extensores carpi radialis
 and the extensor carpi  ulnaris.   Adduction, also, is effected by the ex-
 tensor carpi  ulnaris;  while abduction results from the  action of the
 extensores carpi radialis.
   Flexion of  the fingers is chiefly  effected by the flexor  sublimis digi-
 torum communis, and the extending  function of the phalanges results
 mainly from the action of the extensor communis digitorum.

   Pathological condition of the bone.—The diseased ulna presents all
 the characteristic manifestations of prolonged  inflammatory action of  a
 high grade.  The bone is enormously expanded from  one extremity to
 the other—at the base of the coronoid process it measures in circumfer-
 ence 5\ inches ;  and its weight is 8 oz., minus  20 grs., the weight  of  a
 recent healthy adult ulna varying from 2\ to 3 oz.
   Bony vegetations have assumed  the acicular form on the radial aspect
 of the bone, on a line with tho attachment of  the interosseous ligament,
 as far down as the junction of the middle with the lower  third—the
 acicular  formations also prevail on and bslow the coronoid process.   At
 all other points around  the upper extremity of the bone, irregular mam-
 millated appearances exist, with innumerable  enlarged, round, and  oval
 foramina. These enlarged foramina, in conjunction with the hypertrophied
 condition of the bone, are characteristic  signs of protracted inflammatory
 action, as was long ago demonstrated by the Goodsirs, of Edinburgh.
  Along the inner and  posterior aspect of the bone exist some eight
 cloaca, five of which are in the upper third of the bone : two in the mid-
 dle third ; and  one near the styloid process.  One  of these  clorcce,
 situated between the coronoid and olecranon  processes, communicates
 with the interior of the elbow joint; while  another, situated at the lower
 part of the bone, communicates with the ulno-carpal articulation.
  The  other cloaca pass deeply into the interior of  the bone, ramifying
 extensively, like sinuses, in different directions along the inner texture ;
 some of  the  sinuses containing  portions of bone in  a state of necrosis
 and more or less detached.  From the cloaca, which opened externally
 upon the integumentary  surface, large quantities of purulent fluid mixed
 at times with portions of dead bone were discharged.
  At  the middle third, the crcumference of the bone, by measurement,
is  four inches, being \ in. larger than the shaft of an adult femur.   At
 this part, also, the round and oval foramina are abundant.
  The  lower third  of the bone is also extensively hypertrophied, beino-
 at its upper part, 3i inches, while, at the base of the styloid process'
the circumference is 2| inches.
  The section of the bone, shows the appearance of the central portions.
Here the influence  of high inflammatory  action, and its consequences'
carious ulceration, necrosis, and eburnation, are plainly manifested.   The 
           EXSECTION OR EXCISION OF THE  ARTICULATIONS.        465

greater part  of the  interior of the bone is exceedingly dense ana com-
pact.   The surface of the osseous section  is in some parts tinted of a
dark purple hue ; at  other parts it  is whitish and dense, like ivory, blas-
tema having been here thrown out  so as to obliterate the spongy struc-
ture, the Haversian canals, the lacunae, and  canaliculi.   The right late-
ral  half of the section also shows the presence of two carious abscesses
in the interior of the bone, which communicate externally with cloacae
and  the  inteugments.   In one of these abscesses a piece of sequestrum
is situated, partly detached."
  [Mr. Ewen, of Chester, Eng. has removed six inches of the  ulna, and
Mr. Fergusson states (Pract. Surg. 3d. Loud. Ed. p. 298) that he has re-
peatedly extirpated portions both of the radius and ulna.   G.  C. B.]

                    § IV.— The Humerus  alone.

  The removal of the lower extremity of the humerus, which had been
isolated by a  fracture, and was complicated with wound, was performed
by Hey, (Practical Observations in Surgery^, p. 365, case  7,) in 1801 ;
and by M.  Champion, (unpublished, communicated  by the author,) in
1816.  In this case,  though the trochlea  and  internal  tuberosity had
been removed, the cure was complete, with  a restoration of the  move^
ments of the limb ; in a case of M.  Larrey, (Acad.  Royal  de  Med., 11
Sept. 1828,)  in which a  condyle of the  humerus was separated by a
sabre cut, he confined himself merely to its extraction.  In another case
in which Hey (Opir. cit., p. 367, case 8) removed the extremity of the
humerus, which had been fractured an inch  above its articular portion,
he also effected a cure.  In  another case, Park, (Jeffray,  Cases of the
Excision, &c, 1806,  p. 68,) after having exsected the  upper fragment
of the humerus, which  had protruded through  the skin, removed  also
the  articular fragment of this bone  and the apex of the olecranon.   The
motions of the limb were almost completely re-established.   In a case
of luxation in a child, the  humerus, denuded of  its periosteum, had pro-
truded through  the  skin.   Trye (Ancien.  Jour.  Mid., t. LXXXIV.,
p. 403) removed two and a half inches of it, including also the condyles,
and  effected  a perfect cure.  In  a similar case, in which M. Champion
(unpublished, communicated by the author)  excised the bone with the
two lower thirds of the cavity of the olecranon,  the movements were re-
stored perfectly.  In a  case  mentioned  by  Ansiaux, (Clin.  Chir.,
p. 320,-2e edit., 1829,) an  eschar from  a burn was torn off by a fall, and
left exposed the entire  articulation of the elbow-joint; the olecranon
by itself came away on the fiftieth day.  Everything indicated that the
humerus  would soon  be detached ;  the suppuration became abundant,
and the patient wasted away.  Exsection of the humerus was performed
at an inch and a half above its articular surface, on  the  sixtieth day
after the  accident; the patient recovered, but with a permanent flexion
of the fore-arm, in consequence  of  the destruction of the tendon of the
biceps from the burn ;  the movements of rotation however were  suffi-
ciently marked.
  [In September, 1854,1 was  requested  by my friends Drs. N.  & A.
Deyo, of Newburgh, to visit a lad who by a fall  from a tree had suffered
a compound dislocation of the elbow joint.   The lower end of the hu-
  Vol. II.                    59 
466            NEW ELEMENTS OF OPERATIVE  SURGERY.
 merus protruded at the time of the accident, some  four incnes, and was
 reduced by the  gentlemen above mentioned.   The brachial artery was
 also ruptured.   An attempt was  made for several weeks  to keep  the
 lower end of the humerus in its proper place, but without  success.  As
 a substitute for amputation I removed about two inches  of the protrud-
 ing portion, including the whole articular extremity.   Two months have
 elapsed since the operation and the articular cavity has become closed.
 An artificial joint has formed, and there can be no doubt that the boy
 will have  a useful  limb.   We have recently  seen another lad whose
 arm we saved several years  since, after a  compound dislocation at the
 elbow joint, complicated  with rupture of the brachial  artery.  True
 anchylosis exists in this case, (the limb being in a  flexed position) and
 perhaps it would have been better had  I  removed the lower end of  the
 humerus,  so as to have formed an  artificial joint.   In  either case the
 result has been far more satisfactory than could have been produced by
 the most successful amputation.   G. C. B.]

                   Article V.—The Shoulder.

   In the year  1740, Thomas, a surgeon of  Pezenas, published  the case
of a patient, in  whom  the  head of a necrosed humerus had been suc-
cessfully removed.  A little later, Boucher, in his  Memoir  on  Wounds
 from Fire-arms, demonstrated that the upper extremity of the humer-
us, shattered into splinters, might be  removed without any very great
difficulty,  and without the patient being obliged to  sacrifice his limb.
The same  doctrine was afterwards maintained by Percy, (Eloge histo-
rique de  Sabatier, p.  813,)  who exhibited  nine cases of this exsection
to Sabatier, and  by M. Larrey, and almost all the surgeons of the army.
On this subject, we may consult the thesis of M. Triaud, and that of M.
Legrand.
  As to those cases in which exsection was proposed by E.  Platner,
where the head of the humerus is the seat of an organic lesion,  the ope-
ration has been performed by White, (Cases in Surgery, etc., 1770, p.
57,) David, Vigarous,  (Soc. Mid. cVEmulat., t. III., p. 396,)  Moreau,
the father, MM.  Moreau, the son,  (Moreau,  1803, 1816,  p. 114,) C.
Petit, Brulatour, Textor, (Coulon, Op.  cit., p.  43,) Wurtzer, (Coulon,
p. 43,) Lassere,  (Arch.  Gin. de Mid., 2e serie, t. V., p. 156,) Buzai-
ries, (Journal des Connaiss.  Mid., t.  II.,  p.  109,)  Reynard, (Journ.
des Progres, t. VII., p. 250,) Baudens, (Clin.  des. Plaies d'Armes-d-
Feu,) and others.
  It is known, on the  authority of Sabatier,  that  already,  in 1789  a
child exhibited to the Academy of Surgery,  in his right hand, the scap-
ular extremity of the  humerus, of  the same side which had been re-
moved by  the surgeon-major, of the regiment  of Berry.  The  cases of
this kind,  either  successful or unfortunate, are almost  innumerable.  An
instance of the  loss of the  upper  extremity of the humerus, carried
away by a  ball,  is related by  Seeliger, (Biblioth.  Chirurg. du Nord
par Rougemont, t. I., p.  156.)  The patient operated upon by Ride-
wald and  Camper, (Wachter,  D" Articulis Extirpandis, etc., p. 68,
 Groning, 1820,)  in 1770, was amputated in order to cut off (pour aller
 au devant)  the  exhaustion caused  by  the  suppuration, but neverthe- 
           EXSECTION OR EXCISION OP  THE ARTICULATIONS.        467

less  died.  The head of the humerus, separated by  a sabre cut, has
been  also  extirpated by M. Larrey, (Mim.  de Chir. Milit.,  t.  III.,
p. 27,)  by Percy, (Eloge de Sabatier, p. 75, in 4to,) Chaussier, (Mim. de
la Soc. d'Emulat., p. 400, t. III., an VIII.,) by Roubieu, and  another
surgeon-major, (Annal.  Mid. de Montpellier,  p. 394, t. VIII.,) and  by
M. Yvan,  (Des Plaies d'Armes-d-Feu, p. 17, 1805 ;  These, de Paris.)
In the patient of Vigarous, ( Opuscules citis, p. 106 ; ( (Euvr. Chir. Prat.,
p. 431,)* in  1767, the same as in  that of White,  (Trans. Phil., 1769,
Vol. LIX., p. 39,) in 1769, the extraction of the dislocated head of the
humerus became necessary, after the  necrosed  upper portion of the
body of the bone had been exsected.  For examples of cases wherein
fragments  composing a portion of the head of  this bone have been ex
tracted and removed, we are indebted to Geoffroy, whose case, related
by Boucher,  (Mem. de VAcad. de Chir., t. II., p. 299, in 4to;  t. XII.,
p. 300,) is always  cited under the  name of this last author; also to
Ravaton, (Le Chirurg. d'Armie, p. 267,) and to Chabert, (Obs.de Chir.,
p. 156,  1724 ; he was afraid to amputate, says M. Velpeau,) who pub-
lished, in 1724, a remarkable  case of this kind ; to  Nicolas, the  son,
(Manuel  du Jeune  Chirurgien,  p.  425)  to  Bourienne, (Journel  de
Mid. de Dehorne, 1.1., p.  206, 1782,) who removed at the same opera-
tion, and in succession, the pieces of bone which had  composed  the up-
per portion of the humerus, as far as the insertion of the deltoid muscle ;
to Massot, (Ibid., t. III., p. 362,) who took away a  large number of
splinters, (esquilles ; ) to  Percy,  (Eloge de  Sabatier, in  4to, p. 83,
en note ; to M. Larrey, (Relat. Hist, et  Chirurg., etc., p. 310 ; Mem.
de Chir. Milit., t. II., p. 171,) who gives ten cases of this kind ; to M.
Yvan, (De VAmp. des Membres d la suite  des Plaies d> Armes-d-Feu,
p. 19, 1805 ; ) and to M. Arbey, (Coup-tf' (Eil sur VAmput. des Mem-
bres, etc., p.  13, Strasbourg, 1805,)  who speaks of the immediate and
successive extraction of fragments which had  formed the upper third
of the humerus.
   Disarticulation, with the removal of the head of the fractured humerus
and exsection of the body  of this bone, have also been performed by M,
Champion, (Unpublished—communicated- by the  author.)  In  another
case his nephew, M. Neve, (Ibid.) exsected a portion of the body  of a
fractured humerus, which had protruded through the  skin, and  become
irreducible, and then disarticulated the head of the bone.
   A case  of exsection of  the  anterior half of the  head of the nume-
rus, notched  by the passage of a ball, is also related by M. Baudens
(Clinique des Plaies d'Armes-d-feu, p. 553, Paris, 1836 ;) and cases  of
the exsection of the  head or of a portion of the  body of the fractured
humerus are  also related by Grosbois  (Diss, sur VAmput. du Bras dans
VArticle, p.  34,  1803,) Bottin, (Hist, de VEtat  et des Progres de  la
Chir. Milit., par Briot, p. 161, 1817,) Courville, (Ibid.,) M. Willaume,
(Jaeger, Op.  cit., p. 3, Nos. 8 to 35,) and M. Guthrie, (Jaeger, id., No.

  *M. Vigarous, the son, says M. Velpeau, censures M. Champion for having said, (Journ.
de Med. continue, XXIII., p. 244,) that  his father had not exsected the head of the hu-
merus, but only extracted  it  ((Euvr.  Chir.,  cit., p. 431, 1812.)   The  evidence of this
simple extraction, however, is contained in a paragraph in a letter from Vigarous, the father,
to Sabatier (Mem. de I'Institut. Sciences Phys. et Math.) but which Vigarous, the son, was
unacquainted with. 
468
NEW ELEMENTS OP OPERATIVE  SURGERY.
 8,8»\and anotner English army surgeon, (Ibid., No. 30.)  A portion of
 the head of the humerus and of the clavicle and  scapula were also re-
 moved by  Morel, (Medico-Chirurg.  Trans.,  Vol. VII., p. 161;) but
 this case might be placed under the head of examples of caries resulting
 from comminuted fractures, and nothing  shows that the  cases of MM.
 Willaume, Guthrie and Textor, (Jaeger,  Op. cit., p. 4,  No.  47,)  which
 last again performed this operation successfully in 1836,  (Communicated
 by M. Sprengler, 1838,) belong to exsection rather than to  extraction.
 In another case, related by M.  Baudens,  (Clinique des Plaies d'Armes-
 d-feu, p. 550, 1836,) where  the head of the humerus was fractured by
 a ball which remained  unextracted at the  bottom of the perforation,
 exsection having been performed,  the end of the body of the bone  was
 rasped and  rounded off, (arrondi,) as recommended by M. Reynaud.
   The case of Poret and Fayet is one of  fracture  from a fire-arm, with
 splinters and complete solution of continuity between the  head and body,
 followed by a diffused callus uniting  the two  parts and accompanied
 with caries.
   In cases of caries, exsection  of the humerus has been  performed by
 Lentin, (Jaeger, Op.  cit., p. 3, No. 2,) Bent, (Trans. Philosoph., Vol.
 LXIV., p. 353, 1774,) Orred, (Ibid., Vol. LXIX., part 1, art. 2, p. 6,
 London, 1780, for the first  case, and Medical Commentaries, &c., for
 the second ; the operation in both cases was performed in 1779,) Moreau,
 the father,  (Obs. Prat.  Relativ. d Res. des  Art. aff. de  Carie, by
 Moreau, the  son, p. 79, 1803, and  Essai  sur  la Risect.  des  Os, etc.,
 p. 10, by the same,) David, the father of Rouen, (lnutiliti de VAmputat.,
 etc., p. 55, Paris,  1830,) Porct  and Fayet,  (Briot,  De VEtat  et des
 Progres  de  la Chir.  Milit.  en France, p. 164,) Rossi, (Mid. Opir.,
 t. II., p. 233, 1806,)  Moreau, the  son, (Essai  sur la Resection, pp. 14,
 16, 27,) Textor (Jaeger,  Op. cit., p. 4, No. 5,) Syme,  (Ouvrage cite,
pp. 51, 52, 58,) Jaeger (Op. cit.,  p. 4, No. 51) and Fricke,  (Ibid., No.
53.)
  The  indications for  exsection of the head of the humerus are :—1,
 Comminuted  fractures with wound of the integuments; 2, partial frac-
 tures in the thickness  of the bone with contusion and wound;  3, com-
 plete fractures of the bone with wound, and leaving only the cartilaginous
 head for the upper fragment; 4, complete fractures of the head of the
 humerus below its neck, with contusion  and wound ; 5, fractures of the
 neck, with luxation of the head of the humerus unreduced, (Exsection
 proposed by Delpech, Chir. Clin., t. I., p. 242,) and becoming protruded ;
 6, necrosis;  7, caries and spina ventosa;  8, osteo-sarcoma;  and 9,
 exostoses.
   The process to be  adopted in this operation must necessarily  vary
 according to the morbid conditions.

                       § I. Process of White.

   When the greater portion of the surrounding tissues are sound, or the
 bones are crushed into fragments, we may, after the example of White,
 M. Larrey and M. Portet, confine  ourselves to one incision parallel with
 the fibres of the deltoid, reaching from the apex of the arcomion to four
 or five inches below, and which  penetrates down to the  articulation, as 
EXSECTION OR EXCISION OF THE  ARTICULATIONS.        469
 in the process of Poyet for the removal of the arm.   Then grasping the
 elbow with tho whole of the hand, White made use of this [purchase] to
 give pendular motions to the humerus from below upwards, and in order
 to luxate the head through the soft parts.

                                 §11.

   M.  Larrey causes the lips of this first incision to be held apart, opens
 into the fibrous  capsule, and then divides by means of a blunt-pointed
 bistoury conducted upon  the finger, the tendons of the supra-spinatus,
 infra-spinatus, sub-scapularis and teres minor muscles, in such manner as
 to  remove every difficulty in bringing the head  of  the humerus to the
 exterior.   When the operation is arrived to this point, a thick compress,
 or  some  protecting substance is glided between the neck of the bone
 and the integuments on the upper part of the arm, in order to saw the
 diseased portion, and thus exsect it.

                      $ III.—Process of Moreau.

   Moreau remarked with reason  that  the simple incision recommended
 by White, even  when  combined  with  the modification of M. Larrey,
 would, in a majority of cases, be found insufficient.   According to him,
 two incisions of four inches long, made, one on the anterior, the other on
 the posterior border of the arm, and united below the apex of the acro-
 mion by a transverse incision, would be infinitely preferable for forming
 a trapezoidal flap to be dissected and reversed upon its apex from above
 downwards or towards the insertion of the  deltoid.   By this means we
 lay bare all  the  anterior portion of the articulation.   Nothing then  is
 easier than the division of the capsule, and to bring  to the exterior the
 head as well as the upper portion of the humerus, in order to make their
 exsection.   The  flap, then raised up on the wound,  should be fastened
 above, and on the sides by a few points of suture.

                     § IV.—Process of Manne.

  Moreau's plan  for exsection of the  humerus is evidently easier than
that of White ; but the large flap which differs only  from the  deltoidal
flap of La  Faye, in being  dissected and reversed at its base instead of
detaching it  at  its apex, renders immediate  reunion difficult, exposes
to the formation of purulent openings, which ought  to be avoided, and
should be adopted with scrupulous fidelity.  It is better, in case the sur-
geon wishes  to have  a trapezoidal flap, to follow the advice of Manne,
that is, to  make two  lateral incisions, like Moreau,  then unite them at
their lower extremities, and dissect and raise up this  flap from its point
to its base, precisely  in fact as La Faye advises for amputation of the
arm at the  shoulder-joint.

                     § V.—Process of Sabatier.

  In place of adopting so many  precautions to preserve the soft parts,
Sabatier formally advises to  circumscribe the flap by  a large V incision, 
470           NEW ELEMENTS OF OPERATIVE  SURGERY.

with its base above upon the tissues of the  deltoid, then  to excise out
[that is, to cut out completely. T.] this triangle, in order to lay bare the
articular capsule.   It  is difficult  to comprehend  what should have in-
duced  Sabatier into such a  process, and why he should direct the re-
moval of the flap  in question  rather than to preserve it.   In restricting
ourselves merely to raising it up as M. Gauraud did in 1801, and as M.
Smith in America has also done, we may extract and exsect the bone with
case.
                      § VI.—Process of Bent.

  After having in vain endeavored to make trial of the process of White,
Bent, who was one  of the first  to perform the operation of exsection of
the humerus, believed it preferable to detach the fibres of the deltoid first
outwardly, near the acromion, and then on the inner side at the clavicle
and transversely, in such manner  as to form  a  T incision, which enabled
him to dissect two triangular  flaps—the one on the outside, the other on
the inside—whereby he could freely come down to the joint.

                    § VII.—Process of Morel.

  M. Morel, who was not satisfied with any of these methods, confined
himself  to the formation of a semilunar  flap,  with its convexity down-
wards upon the front of the shoulder.  The operation was long, but his
patient recovered.
                              § VIII

  M.  Syme, who has twice exsected the numerus successfully, cuts his
flap on the outer half of the deltoid, and gives it the form of "a triangle,
the anterior branch of  which corresponds to  the incision of White,
while the  other, which  is mucn  shorter, passes obliquely from below
upwards and backwards towards the  spine of the  scapula.   This sur-
geon, after having  raised up this  flap, brings  the elbow in front of the
thorax ; divides the capsule ; luxates the head of the humerus ;  excises
it;  brings down the flap, and proceeds to the dressing.

                   § IX.—Process of M. Robert.

  The modification proposed by M. Robert, consists in an incision which
sets outs from the anterior border of the clavicle, at two finders' breadth
from its outer extremity, and which is  then carried, in a direction par-
allel to  the  axis of the arm, to the  anterior part of the  stump of the
shoulder.   The bistoury being directed to the  middle of the acromio-
coracoid space, divides  transversely the ligament of the same name
and thus enables  us to arrive directly down  upon  the articulatiou!
Thus modified, the operation has the advantage of rendering  the  dis-
articulation more  easy, and also  of enabling us to avoid the circumflex
nerve.                           * x

   Finally, exsection of the humerus is performed by two  principal me-
thods, viz.: methods  or processes of  necessity, and those  of election.
A single vertical incision, placed  towards the outside, suffices for Vi<mr- 
EXSECTION OR EXCISION OP THE ARTICULATIONS.         471
ous, White,  Orred, MM.  Larrey,  Rossi,  Baudens,  (Clin,  des Plaies
d'Armes-d-Feu, p. 551,  le opere,) and  Thomas.  MM.  Robert  and
Malgaigne, who bring down this  incision from the apex  of  the coraco-
clayicular triangle, prefer placing it in front.  It is this incision in front
which  M. Baudens (Ibid., p. 555, 2c opere) transforms into a T,  by di-
viding the incision into the deltoid  muscle, to the extent of ten lines on
each side, without implicating the skin.  With him the vertical incision
commences  on the outside of the  coracoid process, and is continued
through the furrow, wliich divides the pectoralis major muscle from the
deltoid.
  A single angular flap, horizontal  or lateral and above or in front,  was
preferred by M. Neve, (unpublished  case, communicated by M. Cham-
pion,) on account of  the situation of  the wound  and the protrusion of
the lower fragment of the fracture.  M. Champion,  (Ibid.,) in another
case, cut a horizontal angular  flap above and behind, on account  of the
situation of the gun-shot wound.  The  incisions then represent a 7, or
nearly so, and implicate, by their  IWrizontal branch, the fibres  of the
upper  insertion of the deltoid.   The two angular flaps, with the  simple
 T incision, constitute the  process of Bent, while the two flaps resulting
from the T  inverted, or a species of anchor, represent  the  process of
Bromfield,  (Chir.   Observations  Sr Cases, Vol. I., p. 300, and plate 3,
1773.)  A  single vertical flap outside, pyramidal,  reversed, or in V,
comprises the  process  of Sabatier, and those of Briot, (Histoire de la
Progres de la Chirurgie  Militaire  en  France, p.  164, 1817,)  Poret,
Fayet, (Journal Mid. contin., t. XXII., p.  485,1811,)* Gouraud, Smith,
and Syme, (page 50 and planche 5, fig. I.)
  A single outer vertical flap, trapezoidal or quadrilateral, with its  base
downwards, characterizes the process of Moreau, the father, ( Observa-
tions Pratiques Relatives d la Resection, p. 79,) while this flap, in the
process of Moreau the  son, (Essai  sur VEmploi de la Resect., etc., p.
16,) has its base above.  If terminated  by a lower border, which is
rounded off or buckler-shaped, (en rondache,) it forms the  process of
Morel, (Medico-Chirurgical Transactions, vol. VIL, p. 161.)

                        § XI.—Appreciation.

  The diseases which  indicate exsection  of the humerus, are the same
as those for which disarticulation of the arm was formerly  performed;
consequently, the  different operative processes employed  for this  last
are  applicable to exsection.   Thus, in  place  of cutting out a flap by
three incisions, as La Faye did, it is much more simple to imitate Morel,
and to form it with a single incision, like  Dupuytren, or even to adopt
the process  of M. Onsenort.   It is, moreover, manifest that  exsection
differs from amputation of the arm at the  articulation, only in the  last
stage of the operation.
  A. We may, therefore, adopt  sometimes one process  and sometimes
another, according as it shall seem more easy to isolate the head  of the
humerus by penetrating from  above downwards, or from the outer to-

  *  Porct and Fayet, says M. Velpeau, whose names  are mis-spelt  by Briot and their case
misunderstood by M. Gourard, in reality exsected the upper extremity and  head of the hu-
merus, which had been fractured, and then become reunited by a defused callus. 
472            NEW ELEMENTS OF OPERATIVE SURGERY.
wards the inner side, or in any other manner, and according also as the
integuments and muscles shall be more or less altered in one direction
than in another.   M. Guthrie recommends that, in whatever manner the
operation is performed, we should remove as much of the articular cap-
sule as  possible, because, says  he, the more of this  fibrous pouch we
leave behind, the less chance will there be of obtaining a free, immediate
reunion.   This practice, though proper to be adopted in cases of ampu-
tation, is not  suitable  to  exsections, because, in these last cases, the
limb will have so much the better chance  of recovering its strength and
steadiness, (fixite,) in proportion to the greater  quantity of fibrous tis-
sues preserved.
  B. As soon as the extremity of the humerus is removed, we examine
into the condition of the acromion, the coracoid process, and the glenoid
cavity of the  scapula.  If these  different  parts are  not changed, we
proceed at once to the dressing ; in  the  contrary case, they arc  to be
removed with the cutting  pliers, the gouge, chisel, or saw, in the  man-
ner described for the removal of tm? arm ; that is to say, if the degene-
ration of the bones extends to a certain distance, it will become neces-
sary to prolong backwards, under the spine of the scapula and upon the
inner side of the coracoid process, the incisions  which circumscribe the
base of  the  flap, in order to lay bare the  whole  extent of the  diseased
parts.   It is known, also, that, in a  case  of  this kind, M. Larrey did
not hesitate to remove the three processes just mentioned, together with
the acromial extremity of the scapula.  M. H. Hunt adopted the same
course in a patient  in whom M. Brown  had already removed the  head
of the  humerus, in  1818.  It is also known  that this bold step was
crowned with complete success.
  C. Moreau  had  this excision of  the scapula in view, when he recom-
mended to reverse the deltoid from above downwards.   In that case noth-
ing would prevent our forming another flap in an opposite direction, which
would render the removal of  the processes of the scapula an easy  mat-
ter.  But as it will  always be possible if  we cut  the flap in the  manner
of La Faye  and Dupuytren, to preserve a sufficient degree of thickness
at its root to prevent its mortification, the motive which influenced Mo-
reau, is  not  of importance enough to permit us to adopt his  views.
  D. The exsection being terminated, we replace the  extremity of the
body of the humerus  into the wound, thus again giving  to  the arm its
natural  direction.   Whatever may be the form of the flap, the lips of
the wound  are to be accurately brought together, except  only at its
most depending  angle.   In order to keep the edges in contact we are
to apply to the root of the limb, pieces  of agaric, gateaux of lint, or
graduated  compresses.  A bandage  with separate bandelettes,  (vid.
Vol. I.,) cushions, splints, or better still the starch bandage, will main-
tain the wholo in such  manner as to enable us to dress the wound  as
often as we  judge it convenient to do so,  [See notes above  on the use
of the starch bandage, where the articulations are implicated.   T.]
  E. Some persons have imagined that the portion of the bone removed
might be reproduced.   In the case of Chaussier, (Mim. de la Soc Med.'
dyEmul., t.  III., p. 400,) it is seen that an osseous conical-shaped  mass
filled up the glenoid cavity, and ultimately it  is true, placed itself in re-
lation  with the upper extremity of the body of the humerus, which had 
           EXSECTION OR EXCISION OF THE  ARTICULATIONS.        473

become slightly excavated, and thus actually produced a new articula-
tion, and  enabled the arm to execute almost all its movements.   In one
of the cases related by Moreau, the upper part of the  humerus was
drawn to, and fixed against the chest, where a sort of accidental articu-
lation  was ultimately established.   But nothing in these two facts bears
any  resemblance to  a  reproduction of the bones, and most usually the
upper extremity of the  humerus remains  movable in the midst of the
muscular tissues.  In the patient of M. Yvan, (Arch.  Gin. de Mid.,  2e
ser., t.  XIX., p. 619,) or that of M. Cloquet, there was no osseous re-
production in front of the shoulder.  In the suggestion of M. H. Roux,
(Riv. Mid.,1835, t.  IV., p. 389,) that  we should excise (lie humerus
by  a curved section, so as to obtain a sort of head which can accommo-
date itself to the glenoid cavity, he has not reflected that the arm-bone
and scapula after the operation are no longer in contact.
  F. The patient, nevertheless, most usually retains the movements of
his fingers, hand and fore-arm.  He may even be enabled to raise the
whole limb to a certain  extent in all directions ; but it will not be possi-
ble for him to raise it either to a right angle to the trunk, or to separate
it to any considerable distance from the chest.  It remains therefore in-
firm, after  an operation of this kind ; but it is much better to have an
imperfect  limb, which can execute only a part of its functions, than to
have  none at all, and the last cases reported by  M.  Syme, conclusively
demonstrate, that the uses of the arm in these exsections, may sometimes
be almost completely re-established.

                               §  XII.

  This is an operation  moreover which exposes  to almost as many im-
mediate or consecutive  dangers as  disarticulation of  the  arm: the pa-
tient of Vigaroux died  from the effects of it.  Other fatal terminations
have been passed over in silence by authors.  De  la Touche, (Disserta-
tion sur VAmput. dans les Fractures des Articul., p. 34, Strasb., 1814,)
does not know what  was the result of the  case he speaks of.  Grosbois,
(Dissert, sur VAmput. du Bras dans VArticle, p. 34,1803,) is in the same
predicament.  The two  cases of Vernet, (Lettre Autographe de Vernet,
1816, Bayeux,) former surgeon in chief of  the armies, terminated fatally.
The three operated upon by Delpech died  between the sixth  and ninth
days, in consequence of spasmodic accidents.  Two also operated upon
by Legrand, (Dissert,  sur la Resection de la Tete de VHumerus, p.  9,
1814,) died  from tetanus.  Two also that were operated upon by sur-
geons of the  English army, likewise perished, (Jaeger, Op. cit., p. 41,
Nos. 40-41.)  M.  Baudens, (Gaz. Mid., t. VI., p. 425,1838,)  lost
one from secondary hemorrhage, and two from cholera, at the moment
when the cure was going on well.
  In a patient of Moreau, the father, (Essai sur  VEmploi de la Risec-
lion, par Moreau, fils, p. 18,) the caries after the  operation extended to
the body of the  bone.  In a case of Briot,  (Histoire de  VEtat de  la
Cfiir. Mil. en France, p. 164, 1817,) the caries was followed by a fistu-
la, the result of  which  is not known.   M. Jaeger, (Op. cit., p. 4, No.
52,) cites a case where amputation became necessary in consequence of
necrosis of the medullary canal.  In a case mentioned by Knox, (Edin-
  Vol.  II.                    60 
 474            NEW ELEMENTS OF OPERATIVE SURGERY.

 burgh Medical and Surgical  Journal, t. XVIIL, p. 62,) the condition
 of the parts after exsection had been performed, made it also necessary
 to have recourse to amputation.
  A surgeon who divided the brachial artery, during the operation, im-
 mediately resorted to amputation of the limb.  (This operation says M.
 Velpeau, was made in presence of a physician who communicated the
 fact to M. Champion.)  A case in which M. Roux, (Melang. de Chir.
 et de  Physiol., p. 240, 1809,) had  exsected  the  head of the humerus,
 and  rasped and cauterized  the glenoid  cavity, without reuniting the
 wound, also  ended fatally.   In the case mentioned  by M. Gouraud,
 (DemonstP. des Principes,  Oper. Chir., p. 178,) the operation was un-
 dertaken, when the patient was in a condition which should have deter-
 red the surgeon from  performing it.  One  of the  cases cured by M.
 Syme, (Ouvrage cite, p. 58,)  afterwards  died  of phthisis.   In the
 greater number of cases however, the cure has been complete, as in the
 case operated upon by M. Textor in 1836.  It seems just also to distin-
 guish the cases  of death consequent upon the operation,  from those that
 had no connection whatever with it.

                   Article VI.—The Clavicle.

  The clavicle, it is true, is  situated very superficially, but as it rests
 posteriorly and below against  organs, the wounding of which would be
 extremely dangerous, surgeons have scarcely dared  to undertake its
 exsection.  Nevertheless, circumstances may occur, and these frequent-
 ly, which  seem to demand  this operation, unless we wish to abandon
 the  patient to certain death.   Sometimes the disease is confined only to
 the  outer extremity of the clavicle, in other cases situated upon its ster-
nal extremity, or in its  middle  portion,  or it may even occupy the whole
 extent of the bone.
  The removal  of a sequestrum of  the diaphysis or body of the clavicle,
 and which was followed by regeneration or reproduction of the bone,
was performed by Moreau and  Dangerville, (Mim. de VAcad, de Chir.,
t. V., p. 361, in 4to ; t. XIV., p. 160, in 12mo,)  also by Bayes, (Brun,
 Mim. de VAcad, de Toulouse,  t. I., pi.  1, fig. 1, et 2. Lettre d'un Eleve
en Chirurg. de  VHotel-Dieu de Toulouse, 16 Aout, 1792, p. 16,)  Otto
de Weissenfels, (Gaz.  Mid. Nat. pour VAllemagne, No. 46, 1798,) and
by Pelletan, the father,  (Champion, Convers. d-V Hotel-Dieu, 1802,) who
 stated in 1802,  that he had extracted the clavicle  entire in a child in
 whom this bone was necrosed in consequence  of an abscess  supervening
 during small-pox, and which was then afterwards reproduced.
  [A large central portion of the clavicle which had been necrosed  from
 syphilis and  fractured into two portions, the  sternal fragment riding
 over the acromial, was successively exsected and extracted by its two
 fragments,  (the sternal  first,) by M. A.  Asson,  (see  Giornale des
 Progressi, August  1843, Arch.   Gin. de  Mid.,  Paris,  July, 1844
 D. 374-5-6.)   T.]
  Pezoldi, (Obs. Mid.  Chir., etc., C.  Pezoldi, p. 126,) who wrote in
 1715, thus speaks of a case of exsection of the clavicle : Necrosis, the
 consequence of  abscess ; incision ;  dilatation with a sponge ; the clavicle
 fractured  or separated on one side; exsection by  means of a cutting 
            EXSECTION  OR EXCISION OF THE  ARTICULATIONS.        475

 forceps, of the greatest portion of the bone ;  extraction of one or two
 splinters, six days after.   The child aged nine years, recovered perfectly,
 and could use its arm as before.   A reparation took place of the loss
 of substance,  (F.  Cosme D'Armbruste, in  Pezoldi, Obs.  Mid.-Chir.,
 etc., obs.  62,  p. 129,1715.)
   In the case  of Kulm, (De Exostosi Steatomode  Clavicular, Dantzick,
 1732,)  the osteo-steatoma or tumor, a foot in .length, four inches in
 breadth, and two feet in circumference, and  extending from the clavicle
 to the mamma on the same  side, weighed  five pounds.  Morgagni (De
 Sed. et  Caus.  Morb., epist.  L., § 58) speaks of an exostosis of the cla-
 vicle, which he declared could not be cured  without the intervention  of
 the saw, an operation which the feebleness of the little patient  was not
 able to sustain.
   The mode by which  this  bone should be  excised or extirpated, is a
 difficult matter to describe, seeing  that the  disease which  might make
 it necessary always causes  extensive alterations in the anatomical ar-
 rangment of the  surrounding parts.

                   § I.— The  Acromial Extremity.

   In 1828, in  the  case of a woman who had  been for a long time at-
 fected with necrosis in the outer  third of the clavicle, I first made a
 crucial incision, the two incisions composing which, were each about four
 inches in length.  After dissecting and reversing the flaps, keeping them
 apart, and dividing  the acromio-clavicular ligaments, and some bundles
 of fibres of the origins  of the  deltoid and trapezius muscles, I was
 enabled, by means of a piece of wood inserted into the articulation as a
 lever, to raise  up the diseased bone, and to detach it in this manner from
 the sound parts.   If it had  offered too much resistance, a hand-saw, or
 better still, a crested saw, would have sufficed to effect its exsection from
 above downwards, or from before  backwards.   Supposing  it should be
 buried too deep [to  do this,] it would be necessary  to isolate it carefully
 from the soft parts, in front and behind, and  then, to introduce under its
 lower surface a chain-saw, dividing the bone from behind forwards, and
 afterwards disarticulating and  removing it.
   If the skin  should not be ulcerated, nor even actually diseased, we
 might succeed equally well or even better, I  think,  by cutting a triangu-
 lar flap, by means  of an  incision parallel to the anterior border of the
 clavicle,  which incision  should be  prolonged as far as the apex of the
 acromion ; then another much shorter, which should fall at a right angle
 upon the outer  extremity of the first.  The flap being reversed backwards
 would lay bare the diseased bone completely, enable us to apply the saw
 upon the sound portion, and afterwards to detach the fragment by means
 of a strong pair of  forceps or the elevator.  It would also enable us to
excise the corresponding  border  of the acromion, should  the  disease
have extended to  that part.  The rowel saw, and M. Heine's osteotome,
or M. Liston's sector, should the patient be young,  would at the present
day render the division  of the clavicle in such cases a very easy matter.
M.  Roux informs me that he  has also, in one instance, performed this
operation, and with success. 
476
NEW ELEMENTS OF OPERATIVE SURGERY
                    § II.— The Sternal Extremity.

   Since M. Wurtzer (Jaager,  Op. cit., etc., p. 3) set the example, the
 exsection  of the inner extremity of the clavicle has been performed in
 a number of instances.   The  most curious  case we have of this kind,
 and which is anterior to that of Wurtzer, belongs to Davie, (S. Cooper,
 Diet, de Chir., t. II., p. 104.)   A deviation of the spine had depressed
 the head of the clavicle towards the oesophagus in such manner that the
 young girl could not swallow.  Davie made an incision of two  to three
 inches in length along the depressed bone, and then in order to exsect it,
 made use of the turning saw  of Scultetus.   An  incision in L, the short
 branch of which should ascend vertically from the sternum to the  trachea,
 would  answer better.  A triangular flap would result from this, which,
 being raised upon the neck, would lay bare the articulation with the in-
 ner third  or half of the clavicle, which should then be divided, and de-
 tached from without inwards.  This process would be of more easy ap-
 plication than the  preceding to  the sternal  half of the clavicle;  but
 whether it be at one extremity  or the other, the operation is rendered
 so much the more delicate and  dangerous, in proportion as the saw is to
 approximate  nearer to  the middle  portion of the bone, because of its
 neighborhood then to  the axillary vessels.

                         § III.—Extirpation.

  In the dead body the clavicle  is  extirpated without  difficulty.   An
incision parallel to  its cutaneous  border, and which  extends a little be-
yond its extremities, will  ordinarily answer for  this purpose.   Or  we
may make two other vertical  incisions of one to two  incisions in length,
one on the outside, the other  on the inside of  the first incision, the flap
resulting from which divisions, on being raised up, completely lays bare
the bone.   We then disarticulate  either the sternal or acromial  extrem-
ity, and grasp it with the left hand in order to raise it  up, while with
 the right,  we detach  with the bistoury the  adhesions upon  its lower
border.  We might also saw the bone  through its  middle, and remove
 the two halves separately.  When the bone is in  a state of disease, this
 operation must be one of the most difficult in  surgery.   Notwithstand-
 ing which, it was performed  with entire  success by M. Mott, on  tho
 17th of June, 1827, for osteo-sarcoma in a young man aged  nineteen
 years.
   The tumor was double the  size of the fist,  and extended in one di-
 rection to near the angle of the lower  jaw and os hyoides, and in the
 other to the stump of the shoulder and the sterno-clavicular articulation.
 The author in his letter to me,  September 2d, 1838,  says : " It is  the
 most important and most difficult of all the operations I have ever per-
 formed."   More than forty ligatures had  to  be applied before it was
 finished.                            ...
   M. Mott commenced by a semilunar incision with  its convexity down-
 wards, and extending from one extremity of the clavicle to the other, as
 if to detach the tumor from below upwards; he then made a second in-
 cision above, reaching from the acromion to the  external jugular vein, 
           EXSECTION OR EXCISION OF  THE ARTICULATION3.        477

divided the platysma myoides and a portion of the trapezius, introduced
a grooved director, and then,  by means of an eyed probe, passed the
chain-saw under the clavicle, and divided it a little nearer the acromion
than the coracoid process.
  Being still unable to turn back the morbid mass, the operator united,
by a third incision, the sternal extremity of the  first  with the second,
tied the external jugular at two points, and divided the vessel on the
internal, divided also, the  outer  portion  of the sterno-mastoid muscle
at two inches above its origin, and  turned it down upon the sternum;
was then enabled to push aside  the omo-hyoideus  muscle upwards and
backwards, and was obliged to tie and divide also  the internal jugular,
and to separate, with great difficulty, by means  of cuts of  the bistoury
or the handle of a scalpel, the subclavian vein,  and even the thoracic
duct from the degenerated tissues ; numerous branches, coming, doubt-
less,  from the inferior  thyroid, transverse  cervical, supra-scapularis,
acromial,  and other arteries, were also tied  in  succession as they were
divided.
  A last  incision, the utility of which  I cannot  well understand, and
which sat out from the first, was made in the track of the fourth rib, in
order to divide the fibres of the pectoralis major  muscles.   After hav-
ing divided  the costo-clavicular  ligament and the  sub-clavius  muscle,
M. Mott was finally enabled to remove the whole tumor, and  to  finish
the operation by disarticulating the sternal extremity of the clavicle.
   The wound was filled with  lint, after which, long strips  of  adhesive
plaster maintained its edges as closely approximated as possible.   No
serious accident  supervened.   The  cure was nearly completed by the
end of July, and by means of an appropriate apparatus, which  in some
measure replaces the clavicle, the patient retains almost all the uses of
his arm.
   As an operation of this description ought not to  be  undertaken  ex-
cept by surgeons of consummate ability, it is unnecessary,  as I think,
to enter into any detail in order to show in what particulars  the pro-
cess of M. Mott  might be advantageously modified.  Any  person may
comprehend this matter without difficulty, by recalling to mind the ana-
tomical  relations of  the region affected, and will thus be enabled to
conform himself to the special exigencies of the case.  Thus, Beauchene,
who was obliged to remove a great portion of this bone and  the remain-
der of the shoulder, deemed  it advisable to adopt  other incisions than
those of M.  Mott.  Kulm, (These,  Chir. de Haller, trad., t. III.) who
appears to have also made the extraction [l'extraction—see note a little
farther back. T.]  of the clavicle, at the beginning of the last century,
equally found himself under the necessity of adopting a process for him-
self.   I do not  see, moreover, why  the  ligature en masse,  so much ex-
tolled by M. Mayor,  might not then be  advantageously had recourse to
by the surgeon, as soon as he has found that the  hemorrhage cannot be
prevented without a great deal of difficulty.
   The patient in whom M. Warren, (On Tumors, Ac, p. 148,) had re-
moved the clavicle by means of a crucial incision, died a month after.
M. Travers, (Journ. des Connaiss.  Mid.,  1838,  p. 181,) on the con-
trary, who, in a  young  girl, aged ten years, extirpated the clavicle en-
tire with the exception of its sternal head, states that he  effected the 
478
NEW ELEMENTS OF  OPERATIVE SURGERY.
 cure of his patient.  M. Roux, who  also performed  the same operation,
 leaving behind only the inner extremity of the bone, informs me that he
 was equally  fortunate.   In conclusion, it would  seem, upon the whole,
 that the quadrangular  flap which I  have spoken of, would render the
 operation easier than by the different incisions of M. Mott.
   [The clavicle has been  removed,  either entirely, or in  part, by the
 following named surgeons, who are  not  mentioned in the text:  viz :
 McCreary, Mussey, .McLellan, Mutter, Syme,  Bartlett, Cuming,  Roux,
 Meyer, Chauraet, Regnoli, Liston, Fergusson, Rigaud, Gilbert, Wed-
 derburn, and Sedillot.   G. C. B.]

                         Article I.—Foot.

   Having treated of exsection of the  body of the  bones  of the foot in
 another article, I will not re-enter into the details of this subject; for
 so much the greater reason, that it is  subjected  to the same  rules as those
 of the bones of the hand.   1 will add only a few words on their extrac-
 tion, and on the excision of their head.
   Already, in the Encyclopedie Chirurgicale, (Encyclop. Meth., part.
 Chir., t. I., p. 107,) on  the subject of caries of the  bones of the foot,
 we read this remarkable passage : " It ought to be laid down, as a gene-
 ral rule, that we should  never amputate any parts except those that are
in a state of disease, even if there should  remain but two sound bones in
the whole foot; for, by  means of a shoe, properly arranged and with a
strong sole, a very small part of the foot may become exceedingly useful,
especially where it is the bones of the inner side which remain; that is
to say, those which correspond to the great toe, and those  which are the
nearest to these.
  " If the disease is situated in  the middle of the foot, and the bones
of the metatarsus  on each  side are  in a sound state,  (bon  etat,) these
are not to be  touched; we must confine ourselves to removing the bones
affected, separating them at their articulations,  whether they  be  diseased
throughout their  substance, or only in one  portion  of  it; for though it
might not be impossible to contrive instruments  by which we mio-ht cut
through a single bone in the middle of the foot, this operation would be
much longer and much more painful than  the incision of a  bone made in
its articulations, (jointures ;)  there  would not, moreover, be any great
 advantage to  hope for in preserving only  one of its extremities.   But
 when there are one, or two, or three  bones affected on either side of the
 foot, as it is inadvisable  to save as much of this organ as possible  we
 must endeavor to saw the bones in a  sound  portion, and as near as  pos-
 sible to the part diseased."  Here have we clearly the whole  doctrine
 of the moderns.

                    \ I.—The First Metatarsal.

   *. lady, in  the year 1761, attacked with caries in the first bone of the
 metatarsus, lost by  piecemeal  the whole of this bone, except the poste-
 rior epiphysis, which remained.  There was no reproduction ; the action
 of the muscles brought the phalanx  towards the  epiphysis,  but the pa-
 tient limped as much after as before the cure.  This  circumstance in- 
            EXSECTION OR EXCISION  OF THE ARTICULATIONS.        479

duced Lalouette (Tr. du Scrophule, t. II., p.  20 et 36) to place a blade
of steel  in  the  sole (entre les semelles) of this lady's shoe;  this was
done  so  successfully that she was enabled to walk as firmly upon this
foot as  upon the other.  M. Larrey (Clin.  Chir., t. III., p. 476) had
an idea similar to this, since he  proposed to remedy the void left in the
foot of a hussar, by means of an elastic sole.  Complete luxation of the
first metatarsal bone, separated from the first cuneiform bone and placed
perpendicularly, rendered its extirpation in another case more easy than
in that  of  M. Barbier.   M. Bell (Cours de Chir., t. V., p. 314) per-
formed this extirpation for case of exostosis or osteosteatoma.   M. Ar-
bey  Coup-d'CEil sur VAmput.  des  Membres, etc.,  p.  11-12, Strasb.,
1805) states that, having removed the  first metacarpal bone  in a state
of caries, there resulted  from it a proportional shortening of the finger,
at the root of which nothing was perceived  but a slight cicatrix.
  The disarticulation  of the first bone of the metatarsus was also per-
formed by M. Barbier, in the year 1795.  Not being able to reduce itslux-
ation, this surgeon decided upon removing it, while preserving at the same
time,  the great toe.  Beaufils, (Mim.  de la Soc Mid. d'Emul., t. X.,
p. 218,)  who published the case in 1797, says the patient was complete-
ly cured  at the expiration of forty days.  M. Petrequin also (Gaz. Mid.
de Paris, 1837, p. 36,) says that Monro had already performed the same
operation successfully for caries.   M. Blandin (Biblioth. Mid., 1827, t.
I., p.  458) has been no less fortunate since.  A young man, upon whom
I operated in this manner in 1833, at the hospital of La Pitie, also reco-
vered perfectly.   The case of M. Lisfranc (Petrequin, Gaz. Mid., 1837,
p. 36) had an exostosis only, and the angioleucite and abscesses which
supervened, did  not prevent his recovery.
  It appears to me, however, that  we deceive ourselves upon  this sub-
ject ;  after  the  extraction of the first metatarsal bone, the deformity in
reality is greater than  after its  simple amputation ; the toe is liable to
be turned inwards, and to change its position and interfere with  the uses
of the foot.   Drawn  backwards by the cicatrix, and supported only on
merely soft  parts, it  floats about like an inert appendage, incapable of
any use in standing.   On the other hand, it is incorrect to say that ordi-
nary  amputation is habitually followed by  reversion of the foot.  It is
an accident  which doubtless may be met with, but very often  does not
happen.  Authors abound in facts in support of this proposition.   The
first evidence I had of it was in 1829, at the hospital of Saint-Antoine.
I amputated in  the usual way ; the patient was cured promptly; I have
seen him many times since his recovery; he walks continually, and does
not even take the pains to support his shoe on its inner side.   I have
since  seen two other instances at La Pitie and five at La Charite.  The
same result  took place in the patient of M. Philips, (Bull, de la Soc. de
Gand, t. II., 229.)   Therefore, it would be  prudent  to wait for more
facts,  before  asserting that the   extraction  of the first metatarsal bone
ought to be preferred to its amputation. This operation, moreover, ap-
pears  to  have been clearly pointed  out by Hey, of Leeds: " When the
caries is limited  to the metatarsal bone of the great toe, it is usual, says
this practitioner, after making a longitudinal and then a transverse  in-
cision, to remove its diseased portion with the saw.  But as it is some-
times  difficult to recognize exactly the extent of the caries, I  think it 
480
NEW ELEMENTS OF OPERATIVE SURGERY.
 more advantageous to separate the totalitv of the bone at its articula-
 tion with the first cuneiform bone."   If the"evulsion of the bones of the
 metacarpus  has met with general approval, it is because, in preserving
 the fingers,  it alters but in a very slight degree the form and important
 uses of the hand; while in the foot we cannot count on the same advan-
 tages, nor on  the same results.  We should operate, moreover, by the
 same  processes, unless  some  complication should  force us to adopt the
 course of M. Barbier.   At present, also, the process has many modifi-
 cations.   We either excise or disarticulate this bone.
  _ The disarticulation  of the  first bone of the metatarsus  is sufficiently
 difficult.   By the ordinary process,  we make an incision into  the soft
 parts extending from the scaphoid tone to tlie dorsum of  the first pha-
 lanx of the great toe, which we in  the first  place  disarticulate.   Then
 causing the lips of the wound to be separated and the extensor tendon to be
 pushed aside, the surgeon detaches, draws  towards  him, luxates and
 raises the head of the bone, isolates  it upon  its sides by means of the
 bistoury, and finally separates it from the first cuneiform  bone behind.
 For  myself, I have found it more  convenient, after the  first incision is
 made, to divide the bone in the middle by the chain-saw, and afterwards
 to extract its two halves separately.   In whatever way it is done, there
 will  be left a  considerable void which the cicatrix never  completely fills
 up.  No reproduction need be  hoped for ;  hence the  extreme  mobility
 of the toe which has been preserved.
  Excision has not this inconvenience.  If it is made only in the body
 of the bone,  as in the  patient of M. McFarlan, (Arch.  Gin. de Mid.,
 3e serie,) there  is a chance that the void (echancrure) may be  filled
 up.  In the supposition  that it may be  necessary to remove also its an-
 terior extremity, the operation besides being much  easier, would enable
 the toe to obtain ultimately a point d'appui behind.  The extirpation of
the entire metatarso-phalangeal articulation which  has  been  performed
several times  successfully by M. Fricke, (Ibid., 1837, t. II.,p. 187—208,)
would still be preferable to  the total removal of the  first bone of the
metatarsus.
  A  quadrilateral flap with its  base  posteriorly, was  first proposed by
M. Blandin for these  cases.   It would seem also that a 1-3 incision placed
horizontally and looking forwards (couche en avant) had been preferred
 by M. Roux, (Journ. Hebd., t. II., p. 357.)   Flaps cut in the form of
 folding doors of windows hh (en battants de fenetre,)  which were disap-
 proved of on  account of the queue (see Vol. I.—incisions) by M. Syme,
 and  employed in 1813 and 1814 by  M. Champion (These de 1815, No.
 11, p. 94, Obs. 24) in two cases of extirpation of the fifth metatarsal bone,
 can neither wound nor destroy any of the muscles here.   A single quadri-
 lateral flap with its base above or even below, would be better nourished
 than the flap  with its base posteriorly, of MM. Blandin (Paris, These de
 Paris, 1829,  No. 162, p. 17) and Jobert.  In consequence of the altera-
 tion and  adhesions of the soft  parts  which covered the body of the me-
 tacarpal  bone, M. Barbottin made an ovalar incision  from  which he
 extirpated the flap.   But the window-door flaps, (see a few lines above,)
 properly extended, and which offer precisely the most liberty at the  very
 spot where we have  to lay bare  the articulations,  have the  advantage 
           EXSECTION OR EXCISION OP THE ARTICULATIONS.        481

also of ensuring the nutrition of the skin  better than the quadrilateral
flap.  Both kinds, however, may be useful.
  Though  some  practitioners commence  with  the disarticulation, M.
Roux on the  contrary has preferred sawing at first the first metacarpal
bone in its body by means of Aitken's saw.  It is evident that we mani-
pulate better around this bone when it is movable, [See notes  above in
reference to this principle of M. Chassaignac's  exsections—also the
abrege of his  memoir  below. T.]   " I also,  says M. Champion, should
prefer this mode  of procedure for any  one who  is in the habit of using
the chain-saw," but in the contrary case, and  when we reflect with  what
readiness this instrument catches, I think we should do better to use the
small cultelaire saw, or one of the known osteotomes,  and  which could
be worked without any preliminary practice.  M. Kramer (Jaeger, (Eubvr.
cit., p. ll, No. 1) exsected the anterior extremity of the first metatar-
sal bone in 1826, for a compound dislocation.  M. Josse (Mel. de Chir.,
p. 352,  1835) speaks of a case  in which the luxated head of the first
metatarsal bone was exsected, and the movements of the great toe  after
the cure were preserved.   This excision also must have been successfully
performed in the  following case related by M. Cruveilhier, (Arch.  Gin.
de Mid.,t. IV., p.  163.)   An internal sequestrum was found in a dead
body  in the anterior extremity of the first metatarsal bone, which bone
was of double its natural size.   Almost the  whole of  the bone was ne-
crosed and mobile, in a shell of thin walls, shut up by the most superficial
layer of the compact tissue.   The cartilage was  sound.
   M. Blandin, (Nouv.  Bibl.  Mid., Janvier 1828,) who in one case ex-
sected the anterior half of this bone for a spina ventosa, in another case
removed  the three anterior fourths of  it,  (Journ. Hebd. Mid., 18  Octo-
bre, 1828, p.  75,)  being an inch and a half in length, while M. Jobert,
(see  Lancette, t. V., No.  119, 28 Fevrier, 1832,  for both these cases,)
has removed  the anterior  half for caries.  M. Roux informs me that he
has performed this operation three  times with success.  In  a case of
caries of the first metatarsal bone, Heister (Instil.  Chir., liv. V.,ch. 9)
exsected only the middle and posterior portion which were the only por-
tions  found affected.  M. Graefe (Jasger, (Euvr. cit., p. 20, No. 1) also
in the year 1828, removed  a portion of the first metatarsal.  M. Fricke,
(Guernet, Arch.  Gen.  de Med., 1837) who  states that he succeeded in
exsecting the  whole metatarso-phalangeal articulation of the great toe,
appears  to have been no less fortunate  in removing the phalangeal articu-
lation of the same member in another case ! M. Champion ( These, p.  93,
1815) has twice exsected  the posterior extremity of the first phalanx
of the great toe, in a state of caries,  and in both  instances the patients
recovered perfectly.

                    § II.—Bones  of the  Tarsus.

   Horstius speaks of a case in which a portion of  the bones of the foot,
of three fingers'  breadth in dimensions, was extracted, and  in which
the patient nevertheless was  enabled  to walk without  limping.   De la
Motte (Trail'e  de Chir., obs. 264) also extracted with success what re-
mained of the third cuneiform bone, after it had been crushed by a ball.
A Captain Franckenburg  received a gun-shot wound  in the foot; Bil-
   Vol.  II.                  61 
482
NEW ELEMENTS OF OPERATIVE  SURGERY.
 guer  (De VInutiliti de VAmput. des Membres, p. 124, § 136) took out
 nearly all  the bones of his foot, and  then brought into coaptation the
 two portions that remained.  The operation was so successful that this
 officer was enabled  to walk and to resume his duties by means of a heel
 of  double  the usual thickness!  Saviard, (Observ.  Chirurg., etc.,)
 who removed a cuneiform bone and  some  fragments in a case of necro-
 sis, was  imitated by De la Motte, who with like success extracted the
 second and third cuneiform bones, and  the fifth metatarsal, which were
 also necrosed.
   M.  A. Severin, (Mid  Efficace, §  2129, p. 579,) who in the year 1646,
 extracted carious portions of the  astragalus,  os  calcis, and  scaphoid
 bone, with  a knife heated  to read heat, say3 ho left  in  this manner a
 hollow sinus around the malleolus, which resembled the mouth of a wolf,
 but that nevertheless his patient got well.  A scrofulous caries, which
 a student of law had been affected with  for a long time, resisted every
 kind of remedy,  both internal and  external, and even the repeated ap
 plication of fire.  A. Didier  (Disc. Prilim. sur la Chir. Prat. p.  2S,)
 removed the whole  of the caries by means of the  gouge acted upon by
 repeated slight strokes  of the hammer, and the wound  cicatrized in a
 month.
   Pezoldi  (Observations  Medico-Chirurgicales,  observat.  70, p.  175,
 Vratislaviae, 1715, in 12mo) speaks of an operation performed by F. C.
 D'Armbruste, a  celebrated surgeon of Breslaw.   A little girl,  aged
 twelve, had had for five  years  an ulcer situated  upon the left  foot.
 Twenty-seven bones of greater or less  size were extirpated from the
 middle and outer portion of the  tarsus.  There remained only those
 which were connected with the  great toe, and the operation was  per-
■ formed with the customary skill  of this  surgeon.  A poor child,  aged
 nine  years, who had been affected a long time with swellings of the
 joints, and whose sufferings were such as to make her wish for death to
 put an end to them, was operated upon, and cured in the same manner,
 by the same  practitioner.   In another case, in spite of the existence of
 an ulcer, with caries of the great too of the right foot, and much other
 disease in the left  foot,  Armbruste,  (Ibid., obs. 89, p. 187,)  who is
 known also under the name of Frere Cosme, did not despair of success.
 Dilating the narrow fistulas (ulcjres)  of  the left foot  by means of gen-
 tian,  sponge, or  incisions,  he  attacked  the carious bones with the rasp
 or red hot  iron,  or removed the whole of them completely.   The opera-
 tion being  terminated, he  filled the cavity with plumasseaux, saturated
 with  a particular remedy.   The  patient was put  upon the use of  anti-
 scorbutics, and got  well in a  few weeks.
    De Housse, (VEsprit des  Journaux, Fevrier, 1775, t. IL, p.  351, in
  12mo,) a  surgeon  of  Liege, relates a no less curious  fact.  M.  * * *,
  aged  thirty-six  years, sprained his foot when fourteen years of  age ;
  having been improperly treated, the injured part suppurated repeatedly.
  Dilating the ulcerous openings into one wound, by cutting through the
  bridges which united them, and then laying bare a portion of the bones
  De Housse was  enabled to take away in succession the three cuneiform
  bones.  In order to remove  the cuboid  bone, he enlarged  the  wound
  near the tendo Achillis, and divided the  peroneus longus muscle.  Two
  days after he removed  the scaphoid  bone.  All  these  bones could be 
            EXSECTION OR EXCISION OP THE  ARTICULATIONS.        483

identified, and were black and cragged in their appearance, as if rotten.
The void left by their extraction, and by that of some portions of the
neighboring bones was so considerable, that De Housse made a counter
opening ou the inner side of the foot, to do which nothing more was neces-
sary than to puncture through the skin.  In a very short time this void
was filled with' sound flesh, and the cure was complete at the end of two
months.  The cicatrix was firm and deep.   The patient was enabled to
walk without  anything to assist  him, and  without being fatigued, tho
distance of ten leagues !  Moreau, the  father, (Essai sur V Emploi de
la Resection des Os, p. 109,) in  1788, extirpated the  cuboid, the third
cuneiform, the  posterior extremity of the  fourth  metatarsal,  the inner
side of the  same  extremity of the fifth, and  the articular surface  by
which the os calcis is united to the cuboid.
   Dunn, (S. Cooper, Diet, de Chir., t. I., p. 96,  col. 2,) in a case  in
which he extirpated several  bones from the tarsus, and also the upper
portion of the astragalus, had a hemorrhage come on so abundant  that
he found it  difficult to arrest it.   There is a case of Durand, (La  The-
orie du Chir., t. II.,) of a patient, aged  sixteen years, who in the  year
1745, while sliding, injured the  foot in such manner as to lead to the
supposition  that  the  fibula was dislocated.  Abscesses formed, and  on
opening, left fistulas; the foot was so swollen and round as to resemble
a ball; while  the leg and thigh  became atrophied.   Durand, after as-
certaining the existence of caries  of the os calcis, astragalus and cuboid
bone, made  two incisions, dilated  the fistulous  openings into  one wound,
laid bare the diseased  bones and instantly removed  to the number  of
about ten fragments, which were entirely separated.  The swelling sub-
sided ;  twenty-one cauterizations  with the red hot iron were now had
recourse to, and the whole number of pieces  of bone that were taken
away,  amounted  finally  to  37.   The  patient  enlisted, and served  13
years,  dating from the year 1751, his foot and leg not differing appa-
rently  from the  other limb.  M. Liston, in 1821, (Jasger,  Op. cit., p.
26, No. 3,)  removed the astragalus, scaphoid and  two  cuneiform bones,
together with  the internal malleolus at  the same time, and M. Arbey
(Coup-d?' (Eil sur VAmp. des  Membres, p. 11, 1805;   These de Stras-
bourg) says that in 1805, he was an eye-witness to the extirpation of
the cuboid, and  third  cuneiform  bone.   The extirpation of the  cuboid,
and of a part of the neighboring  bones was made by M. Syme,  ( Trea-
tise on the Excision of Diseased  Joints, ch. IX.,  p. 143.)  M. Malvani,
(Gaz. Mid., p. 314, No. 24, 1838,) after extirpating  the  two last cu-
neiform bones, had recourse to repeated use of the hot iron to the sca-
phoid,  and cured his patient, a child, aged twelve years.  M. Champion,
(communicated by the author,) after having extirpated the cuboid, sca-
phoid,  and three cuneiform bones, and the tarsal extremity of the third,
and also of the fourth and fifth bones of the metatarsus, found the caries
re-appearing in the other bones before cicatrization took place.   A sim-
ilar case, which has  not been published, occurred in the  practice  of
Moreau, the son.   The case in which M. Liston, in 1832, removed tho
os naviculare, two cuneiform  bones, and  the upper surface of the astra-
galus, did not  succeed.   Jasger (Jaeger, p.  26) also has extirpated the
astragalus and scaphoid bone.
  The cuboid scaphoid and great cuneiform bones, should they be alter- 
484
NEW ELEMENTS OF  OPERATIVE SURGERY.
 ed to such extent that they could not be preserved, might be separately
 removed, as for example in a case of dislocation, complicated with caries
 and rottenness, or with necrosis.   M. Moreau in this manner was enabled
 to save the greater part  of the foot to one of his patients, by confining
 himself to the removal of the  cuboid bone, the third  cuneiform, a part
 of the os calcis, and the posterior half of the fifth  metatarsal bone.  It
 was thus, also, that in the year 1636, Heurnius (Patrix, Lancette Fran-
 gaise, t. IV., p. 88) extracted with perfect success the cuboid and third
 cuneiform bones, and it is in this manner we ought to proceed, in reality,
 wherever the disease is found to be perfectly circumscribed, and we are
 certain of removing it totally without being obliged to sacrifice the other
 portions of  the foot.  But here also  there are no precepts that can be
 laid  down.  The enlightened surgeon will always know how to regulate
 his conduct by the circumstances  in which he is placed, and to select the
 process which is best adapted to each particular case, while he will  not
 forget also that these partial amputations are not unattended with  danger,
 and  that they are often followed by consequences more formidable than
 actual amputation of the foot or leg.
   Now that we possess rowel saws, flat or mushroon-shaped, we  can ex-
 cise  these bones with less danger than if it were necessary to disarticu-
 late  them.  By means of a T  incision,  whose horizontal branch  was
 placed on  the outer border of the foot, I was enabled with the mushroon-
 shaped rowel saw to lay bare and remove almost the whole of the cuboid
 bone and the posterior extremity of the fifth metatarsal bone, in the case
 of a young  man  (Petrequin, Gaz. Mid., 1837, p. 36) who recovered
 with scarce any deformity remaining.
   Os Calcis.—I shall be obliged for other matters appertaining to this
subject, to refer to the chapter on  Articular Exsections.   The  subject
of amputation of the  projecting portion  of the os calcis, which  I have
performed six or seven times successfully, will have to be resumed upon
that  occasion.

                         §  II.—Astragalus.

  The extraction of a portion of  the astragalus, dislocated and  with or
without fracture, and either  necrosed or retaining its vitality, has been
performed by Duverney, (Traiti des Malad. des Os, p. 458, t. II., Obs.
8 ;) while this  bone in another patient exfoliated  almost  entire, yet he
could walk with this  leg  as with the other, though it was anchylosed.
 In the case of Aubray (Anc Jour, de Mid., t. XXXVI., p.  361, 1771)
the astragalus was extracted on the first day of the fracture and luxa-
 tion  ; and in that of Rumsey  (Dislocations and  Fractures,  etc., by
 Astley Cooper, p. 230) the loss of the greater  portion of its  body  did
 not prevent  the almost entire restoration of the movements of the foot.
 Charley (Pract. Obs. in Surgery, by Hey of Leeds, p. 386) succeeded
 in a  case in which the extraction  of the body of this  bone  which  had
 been luxated and fractured, was not made till the twelfth day after  the
 accident.   In a case of unreduced luxation, Hey (Ibid )proposed exsec-
 tion  ; the patient refused ; gradual exfoliation of the protruded  portion
 of the  astragalus, in  small fragments, then followed.  In a patient of
 Battley (A. Cooper, (Euvr.  Chir., etc., p. 202) a portion  of the astra- 
EXSECTION OR  EXCISION  OF THE ARTICULATIONS.        485
 galus which had been fractured in its position (sur place) was extracted
 through the  accidental wound.  Lynn (Ibid.) saw a case in which the
 astragalus exfoliated in two  portions with  an interval of six  weeks.
 Trye, (H&f, (Euvr. cit.,  p. 383,) in the case of Madame  Palmers in
 1789,)  in which the astragalus was luxated, complicated with laceration,
 and irreducible, exsected  it with very little difficulty.
   The successful cases of extraction or removal of the dislocated astra-
 galus are moreover numerous and of various kinds.  Fabricius of Hilden,
 (Opera, p. 140, Obs. 67,  cent. 2, t. I.,) published a case of  this kind in
 1582.   This operation has been performed since by Vonder Broille ( Ges-
 chite und Versuche einer chirurgischen Privalgesellschaft, etc.) in 1773,
 also by Marrigue (Diss, swr les Fract., par Michault de Versailles, p. 55,
 1782,)  Ferrand, Mauduyt, (Mid. Eclairie, par Fourcroy, t. II., p. 63,
 1791,)  Laumonier, (Ibid., p. 60,) and Desault, (twice,) and who also
 saw other cases ; by Boyer, Hey, (Practical Observ. in Surgery, p. 383,)
 Collin,  (Journ. de Mid cont., t. XVII., p. 438,) Percy, (Operatio Re-
 seclionis Conspectu, etc.,  Jaeger, p.  25, No.  12,) Despault (Journ.  de
 Mid. cont., Dec, 1812, p. 388 ; et Bull,  de la Fac  de Mid., Paris, t.
 III., p.  238,) Daniel,  (Journ.  Gin. de Mid., t. XLIV., p.  293,) and
 Evans (Practical  Observations, &c, 1815 ;  and S. Cooper, (Diet,  de
 Chir., t. II. p.  127-128 ;  by Dupuytren, the  third of April, 1818, on a
 woman, the nature of whose injury was unknown during the first days ;
 by M. Roux  the 20th of  September,  1817, and again by him a second
 time (communicated by the author;) also by M. Larrey, (Jaeger,  Ouvr.
 citi, p. 25, No.  16,)  Dufaure, (Journ. de Mid., continui,  t. XXII.,
 p. 348,) West, (A  Treatise on Dislocation and Fractures of the Joints,
 p. 263,) and  A. Cooper, (A. Cooper, Ibid., p. 268.)
   Many other  surgeons also have performed the evulsion of the astra-
galus, and by this means  preserved to the patient the uses of his foot
 and  leg.   Additional examples are related  by Dupuytren,  (Journ. de
 Mid., 1812 ; Bull, de la Fac, t. III., p. 238 fthis case, says M. Vel-
 peau, as well as that of Despault, belong to De Cugnieres,) by  Follot,
 (Arch.  Gin. de  Med., t. XVIII., p. 462#;  t. XX., p. 293,) Dassit,
 (Bulletin de  Firussac, t.  VIII., p. 325,) and De Cugnieres.   In a ca^e
 operated upon  by M. A. H. Stevens,  (Medical  aud  Physical Journal,
 Vol. V.,) in 1826, the tibio-tarsal  articulation continued movable, and
 the limb scarcely deformed.  But the cases are rare, except after luxa-
 tions with  laceration of the soft parts, that such an operation is either
 indicated or practicable.
   As the state of the  parts after the wound, is scarcely ever the same
in two different persons, it is impossible to lay down  any fixed rules to
be followed for the process.   We  dilate  the  wound sometimes in one
direction, sometimes in another, according as the exigencies  of the case
require, taking  care, however, to divide the tendons no more than is
absolutely  required, and  to operate before the  constitutional reaction
has had time to set in, and as soon as possible after the accident.
   This operation  has  been performed also by MM. Barbieux brothers,
(Journ. Complem. du Diet, des Sc. Mid., t. IX., p. 285,1821,) Weber,
 (Jaeger, p. 26, No, 23,) Lochmann, (Bull de  Firussac, t. II., p. 333,)
Champion, (unpublished—communicated by the author,) and  Cloquet,
 (Jaeger, Ouv. cit., p. 26, No. 26.)   In the cases mentioned by G. Nor- 
 486            NEW  ELEMENTS OF OPERATIVE  SURGERY.

 man  (A. Cooper, Ouv. cit., p. 252) and M. Green, Illustrations of some
 of the  Injuries to which the Lower  limb is exposed, p.  30, 1802,) the
 extraction of  the astragalus, performed  in  consequence of  luxation,
 appears to have been  followed by retraction of the tendo Achillis or a
 pes equinus.                                              *
   The extraction or excision of  the astragalus in a state of caries, but
 still in its natural  position in respect to the leg and foot, has been per-
 formed, 1st, by Moreau, the father, (Essai sur  VEmploi de la Resection,
 par Moreau, fils, p. 89,) who removed the superior articular surface, and
 a great portion of the  body, by means  of the gouge; 2d, by Moreau,
 the son,  (Ibid., p.  93,) who removed it entire with the gouge,  the pres-
 ence of a sound fibula  preventing him  from luxating the foot;  3d, by
 M. Champion, (unpublished case, communicated  by  the  author,)  who
 extirpated the entire tibial portion with  the saw ; 4th, by the same sur-
 geon after excision of the fibula and tibia, (Ibid.)
   In a patient of Desault, who died two  months after  the operation,
 of hospital fever, the tibia was found in  a state of almost complete con-
 solidation with the os  calcis.  In a case of Hey,  (Pract. Observations
 in Surgery, p. 383,) the patient at first  did very well; but being asth-
 matic, he died between the second and third week ; the patient of Nor-
 wood, (Jaeg., CEuvr. cit., p. 28, No. 18,) also  died, as did one of those
 of July, 1830, (Journ. Univers. Hebd., et Journ. Comp1em.,t. XXXVII.
 p. 33, 1830,)  that of M.  Dassit, (Journ.  Gen.  de  Med., t. XCIIL,
 p. 183, 1825,) that of M. J. Cloquet, (Journ. Hebdomad.,t. I., p. VII.,
 1831,) and one of my own.
  The success of the operation was doubtful in the case of M. Hessel-
 bach, the  son, (Jaeger, p. 26, No. 27,) and amputation had to be had
recourse to in the patient of Duvereuy, (Maladies des Os, t. II., p. 276,)
who nevertheless died.  The patient of Bromfield, (Practical Obs. in
 Surg., by Hey of Leeds, p. 382,) also died, and that of  Gooch,  (Tome
II., p. 369,) perished on the twenty-seventh day in consequence of im-
prudence ; while in the cases of Castel, (Bornemann, Sensibilitii des
 Tendons, Th.  de Haller, t. III., p. 307,)  A.Cooper, Boyer, (Traite
des Mai. Chir., t. IV.,) and dupuytren, (Trad, du Diet, de M.  S. Coop-
er, p. 64,) the cure on the contrary took place without any delay.

          Article II.—The  Tibio-Tarsal Articulation.

  Gooch (Wounds and other  Surg. Subj., 1667,) a long time  ago per-
formed with success the operation of  exsection of the lower extremity
of the tibia.  This operation was repeated by Cooper, ( Trad, de Park,
p. 7,) Hey, (Pract. Obs., 8cc, 1814,)  Deschamps, (Bull  de la Fac. de
 Med., le annee, p.  141,) White, (Cases  in   Surgery,  1770,)  Park,
 (Jeffray, Op. cit.,]). 71,) Delpech, and Moreau, (Op.  cit., 1803,1816,)
 the father and son.  Josse, (Bull, de la  Fac. de Med., t. VI.,  p. 414,')
 and M. Roux, (Journ.  Hebd. Univ., t. II., p. 357,) have also  success-
 fully  exsected  the tarsal  extremity of one or  both bones of  the le<r.
 Though they removed two inches of  the  right tibia, in  one case  and
 more than an inch  from the left tibia and fibula in another, the pa'tient
 of Josse  at the end of three  months  walked with the  aid  of a cane
 which she  has since  been enabled to dispense with.  Repeating thi< 
           EXSECTION or excision of the articulations.        487

operation on  a woman, in whom he exsected only the tibia on the fifth
day of the accident, on a man aged seventy-three years, and on another
man aged sixty-five, Josse, (Melang. de Chir., p. 310, 315, 321, 332,)
was  alike successful in all  of them.   M.  Veiel,  (Gaz. Med., 1834,
p. 747,) was  equally fortunate though he did not operate until the eighth
day.   MM. Walther, Textor, Jaeger and  Heine, (Ibid., p.  644,) also
speak  very highly of this exsection, which I have  performed twice on
the tibia ftnly, which M. Patry, ( These No. 289, Paris, 1837,) has seen
twice  performed by M. Thierry, and of which he relates sixteen cures
out of seventeen cases, taken chiefly from M. A. Cooper.
   The numerous cases of dislocations of the foot, complicated with
fracture  and protrusion of the bones through the skin, in which it has
been found necessary to extract the astragalus, exsect the tarsal extre-
mity of the tibia, or fibula, at the same time or separately, either to re-
duce  the displacement, or to  prevent  or arrest the  accidents, which
menaced  the patients; and  the  advantages which the patients  have
thereby obtained, have now consecrated the utility,  of this kind of ope-
ration.   Emboldened by his experience, Josse, (Melang. de Chir., Prat.,
p. 310, obs. 26,) has  even extended the  application of this exsection
to luxation of the  tibia, with fracture of  the fibula and displacement,
but without any  wound, in order to combat symptoms of a very  serious
character.
   It is true, that in almost all these  cases, this  excision has not been
decided upon, except in those of compound dislocations, or comminuted
fractures ; but many persons  have employed it also  for organic lesions,
that is to say, where the parts had not changed their natural relations.
In 1792, Moreau, the father,  performed the  peroneo-tibial exsection, in
a case where the articulation was entire,  and where there was  no dis-
placement of parts.   The leg of the patient was seen and  admired by
A. Dubois.   Moreau, the son operated upon a man of the name of Meu-
nier, in 1796.  The most serious objection to this  last  operation was,
the omission  to exsect the fibula, which  left the  patient  a cripple.  In
1810, Mulder, exsected five inches from the fibula  affected with caries.
In 1832, Jaeger, (Op. cit., p. 9,  No. 4,)  could not yet say what had
been  the  result of  this operation.   On  the  6th of  March,  1813,
M. Champion operated in the same manner on Therese  Peru, who has
repeatedly since, walked three leagues  on foot  to  show  herself to
MM. Roux,  Flamart, Fodere,  <fec.   M.  Liston, (d'apres Jaeger, p. 9,
No. 5,) also  as I have said above, removed in the same  manner, in
1821, the internal malleolus, the astragalus, the scaphoid and  two  of
the cuneiform bones.   The details of these cases would doubtless elu-
cidate  the history of the preservation of the fibula, when the tibia has
been exsected with the astragalus.   On the 3d of April 1830, M. Cham-
pion also operated for caries upon Etienne Chauvel, who at present can
use his foot very advantageously.   In 1832, M. Roux was  less fortu-
nate, and lost his patient.
  I.  Process  of Moreau.—Moreau recommends that we should make
two incisions  on each side of the leg, one which should reach from the
apex of the malleolus  to three or four inches above  it; the other which
is to commence  at the .same point, and to be brought transversely in
front to the insertion of the peroneus tertius muscle, for the outer side, 
488            NEW ELEMENTS OF OPERATIVE SURGERY.
or that of the corresponding tibialis  anticus, for the inner side.  The
longitudinal incisions  should go down to the bone and the others com-
prise only the skin.  We commence with the dissection of the outer flap
in order to disengage  the fibula  from the tendons  which  surround it,
and then to exsect it  with the chisel or the crested  saw above the part
which is diseased,  disarticulating it  from above downwards, while di-
viding the  fibrous bundles which  unite  it to the tibia, astragalus and
os calcis.   The same manipulation is employed to isolate the flbia from
the soft parts, in order to exsect and then disarticulate it.  If  the  as-
tragalus  itself should be diseased, it would be requisite  to remove it
also, in whole or in part, as was done  by Moreau, the son.  After  the
operation, the foot should be  brought gently into  approximation with
the lower extremity of the leg, and maintained in this position by strips
of adhesive plaster, and a suitable starch bandage.

                   § II.—Process of M. Roux.

   We perceive that Moreau follows in this  operation the  same process
he adopts for the carpal  extremity of the fore-arm.  In  place of  the
chisel or mallet, it would be  more advantageous at the tibio-tarsal artic-
ulation than anywhere else,  to use the trephine or the  link-chain saw.
In spite of the narrowness of the  inter-osseal  space, M. Roux was  en-
abled, on one occasion, to  insert a compress  through it, which thus
enabled him, after introducing Jeffray's saw between the bones and  the
soft parts, to exsect without danger, first  the fibula  and afterwards  the
tibia.   The  osteotome of Heine, or the rowel saw, moreover, would, at
the present time, render the section of the bones  by these processes
quite  an easy matter.

                        § III.— The Author.

   I should prefer, however,  if the tibia or fibula alone were concerned,
to lay bare the diseased malleolus, by means of a large semilunar flap,
whose convex border should face upwards and forwards.  By reversing
this flap backwards and downwards, we  should have every facility  for
exsecting and removing the diseased bone.   Two such flaps  would
equally enable us to exsect both bones.

                        § IV.—Appreciation.

   This exsection, which  is  always a difficult operation, will sometimes
be followed by severe accidents.  A case operated upon  by M.  Roux
terminated  fatally.   After the most  perfect cure,  tho limb will have
necessarily  lost a portion of its length, and the patient  cannot  walk
without the aid of a shoe more or  less elevated.  It presents, then,  but
few advantages over amputation of the leg.   The exsection of the tibia
alone, especially, does not seem to answer the  purpose the surgeon  has
in view.  The foot thus losing its  principal point d'appui, will be  inca-
pable of sustaining the weight of the body, and everything leads to the
belief that it will be turned inwards, as Moreau  remarked in one of his 
EXSECTION OR EXCISION OF THE ARTICULATIONS.        489
patients.  It would  appear, therefore, that the fibula,  although  it be
sound, ought in these cases to be excised at the same time with the tibia.

                               §V.

  When the  tarsal  extremity of the fibula is to be removed, would its
loss  necessitate  also the  exsection of the tibia ?  " To judge of this
question,"  says M. Champion, " by what happens in cases of fracture of
the lower extremity of the fibula, when we cannot reduce it as we wish,
we may answer, as I have done in 1815, in the  affirmative ; but at the
present time, and in  other cases, I should  willingly leave  this question
open."
  Gouey, (La Veritable Chirurgie, Rouen, 1716, p. 130,) in 1716, pub-
lished the case of a  man,  in whom an  empiric extirpated, without any
apparent reason, the lower part of the fibula which had been fractured
at three fingers'  [breadth] above  the malleolus,  and  had  protruded
through the flesh.  Improper treatment resulted in necrosis, and made
it necessary to resort to extraction of the astragalus.  Nevertheless, and
in spite of  other accidents still, the  patient got well, and could  walk
without a cane, and as though he had not lost  the  astragalus.   Gouey
attributes this result to  an osseous  juice, which, having oozed out and
coagulated in the void left, had formed an irregular callus, which could
be felt through the  integuments at  the spot and place  which the fibula
had  occupied.
  Faure (Prix de VAcad. de  Chir., in 12mo., t. VIII., p. 50, Obs.  2 ;
et in 8vo, t. III., p. 352,1819,) quotes from Read, a case of wound from
a fire-arm,  in which it became  necessary  to extract the lower third of
the fibula, several portions of the lower extremity of the tibia, and some
fragments of the astragalus.  The fibular portion was not produced ; the
osseous juice had formed a species of incrustation  which  had become
united to the tibia, and the whole formed but one bone.   It would ap-
pear that an anchylosis had taken place between the tibia and the astra-
galus, and  that it was this consolidation which must have prevented the
deviation of  the foot.  It is much to be regretted  that  the cases which
M.  Cooper (ffiwy., Sfc;  trad. Fran?., p. 42-56)  obtained from  MM.
Ransome, Maddocks, Ormond and another  person whom  he does not
name, and  in which the external malleolus (without anything being said
of deviation) was removed, are too deficient in details to afford any light
upon this point of practice.  I would  express the same  regret of the
case of exsection performed by Mulder, (Watchter,  (Euvr. cit., p. 154,)
in which he removed five inches of the lower and and articular extremi-
ty of the  fibula affected with caries, but of the result of which we are
left in ignorance.
  The organs to be avoided are : 1, in front, the tendons of the  tibialis
anticus muscle, those of the extensors of the toes, and of the peroneus
tertius; 2, outwardly, the peroneus longus and peroneus brevis muscles;
3, on  the  inner side, the tibialis posticus muscle and  the  flexors;
4, behind the semi-muscular portion of the same organs;  5, finally, the
anterior tibial artery in the first direction, and the  posterior tibial with
the nerve, behind the internal malleolus.
   Vol. II.                    62 
490
NEW ELEMENTS OF  OPERATIVE SURGERY
                               §  VI.

  Exsection of the tibia, in consequence of fracture of its tarsal extremi-
ty, was successfully performed by Hey, (Pract. Obs. in Surg., p. 363,)
in 1799, and that of the malleolus internus, with removal of the astraga-
lus, has been performed by Weber, (Jaeger, p. 10,No. 25,et p. 26, No. 23.)
Examples of exsection of the tibia  in  cases  of tibio-tarsal luxations
with laceration of the integuments,  have been related by Serrin, (Obser-
vation  addressed to the Academy of Surgery, recompensed  with a medal
of gold, 1776,) Marrigues, (Dissert.  Physiol, et Chirurg. sur la  For-
mation du Cat., $c, p. 26,1783,) by Taylor, (Pract.  Obs. in Surg., by
Hey, p. 381, 1805,) who performed  this operation four times, by Kerr,
(A  Treatise on Dislocations and Fractures of the Joints, p. 67, Sir A.
Cooper, p. 229, 1831,) who performed it several times, (plusieurs fois,)
Lynn,  (lb., p.  239,) Flour, (Ann.  de Med. de Montpellier, 1809,) who
performed it three times; by Averill, (In A. Cooper, p. 228 ; trad.,p. 52,)
Cooper of Brentford,  (lb., p.  237,)  by A. Cooper,  (lb., p. 235; trad.,
p. 54,) Vernhes,  (Ann. de Mid. Clin, de Montpellier, t. IX., p. 186,
1820,) Sandfort,  (A.  Cooper, p. 226; trad., p. 51,) Graefe, (In Jaeger,
Oper.  res  Consp., etc., p.  9 ; A.  Cooper, tr.  Fr.,  p.  55,) and Tyrrel,
(in Jaeger, p. 10.)
  Examples, on the other hand,  of exsection of the tarsal extremity of
one or both bones  of the leg, are related by Kirkland, (Ibid.,) Moreau,
the  father, (Essai  sur VEmploi de la Resect, des  Os, p.  94,)  who ex-
cised  the  lower extremity of the  tibia, sawed off the two fragments of
the  fracture of the fibula, and left the external malleolus; by Hicks,
(A.  Cooper, cite, p. 233; trad.  Fr., p.  54,)  Fletcher, (Ibid., p. 238 ;
trad. Fr., p. 54,) and A. Cooper, Ibid., p.  225 ; trad.  Fr.,  p. 51.)  The
excision of the tarsal extremity of the bones of the leg, with partial ex-
section or  removal of the astragalus in a state of caries, has been per-
formed once by  Moreau, the father, (Essai  sur VEmploi, <fec, p. 87,)
and twice  by  M.  Champion, (Unpublished Observation, communicated
by the author;)  M. Roux, in going to Plombieres sixteen years since,
had  an opportunity of seeing the first of these two  cases.   This exsec-
tion  has  been once performed  also  by Moreau, the  son, who confined
himself to the exsection of the the tibia alone, and the  astragalus. Ran-
some removed the  external malleolus which had been separated by frac-
ture, and  Moreau, the  son, (Essai citi, p. 98,) removed in this manner
the anterior half in a state of caries.

           Article III.—Exsection op the  Knee-Joint.

                               § L

  Caries, necrosis, abscesses, tubercles, cancers, and all those kinds of
lesions comprised under the name of white swellings, often become so
serious as to be beyond any other remedy than the removal of the dis-
eased  parts.  As amputation of the  thigh removes  the whole of the
limb, and obliges us to sacrifice a great extent of sound parts, the ques-
tion has been asked  if it would not be possible to  restrict ourselves to 
EXSECTION or  excision  op the articulations.        491
the removal  of the  tissues and the portions of bone actuully diseased:
from  whence has originated the idea of exsection of the knee-joint.   It
is an operation which consists in the extirpation of the articular extremi-
ties of the femur or of the tibia, or of  all those parts at the same time.
  The excision of the bones which form the femoro-tibial articulation,
has now been performed upon living man a great number of times ; once
by Filken, (Jeffray,  Op.  cit.,  p. 52) in 1762 ; once by Dr. Park, and
with such success as to enable the patient to walk without a cane, (Nouv.
Mith. de  traiter  les  Maladies  qui Attaquent  le  Genou, trad.  Fran<j.,
1784,) the third time by Moreau, (Obs. sur la Risect. des Art.,  1803,)
and once by Moreau, the son, (Essai sur la Risect. des Os, 1816,) whose
patient for a long time was obliged to make use  of crutches.  Mulder
(Watcher, De Articulis Extirpandis, etc.,  1810) related a case  of this
kind in 1809 ; M. Roux (Private Correspondence, 1831) has published
another case ;  his patient died on the nineteenth day.  M.  Crampton
(Syme, Excisions of Joints, 1831) has performed this operation twice:
on a girl aged twenty-three years  on the 7th of May, 1823, and on his
second patient in 1834.  The  first survived, and actually is enabled to
walk without crutches, notwithstanding the deformity of the limb;  the
other died from the consequences of  the operation.  M. Syme (Op. cit.,
p. 29) also has performed this operation twice : one of his patients died
on the eighth day, the other, a child  aged eight years, recovered and
walks very well.  M. Fricke informs  me that he has performed it four
times.  MM.  Jaeger  and  Textor  also have  each performed it once,
(Coulon,  Op. cit., p.  45.)
   [Writing in 1831, Mr. Syme gives the following  satisfactory account
of his first case:—" In  the course of four weeks after the operation,
the wound was all but healed, and  the limb, before  the  expiration  of
three months, had regained so much strength that the patient could make
some use  of it in walking.   It  has. been progressively improving since,
and is still doing well.  I have no doubt that ultimately it will be nearly
as useful to him as ever ; but even at present he would be very  sorry to
exchange it for a wooden one.  He can walk and run, though with a
halt, without the constrained appearance of a person with an artificial
leg, and  merely requires  the heel of  the shoe to be  two  inches higher
than the other.   The limb is stout and well nourished, and though slightly
bowed outwards, does not occasion  any disagreeable deformity ; it allows
a slight degree of flexion and extension."  Seventeen years later;how-
ever, a much less satisfactory account of the same patient is given.   In
speaking  of excision of the knee-joint, in 1848,  Mr. Syme says :—" I
tried the  operation nearly twenty years  ago  on a boy, who recovered
perfectly  from it, and seemed at first to possess a limb little  inferior to
its fellow, except in so far as it  was stiff at the knee.  But in the course
of time it was  found that  the  growth  of the two limbs was not equal,
and that the one which had been the subject of operation gradually  di-
minished  in-respective length, until it wanted several inches of reaching
the ground, when the patient stood erect."  G. C. B.]
   Exsection of the knee in consequence of compound fractures, also  re-
quires to  be mentioned.  In the patient operated  upon by Read (Prix.
de VAcad. Chir., in 12mo, t. VIII., p. 47 ; in 8vo, t. III., p. 352) the
external condyle of  the femur and a  portion  of the  patella had  been 
492
NEW ELEMENTS OP OPERATIVE SURGERY.
crushed to pieces bv a ball.  After having dilated the wound in order
to extract the detached fragments, crowns of the trephine were applied
to a part of  the bone in order to remove a portion of it of the width of
two fingers' breadth.  No serious accidents  supervened.  An abscess
which formed at the lateral and posterior part of the thigh, enabled the
surgeon to extract the ball four months  after the accident;  a  large se-
questrum  of three fingers' breadth, was removed at a later period by
means of an incision, and  the cure was  not completed until at the end
of eleven months.  The patient was enabled to walk without any assis-
tance but  with a thigh  shorter than the other by four inches. ^ Heaven
forbid that I should give this operation for a pattern, although it  is very
remarkable!  Read was  like Gelee, more fortunate than skillful.  In
another case M.  Travers (cite par Jaeger, p. 8, No. 13,) confined him-
self to the exsection of  the external condyle of the femur.   Three inches
of the tibia and of the  head of the fibula, a small portion of the patella
and of the condyles of the femur, were, says Percy, (Manuel du Chir.
d'Armie, par Percy, p. 262,) carried away by a small bullet.   Serious
accidents and danger of the loss of life succeeded to this wound :  the
commotion,  however, subsided,  and the exfoliation of  the  bone was
promptly followed by a cicatrix with anchylosis.
  A fracture existed at two fingers' breadth from the knee, and the tibia
protruded outside to  the extent of three fingers' breadth.  The reduc-
tion was difficult, notwithstanding the usual dilatations ; the  cure was
protracted to eight months in consequence of the exfoliation of the tibia,
all the upper part of which was removed; the cicatrix which  remained
being so deep that the patient in putting on his  boot was obliged to fill
it up with a pelote of linen of the size of a tennis ball.   Saviard ( Observ.
de Chir.,  Obs. 28) who relates  this case, does not say what effect  this
accident had on the walking of the patient.
  A young  man whose case  is  given  by Janson (Compte-rendu de lu
Prat. Chir. de VHotel  Dieu de Lyon, p. 77, 1822) fell  with  his knee
upon the cutting edge of a scythe.  The articulation was laid  open  to a
great extent.  The lower extremity of the femur, which was  luxated
upon the leg, was split from below upwards to the extent of two inches.
The laceration was so extensive, that no other  resource was  left but
amputation of the thigh ;  the patient objected to this, but consented to
exsection.   The  operation was very long and very laborious.  After
having  disarticulated the femur, Janson passed an amputation knife into
the popliteal space in order to detach the soft parts and artery from the
bone; the bone  was then sawed off and the whole united as accurately
as possible.  Some hope of recovery was  entertained until  the fifteenth
day ; but the impossibility of maintaining the extremity of the femur in
a fixed position, from the rotating muscles of the thigh constantly turn-
ing it  outwards, together with the abundance  of the suppuration and
some aberrations in the regimen, caused death on the thirtieth day.
   In a case of caries  of  the inner  condyle of  the tibia, M*. Champion
 ( These de 1815, p. 7) having cut out a square shaped flap, was  enabled
by means of the gouge and chisel, to remove the whole of the diseased
portion of the bone to the depth of near an inch, together with  the ball
which  had become embedded  in it.    Desport (Traiti  des  Plaies
 d?Armes-d-Feu, p. 225) also thinks that in cases of fracture of the loo- 
            EXSECTION OR EXCISION  OF THE ARTICULATIONS.        493

 we ought not to be in too great haste to amputate, if no other part is
 fractured but  the  upper portion of the fibula, unless the neighboring
 bones or some  other  important  parts should be implicated.   Scultetus
 (Arsenal de Chir., 2e part., p. 104, obs. 81, 1712) having extracted a
 sequestrum of considerable size  from the tibia, removed by means of the
 trephine the head of the fibula which was in a carious state and cured
 his patient.  Beclard was equally fortunate in exsecting the extremity
 with the  upper  third of the fibula, for a spina ventosa  or medullarv
 fungus.

                                k  II.

   It is certainly not  because of the difficulties which exsection of the
 knee joint presents that  it ought to be proscribed, but because it is infi-
 nitely more painful, tedious and dangerous, either  immediately or sub-
 sequently, than amputation in the continuity of the  thigh ; and especial-
 ly because in the most fortunate cases the limb preserved is in reality
 not as useful to the patient  as an artificial leg.   As a necessary conse-
 quence  there must  be a shortening of from  three  to eight  inches; the
 articulation cannot be restored; the limb if it preserves  the faculty of
 motion  performs it only  in a very irregular manner, and most usually is
 strongly deviated outwards.  Of the cases that have fallen under my
 observation, ten at least have perished, some  like the case of M. Roux
 at a very short interval after the operation, others  after having suffered
 for a long time ;  all those who have been cured have obtained this resuk
 only by means  of extraordinary care, and not without having  incurred
 the  greatest danger of  losing  their lives; it is also certain,  notwith-
 standing what M. Syme may say, that none of them can do with  their
 misshapen limb what they would be enabled  to execute with a wooden
 one properly made.   The case of Moreau, the father, (Op. cit., p. 57,)
 died  three  months after  the operation, of an epidemic dysentery; the
 limb had undergone much shortening.  A second case operated upon by
 Park in 1789,  died from exhaustion at the expiration of four months,
 (Syme,  Op. cit.,  p. 129.)  The first case of  M. Crampton died three
 years and a half after the operation, without ever having been perfectly
 cured ;  the  other walks with a sole  which has to be  four inches thick,
 (Dublin Hospital Reports, Vol. IV.)   That of Mulder terminated fa-
 tally.  M. Fricke, who cured only one out of four cases, hopes  never to
 repeat the  operation.  The first case  operated upon by M. Textor also
 died. Another patient whom this surgeon operated  upon in 1836 (Com-
municated  by M. Sprengler, November, 1838) was  equally unfortunate.
In the case of M. Jaeger (Rust's Handb. der Chir., Band V., p.  626;
et Op. Ris., p. 8, No. 12) the result at first was most  flattering, since
from  the figure that M. Adelmann  sent me of it, and especially from
what this physician who  attended  to the progress of the  case  has told
me, the patient  scarcely limps, and can without any  impediment  undergo
the most fatiguing labors ; but as he has not been cured but five months,
and as the limb which is shortened three inches  is  strongly deviated
outwards, and that one side of  the  anchylosis constantly threatens to
ulcerate through the skin, the question may still  be  asked if amputation
of the thigh  and an artificial limb would not have been preferable.   The 
494            NEW ELEMENTS  OF OPERATIVE SURGERY.
 operation, therefore, is one whose utility may still be questioned at the
 present day, as it was at  the time M. Denoue wrote his Thesis, (Paris,
 1812.)
   [The operation of excising  the knee joint  was  revived by Mr. Fer-
 gusson, in 1850.  His first patient  died  on the ninth  day  from acute
 necrosis of the femur, which also destroyed the one on which Mr. Syme
 operated  in 1830.  Mr. Fergusson's second case in Oct. 1852, was suc-
 cessful.   His third patient, in Jan. 1853, died on the fourteenth day from
 purulent  infection.   Mr.  Jones, of Jersey, appears to have  had  the
 greatest experience with this operation, having operated in noless than
 six cases, and  with the exception in which  one  of his patients was
 craried off by dysentery, all seem to have  been successful.  A paper by
 Mr. Jones was  read before the Royal Medical  and  Chirurgical  Society
 of London, April 11th, 1854, which  gave rise to  a discussion  of the
 question of the propriety of this  operation.  Mr. Fergusson  remarked,
 that " his  own conviction was, it is a proceeding as justifiable as ampu-
 tation of the thigh, and far more beneficial, inasmuch  as it saves the
 limb."
  We give the  details  of Mr. Jones' first and sixth cases togetner with
 two successful examples by Mr. Mackenzie, of Edinburgh.
  Case 1.—A female,  aet. 25.   Tne operation  was  performed January
 19, 1851.   Unfortunately this patient was residing at a distant part of
 the island from St. Heliers, and during my short stay of  a  few hours
 I was unable to see her.  Mr. Jones has furnished me with the following
 account of her  present condition ;—She is in perfect health, the parts
 about the  knee  having been long entirely healed.  The shortening of
 the limb  is a little over  three  inches.  Complete  anchylosis has not
 taken place, so  that she requires a support on the inner side of the bone,
 with which she  can  move  about freely, and  can stand at her washing-
tub for hours together. She is perfectly satisfied  with her  condition,
 and, with  a more secure support for the knee, which is being made for her
at present, the  limb will be rendered still  much more  servicable than
it now is.
  Case 6.—William Livermore, aet. 12, was admitted  into the  Jersey
Hospital on the 12th of October last, for an  affection of the right knee,
 of upwards of a year's  standing.   His general health was not  very much
impaired,  and the condition of the limb was—general inflammation of
the knee-joint, and the  textures  surrounding it.  A careful investigation
led to the  supposition, that ulceration of the cartilages had already much
 advanced.  There was general distension of the joint, as if by contained
 fluid.   A fair trial of the following means was carried out:  The patient
 was kept in bed:  the joint frequently covered with leeches ;  then cup-
 ping, blistering, mercurial and iodine frictions, tartar emetic ointment,
 each combined  with  appropriate  constitutional remedies ;—all  failed.
 The operation was performed on the 17th of April last.   A longitudinal
 incision was made on  each side of the knee-joint, midway between the
 vasti and  flexors  of the  leg, full five inches  in  extent; rather more
 than half  the length was  over the femur, and rather less than half over
 the tibia.   These  two cuts were down to the bones ; they were  connected
 by a transverse one just over the prominence of the tubercles  of the
 tibia, care being taken  to avoid cutting the  ligamentum  patellae by this 
            EXSECTION OR EXCISION «F THE ARTICULATIONS.       495

incision; the flap  thus  defined was reflected upwards, the patella, its
ligament, and the  joint, thereby exposed.   The synovial capsule was
cut  through as far as it could be seen ; the patella  and its ligament
were now drawn over the internal condyle, while the joint was kept ex-
tended.  It was next  forcibly flexed, the  crucial ligaments, almost
breaking in the  act, only  required a slight touch of the knife to divide
them completely; the articular surfaces of both bones were thus com-
pletely brought to view, and nearly two inches of the femur and half  an
inch of the tibia were sawn off, the  soft parts being drawn aside by
assistants.   The external condyle of  the femur was found hollowed out
by a large  abscess, and it was  necessary to saw off a portion of the ca-
rious bone, and to gouge the remainder, until healthy cancellous tissue
was reached.  The entire synovial membrane  was in a state of pulpy
degeneration, and was  carefully  dissected  off.  The   hemorrhage had
been rather great, but had now almost ceased, and no vessel required
deligation.   The blood was sponged out of the wound, the patella  (after
the diseased  portion  had been  gouged  out) and its ligaments were
replaced, as nearly as possible, in their natural state,  the bones brought
in apposition, the flap brought down and  held by sutures, the limb ban-
daged on a slight under-splint and laid in a box, the wound covered with
moist lint, and the boy put to bed yet asleep.   The operation occupied
full twenty minutes, and was performed while the patient was under the
influence of chloroform.
   Opiates  had, for some time,  to be freely  administered every night;
and the boy's appetite, always excessively small, having entirely failed,
the stimulating plan of treatment was  followed out  more rigorously than
I had pursued it in  other cases.  The seventh day after the operation,
a slough of some extent was  perceived on the lower part and  sides of
the flap.  This went on increasing for some days; the ligamentum pa-
tellae was, however, never bared.  Mild, stimulating applications arrest-
ed its progress ; healthy granulations  sprang up;  and soon the suppu-
ration, which  was at one  time  very considerable, lessened in quantity.
At present  it amounts to a mere nothing, the wounds being now all but
healed.
   Not seven weeks have yet elapsed since this operation was performed,
and it is most satisfactory to witness  its favourable and rapid  progress.
The little patient never experiences the slightest pain  in any part of the
limb ; he turns it  from side to side easily and  quickly, and without
either assistance or appliance of any kind, can, while lying on his back,
raise the leg from the hip upwards.   The knee bows  slightly inwards ;
but my  previous experience in these cases leads me to believe,  that a
very slight mechanical contrivance  will entirely remedy this.   The pa-
tella is adhesive to the femur  and tibia, and its ligament preserves  its
integrity.
  The integuments  covering  the joint had been so much  deteriorated
by the disease itself, and perhaps also by the remedies  used, as, together
with the  length of the flap, to account naturally for the slough.  Proba-
bly two  smaller flaps, reflected upwards and downwards from the centre
of the patella, might have answered better.
  I am very unwilling to be supposed to recommend this plan of opera-
tion, as  one adapted to all cases  of knee  excision,—very far from it; 
496           -NEW ELEMENTS  OP^OPERATIVE SURGERY.
 there  are  cases in which it is altogether  inadmissible ; and I feel  per-
 suaded, that whoever adheres to one mode only, will often find himself
 wofully disappointed in the result.   The general rule of acting accord-
 ing to the features the case presents, is quite as applicable to these  par-
 ticular cases as to others generally.
   Preserving the  patella, and not  dividing its ligament, makes the  ope-
 ration more tedious and difficult;  but this is a very secondary consider-
 ation,  where it results in obtaining a more  favourable issue.   That it
 proved so in this instance is abundantly established by the fact already
 mentioned, that, in less  than seven  weeks after the operation, this  pa-
 tient  is  able to  raise his foot without any assistance ; while a  young
 man who occupies the next bed, and in whose case everything has gone
 ou favourably was only able to do  so in as many months.—Med.  Times
 and Gazette, July 1853, p. 11.
   3. Dr. Mackensie's Cases.—Case 1.—Wm. Harrison, aet. 42, a host-
 ler, from Carlisle, was admitted under my care,in the Royal Infirmary,
 September  28,  1852, suffering  under disease of the  left  knee-joint of
 five years' standing.  The symptoms were those which are usually at-
 tributed to ulceration of  the cartilages, uniform thickening of the parts
 around the knee, severe gnawing pain, especially during the night, and
 much  aggravated  by the  slightest motion of the joint.  Considerable
 relief was obtained by the joint being kept immovable in leather splints,
 and by the  repeated application of the actual cautery.  The thickening
 of the  soft  parts  became diminished, and I hoped the patient was to
 recover with a stiff joint.  A painful spot, however, remained  over the
inner  side of the  head of the  tibia, on account of which the  counter-
irritation was continued, and the joint retained for a long time fixed by
the leather splints.  He continued in this condition till about the mid-
dle of  January, when, without  assignable cause, the pain in the knee,
especially on each side of the head of the tibia, became much aggravated.
The pain was now so severe and constant that, in spite of the free and
frequently  repeated use  of morphia, he scarcely slept night  or day.
The swelling of the joint again increased, and the foot and  leg became
cedematous.  On  the 26th  of  January  I called a consultation  of my
colleagues on the  case, as it appeared to me that the  removal of  the
disease by operation was alone likely to save my patient.  It was thought,
however, that a repetition of the same measures as had been already
adopted, might still save the joint.  The leather splints were accordingly
readjusted, and the cautery once more applied in front of the joint.   No
relief, however, was obtained, and  after ten days'  further delay 1 yield-
ed (with the  consent of my colleagues, who saw the case with  me) to
the earnest solicitation of the patient, to remove the disease by operation.
  The  operation was performed, February 5, 1853.  A straight incis-
ion was made across the  front  of  the joint,  a little  below the level of
the patella,  and extending to rather  less than half the circumference of
the limb, and at right angles to each end of  this  transverse incision, a
longitudinal incision of about two inches in length gave the wound some-
what the form of the letter H.  The operation was  performed quite ac-
cording to the plan of Moreau,  the patella being first removed, then  the
condyles  of the femur, and  lastly  the articular surface of the head of
the tibia.   It was accompanied  by  smart hemorrhage from the articular 
           EXSECTION  or excision of the  articulations.        497

arteries, which was at once arrested by applying ligatures to them.  On
dividing the tibia with the  saw, the cavities  of two abscesses in the can-
cellated texture of the bone, were laid open, each of a size capable of
containing a  grape.  I carefully removed the remaining portion of the
walls of these abscesses with the  gouge,  and then, finding that the dis-
eased portions of bone had been entirely removed, I placed the ends of
the tibia and femur in apposition, united the  wound by  sutures, and
fixed the limb in the straight position, by applying a  splint on its pos-
terior surface.   (The articular surfaces of all  these  bones were found
almost entirely deprived of cartilage;  and both the cancellous and  la-
minated structure of the bones, at various points, were in a state of sup-
puration and caries.  The primary disease evidently consisted of suppu-
ration of the cancellous texture of the head  of the tibia.  The extent of
bone removed in the operation  amounted to rather more than two inch-
es—an inch and a half of the femur, and a little more than half an inch
of the tibia.)
  The progress of the patient for the first two  days following the ope-
ration, was  most satisfactory.  He  slept well, which he  had  not done
for weeks before ;  his pulse never rose above 80 ;  he expressed himself
as entirely relieved from the severe pain which he had been previously
suffering.  On the  evening of the third day he began to suffer from
hiccough, which very soon became constant, and continued unmitigated
by  all the remedies which were employed to relieve it, for six succes-
sive days and nights.  The spasm of the diaphragm  at length yielded
on  the seventh day  under  the continued  pressure of a  seven  pound
weight, over the epigastrium, and the pretty free  use of the tincture of
Indian hemp, and everything went on favorably till about Feb. 23, when
he  began to  complain of pain in  the region of  the diaphragm, and on
pressure over the right hypochondrium.   Obstinate diarrhoea succeeded,
the evacuations presenting no appearance of bile.   He lost all appetite,
became desponding,  as  to his recovery, and  lost flesh rapidly.  The
wound, however, during  this time, never  presented any unfavorable ap-
pearances.   Primary union failed, but the discharge was moderate, and
the entire surface covered by healthy  granulations.   In consequence of
this constitutional disturbance, even at the  end of four months osseous
anchylosis was not complete, though in  the opinion  of Mr. Mackenzie
two or three weeks would suffice for the  purpose.  His second case, was
that of a fisherman, aged 28, suffering from disease of right knee-joint,
of  about ten months' standing.  The affection  had commenced, without
assignable cause, by pains and swelling  of the joint, which gradually
increased; and, for two or  three months previously to  his admission
into the hospital, had  entirely disabled  him from moving about.  The
condition of the joint was  similar to that of Harrison, but  the symptoms
were less severe.   The pain was considerably mitigated by the joint be-
ing kept immovable in leather splints, and by the repeated application of
blisters.   About a  month after his admission into the hospital, the pain
again became more severe, and was  referred chiefly to  the outer side of
the head of the tibia.  The actual cautery was freely applied, but with-
out giving any relief, while increasing deformity  of the joint, and pain
on slight motion, gave evidence of the morbid changes which were in
progress in  and around the articulation.  Shortly after this, he  had an
   Vol.  II.                    63 
498            NEW ELEMENTS OF  OPERATIVE SURGERY.
attack of modified  small-pox, from which  ho speedily recovered.  No
improvement,  however, took place in  the  condition of the joint.  He
continued to lose flesh ; the pain and the deformity of  the  joint contin-
ued to increase ; and symptoms denoting suppuration of the joint pre-
sented themselves.
  Sir George Ballingall, Dr. Dunsmure, and Dr. Gillespie,  who saw the
patient with me in consultation on the 2d of May, agreed with me in the
necessity of performing amputation, or excision  of the joint, to  either
of which measures the  patient willingly gave his consent.
  I performed the operation of excision of  the joint on the 5th  of May,
1853.  Having found  the disadvantages of  the H-shaped incision in
my first  case,  I now exposed the  interior  of the  joint by a semilunar
incision, extending.from the inner side of the inner condyle  of the femur
to a corresponding point over the outer condyle, the incision passing in
front of the joint nearly as low as the tuberosity of the tibia.   The flap
thus formed was dissected back, the ligamentum patella  being  divided,
and the patella itself left in the substance of  the flap.  The rest of the
operation was  completed, as I have already  described, with the impor-
tant exception, that the patella was left in its place, and its immediate
attachment left undisturbed.  The cartilage, however, which remained
on its surface  was removed by the gouge, as  well as the rough sur-
face of bare bone around its  articular margin.   The amount of bleed-
ing was very trifling : one of the articular branches and several small ves-
sels were secured by ligature, and the  wound was dressed  and  the limb
supported, as I have already described in my former case.    (The inte-
rior of the joint presented the usual appearances accompanying advanced
strumous  disease of the synovial  membrane, suppuration  of the joint,
universal thickening and degeneration of the  membrane, and ulceration
of the margins of the cartilage in  nearly  their entire extent.  Great
part of the cartilage covering the articular end of the bone was  as yet
unaltered.  Three-fourths of an inch of the  tibia, and fully an inch and a
half of the femur, were removed.)  With regard to the progress of this
case  since the performance  of the operation, I need only say that the
patient has suffered as  little local and constitutional disturbance as usu-
ally  follows excision  of the elbow-joint, and certainly very much less
than usually follows amputation of the thigh.  He has been almost entire-
ly free from  pain, and has  slept and eaten well, whilst his general ap-
pearance has been such that no one, who was unaware  of the operation
which has been performed, would, on seeing him, have imagined that he
had undergone an operation which was dangerous to life.  Nearly a half
of the wound is already healed, and the remainder is covered by healthy
granulations.  The  discharge, which has never been  great, is already
diminishing in quantity. There has not been the slightest tendency to
displacement of the bones from the straight  position,—a circumstance
which I attribute, in a  considerable measure, to the patella and its at-
tachments  having been  left undisturbed.   Little more than a fortnight
has elapsed since the operation was performed, and I am, therefore, un-
willing to say more of  the case at  present  than  that it promises, as far
as it has gone, a most  favorable result.   There  is one  point, however
to which I wish to direct attention.  It has been  recommended that a
considerable portion of  integuments should be removed by a double lu- 
           EXSECTION OR EXCISION  OF THE ARTICULATIONS.  *      499

nated incision, to prevent the redundancy of skin which might be expect-
ed from the large amount of bone removed in the operation.   I believe
that this advice, if followed, will lead to great annoyance.  I have not
removed any portion of  integuments  in cases the in  which I have
performed  the  operation, notwithstanding which, the retraction of the
skin was such as to cause, in each case, more or less  gaping of part of
the wound.  Mr.  Fergusson  mentioned to me that he had removed a
small portion of integuments in the  operation, in the case now in King's
College Hospital, and that, during the  patient's convalescence,  he had
much reason  to regret  having  done so, as the retraction of the int^u
ments was  such as to leave part of the end of the femur uncovered, and
a thin cicatrix only now covers this point of bone.  (Lond. Med. Times
and Gazette, July and August, 1853.)
  Mr. Syme regards  excision of the knee joint  as " a dangerous and
unprofitable proceeding."  Now, with the cases  to which  our  author
refers, we have  collected  in all 28  cases.  Deduct  from this number,
the 6  in the practice of  MM. Fricke, Jaeger, and Textor, the results of
which are  not  mentioned, and  we have 22  cases, and 7 deaths.  The
mortality therefore seems to be about the same as that following ampu-
tation of the thigh.  As to the  utility of the limb, after the operation,
we subjoin the remarks of Mr. Henry Smith, of London, who has devoted
much attention to this subject, and whose  paper  in the  Lond. Med.
 Times Sf Gazette, for August, 1853, is worthy of attention.
  There is still one point of great importance, in reference to this par-
ticular operation, which is to  be  considered,—viz.,  the utility of the
limb as a means of progression after the  joint has  been excised, and a
cure has been  effected.   The evidence on this subject, so far as it can
be obtained at present, is on the one hand of a nature highly satisfactory,
while on the other it is the reverse.   In the remarkable case where Park
first operated so successfully, the  man returned to his occupation of a
sailor, and " was enabled to go aloft with considerable agility, and to
perform all the duties of a seaman;" ourely this is more than could be
reasonably expected.  Mr. Jones wrote to me some time ago as follows
concerning one of his  cases :—" He walked  without the  assistance of
crutch, stick, or any  appliance  whatever to the limb, up and down the
largest  room in the hospital, quite as fast as I could. "   On the other
hand, Mr. Syme's patient  did not, I believe, have much use of his limb
eventually.  Although the exact particulars of the condition and aptitude
of the member  have not lately been  obtained, there is reason,  however,
to believe,  that it is not satisfactory, as Mr. Syme has evinced great op-
position to the  operation.
  However, there is no doubt  that  strong union of  the parts in the site
of operation does take place, and that, by careful attention to position,
a very useful  substitute for a sound limb may be  effected.  In some
instances the union is only ligamentous, but in others it is bony, as was
the case in Sir  Philip Crampton's patient.
  Here, however, the limb was not of very much use; and any gentle-
men who will take the trouble to walk into the pathological department
of the Hunterian Museum, and examine the large glass case on the base-
ment  floor  will see the  reason of this, for he will there find the prepa-
ration of the parts, and will observe, that the divided bones had become 
500            NEW ELEMENTS  OF OPERATIVE SURGERY.
 joined by strong  bony anchylosis, almost  exactly at right angles.   Sir
 Philip Crampton informed a friend of mine, that  the limb had not  been
 kept steadily in the extended position  after the operation ; thus arose
 the awkward anchylosis.  But  this case, instead of proving any thing
 against  the  operation, speaks  much  for it, as the parts are firmly knit
 together by bony junction. "And  doubtless this  union might have  been
 effected in a straight position.  The tediousness of the convalescence is
 another objection, to this operation, varying as it does from three or four
 weeks to as many months ; but as Mr. Mackenzie  observes, this period
 of  time generally elapses before a patient, after  amputation, can  bear
 the weight of his body on the face of the stump."  G. C. B.]
   The following, however, are  tho principal processes which have  been
 employed, and which  may be adopted, should any motive induce us to
 attempt the operation.
   A. Process of Park.—A crucial  incision, whose  transverse  branch,
 placed above the patella, would  comprise the half of the  circumference
 of the limb, constitutes the characteristic feature of the process of Park.
 After having divided  the tendons of the extensor muscles of the  leg,
 and turned back the four flaps, raised up the patella, made the section
 of the lateral ligaments, and divided through the articulation from be-
 fore backwards, Park inserted a large knife along the posterior surface
 of the femur, in order to detach the soft parts from it, while taking  care
 to avoid the popliteal vessels.  Nothing more remains than to saw the
 bone above the condyles; the extremity of the tibia is afterwards ex-
 sected with the same precautions.
  B. Process of Moreau.—The articulation of the knee being, in almost
every respect, similar to that  of the elbow, Moreau thinks that the ex-
 section of the one ought to be performed in the same way  as that of the
 other.   Consequently,  he begins with two lateral  incisions, a little in
front of the borders of the ham, which  incisions he unites by dividing
transversely the skin and ligaments  below the patella, in such manner
as to penetrate down to the articulation  ; afterwards he detaches from
the posterior surface of the bone, the soft parts which surround it; then
dissects and  raises up the quadrilateral  flap circumscribed by the three
first incisions ; and afterwards performs the section of the femur, with
the same precautions used in the process of Park.   If the bones of the
leg are also affected  at  the same time, the outer incision should be pro-
longed  as  far as the head of the fibula.  Another is made on the crest
of the tibia, by which means we  have two lower flaps, one on the inner
and the  other on the outer side, which flaps are to be dissected and turn-
ed down.   The posterior surface of the tibia is then  to be  isolated from
the vessels and nerves, as well as from the origius of the gastrocnemii;
 and, finally, all the portions of the diseased bones are to be removed by
means of the saw.
  C. Process of M. Begin.—In place of cutting at first  a large quad-
rilateral flap, the new editors of Sabatier commence  by a transverse in-
 cision below the patella, which extends from one lateral ligament to the
 other, and penetrates at once into the articulation.   This being effected
 the femur is disarticulated, or the tibia only, in case only one of the  two
 bones should be diseased, by drawing two lateral incisions from the ex-
 tremities of the first  Drolonging them  upwards or downwards, to  a 
            EXSECTION OR EXCISION OF THE ARTICULATIONS.        501

 greater or less extent, according to the length of the portion  of the bone
 which is affected.
   D. Manne had already proposed the following  operative process, to
 excise the head of the bones of the leg :  " If the caries affects the up-
 per extremity of the tibia, without invading the condyles of the femur,
 we may separate it from the patella and saw it off, as well as the upper
 extremity of the fibula, below the part affected.  To effect this, we make
 an incision more than semi-circular at the anterior part of  the integu-
 ments, below  the ligamentum patella; we raise them up, divide the liga-
 mentum patellae, the anterior and  lateral  portions of  the capsular liga-
 ment, and then the crucial ligaments; after which we  detach the tissues
 adherent  to the . posterior part of  the tibia and fibula, by directing the
 cutting edge  of the instrument  downwards and forwards, to avoid the
 popliteal  artery and nerves.   We then divide the periosteum circularly,
 and having drawn aside the tissues from  the bones by means of a linen
 bandage or band, complete the exsection.   If any portions of the semi-
 lunar cartilages are left behind, after dividing the capsule, they are also
 to be divided.   The tibia and fibula are then to be approximated to the
 condyles of the femur.
  *E. The Process of M.  Syme differs from those above, in more re-
 spects than one.   The operator makes, in  front of the articulation, two
 semilunar incisions, one above and the other below, which are  united
 together on a line with the lateral  ligaments, and circumscribe a trans-
 verse ellipse, including  the patella ; he then excises this ellipse and
 the bone which is comprised within it, divides the ligaments and opens
 into the articulation, and exsects in succession the diseased extremities
 of the femur and tibia.

                     § III.—Different Processes.

  In order to exsect the whole knee-joint, Manne   (Ouv.  cit., p. 52,
 1789) cuts an anterior quadrilateral flap which he extirpates.  Jeffray,
 after making his two longitudinal and lateral incisions, finds it unneces-
 sary to encroach to any farther extent upon the integrity of the mnscles.
 When it happens that the patella has remained unaffected in the midst
 of the alteration of the other bones, as Portal (Traiti de VHydropisie,
 t. II., p. 295 a 297) has seen in two instances, this  process is one of
 the best that can be adopted.  If the soft parts which  cover or surround
 the patella are degenerated or destroyed by ulcers and  fistulas, it may
 be found  necessary to operate in the manner of M.  Syme.   I am not
 acquainted with the process by which Filkin has exsected the bones of
 the knee.   Park led the way in sawing the femur before  disarticulating
it, and every  one has since imitated him.   But it was Manne who pro-
posed to remove the  extremities of the femur and  tibia in mass, (en
bloc,) without disarticulating  them.   The anterior quadrilateral  flap
being removed, and the tissues detached with the  greatest care,  " we
 divide, says he, the periosteum around the  bones, which  latter are then
 to be sawed above and below the articulation."  This advice was for-
 gotten and unknown.   Mulder (Wachter, De  Articulis Extirpandis,
 p. 34, 1810) adopted it without knowing that it  had been recommended
 by  others; and  Wachter adds  that the removal of  the bones is thus 
502
NEW ELEMENTS OF  OPERATIVE SURGERY.
 made with the greatest ease.   M. Sedillot has succeeded equally well
 in applying the process of Manne or M. Syme to the elbow.
   I have said above that Manne, in those cases where he had to remove
 only the carious  extremity of the tibia, had, before  sawing this  bone,
 dislocated  the articulation at the knee, a process indispensable  under
 such circumstances.  The  head of the fibula, when it is not  diseased,
 should be saved on account of the biceps.   Park left it intact; Moreau,
 the son, (Essai, Sfc, p. 70,) was obliged to remove it.

                               §IV.

  The approximation of the bones after the exsection must be left  to the
 muscular action.   This remark was made by Moreau, the son, with much
 reason.   After the cure, the limb will require for some time the employ-
 ment of a prop, encasement, splint, &c, in consequence of the tendency
 of the bones to be deviated into a false direction.  It is equally important
 to prevent their riding upon each other. M. Syme  has insisted the most
 and with the best arguments, on the necessity of exercising certain  move-
 ments in the new articulation during the treatment; but the  patients he
 operated upon were very  young, and there is nothing to show that  reme-
 dial means and time would not have cured more than one of  these cases
 without the necessity of exsection.
   In whatever way the  operation is performed, the bleeding surfaces
 should be brought into contact and take  the place  of  the bones that
 have been removed ; points  of suture, simple  adhesive  straps, lint  and
 compresses, cushions and splints, in fact all the  articles required in a
 compound fracture  of the leg, are necessary to  complete the dressing
 and to keep the limb in a state of  the most perfect immobility.
  All these  processes  will  enable us  to  obtain  the object  we have in
view.  Whether we adopt the crucial incision  of Park, or  cut  out a
large quadrilateral  flap like M. Moreau, or like M. Begin penetrate into
the joint with the first incision, or remove the patella  or not, like M.
 Syme, the operation is practicable.   It is, therefore, as I ha've said  in the
beginning, not in consequence of the manipulating process employed, but
from the results which the operation may produce, that it becomes so
formidable, and ought, in my  opinion, to be generally  proscribed.   I
would except those cases only where  the articular surfaces alone  are
altered in such  manner  that  we  would be enable to  remove the  whole
 disease by excising an inch  or two  of each bone, as for example in  the
case of M. Jaeger.

                   Article IV.—The Patella.

  If the patella alone were carious or degenerated, it should be removed
without any  hesitation, though we should have to open into the articu-
 lation.  The  Journal of  Hygie contains an example of this  kind, and
the patient, it is said, was perfectly restored.   I have seen two persons,
who walk sufficiently well, though  the fragments of their  patella,  which
had  been formerly fractured, leave an  interval between  them of more
than four inches.  M. A. Severin,  (Med. Efficace ; Corps de Mid.  de
Bonet, t. L,  p. 313, §,  953,) being consulted by Father Mathias, who 
           EXSECTION OR EXCISION OP THE ARTICULATIONS.       503

was unable to go up and down stairs, from his patella having been  frac-
tured several months before, answered, that there was no other remedy,
unless after having made an incision through the integuments, the  frac-
tured surfaces of the petella should be abraded, and  afterwards bound
tight  together, adding, that this process was rude  and unpleasant, but
nevertheless necessary if he wished to recover promptly the function of
the foot.  But the patient  refused to comply with this advice, and did
well.
  In the museum of the Faculty of Medicine, of Strasbourg, there is a
skeleton in which the knee had no patella, (Musse de Strasbourg from
1820, p. 106, No. 219.)  " I saw some years since," says Diemerbroeck,
(UAnatomie du Corps Humain t. II., p. 683, ch. XIX.,) " a German
gentleman, whose patella was carried away entirely by a musket ball,
and who thereby wholly lost the ability to walk.  He was, nevertheless,
in some sort restored here, in our village of Utrecht,  by an artisan who
applied to the knee an apparatus constructed of iron, by which the thigh
bone was bound down and  kept united to the tibia;  so that when this
instrument was adjusted, he could walk  tolerably  well.  Nor could he
ever, from the moment he laid it aside, advance the foot to  make a single
step, or even support himself a single instant.
  In the following case they went  farther :—The patella was fractured
longitudinally, and the attempt at reunion failed; swelling and tension
of the whole thigh, leg and foot succeeded, with apprehension of speedy
mortification.   Gelee (Journ. de  Mid.  Milit., par  Dehorne, t.  IV.,
p. 503) being sent for eight days after the accident, judged that it would
not be advisable to count on topical applications.  Though the parts
were dilated by incisions which specially implicated the  tendinous and
ligamentous attachments of the patella, the progress of the disease was
not thereby arrested.  The fever placed the life  of  the patient in immi-
nent peril.   Having remarked, says Gelee, that the  strangulation was
owing to the two portions of the patella, from their constant tendency
to separate, drawing each of them respectively on tho attachment  of
these bones, " I looked  upon them as a double cause of the  accidents
which would not terminate unless  one  of the two portions was  extir-
pated."  One appearing to be sufficient to maintain the articulation, he
removed the  smallest portion, which was that on the outer side.  The
results of this singular operation proved  successful.   The swelling obvi-
ously diminished, and on the  eighth day, it had  quite subsided.  The
cicatrix was completed in six weeks, with  permanent extension of the
limb by anchylosis.
  The fear of placing the articulation in  contact with the  air, was the
reason why Theden (Progris ultirieurs de la Chir., p. 138) disapprov-
ed of amputation of the patella, " which was unfortunately performed,"
he  says, " in a case of gun-shot wound, since, it resulted in gangrene
and death. "  We have seen, says Percy and Laurent, (Diet, des Sciences
Mid.,t. XLIIL, p. 65) the patella separate itself from the knee, and
have more than once removed it entire, without the patient having there-
by lost the ability to walk.  " If a dislocated patella could not be reduc-
ed, I  would recommend," says Manne, (Trait'e Elim. des Mai. des Os,
p. 347,  1789,)  " that it should be removed, by making a longitudinal
incision in the integuments which cover it, and then dividing transversely 
501
NEW ELEMENTS OP  OPERATIVE SURGERY
above the base of the patella the tendon of the extensors of the leg, the
ligament which attaches the point of this bone to the tibia, together with
the membranous and aponeurotic portions which are adherent to its lateral
surfaces.   The extraction  of the patella  having been effected, the lips
of the wound should be brought together, or kept approximated to each
other, by maintaining for a length of time, the leg extended and the thigh
flexed by means of suitable dressing."  This operation, it would appear,
was successfully  performed in 1835 or 1836, by M.  Thyrion,  a surgeon
of Belgium.

                 Article  V.—Head of  the  Femur.

  White, (Cases in Surgery, 1770 ; or London Med.  Gazette, March,
1832,) having, it is said, about the middle of the last century, removed
the head and four inches of the femur in a child of fourteen years of age
affected with coxalgia, and  cured his patient,  ventured to propose this
operatiou as one that ought to be adopted in analagous cases.   A simple
incison on the outside of the thigh, enabled him to lay him  bare the ar-
ticulation, open the capsule, luxate the bone, and bring it to the external
surface in order to perform its exsection.   Vermandois (Journ. de Mid.,
t. LXVL, p. 49, 1786) and Petit-Radel (Encyclop.  Mith., part  Chir.,
t. I.) revived this suggestion without modifyingit. But Rossi (Med. Op.,
t. II., p. 225) soon  perceived that the incision proposed by White would
not answer, and that in order to arrive at the articulation, it was advisa-
ble  to cut a triangular flap upon the outer side of it.   Chaussier, (Soc.
Mid d'Amul.  t. III., p. 399,) about forty years since, undertook a series
of experimetns upon this subjec tand upon exsections in general.  Accord-
ing to him excision  of the head of the femur in dogs is not much  more
dangerous than that of the humerus.  There forms in place of the ex-
sected bone a fibro-cellular matter which afterwards becomes  cartilagi-
nous, and ultimately acquires a solidity almost  equal to that of the  os-
seous substance.  Watcher in his dissertation maintains nearly the same
opinions.
  In 1831 I knew of but a single example of exsection of the  coxal ex-
tremity of the femur  practised on living man.  At that time I confined
myself, to  the following  language: " If the  head of the  femur should
have escaped through the lacerated soft parts, and it became impossible
to reduce it, we could unqestionably  and ought to  remove it with the
saw, especially if it were  fractured; but what disease is there  of so
grave a nature as to require exsection of the bones, or that could attack
this point without being propagated to the cotyloid cavity ; and when the
bone of the pelvis is implicated, what advantage would there  be in ex-
section of that of the thigh ?   If, however, it should ever be decided
upon to undertake it, the most simple process, supposing that there was
no wound at the exterior, would consist in cutting,  by means of a semi-
lunar incision, extending from the anterior superior spinous process of
the  ilium to the tuberosity of the ischium, a large flap with its convexity
downwards and behind the articulation, at the expense of the  tissues at
the  root of the limb.  After the surgeon has raised up this flap and di-
vided the  posterior half of the capsule, he would be enabled by bring-
ing the thigh into adduction  and flexion, to divide  tho inter-articular 
           EXSECTION OR EXCISION OF THE ARTICULATIONS.        505

ligament, to insert the knife between the head of the femur and the co-
tyloid cavity, and to arrive on the inner side and in front upon the gorge
of the neck of the femur, in order to detach from it what remains of the
capsular ligament, and to bring out of the wound the whole of the por-
tion of the bone we wish to remove.   Nothing afterwards would remain
to be done but to place the thigh back to its natural position, bring down
the flap to secure it with the suture or adhesive straps, and to proceed
in other respects as in compound fractures of the  upper portion of the
thigh bone."
   At the  present day I must  speak in other  language.  A young girl,
affected  with  coxalgia, had the haunch perforated with fistulas.   The
head of the femur having become movable, says Vogel, (Bibl. Chir. du
Nord, p. 391, 393,) was extracted, and the child got well.  In the case
of another girl; aged fourteen years, mentioned by  Schlichting,  the
opening of a pre-existing atbscess was enlarged and the head of the femur
then exsected with success.  Are these the same, or other cases of des-  •
truction of the head  of the femur, than  those related  by Ficker and
Albert,  (Wachter,  De Art.  Extrip., etc.)  According to  M. Leopold
(Uber die Resection, etc., Wurtzburg, 1834,) this exsection  has  also
been performed successfully  by Kohler  and  M. Heine, of Wurtzburg.
M. Schmalz, (Hedenus, De Femore in Cavit.  Cotyl. Amput., 1823,) of
Pirna, in  Saxony, also removed the carious  head of the femur which
had already  separated from  the rest of the bone.  The boy was three
years in getting well; the new  articulation being formed by the  great
trochanter.  M. Kluge (Wagner, t. IV., de  VEncyclopidie  de  Bush,
Graefe) had  also exsected the  head of  the femur in a state of caries ;
but the patient died two days after the operation.   Brandisch (Simmons,
Journal de Midecine, translated from the English, t. VI., p. 114, 1786)
had also published  the following case :—A wound of the thigh from a
fire-arm.  A portion of the  head of the  femur, representing about  the
whole extent of its upper half, came away in exfoliations.   The patient
got well.  The limb which was scarcely any shorter than the other, could
be brought into extension, and  the patient use  his limb, so as to walk
with ease by means of a crutch.   In the case of Schlichting, (Transact.
Philos., p. 284, No. 466, 1742 ; Bibl.  Chir. du Nord, p. 392,) the cure
was accomplished in  six weeks, and the  patient could walk with ease,
but not  without  limping.  M. Hewson, of Dublin,  (Leopold, Op cit.,
p. 16,) in the year 1823, in  a case of caries, adopted  the process of
White, and exsected  the head of the bone above the  little trochanter.
The patient died three months after the operation in consequence of
purulent collections, which extended from the cotyloid cavity by means
of an opening into the pelvis.   M. Seutin (Bull, de Thir., 1833 ;  Gaz.
Med., 1833, p. 165) in the year 1832, exsected the head of the femur,
in a case of comminuted fracture from a cannon ball.  The patient died
in consequence of gangrene of the soft parts.  It would appear also
that M. Oppenheim (Leopold, p. 17, Gaz.  Med., 1835, p.  183)  once
performed this operation at Schumla.  Jaeger and M. Textor (Leopold,
Op. cit., p. 17) also  had recourse to  it  in 1834, at Wurtzburg, in the
case of a  boy aged seven and a half years, and who had fracture of the
neck of the femur with abscess.   The head and neck of the femur were
removed, with two inches of the great trochanter. The child died at
   Vol.  II.                   64 
506            NEW ELEMENTS OF OPERATIVE SURGERY.
 the expiration of twenty-three days.   According to M. Jaeger, exsection
 of the femur would be indicated : 1, In cases  where there were splinters
 of the  neck and  head of this bone or of the great trochanter from
 wounds of fire-arms;  2, In cases of fracture of the neck of  the femur
 where suppuration and caries have  supervened ; 3, In cases of disloca
 tions complicated with fracture and laceration of the soft parts ;  4, In
 cases  of anchylosis of the articulation where the limb  could  not be
 made use of;  5, In caries of the  head of the femur in consequence of
 coxalgia, nor  would it be  contra-indicated then except there was at the
 same time  caries of the cotyloid  cavity or of the pelvis in general, and
 extensive purulent collections along the course of the  femur.
  [A diversity of opinion seems to prevail as to the operation of excising
 the head of the femur in cases of morbus coxarius. Mr.  Syme denounces it
 under all circumstances.  Sir Benjamin Brodie says, this operation should
 be performed  " only in those cases where unequivocal  advantage may be
 gained by it."  Mr. Fergusson has  performed it in at least  four  cases,
 and is of the opinion that under certain circumstances it may be resort-
 ed to with benefit to the patient, though he admits that thus far the ex-
 perience on this subject in London has not been very satisfactory.   Mr.
 Henry Smith, who has himself had an unsuccessful case, published  some
 statistics of this operation, in the London Lancet. April, 1848.  Of 16
 cases which he had  collected, in  one half it had proved  successful.
 In 3 of these, however, it was  performed for a communicated fracture
 of the joint by a ball, necrosis from an old fracture into the joint, and
 in one case  for caries of  the  great  trochanter and neck of the  femur.
 The  acetabulum is not always involved, as was supposed  by Mr. Ford,
 and as is even yet  maintained  by M. Syme.  This was proved in the
case in which Mr. French operated, where the disease was of long stand-
ing ; and  even if the  cotyloid  cavity be involved, we may, as did  Mr.
Walton, with a gouge remove the carious portion;  for this caries, Prof.
 Syme assures us, does not affect the bone deeply.  Again, this  part pos-
 sesses far  greater  reparative powers than the head of the femur, and
may, if but moderately affected, undergo a spontaneous cure.   A recent
writer on  Surgery, Mr. Erichsen, observes, that if the head of  the  bone
 still  continue in its socket, the operation  should not be undertaken.
 Now, if this rule be strictly followed, it will seldom be performed, for
 cases of dislocation are beyond all  question  very  rare.  We  know of
 no writer  who has more  satisfactorily  established this fact  than  Dr.
 March, of Albany.  In his paper On Coxalgia, in the  Trans.  Amer.
 Med. Association, Vol. VI. 1853, he has collected  evidence on this
 point sufficient to convince the most sceptical.  M. Bonnet, in his  Traiti
 des Mai. des Articulations, Vol. II.,  pp. 394, 400, has shown   how fre-
 quently mistakes have been  made in this  matter, and Mr. Fergusson
 agrees with the writers already quoted, that  spontaneous dislocations
 in coxalgia are  very rare.   In the  spring  of 1847,  we saw  M. Roux
 exsect the  head of the femur.  The  patient was a little  boy who sank
 in two or three days after the operation.   The cotyloid cavity and the
 great trochanter were found in a carious condition, the upper extremity
 of the femur was inflamed and surrounded by numerous large abscesses
 in the soft parts.  In this case, the  head of the bone, previous to  the
 operation, was in its natural position.  M. Sedillot, who is an  advocate 
           EXSECTION  OR EXCISION OF THE  ARTICULATIONS.        507

for the operation, states (Trait'e de Med. Operatoirc, Vol. 1st. p. 512)
that in 1850, he saw at Wurtzburg, in the hospital of M. Textor, a young
man on whom this  surgeon had operated some  years before, and who
walked and bore his weight on  the limb without  difficulty.  We believe
that Dr. Bigelow, of Boston, has had a case which terminated fatally,
but Dr. Sayre  has been  highly  successful, although a portion  of the
socket, in a diseased state, required removal.   Through the  politeness
of Dr. S.  we have had frequent opportunities of watching the progress
of this case, than which nothing could be more gratifying, or  calculated
to strengthen our confidence in  the operation.  G. C. B.]

                                §1.

   Leopold describes the operative process in the following manner ; the
patient is  laid upon his sound  side and the operator places himself be-
hind him.
   A.  First Stage.—The articulation is laid bare, 1, by a simple longitu-
dinal incision on the  outer side of the haunch, or upon the  trochanter
itself,  as was done by White, Park, Vermandois, MM. Hedenus, Syme,
and Seutin;  or 2, by a semi-lunar  incision going  round the  great tro-
chanter, as recommended by Jaeger, and as I have mentioned above, or
by dividing the gluteus  maximus muscle, as recommended by Hewson,
who also cut a semi-lunar flap about the great trochanter ; 3, a posterior
square-shaped  flap, situated upon the outer  part of the  articulation,
would be  preferred by Percy and M. Roux ; Jaeger, who commences by
a longitudinal incision at two inches or two inches and a half above the
great trochanter, and which is to descend to three inches below it, adopts
a triangular  flap of five to six  inches in length, which he completes by
another incision of four inches in length, placed posteriorly and below
in such manner as to divide the insertion of the muscles on the antero-
superior part of the trochanter, while opening  into»the capsular  liga-
ment.
   B.  Second  Stage.—The  head of the femur is most usually removed
by means  of  the  common saw; but in muscular patients, Heine's saw
would present some advantages.
   C.  Third Stage.—Dressing.—According to  Jaeger the union of the
wound by the suture  or adhesive plasters, and  dressing with lint, com-
presses and a spica to the groin are injurious.   This surgeon leaves the
wound untouched, or unites it only at one part by a suture, and applies
to it cold fomentations.  The  patient is to lie upon his sound side, with
the femur and leg slightly flexed.

                        § II.—Appreciation.

   Without recurring  to what  I have  said of it at first, or adopting in
every particular the favorable opinion which Jaeger has of this operation,
and of which the thesis of Leopold  appears to be an exact  transcript,
I will say then in  conclusion,  that exsection of the head of the femur
stands in  the same relation to disarticulation of the thigh, that that of
the head of the humerus does to disarticulation of the arm.   The modi-
fications of the process also must be the same  in both cases.   More- 
508            NEW ELEMENTS OF OPERATIVE SURGERY.
over, if White is in reality the first who recommended it, I am not sure
that M. Coulon and Leopold have not, in the cases they attribute to this
author, confounded the  recommendation with the fact of the operation.
To illustrate the effects of this exsection, experiments have also been
made upon dogs by Vermandois, (Ancien. Journal Med.,t. LXVI.,p. 74,)
Kohler, (Exper. circa Regener. Ossium, Goett, 1786, p. 84  et 91, Exp.
XIV. etXV.,) Chaussier^ (Magasin Encyclop., an V.r t. VII., p. 248,)
and by Wachter, (De  Arliculis  Extirpandis, p. 91—94 ;)  upon which
subject Vermandois, (Ancien Journ. Mid., t.  LXVI., p.  70, 1786,)
Rougemont, (Bibl. Chir. du Nord., 1788, p. 392,) Petit-Radel, (Ency-
clop. Mith. Diet, de Chirurgie,) Rossi, (Midec  Op., Turin,  1806, t. II.,
p. 224,) Wachter, (Euvr. cite, p. 85,) Briot, (Hist. Chir. Milit., p. 177,
(817,) Jaeger and Kluge,  (Coulon, sur la Carie, p. 41,) MM.  Seutin,
p. (Euvr. cit., p. 41,) Coulon,  (CEuvr. cit., p. 177, 178,) and Baudens,
(Ibid., p.  124,) are subsequent to White.
  Briot, (Ibid., p.  88,) who  supposed that  the idea  of the operation
first originated  with  him, and who wished to perform it on a child of
thirteen or fourteen years  of age, proposed to cauterize the caries of the
cotyloid cavity, after having removed the extremity of the  femur.   M.
Syme  (Hist, de la Chir. Milit., p. 177, 1817) regards the operation as
altogether useless in cases of coxalgia, for he admits with me, that the
cotyloid cavity almost always diseased at the same time, is generally  af-
fected  to a greater extent than the femur.   Moreau, the father, however,
with the  hope  of removing the  carious portions of the cotyloid cavity
by means  of the chisel and gouge, proposed to two patients,  in presence
of M. Champion, to perform upon them the operation of exsection of the
femoro-iliac  articulation ; but they refused and recovered.
  White, Vermandois,  Petit-Radel, and Wachter, who  assert  that  the
touch in such  cases is as sure a guide as  the eye, confine  themselves to
a single incision.   "The following, says Briot, is the method I projected
for this operation .•• I would  have made at the upper and  outer part of
the thigh a  long and deep incision, the borders of  which I  would have
held apart, and if necessary divided.   I would have laid bare the upper
part of the femur, divided transversely the capsule,  and triangular liga-
ment, examined the condition of the great trochanter, and respected the
tendons which are inserted upon it, if I had found it sound ;  in the con-
trary case I  would have divided those tendons, directed  the knee inwards
and the upper part of the thigh outwards ;  then with a  small saw would
have exsected the whole of the diseased portion of  the bone.  If I had
found  the cotyloid cavity carious or diseased, I  would have immediate-
ly cauterized it; afterwards I would have endeavored, by means  of the
dressing and a bandage methodically applied, to  place the  femur in con-
nection with the tuberosity of  the ischium, with which I would have en-
deavored to  make it contract an artificial articulation."
   Rossi (Med.  Op., t. II., p. 224)  prefers a  flap in L and not in  V.
M. Montfalcon (Mem. sur VEtat Actuelde la Chir., p. 103, Paris, 1816)
also prefers  this form  of incision.  M. Roux (De la Resection ou du
Retranch. des Portions d'Os Malades, p. 49, Paris, 1812, in  4to)  thinks
that here, as at the shoulder,there is no necessity of economizing  space;
and that  it  would be preferable to make outside of the  articulation a
large square-shaped flap, adherent by its upper border, in the same man- 
           TREPHINING  OR OPERATION WITH THE TREPHINE.        509

ner as Voehler or Puthod, and all these who have described the extirpa-
tion of  the  thigh before the time of M. Larrey, proposed that it should
be  made for this last mentioned operation.  Percy (Diet, des Sciences
Med., t. LXVIL, p.  554) also recommends a square-shaped flap, and
M.  Champion has often seen Moreau, the father, go through the manipu-
lation of exsection  of the head of the femur, by means of an enormous
quadrilateral flap, formed  upon the outside.   But the semi-lunar flap
which I have  recommended, and  which M. Begin (Nouveaux Elim. de
Chir., Paris, 1838, t.  II., p. 821) adopts, is I think preferable to all the
above forms of incision.
                 SECTION  ELEVENTH.

                            TREPHINING.

  Trephining appears to have been practised from the remotest antiqui-
ty.   Its origin is  lost in the night of time.  It is performed on almost
all the bones of the body, particularly in connection with their exsection ;
but more especially upon the bones of the cranium.
                           CHAPTER I.

                    Arricle I.—The  Cranium.

  Trephining, notwithstanding the improvements which it received from
the physicians of ancient Greece, and its  relinquishment in the middle
age to that species of charlatans whom Sylvaticus denominates circula-
tores, is one of those operations which, since the time of Guy de Chau-
liac, have more  especially occupied  the attention of  surgeons.  For a
long time it was believed  to be the principal and  only remedy for acci-
dents which supervene  from blows, falls, and most of the traumatic  le-
sions of the head.   Panaroli and F. de Hilden (Bonet,  Corps de Mid.,
t. II., p.  374) applied  the  trephine for a simple chronic  cephalalgia,
and  Marchettis  for  epilepsy, M. A.  Severin, who formally advises tre-
phining in this last case, is sustained by the example of Sala, Boucher,
De La Motte, M.  Dudley, and M. Unger, (Encyclogr, des  Sc Mid.
1838, p.  171.) a surgeon of Chateau-du-Loir, whom I saw operate in
1813, have since done the same thing. M.  M. Guild (Rev.  Mid., 1829,
t. IV., p.  301) and Warren, (Communicated by  the  author,  1837,) in
these latter times, assert and they have also each performed this opera-
tion with  success (for epilepsy.)   The epilepsy however reappeared in
the young man operated upon by M. de Renzi, (11 filiatre sebezzia, Oct.,
1837.)  A wound in the sinciput was followed by vertigo and paralysis;
Scultetus (Arsen. de Chir., p. 23, obs. 13 ;  Diet, des Sc. Mid., t. I., p.
15) applied  two  crowns of the trephine at the expiration of nearly two
hundred  days, and cured his patient.   A  man mentioned  by Wepfer,
oaused his cranium to be perforated with a  wimble by a blacksmith, who
thus cured him of an ancient cephalalgia:  Fractures of  the internal ta- 
510            NEW ELEMENTS OF OPERATIVE SURGERY.
ble of the bones, which Garengeot has so often spoken of, and attrition
and  simple contusion of the diploe, have also  been ranged  among the
cases which require the employment of the trephine ;  but we must take
care not to  go too far in such cases.   M. Ramsden, who ventured to
perforate the frontal bone for a simple supra-orbitar pain, saw his patient
die on the fourth day from meningitis, and I could easily cite other sim-
ilar  unfortunate cases.  What I have said of exsection of the cranium
renders it unnecessary for  me to treat at length of the trephine, the
more so as I have elsewhere (De VOper. du Tripan dans les Plaies de
la Tile, etc., 1834) considered all that appertains to this last-mentioned
operation.
   [Dr. Dixon, of this city, reported in the Boston Medical and Surgi-
cal Journal, August, 1846, a case of neuralgic affection of  the  cranium
cured by trephining.   G. C. B.]

                         § I.—Indications.

   The object of the trephine is to give egress  to the. foreign liquids
which may have become effused in  the cavity of the cranium, to allow
of the removal of  splinters which have  penetrated into  the brain, and
the extraction of any extraneous body whose presence might interfere
with the cerebral functions.
   A. Fractures.—Nothing  is more vague than the signs  by means of
which  authors pretend to recognize the various  lesions which require
trephining.  The sound of a cracked pot and perforated at the moment
of its fall, or that  which is emitted by bones when they are struck by a
small stick, as mentioned by Lanfranc, are altogether insignificant.   It
is the  same with  the inclination of certain patients  to carry the hand
mechanically to some determinate  point of the cranium; the concussion
experienced by others at the moment when a piece of linen which they
compress between their teeth is suddenly snatched  from their mouth;
and the painful sensation they experience in making a long inspiration,
and upon which Roger, of Parma, has  so much insisted.  All  those
signs may fail though there exists a fracture, and on the contrary, may
be present in lesions infinitely more unimportant.  Besides, it is not the
fracture properly  so called, but rather  the compression which  it has
caused, which should justify the operation of the trephine.
   B. The presence of effusions, whether  sanguineous or purulent, is also
equally difficult to ascertain.  We may especially find it extremely em-
barrassing to  identify their situation.  Sometimes it is immediately un-
derneath the point injured that they are  formed, sometimes at the point
diametrically opposite, and  frequently also at a less remote  distance
from this point.  The paralysis which indicates that the injury is situat-
ed on the opposite side of the cranium, may  be found  to be on the cor-
responding side, (Bayle, Rev. Mid.)  If the integuments of the crani-
um are not altered; if no contusion or  division is observed  there, it is
almost impossible  to determine (prevoir) within half  an inch, and often
within several  inches, what is the precise locality of the effusion.  The
application of a cataplasm over the whole head, as recommended by the
ancients in order to  ascertain  which part of this topical application
should become dry the soonest, and which would correspond to the part 
           TREPHINING OR OPERATION WITH THE TREPHINE.        511

diseased, is a puerile  resource, the exact value of which has  long since
been properly appreciated.
  C.  On  the other  hand, as it has been found that collections though
they were considerable, have been absorbed (se dissipent) without tre-
phining ; as fractures with depression (I'enfoncement) of  near an inch,
a case of which kind has been related respectively by M. J&nn\n,(Bull.
de la Fac. de Med., t. VI., p. 498—509.)  Physick, MM.  Horner, Pail-
lard,  Graefe, Ribes, &c, have  nevertheless, not prevented certain pa-
tients from recovering without an operation, Desault and his school, con-
testing the doctrine of the ancients, and of Garengeot, J. L. Petit, Do
Quesnay, Pott,  and the  entire Academy of Surgery, and  falling back
upon  the  ideas of Van  Wyck, Aitken, and  Metzger, have  with good
reason  established as a general position, that the operation  of the tre-
phine is rarely  necessary, and often injurious, and that we ought in con-
sequence to dispense with it, in a great number of cases where the sur-
geons of the  last  century recommend it.  This doctrine, which is  sus-
tained by the researches of Briot, and which is advocated by  Professor
Graefe, at Berlin, and adopted by the English surgeons,  has generally
prevailed  in  France, where it has found a zealous, in fact, an extrava-
gant champion  in M. Gama.
  D.   Some respectable  practitioners,  however,  M.  Larrey, M. Roux,
Dupuytren, Delpech and others, have on several occasions used the tre-
phine with success at the Hospital of the Garde Royale, La Charite, and
the Hotel Dieu of Paris.  Beclard and M. P. Dubois were not less for-
tunate in a case of fracture without displacement, though they had been
obliged to apply three crowns  of the  trephine on  the  temporal fossa,
and to  extract  nearly eight ounces  of blood furnished by  the middle
meningeal artery.  M. Toussaint, in 1825, published a similar  success
which he obtained by means  of six crowns [i. e., six  applications] of
the trephine, and  I  have  elsewhere  shown (Opirat. du  Trepan dans
les  Plaies de  Tete, etc., 1834) the little  value [to be attached to] of
most of the  arguments invoked against the trephine by its most zealous
opponents.
  Thus without being as prodigal in the use of the  trephine,  as was the
custom before the time of Desault, and without absolutely admitting with
MM. Foville and Flourens, that it may be useful in protecting the organ
from compression in the inflammatory and other fluxions of the encepha-
lon, it appears  at least, that it ought to be had recourse to more fre-
quently than it  actually is at present.   If it  be true, that we are often
embarrassed in recognising the seat and nature of the diseases which in-
dicate it, it is not the less so, that in some cases the  difficulty  is not
placed beyond  the reach of an intelligent  practitioner.  Moreover the
patients, when it is decided upon to employ  it, are in so alarming a state,
that a simple perforation of the cranium cannot add much to the dangers
with which they are threatened.  If then we  should  have become posi-
tively assured by any means whatever, that a foreign  body, splinter, an-
gle of bone, or extravasation of fluids are the cause of the  unpleasant
symptoms noticed, then  ought we to  trephine; the same must be done
for those effusions, ancient or consecutive, which are  announced  by the
necrosis of the  bones, the separation of the pericranium, the  dark color
of the surrounding tissues, the pale aspect  of the lips of the wound, the
crepidation of  the integuments of the cranium, &g. 
512
NEW ELEMENTS OP OPERATIVE SURGERY.
   A sailor received a blow on the head, which was followed by fracture
of the cranium and compression of the brain.  The  trephine  was em-
ployed, and the patient was cured, (Filled, Gaz.  Mid., 1833, p. 47.)
A depression of the cranium kept up  a paralysis.  M. Warren (com-
municated by the author, 1837,) had recourse to the trephine, and cured
his patient:   A lock of hair which had got folded  back upon the dura-
mater, during the  accident, afterwards became  firmly imprisoned be-
tween the edges of the fracture.  As no cerebral accidents had super-
vened I waited : symptoms  of compression and meningitis now came on.
The trephine was used but the inflammation continuing unsubdued, death
ensued.   I would have operated sooner, had not M. Rey, (These No.
79, Paris, 1834, p. 99,)  in a similar case seen a cure take place  after
the formation of a sequestrum.
   [The  trephine has been  frequently employed by American  surgeons
in the treatment of epilepsy, and Dr. Stephen Smith has  furnished  us
with an  interesting statistical paper on  the  subject in the New  York
Journal  of Medicine, &c. for March, 1852.   Of 27  cases, there  were
unrelieved, none ;  relieved, but not  cured,  3; immediate  relief  after
operation, 2 ; relieved  when  seen at the end of a month, 3 ; between
one and six  months, 3 ; between six months and one year, 6 ; between
one and  five  years, 3 ; set down cured, but lapse of time  from date of
operation to time last  seen, not given, 7.
  Among the causes, we have, external violence to the head, 24 ; scrofu-
lous caries of cranial bones, 1; unknown, 2.
  Appearances.—Thickening of bone,  7 ; fracture, 6; both tables,  4  ;
inner  table,  fractured, and driven  in, 2 ;  spicula  of bone, 5 ; no morbid
aDpearances, 1.
  But little more than a century since, several insane patients in Swift's
Hospital, Dublin, were trephined, on the supposition  that their insanity
was produced by the brain having become too large for the cranium!
                                                        G. C. B.]

§ II.— The parts of the  Cranium which admit of the application of the
                             Trephine.

  The operation being  once  decided  upon,  another question presents
itself: upon  what  region should the  instrument be  applied?   It was
formerly established, that the trephine  should not  be applied above a
horizontal line which  would  separate the base  from the  vault of the
cranium, by passing  near the nasal process [of the temporal  bone,]
and on the external occipital  protuberance ;  nor  upon  the  sutures, nor
track of the sinuses  of  the dura mater, or frontal sinuses, nor  on the
temporal fossa,  anlero-inferior angle of  the  parietal bone, &c.   Not-
withstanding which, Beranger de Carpi, Cortesius,  Hoffman, Bromfield,
and Pallas,  have trephined opposite  the sutures with entire success  ;
while Acrel, Wurm and many others have perforated the frontal sinuses
with good results.   We shall moreover find (under Tumors of the  fron-
tal sinus) that the trephine is frequently required  for the  peculiar dis-
eases of those cavities.
   [In the British and Foreign  Medical  Review, January, 1846,  there
there is an account of a remarkable case in which Dr. Wuth, of Vienna, 
            TREPHINING OR OPERATION WITH THE TREPHINE.       513

trephined the frontal  sinus for the extirpation of a polypus from that
region.   The operation was successful, though the healing of the parts
occupied twelve months, when the  osseous cavity  which had been enor-
mously distended by the  morbid growth, returned nearly  to its normal
form.  A full report of this case  may also be  found  in Ranking''s Ab-
stract, Vol. III. p. 114.   G.  C. B.]
  Warner, Marchettis, Garengeot, Sharp, Pott, Callisen,  Mosque and
Lassus, have laid open different sinuses of the dura-mater, without any-
thing unpleasant resulting, and the experiments of M.  Flourens on ani-
mals, go  to prove that  this may be done almost without any inconveni-
ence being thereby produced.    [See Remarks  of Dr. Mott on this sub-
ject, Vol.  I.]
  Carcano, and Job a  Meckren, had already had the  boldness to tre-
phine upon the  temporal fossa, without regarding the lesion of the fibres
of the temporal  muscle,  while Bilguer,  Copland,  Gooch, Abernethy,
Hutchison, and Giersh, have laid bare the brain  in perforating the oc-
cipital bone.  When we apply the trephine upon the sutures, either the
body to be extracted is found immediately  underneath, and  then their
adhesions have  necessarily been destroyed, or  the seat of  the difficulty
is not there, and then the operation should be  performed  upon  another
point.
  M. Larrey, Boyer, M.  S. Cooper, and C.  Bell, have remarked, that
upon the frontal  sinuses,  we  shall be enabled to avoid  wounding the
membranes, by  commencing the operation  with a crown larger than the
one that  we are to terminate with.  Moreover  what  danger would there
be in wounding the dura mater ?   When we open into the venous sinuses
of the cranium, the hemorrhage which was so  much dreaded by the an-
cients, generally ceases of itself, or at least  by means of simple  tam-
poning.   [See  remarks of Dr. Mott, supra, on wounds  of  the sinuses of
the brain, Vol.  I., and  on hemorrhage of large  arterial trunks  in this
Vol. II.  T.]   On  the external occipital  protuberance there exists  no
other arterial branches of any considerable  importance except those of
the occipital; and  the lesion of the  trapezius,  or  complexus  muscles
which are attached to these protuberances, can be of  no  consequence.
In the temporal fossa, the section of the muscle, in whatever way it may
be effected, interferes  in  no  wise  with the restoration  of  its  functions.
As to the wounding of the meningeal artery it  could easily be remedied,
by means of a pledget of lint drawn from the interior to the exterior of
the cranium by  means  of  a double thread to be fastened  outside upon
another pledget, as was done  by Physick, or by means of  cauterization
with a probe heated to a  white heat as practised by M. Larrey, or by a
plug of cork pierced in its centre, or by a piece of wax,  or a  plate of
lead  bent in such manner as to compress the two  sides of the bone and
the furrow which contains the artery, to which vessel a ligature was on
one occasion successfully applied by Dorsey  of Maryland.
  Sabatier, reviving the  precept of Lanfranc, recommends placing the
crowns of the trephine  near the depending point  of the extravasation.
As it is almost, always practicable  by changing the  position of the pa-
tient, to incline the opening into the  cranium  downwards  ; as we more
frequently have recourse  to the operation  in order to extract a foreign
solid bodv, than to give issue  to liquid  matters ; and as it is rare that
  Vol.  II.                    65 
514            NEW ELEMENTS OP OPERATIVE SURGERY.

the effusion has any considerable extent, this precept  is  less important
in practice than might be at first  imagined.

                          § III.—Dressing.

   Hippocrates speaks of a rasp known under the name of xistre, with
which he scraped the bones, that he might thin them, or recognise their
cracks.   His trephine was  a sort of gimlet, acting in  the manner of a
drill.  He speaks however, of another also, which must have had some
analogy to the crown-piece  which was described  at a later period.
Celsus gives to this crown  the  name  of modiolus; without  doubt says
Guy de  Chauliac, because it resembled a small wine measure.  He com-
pares the trephine, properly so  called, to the carpenter's auger.   Galen
is the first, who speaks  of abaptistes trephines,  i. c,  with crowns or
perforators, provided with a  border or sheath,  which prevents  them
from penetrating too deeply.   These abaptistes which  are  found men-
tioned in the Works of Lanfranc, and of a  great number of other sur-
geons,  have been long  since  proscribed  from practice.   A lenticular
knife, the  gouge and chisel, as  well  as the  meningo-philax, a sort of
stem terminated by a flattened button, and used for inserting the pledget
of lint,  between the dura mater and the bones at the time of the  dress-
ing, had been  already employed  in the time of Heliodorus  and Galen.
We find, moreover  in the work of Andre  de Lacroix, cutting pliers,
screw-rings,  and elevators, as well  as the  suggestion of  the  famous
triploid, recommended  by Scultetus, and  the disadvantages  of which
J. L Petit took particular  pains to point out.
   The  articles used now,  and  which are  usually contained in what is
called a trephine  case, are  a trephine, properly so called, with its  shaft
and crowns, a screw-ring, a central pin, and its  key, various elevators,
a lenticular knife, a chisel, cutting pliers, a crested saw, a small  brush,
and a leaden mallet.  The trephine and demi-trephine, which  the Eng-
lish and many German  surgeons prefer, should also make a part of this
case.  At  the present  day,  the osteotome-saw  of M. Heine, and the
turning-saw of M.  Thall, could readily replace  the ordinary  trephine,
if they  were  cheaper, or  more easy to  work with.  I have described
farther back the cases where we should have recourse more especially
to the rowel-saws of MM.  Martin and Charriere.
   We are indebted to Dr.  Samuel S.  Purple, senior Editor of the New-
York Journal of Medicine, Src, for the following illustration of  a new
trephine, the advantages of which we give in his  own words.
   " Several years since, owing to difficulties that arose in the operative
management of a case of severe and extensive  injury of the head at-
tended  with  depression of, and extravasation of blood  under, the cra-
nium, in a near relative, I  was led to engage in a series of  experiments
which at last resulted in the construction of the instrument represented
in the accompanying illustration.
   The several parts of this instrument, and their use,  may be described
as follows : The  crown  part of an ordinary  trephine (Fig. a.) attached
at right angles to a straight handle (b.) having a hinge joint.(c.) *  A

   * This  is the joint represented in the engraving, although a button joint that will admit of
more motion, may be used at the option or fancy of the  manufacturer.  The joint for the
attachment of the different sizes of circles or half circles may be easily modified, if desired. 
           TREPHINING OB OPERATION WITH THE TREPHINE.        515

centre pin (Fig. 2 d.) with a sliding handle (Fig. 2 c), which handle
can be moved freely, up or down, and which, when attached to the in-
strument  rests its shoulder (Fig. 2/.) upon the upper surface of the
crown portion.  The  object of this  movement is to allow of pressure,
more or less, being made upon the crown  portion by the operator's left
hand, as occasion requires.   The lower part of the centre-pin (Fig. 2g.)
is screw-shaped, which on being  inserted as far as is deemed neces-
sary into the bone remains stationary and serves to fix  the instrument;
it also answers all the purposes of forceps for  removing  the detached
portion.   In order to use the instrument it is necessary for the operator
to place the centre pin in the crown portion (as represented in Fig. 1.)
and then fix its screw  point into the bone  ; after this, grasp the sliding
handle in  the left, and the handle of the instrument proper in the right
hand, place now the handle at a right angle, by bending the hinge joint,
then pull and push the handle in the same manner as in using the ordi-
nary  amputation  saw.  By so doing the  crown portion will  traverse
one-third of the arc of a circle, or even more if desired, with  perfect
ease and uniformity.
 
516
NEW ELEMENTS  OP OPERATIVE SURGERY.
   This  instrument is intended as a substitute  for  the trephine of the
 present and trepan of former times.   But as the former instrument has
 almost if not entirely superseded the latter, it is only necessary for us
 to confine our remarks to this, while instituting a comparison  of their
 respective merits; and  in  doing so it will  be seen by examining the
 engraving and in using the instrument, that it  differs from the ordinary
 trephine, 1st, in  the  mode  of applying the motive power ;  2d, in the
 freedom  and ease of working it; 3d, in its  uniformity of action ; and
 above all, 4th, in the consequent less liability of injuring the  brain and
 its coverings.
   It is believed that if there is one operation more than  another that
 the experienced surgeon approaches with dread, it is that of applying
 the  trephine, in cases which necessitate its  use.  This  dread lies  not
 only in the acknowledged fact of the extreme delicacy of the operation,
 but  also in the fatigue to the  operator which accompanies as well  as
follows  its  performance.  But by the instrument  here represented the
 motions of the operator's hand and arm are the same as those produced
 in the use of the  amputation saw—a movement  which we  believe has
 never  (at least to  our knowledge) been  brought to bear upon this class
 of instruments before.   If we mistake not, one of the greatest  difficul-
 ties  in the way of  using  the trephine is the  almost  utter  impossibility
 of keeping the instrument in a vertical  position as respects the plane
 of the surface to which it is applied, while performing the movements
 of supination and pronation of the fore-arm.  With the instrument
just  described  there  is no difficulty  of  this kind.  The detachment of
 the motive power, as well as that by which the pressure upon the saw
 is made, from the centre pin, does away  with all such  irregularity, and
 admits of any  amount of. inclination being  given to the saw, in the di-
 rection that the operator may please ; and that too without the possi-
 bility (almost) of  the operator becoming  fatigued, or incurring, by so
 doing, increased liability of injuring the brain or its investments.  This
 feature has long  been a desideratum in the  action of this  instrument,
 and is one, it is believed, which will do away with some of the greatest
 difficulties and inconveniences and dangers of the operation of trephining.
   But it is in the use of  the  half circles that  the superior adaptation
 of this instrument will  be seen.  Take  for instance a case of fracture
 attended with depression of bone, and extensive injury of the membranes
 and brain—the depressed portion being  movable, but not sufficiently so
 as to admit of being  extracted.   Here the application of a full circle
 would cause greater depression and perhaps consequent increased injury
 of the soft  parts  beneath.   In  this caso the  half circle  may be used
 without the least danger of causing motion of the depressed portion  or
 injuring the  soft  parts.   Here, then, the indications  meant to be, but
 never  answered by Hey's convex saw, are satisfactorily fulfilled.  It is
 the writer's conviction of the value of the  foregoing facts, from expe-
 rience, that has led  him to  place this short  and imperfect account of
 the instrument before the readers of the New- York Journal of Medicine."
                                                        G. C. B.]
                       § IV.— Operative  Process.

   The patient being in bed, and having  his head  resting upon a small 
TREPHINING  OR OPERATION  WITH THE  TREPHINE.
517
 pillow, beneath which should be placed a plate  (planche)  or large me-
 tallic vessel, is held in this position by the assistants.
   A. First  Stage.—The  operator, provided with a straight, thick, and
 sharp bistoury, more  or less  dilates in  different  directions, the  wound,
 should any exist.   In the contrary case, an incision whose shape has un-
 dergone much variety, is made upon the integuments of the cranium, which
 have been previously shaved.  Lanfranc, Guy de Chauliac, and Lassus,
 recommend that it should resemble a 7 reversed.  V. Swieten  prefers
 that it should have the form of an  X, and that  its flaps should be ex-
 cised.  In general, we employ the T or crucial incision.
   When we operate  on the temporal region, cotemporary authors, fol-
 lowing Sabatier and  M. Richerand, advise that it should have the form
 of a V, with  its base above,  since according to them, we divide in this
 manner a very small quantity of muscular fibres.   I see nothing censura-
 ble in this mode, only that it  appears to me that there is a delusion as
 to its advantages.   If the apex of  the V  comprises a transverse sec-
 tion of the temporal  muscle, of less extent than its base, we neverthe-
 less divide all the fibres  included  between the  two extremities of this
 last.
   It is now a long  time since  the circular and triangular incisions, and
 all those in which the flaps were extirpated, have  been recommended by
 any one.   Whatever Pott may say of it, the crucial, (en croix) incision
 is that which is preferred.  For  myself, I should prefer  the semi-lunar
 incision, which  allows of  our raising up  and letting fall the flap upon
 the Cranium as everywhere else.
   When we have no apprehensions of encountering fissures, the bistoury
 may  be  carried down to  the bones with the first cut.  The flaps being
 raised up, protected  by fine linen, and held back by the fingers of an
 assistant, the  next step recommended is to destroy the pericranium with
 a rasp.   This is a useless,  and even an injurious precaution. The peri-
 cranium  in no wise  interferes with the action  of the trephine.  The
 wounding it with the saw is not more dangerous than that which is made
 by tearing it with a rasp.  In using the crown of the  trephine at once,
 we lacerate it only  on the  circle which is necessary, whereas the  rasp
 separates it always to a certain extent beyond that, which must evident-
 ly expose to necrosis ; it would be better to divide it circularly with the
 point of the bistoury.
   The vascular  furrows even which had already been pointed out oy
 Hippocrates, as calculated  to lead to the mistake of the  existence  of a
 fracture, would not be effaced  by it, (the rasp,) especially if they coin-
 cided with the abnormal depression of a frontal protuberance, and should
 present a certain depth, as I saw  at  La  Pitie, in 1831.   It would evi-
 dently afford  no assistance in distinguishing from a true fracture, the
lateral suture, which is sometimes found on the parietal bone, the devia-
tions of the sagittal suture mentioned by V. Swieten, Quesnay,  Bontius,
 (De Medecim Indorum, Obs. 10, p. 37,) and  Manne, (Obs. de Chir.,
etc., p. 505, 1729,) or the  arrangement  of the wormian bones,  which
came near  deceiving  Suncerotte.   Nevertheless, if we desired  to make
use of this instrument, it would be necessary  to  grasp its  handle with
the right hand, and  to  embrace its shaft with the thumb and fore-finger
of the left hand; then, by means of combined movements of the two 
518            NEW ELEMENTS OF OPERATIVE SURGERY.
 hands, to manipulate with it in such a manner as to provent its slipping
 or denuding the bones more than is desirable.
   B.  Second Stage.—When  we make use  of the  trephine, of which
 M. Withusen has proclaimed himself the champion in Denmark, the sur-
 geon embraces its handle with  both hands  and makes it act in the man-
 ner of a drill or cork-screw.  If, on the contrary, the trepan is preferred,
 its crown is  adjusted upon it,  after which  the operator  grasps its shaft
 with the right hand in the manner of  a  writing  pen ; directs tho  point
 of the centre-piece upon the centre of the  portion  of the bone which is
 to be removed;  presses on the crown to mark  this point, while the other
 hand supports the rest of the  instrument;  removes  the  crown immedi-
 ately after; puts in its place the perforating trepan, the apex of which
 is applied upon the point marked out by  the centre-piece; embraces by
 means of the  thumb and  finger of the left hand, united in a circle, the
 ebony plate which terminates the handle of the  trepan ; presses on this
 plate by means of the chin or forehead ;  seizes with the right hand the
 body of the  shaft  of the  trepan; causes  it to turn two or three times
 from right  to left; refixcs  the  crown in the  place  of  the  perforator;
 reapplies the instrument as at  first; fixes its  centre-piece  in the  hole
 which he has  just made, and makes this immediately  turn  as  before,
 while taking care to make pressure equally on all the teeth  of the free
 border of the saw, in order to  excavate a circular groove as regular as
 possible.
   As soon as this groove  is sufficiently deep  to hinder the crown from
 escaping, the  centre-piece should be removed:  otherwise it would render
 the operation more tedious and  dangerous.  As it goes beyond the level
 of the crown, it would necessarily arrive upon  the membranes before the
 section of the bones was  completed.   As  soon  as  the  trepan is again
 replaced in its first groove, the  surgeon makes  it act with rapidity while
it  is yet at a certain distance  from the  dura  mater, withdraws it from
 time to time, to see if the section is made with  regularity, and to cleanse
its teeth with  the brush, and also, as Hippocrates had remarked, to pre-
vent it from becoming too much heated ;  gradually  afterwards relaxing
its motion as soon as  it  traverses the  layer of the diploe, the operator
tries from time to time, by means of the elevator, to raise the osseous
 disc circumscribed by the crown, and finally ceases to act with the trepan
when  he hears a  cracking sound, which it is impossible for those who
have ever heard it, to mistake for any other, and which indicates that
we have reached  the membranes.  The bones of the cranium were so
 thin  in  a child, says  Peu,  (Pratiq. des Accouch., p. 197,) that the tre-
 pan penetrated suddenly  into  the brain.  In a patient, mentioned by
 Sellier, (Bibl.  Chir. du Nord, p. 130,) the perforating trepan must have
 penetrated  to  18 lines into the substance of the brain, without causing
 any accident!  The osseous plate, when it is completely divided, comes
 out sometimes at the same time with the crown.   In the contrary case,
 we pry it out with the point of an elevator, which we use as a lever of
 the first kind.
   C.  Third Stage.—If the cut is smooth  it is useless  to employ other
instruments to regulate the contour ; but as there are often found some
points  or  sharp lamellae  at its deep-seated portion, it is the custom to
apply tho lenticular knife to these, the button  attached to which is kept 
            TREPHINING OR OPERATION  WITH THE  TREPHINE.        519

 between the dura mater and the bones, in order to  make its cutting edge
 pass  round the entire circumference of the aperture which has been
 made.  If we  have reached  the seat of the evil,  the liquid matters be-
 gin  to flow  immediately.   If it is  a solid  foreign body, we remove it
 with  the forceps  or any other appropriate instrument.   Sometimes we
 perceive that  the  extravasation has extended to  some distance beyond
 the point upon which we have operated.  When it consists of coagulat-
 ed blood or any other plastic material, a single crown is insufficient to
 give  it exit; in that  case we should not  hesitate to apply a second  or
 even  a third.   The destruction of a large portion of the vault of the
 cranium should not intimidate us when it seems indispensable.   Solin-
 gen says, the Prince of Orange bore the application of the trephine sev-
 en times without inconvenience.  Spigel relates a similar case.   V. D.
 Yiell speaks of a case in which the trephine was used twenty-seven times.
 Thus, as we have seen above, M. Toussaint effected a cure after the ap-
 plication of six crowns in a patient whose case he communicated to the
 Academy, as Cullerier, (communicated by  the author to M. Champion,)
 had  done in another.   All the world, moreover, .know  the facts cited
 by Blegny, Saviard, and Lavauguyon, in which it is seen that almost the
 entire vault  of the cranium was  destroyed without causing death.   A
 patient of Sand, (Th.  de  Holier, t. I., p. 97,)  had in this manner an
 opening in  his head of six inches circumference, and that of Vigaroux,
 ( Opusc. sur la Regin. des  Os,  p. 127,) had lost the greatest portion
 of the frontal bone.  Many Theses of Strasbourg contain facts not less
 remarkable.
   D.  Fourth  Stage.—When  many  crowns are applied with the simple
 view  of obtaining a large opening, iff is no  longer the usage to leave be-
 tween them a species of bridges which were  to be broken up by the strokes
 of the chisel, as was done by many surgeons of the middle age.  We arrange
 them, since  the time  of Z. Platner, (Institut.  Chir., § 160, et Hist, de
 Sprengel,) in  such manner that the circumference of one shall extend
 as close as possible upon that of the other, in order that nothing may
 rest  between them but  angles more or less salient, and  which may be
 readily removed by the cutting-pliers.  If we renew the perforation of
 the cranium, because the  first has  not fallen on the extravasation or
 foreign body, this is a second operation to be performed, and which must
 be conducted upon  the principles laid  down above.   When the morbid
 collection is  found  immediately underneath the  bones, nothing should
 induce us to divide  the dura mater.  But when  the fluids are extravasat-
 ed more deeply, we are no longer fearful since the time of Glandorp,
 of incising this membrane. We should not, however, do  this except in
 cases  where  plausible  grounds  exist to assure us  almost with certainty
 that  we  shall  come down upon  the  seat of  the difficulty,  that is to
say, where  there exists a darkish, livid or  yellow tint, and a protrusion
more or less considerable of the external membrane.
   This  division is  effected by means of a bistoury, the point of which
is  held perpendicularly to  the extremity of one of the principal diame-
 ters  of the osseous opening, in order to bring it to the other extremity
 without making it  penetrate  any deeper.    The  advice  has also been
 given to incise the substance of the brain in cases where no fluid is found
 between  the  membranes.  In  support of this, authors cite a number of 
520
NEW ELEMENTS  OP OPERATIVE SURGERY.
facts, among others a case observed in the practice of Dupuytren, who
had  the courage to plunge the bistoury more than an inch deep into the
brain.   In three lines farther, M. Begin, who had already reached more
than an inch deep into the cerebral substance, would have fallen upon
an enormous  abscess!   [Those desirous of perusing the account of a
very heroic performance of this kind, may find it recorded in the Amer-
ican Journal of the Medical Sciences, January, 1850, p. 86.  G. C. B.]
Such conduct, however, should be  but  very rarely imitated.  When ex-
travasation  has  its seat in the substance  of the brain, how are we to
know where it is to be found ?  Is it not in such cases almost always the
effect of an  internal cause?   By  what sign should  we recognize its
presence, even though it should correspond to the opening of the bones ?
Doubtless a simple puncture of the brain, even though very deep, might
not cause death, or even give rise to any thing more than slight accidents ;
but as  the  contrary is equally possible, it could never be without trepi-
dation that the prudent surgeon, would decide upon dividing in this man-
ner the substance of the encephalon.  In some cases,  the extravasation
is  as it were separated into several portions, by bridles, adhesions or
partitions.   If this condition could be anticipated, we  ought not to con-
fine  ourselves to the application  of a single crown, but apply two of
them, one on each side, as has been advised for example, when we ope-
rate in the  neighborhood of the sutures or the track of the venous sinuses.
When  trephining is employed to extract or remove splinters, the opera-
tion  exacts some special modifications.  In the first place, the point of
the centre-piece  should  be applied upon the border of  the bone which
presents the greatest solidity, while the crown at the same time is direct-
ed upon the two sides of the fractufe.   Afterwards, as soon as the effus-
ion is removed, nothing remains but to attend to  the splinters or depress-
ed portions of bone.   We detach  every thing proper  to be removed,
either by means of the forceps or cutting-pliers, but never, unless in  a
case  of necessity, by the aid of a chisel, gouge or mallet.   To raise up
the parts that have been merely displaced, we have recourse to levers of
different forms. The tripod of the ancients, the triploid elevator of Scul-
tetus, an instrument similar  to  the screw-ring  of the Coopers, are no
longer  in usage.  The  elevator, armed wtth  a bridge,  as proposed by
J.  L. Petit, (Nouv. Elim. de Chir., t. II., p. 679 ;) and the same instru-
ment as modified by Louis, are alike rejected. All surgeons at the present
day confine themselves to the simple elevator, a shaft of steel about six
inches  long, curved in the form of  an italic S, garnished with the teeth
of a file upon the concave surface of its  extremities, which last moreover
are flattened in the form of a chisel or spatula.  In a case  of necessity,
in  fact, this last lever could be replaced by the ordinary spatula.   Fre-
quently, in  cases of fracture, we may,  by  introducing a chisel or some
other instrument into the  crack, produce  a sufficient  separation of the
bones for the effused fluids to escape outwardly, so as to render the ap-
plication of the trephine, properly speaking, unnecessary.  In fractures
with considerable separation, and in simple widening of the sutures, a
remarkable  example of each of which, as noticed in an adult, has been
given by M. Robert and M. Goubert, we should dispense with perforat-
ing the  cranium unless the fluids are effused opposite to some other point.
To remove  a necrosis,  splinter, or solid foreign body, implanted in the
cranium, the osteotome of M. Heine, with which M. Demme, ( Gaz. Med., 
           TREPHINING OR OPERATION WITH THE TREPHINE.        521  •

1834, p.  644,) of Zurich, had already obtained six successful results in
1833, would  be much preferable to the trepan, properly so called.   In
the absence  of this instrument  we  may in the same cases make use of
the flat or convex rowels;  but to give egress to the liquids effused  into
the cavity of the brain the crown of  the trepan still has the preference.
  E.  Fifth  Stage.—The dressing at the present day is much more sim-
ple than formerly.  We no longer  use in practice those oils, tinctures,
balsams, and unguents, of which M. Bertapaglia alone had devised more
than  thirty  varieties, and of which  the ancients  were so lavish.   The
gold  plate of nuck and that of lead recommended by Belloste, are  also
forgotten.  Practitioners at  the present day are satisfied with a disc of
fine linen, traversed in its  centre by a noose of thread which serves to
keep  it outside, and which is inserted with care between the dura-mater
and the bones, by means of the meningo-phylax-, a spatula or simple  but-
ton-probe ; in other cases this  dossil is  advantageously replaced by a
small  fine compress, besmeared  with cerate  and perforated with holes.
Its  middle portion is  inserted into  the aperture of the bone, while the
remainder covers  the  inner  reversed surface of the flaps and the whole
wound.   The  cavity or species of purse which results from this, is filled
up with  small  balls of lint which are covered over by one or more  plu-
masseaux.   Some  compresses are afterwards placed over these, and the
whole is maintained by means of a bandage, which the surgeon  arranges
sometimes in one manner and sometimes in another, or by a simple tri-
angular handkerchief, or the couvre-chef of Galen, or better yet by an
ordinary cotton cap, or serre-tete, or, as Heliodorus had already recom-
mended, by a net-work of hair, which the Spaniards use under the name
of reddizella, and which is worn among us as a head-covering for young
girls.   [For most of these forms of head-dressings, see Vol. I.  T.]
  Mynors and M.  Maunoir  recommend that there should be no portion
of dressing used in the opening in the cranium, but that the integuments
should be brought together and kept  in  contact by means of  adhesive
plasters.  Blount  and Herlich, who  have given the  same advice, say
they have followed it with success.   Others have gone still farther.  A
personage is mentioned  in whom a portion of the cranium had been re-
placed by a  corresponding  piece taken from the cranium of a dog;  and
M.  Maunoir  thinks the opening made by the trepan could be filled up in
this manner!   It would appear even that this unnatural transplantation,
which was made trial of in Germany, has been  attended with some  suc-
cessful results.  (See  Vol.   I.)   To me it appears evident that the ap-
proximation of the borders of the wound, would not prevent the effusion
of a certain quantity of fluids between the dura-mater and the scalp.  It
is  moreover, most usually desirable  to leave  the solution  of continuity
open,  to  give exit  to  the effused fluids, and to enable us to cleanse the
morbid  cavities a sufficient  length  of time after the  operation.   [For
Dr. Mott's views on this subject, see Vol. I.]

                             §V.

  The consequences of trephining exact no care which may not  easily
be obtained for the patient.   The dressing should be renewed every day,
once  or many times, if the  abundance of the discharge appears  to re-
  Vol. II.                    QQ 
 522            NEW ELEMENTS OP  OPERATIVE SURGERY

 quire it.  When the suppuration is dried up, and the cerebral affection
 has disappeared; when, in tine, nothing remains  but  the  wound of the
 operation, we proceed to hasten its  cicatrization.  Consequently we en-
 deavor to approximate its borders, and treat it in other respects like any
 other  simple  wound.  This  cicatrization presents some  peculiar phe-
 nomena.  Sometimes the circumference of the opening of the  bones be-
 comes attenuated  and seems to  approximate to its  centre, to  become
 ultimately blended with the  dura mater  and the envelopes of the  cra-
 nium.   At other times especially when the opening into the cranium is
 very large, its borders only become  blunted and rounded ; cellular gran-
 ulations rise up from the fibrous membrane, gradually fill up the aperturo
 formed by the  crown,  become more and  more solid, and  ultimately ag-
 glutinate with the exterior soft parts, from whence results  a real  plug of
 which  Duverney has  preserved a very beautiful  specimen.  Whatever
 may be done, there generally  remains  after the cure, a sufficiently deep
 depression upon this  cicatrix, the slight  thickness of which sometimes
 allows of  the movements of the brain  being perceptible externally.
  In such cases it has been also recommended, in order to prevent cere-
 bral hernia, to keep applied upon  the cavity which I have just mentioned,
 a convex disc, or plate of lead, or any other metal.  To show the neces-
 sity of these  sorts of plates, Monro mentions tho case of a young girl, who
 thinking she might dispense  with one which she had worn for a long
 time, was  soon seized with cerebral  accidents of which she died at the
 expiration of five  days.   As metallic substances  readily become charg-
 ed with caloric, it has been apprehended that among those persons espe-
 cially,  whose position in society obliges them to remain exposed to the
 rays of the  sun, they might  give rise to serious accidents.  At present
 they are replaced by pelotes  of leather or boiled pasteboard which are
 adjusted like the pelote of hernial bandages.
  If a necrosed plate  of bone  should continue  imprisoned in the soft
parts in such manner as to resist, as has  been sometimes  observed, the
action  of  the forceps, we must then, after  the  manner of J. L. Petit,
lay  it entirely bare and isolate it, and raise it  up and extract it  by
means  of  an elevator or any  other lever.   Colomb. (Obs.  Mid.-Chir.,
etc., p. 263)  thus  laid bare  and was enabled to remove  a  necrosed
portion of the inner table of the cranium.   M. Gerard (These, p. 53,
Strasbourg, 1802,) was less fortunate with an imprisoned necrosis of the
whole thickness of the bone ;  Guenot (Anc Journ. de  Med., t.  XVI., p.
 37) professes to have successfully removed on one occasion the whole
 frontal bone, together  with the ethmoid  and some plates of the nose !
 In a patient  mentioned by Hevin (Pathol., t. II., p. 171) the internal
 table only on reaching it with the trepan was found carious.  In j^oung
 children,  and  even in  some  adults, instances of which are related by
 Morgagni and Pestalozzi, (Lettre d un Med. de Province, p.  65,  1747,)
 the cranium is sufficiently  thin to enable us to perforate it by  scraping
 it with a  rasp, as is recommended by  many authors.   The crested saw,
 or  one of the small ones of Hey, should  replace the crown, if we have
 nothing more  to do than  to  remove  some salient angle of one of the
 borders of the fracture.  If the necrosis should not extend through the
 whole  thickness of the bone, or  if the morbid collection was situated
 between  the two  tables  of the  cranium, the rasp or the perforating 
            TREPHINING OR OPERATION  WITH THE  TREPHINE.        523

 trepan would  doubtless be  sufficient, and we should be on  our guard
 against  penetrating  as far  down as to the dura-mater.  But wherever
 the disease  extends down to the membranes, it would be dangerous to
 follow the advice of  Hippocrates, by leaving at the bottom of the open-
 ing an osseous  lamella, however thin  it might  be,  and counting  on
 its exfoliation to give the effused fluids an opportunity of escaping exter-
 nally.
   De La Motte (Tr. d'Accouch., t.  II., p. 1062,) remarked that on the
 separation of  the  sequestrum the meninges  were found covered with
 fleshy granulations, which protect them, he says, from the vitiated air of
 the Hotel Dieu of Paris.  The bones of the cranium, isolated from the
 dura  mater  and pericranium, do not  die, says Abernethy, (Journ. de
 Lilt.  Med. Etrangere, t.  II.,  p. 341,)  but in  proportion as they  are
 separated to a great extent.    This is a remark, the truth of  which I
 have often had an opportunity of corroborating, especially at the tender
 age of life, and it is one which, though it justifies trephining in cases Of
 necrosis,  should  nevertheless deter  us  from  deciding too hastily upon
 this operation.   1 will  add  to the instructions which I have elsewhere
 given (Operat. du  Tripan, 1834, in 8vo.) upon all these points, that in
 some cases detergent or any other kind of injections, according to the
 indications, will serve to hasten the cleansing  of the morbid cavity as
 well  as the rest of the  wound, and that  it would be improper to neglect
 their employment.
                       [Injuries to the Head.

    Concussion.—Mr.  Guthrie (on Injuries to the Head affecting  the
 Brain, Lond., 1842) differs from the opinion of some, that a diminution
 of the size of the brain, or its subsidence from the interior of the bones
 of the cranium, is the cause of sudden death after concussion.  He justly
 cautions against the practice of bleeding, or strong stimulant  drinks, or
 strong stimuli to  the  nose ; for the patient is pulseless, motionless, of a
 deadly paleness,  &c., all the reverse of sanguineous congestion ; so that
 bleeding would be fatal, or injure even after the circulation  begins; and
 stimulating drinks might strangle him, while stimulant salts to the nose
 would probably subsequently give rise to inflammation of the nasal pas-
 sages and throat.   He  therefore, in such cases, recommends mild stimu-
 lants and disagreeable smelling substances, with partial as well  as general
 friction with the  warm hands, until it is ascertained that  life is  extinct.
 Vomiting is  a favorable  symptom, because it shows  reaction has com-
 menced.  If the  breathing should continue constantly stertorous, it is a
 proof of  continued  irritation,  or of compression and  extravasation,
 rather than of concussion.
   Too much bleeding, early in compression,  will bring on convulsions
 and syncope, contracted pupils, deadly  paleness, and breathing on the
 right  side of the mouth for a few minutes, with  the whiff or  puff so
peculiar in cases of compression of the brain.  At the moment when
 the stage of depression is slowly passing into that  of excitement, it
 would be  hazardous to bleed over five or six ounces.   When excitement
 or inflammation has  fairly begun, and the  patient, though  disposed to
 coma, is,  when roused, still irrational and impatient, we must not tem-
 porize with blisters or purgatives, but proceed to bleed  the patient, to 
524            NEW ELEMENTS  OP OPERATIVE SURGERY.
 whatever extent required to abate the symptoms ;  and this is to be done
 to nearly fainting, and while he is sitting up, the latter  part of which
 injunction, says M. Guthrie, is far  more important  than most persons
 suppose,  as  we may  see strikingly illustrated in apoplexies.   This
 bleeding  must be steadily repeated as the symptoms recur, until relief
 is obtained, or until the powers of the patient can no longer  resist the
 disease or the  remedies.  In  robust persons, two  hundred ounces of
 blood have been thus abstracted with benefit in two or three days.
   Fractures  of the  Cranium.—Mr. Guthrie, (Op. cit., Injuries  of the
 Head,) in all his vast experience of fractures of the cranium in military
 and civil  life, has never actually known the inner table to be  separated
 from the outer, without positive marks of an injury having been inflicted
 on the bone or pericranium, however slight that injury may have been ;
 and although it is not possible to doubt the fact of fracture of the inner
 table alone having  occurred, we should be cautious  not to let any  pre-
 possession of this kind  get hold of our feelings, or the trephine may be
 injuriously resorted to  without  cause.
  In the cases of a clean division of the scalp  and outer  table, as by
 sabre-cuts, &c, without fracture, he  recommends antiphlogistic  means
 and immediate reunion by first intention.   When the instrument even
 penetrates to the diploe, this  practice is to be  preferred, though there
 may be some  slight exfoliations, and that the external wound  may not
 unite by the adhesive process.   If the instrument has penetrated through
 the inner table, this, as is well known, will generally  be found to be
 broken, always to a greater extent than the outer, and to be separated
from it and driven into the membranes or brain, though  on the surface
 of the  bone the edges  may appear to be merely  separated.   The most
careful and thorough probing is here required to ascertain the true state
of the parts, as even where the fragments are driven into the brain,  the
patient may only complain of being  slightly stunned, saying that he is
not much  hurt, and that he will be well in a few days.   Otherwise  the
patient  may, as in a case he  gives, (Op.  cit., p. 85—87,) be, even as
late as  the  fourteenth  day, when all is supposed to be going on well,
 seized with paralysis and coma, ending in death—showing, on dissection,
 a fragment of the  inner table, separated from the  diploe  and driven
through the membranes into the brain, where it had caused suppuration.
 In all such cases, the trephine  or the straight saw  must be used, if it
 be only in anticipation  of  the symptoms mentioned.
  In depression from fracture of the skull in a child, however, the inner
 table is not brittle, but  bends equally, and does not break ; it very often
 does little mischief when depressed, and gradually recovers its level.
 The  brain in young  persons is also softer and more  compressible, and
 can therefore  bear more ; consequently  the trephine, under the age of
 fifteen or sixteen, must be used with caution, as it is also a well known
 fact, continues M. Guthrie, that, in the records of surgery for the  last
 twenty  years, the greater  number of successful cases of recovery from
 depression, or from fracture  and depression of the skull, which were
 not trephined, were in  young  persons.  M. Guthrie gives a case of a
 small child, who fell over  the bannisters of a house in London  and frac-
 tured the parietal bone, producing such a remarkable hollow or depres-
 sion, that it might  have held the half of a small  orange.  At first in- 
TREPHINING OR OPERATION WITH THE TREPHINE.        525
  sensible, it shortly after gasped, the next day was leeched and purged,
  and soon was enabled to walk  about quite recovered, the hollow  still
  remaining for several weeks.  Neither the trephine nor any other means
  than those mentioned were had recourse to.  The long bones in children,
  also, rather bend than break.
    [Dr. Jas. L. Van  Ingen,  of Schenectady, has  reported  in the New-
  York Journal of Medicine, May, 1854, an interesting case of trephining
  in infancy.  The patient was but twelve months of age.  It fell upon a
  " tenpenny " nail sticking in a board, and became inpaled upon  it, the
  nail entering the brain to the  depth of two  and one  quarter  inches.
  The accident occurred at  6 P. M. Sept. 20, 1847.   Convulsions, and
  sinking followed on the 21st, at noon of which day,." the skin was cold,
  there  was no pulsation perceptible at the wrist, and but  feeble at the
  carotids."  On exposing the bone, a small irregular opening was discov-
  ered, sufficient to admit the passage of the nail, the sides of which
  gradually approximated at the bottom, the nail having entered obliquely.
  The portion of bone represented in the cut c was  then removed with the
,  trephine, and on its inner surface  both tables were found  depressed as
  shown in the cuts b and a.
    (a)  A lateral view of the portion  removed, showing
  the actual amount of depression.                     ^
    (b)  An internal view of the portion removed,  show-
  ing the two small portions of both tables of  the skull
  depressed.
    (c) An external view of the  portion removed,  being (b)
  a portion of the right  parietal  bone near the parietal
  protuberance, showing the opening in the bone, caused
  by the entrance of the nail.
   The operation was  followed by an immediate im-
  provement in  the condition of  the  child, and in  a few
  days had entirely recovered.  We saw this patient in (c)
 April, 1854, and found that  the opening made with the
 trephine was nearly closed with bone.
   This  case  shows  that even in very young  children
 the trephine may be indicated, and that even though the brain be softer,
 and can accommodate itself to pressure  more readily than that of the
  adult, yet the most urgent symptoms  may arise, which can be relieved
  only by an operation.  G. C. B.]
   Trephining in crowded hospitals is dangerous, as probably one out of
 ten, Mr. Guthrie  thinks, would, under such circumstances, die from in-
 flammation of the brain and its membranes, &c,   Mr. Guthrie does not,
 according to a modern suggestion, [which finds its germ, we presume,
 in sub-cutaneous  surgery.   T.].consider  such results imputable to the
 admission of air.   He thinks inflammation of  the dura mater, and for-
 mation of pus between it and the  bone, was much more  common from
 injuries of the head in the time of Dease  and Pott than since.  He has
 rarely seen the secondary tumor described by them ; and the same re-
 mark was made to Mr.  Guthrie by the surgeons of the hospitals of Lon-
 don, of whom he made  the inquiry, (Loc. cit., p.  122.)
   M. Aran (See Archive  Gin. de Mid., Janv.,  Feb., et Mars, 1845 ;
 also  Gaz. Med. de Paris, Juin 7, 1845, p. 364—365) combats wholly
 
526
NEW ELEMENTS OP OPERATIVE SURGERY.
✓
 the ancient and still  prevailing opinion of fractures of the cranium, by
 what are called contre-coups;  i. c, where the base, for example, is frac-
 tured by a blow on an opposite  or distant  part.  M. Aran  classes all
 these  fractures by contre-coup under two heads, viz.: 1st, Those that
 are independent, i. e., where the part struck as well as the distant one
 are both fractured ;  2d, Where the fracture is produced  by irradiation
 or prolongation, from the place struck and  fractured to the base of the
 cranium, for example.  The sutures, he thinks, present but little resis-
 tance to these.  In fractures  of the cranium  from falling on the feet,
 he thinks it is the effect of the  direct concussion  transmitted  through
 the whole column, from the feet to the head.   The  thin  bones at the
 base of the brain, he thinks, escape these contre-coups, by yielding when
 the percussion is transmitted from a distance, whereas, if it  had  been
 direct, they would have been  shattered.  So in the  squamous  portion
 of  the temporal, <fec,;  whereas, the  more  solid bones of the vault of
 the cranium would be likely to fracture by their very unyielding density.
   M. Aran  has  made a number of experiments  on the heads of dead ■
 subjects, striking them with  hammers, &c, or precipitating them from
 certain elevations head-foremost.  These are some  of his  principal con- ■
 elusions:   He  has never  known a fracture  at  the  base without  one at
 the point struck also; in other words, he has seen  no  fractures  by con-
 tre-coup, so called, at this region ; that these fractures generally arrive
 at the base of the cranium by the shortest curve, i. e., the  shortest ra-
 dius ; that fractures by irradiation from the base, constitute ninety-nine
 out of one hundred of fractures  at this part; that  those consecutive to
 percussions and fractures on the frontal bone are found, by his  experi-
 ments, to terminate generally in the anterior third or  upper floor of the
 base ; those of the occipital bone, in the posterior  third or lower floor;
 those of  the  temporal bone in  the middle third or middle floor ; while
 those on  the sinciput may follow one of these three directions, but their
 tendency is to the middle fossae.
   Fracture of the Petrous Portion of the   Temporal  Bone.   Hemor-
 rhage from the Ear, Src—A  new Anatomical Point of Diagnosis sug-
gested.—A  case  recently occurred to M. Blandin, at  the  Hotel Dieu,
 Paris,  (Annates de Therapeutiqne, Mars, 1845;  Cormack's London Sf
 Edinburgh Monthly Journal, June, 1845, p.  461, etc.,)  of a man aged
 thirty, who in a fall fractured the petrous portion of the temporal bone,
 causing hemorrhage from the left  ear  and mouth, slight defect in  the
 hearing,  and slight paralysis of  the  muscles of that side of  the  face,
 with paralysis also of that side of the uvula, to such  extent that it was
 drawn to the sight side  of the base of the tongue, by its muscles on that
 side now having no antagonists.   This case has  apparently established
 an important, but hitherto obscure, point in anatomy, and thus furnished
 a new diagnostic mark in pathology in such fractures.   The coincidence
 of paralysis  of the face with that of  the  velum palati  in  several such
 cases (but not always) had been noticed by  M. Monteau.   It is known
 that the uvula receives its nerves from the spheno-palatine ganglion by
 three  filameuts, which go from this ganglion to the  uvula and velum.
 But the  ganglion  itself also  receives a filament from  the  intra-cranial
 portion  of  the facial nerve, as has been shown by MM. Blandin and
 Longet.   This, however, had been erroneously supposed to be a filament 
            TREPHINING OR  OPERATION WITH  THE TREPHINE.       527

sent from the ganglion to the vidian nerve;  whereas, it is now found to
be a distributor of nervous influence from the vidian nerve to the uvula
and velum.  From whence we  have the key  to  the  condition of these
parts in the fractures in question, and the explanation why lesion to the
intra-crauial trunk of the facial nerve must  produce  paralysis in the
filament  which goes to  the spheno-palatine  ganglion, and afterwards
leaves it as the motor nerve of the uvula.  The uvula, consequently, is
only paralyzed when the cause of the paralysis of the face is within the
cranium, close by the petrous portion of the temporal bone.  Therefore,
we have this valuable diagnosis: when there is paralysis of the face
alone, without accompanying paralysis of the uvula,  we may affirm that
the lesion is external, or in the peripheral branches of the nerve.  The
hardness of hearing is sufficiently explained  when the  injury is within
the  cranium.  M. Blandin  considers hemorrhage from the nose and
mouth in such cases as unequivocal signs  of fracture of the petrous
bone; the  blood  emanating, he thinks, from the  interior of  the  tym-
panum, where it is extravasated and escapes anteriorly by the external
ear, (which presupposes rupture of the membrana tympani,) and poste-
riorly by the  Eustachian  tube, through which it finds its way  to the
throat.   M. Blandin has verified these  conclusions, by repeated dissec-
tions.
   Dr. Laugier, (Archiv. Gen de Paris,  Aout, 1845—see also Ranking's
Half-yearly  Abstract, &c, Amer. ed., New-York,  1846, Vol. II., pp.
84-5-6,) after remarking upon the usual discharges of blood  from the
ears, nose, &c, which for centuries surgeons have usually  halted at as a
sufficient mark of the mischief within; shows by attending to the modern
and more minute and thorough modes of post mortem  investigations of
organic lesions and structural changes, that after the discharge of blood
on the immediate occurrence of contusions and fractures of the cranium,
(as on the  vertex  from a  fall, <fcc.,)  there will be also  frequently found
a remarkably  large  and constant discharge of watery serum from the
ear, sometimes to the amount of half a pint; and that this limpid fluid
denotes fractures of the os petrosum, with or without displacement and
laceration of the dura mater, but with laceration of the membrana tym-
pani. The fluid being, as Dr. Laugier supposes, the serosity of the blood,
which, after the hemorrhagic extravasation within the  brain has coagu-
lated, filters as it were through a chink (or mere fissure—displacement
of the fragments of the fracture not being essential)  in the os petrosum
into the cavity of the tympanum, and thence into the external meatus.
[Doubtless  the same fluid oozes also through the eustachian  tube into
the  fauces. T.]   A similar serous discharge may also ensue into the
nasal passage from similar fracture-cracks [as they may be called. T.]
in the orbitar  plate of the temporal  bone, that of the ceribriform plate
of the ethmoid, and the salla turcica of the sphenoid bone.
  From the whole of the cases which have been examined, Dr. Laugier
infers :   1. That  the appearance of the watery fluid in the ear always
indicates fracture of the petrous portion of the temporal bone, but with
hardly any  appreciable separation of the pieces from each other. 2. That
an effusion  of  blood  between the dura mater and the bone is constantly
observed over this fracture.  3. That laceration of the membranes  of
the brain is not essential to the production of this symptom.  4. That 
528            NEW  ELEMENTS OP OPERATIVE SURGERY.
if the fractured  portions of the petrous bone be separated a line or two
from each other, blood alone continues to be discharged from the ear,
but no watery fluid.
  The fluid  cannot be that of the cerebral cavities, but is the serosity
of the effused blood, squeezed out by the pressure and motions of the
brain, and  filtered through  the narrow fissure.  The objections to this
opinion are:  1st. The  quantity of watery  fluid which sometimes es-
capes.  2d.  The differences observed  between the  fluid and  the serum
of the blood.  In one case nearly twenty ounces  were  discharged in
three days, and  in another ten ounces in forty-eight hours.   This ap-
pears too  large a proportion  to  the coagulum found  under the fissure,
but the latter, having been subject to  compression, is found almost dry,
which at least proves it to be one  source of the fluid.  In wounds of the
soft  parts, with  effusion  of blood into the wound, when this ceases to
flow externally, a serous  discharge, which saturates the lint and com-
presses, succeeds, and this is exactly what happens in  the case of the
ear.   Dupuytren always concluded, from  the appearance of this watery
discharge from deep wounds, that hemorrhage had  taken place within.
In both cases it comes from the effused blood, and also from the lacera-
ted vessels themselves, after  they have ceased to pour out blood.   The
fluid from the ear differs chemically from serum, in containing a double
portion of chloride of sodium; and, although heat  and  nitric acid pro-
duce no coagulation,  shreds of coagulated albumen or fibrin  are obser-
vable in it;  but  Dr.  Laugier does not consider the analysis sufficiently
exact to confer much weight on any objection that might be raised. That
the origin of the  fluid is not from the natural cerebro-spinal fluids is
obvious, from the membranes of the brain being in many cases uninjur-
ed.  That it is not the fluid of Cotugno is plain from its quantity, and
from the fact that in many cases the openings  of the internal ear remain
intact.
  On the other hand, Drs. Lawrie and King  have recorded twenty-two
cases of cerebral concussion  (Cormack, Loc cit., p. 462;  also same
Journal for 1843, p. 673) at the Royal Infirmary of Glasgow, in which
there was hemorrhage both from  the ear  and  mouth, and yet  twenty of
these cases recovered, and in one only of the two fatal cases  was there
fracture of the base  of the cranium found on  dissection.  Dr. Cormack
(Ibid., Loc. cit.) speaks of three similar cases, all of which were cured,
and which place in doubt the opinion that hemorrhage from the ears and
throat, even where it is abundant  and  accompanied with violent concus-
sion and alarming cerebral  reaction, as  it was in all  these  cases, is a
conclusive evidence of fracture of the petrous or any other   bone.   In
one only of  these three  patients  there were both paralysis of the face
and deafness; but the uvula was not examined.  Dr. Cormack considers
in fact that fractures even of the petrous  bone may recover.
   M. Gerdy  (lb., Loc. cit., p. 463) is stated  to concur  also  in the be-
lief  that the  hemorrhages in  question do not always  indicate fracture.
   Again,  in  the  Annates de  Therapeutique  of Paris, for May, 1845
(See also Cormack's Lond. and Edinb. Month. Journ., Loc.  cit., June
1845, p. 463, &c.,) we have three illustrative cases at La Charite, two
belonging to M. Gerdy himself, and one to our author M. Velpeau.   In
the first a stout  young mason received only slight contusions apparently 
TREPHINING OR  OPERATION WITH THE TREPHINE.        529
 on the head  from a fall from a scaffolding, and was stated to have been
 at first insensible for a few minutes.  For three days there had been, it
 was said, abundant hemorrhage from the right ear, which continued on
 his admission into the hospital the evening of  that day, also slight head
 ache, strong pulse and hot skin.   After  two or three venesections and
 doses of tartar emetic [!] and antiphlogistic regimen he left the hospital
 well.  The discharge  from the ear had ceased on the fourth day, and it
 was found that the membrane of the tympanum had  been ruptured, as
 the air hissed out freely through it, in making an effort to blow with his
 mouth and nose shut.   There was no palsy of the face, deviation of the
 uvula, or other symptom of compression, which latter M. Gerdy con-
 sidered would  have resulted  from accumulation of blood at the base of
 the cranium, had there been fracture of the  petrous bone.
   The second  oi.se was also a robust  young  man who fell down stairs
 and struck the  right  temple.  He was almost insensible, and the ear on
 that side soon discharged blood and became slightly deaf.  On the fourth
 day after the accident he was admitted into  the hospital, and was found
 to have a large  bloody tumor on the temple.   The discharge of blood
 from the ear had ceased ; the deafness continued ;  the pulse was hard,,
 and the patient complained of a throbbing head-ache on the side which
 had been  struck.  There were, however, no symptoms  of compression,.
 and no facial paralysis or deviation of the  uvula ; nor was the  membrane
 of the tympanum torn.  So that  the blood must have come from the
 outer ear.   M. Gerdy cannot think there was fracture in this case.
   The third  case was  that of M. Velpeau, of which we regret to have
 met with  no  other details except that the patient was admitted on ac-
 count of various injuries, and had a discharge of blood from the ear,
 which  however was  not apparently connected with any deep-seated
 lesion.
   The editors  of the Paris  Journal in  which these  cases are given,
 (Annates de  Thirap.) conclude  from all the above  facts, that in the
 present state of science, hemorrhage from the ear under the circumstances
 described, does  not permit us to  pronounce that a fracture exists, even
 though  the  hemorrhage may be accompanied  by paralysis of the face
 and uvula.
   It is to be borne in   mind that  in fractures of the os petrosum of the
 temporal bone,  the diagnostic mark of deviation of the uvula to one side
 by the preponderating  antagonism of the muscular fibres on the sound
 side, cannot take place (unless through the muscular fibres of the velum)
 if what M. Lisfranc  says (Clinique  Chirurgicale de la  Pitie, Paris,,
 1842) that this projection is sometimes destitute of any deep fibres.
   Fracture of the Frontal Bone and Depression.—It is true, nature can
and will at times make apparently almost  more than superhuman efforts
in the work of  reparation to  the  organization, even where she has had
to contend (as the ancient fable has it) against the fearful alliance both
of empiricism and the  disease.  But this is no argument  why we should,
with a full knowledge  of our duty, stand by idle, and compel and torture
her to put such  powers to  the  test.  Thus  with the indisputable truth
before us so often demonstrated, that a depressed portion of a fractured
bone of  the cranium will almost inevitably cause either immediate rup-
ture of the vessels of  the brain, with convulsions, coma and death, or
   Vol.  II.                    67 
530
NEW ELEMENTS OF  OPERATIVE SURGERY.
subsequent  extravasation, separation  of the*  dura mater, inflammation,
and suppuration, and death in that shape also ; and with the extraordinary
fact that a recovery may take place, and leave the patient ever after
subject to epileptic convulsions ending in idiotcy ; how, we repeat, with
this knowledge before us multiplied in ten thousand examples, and with
the knowledge also of the equally established precept in surgery, that
all. these accidents in ninety-nine out of one hundred cases have no other
chance of cure than by  the elevation and  exsection of the depressed
fragment, can we  conscientiously look silently on and see a case of this
kind pass  on through this fearful ordeal of symptoms without at once
applying the needful remedy !   Yet such appears to have been the fact
in the  case  of a boy, aged 5 years, described by Dr. Pinefoy of Clogh-
jordan, Ireland, (See London  Lancet, Dec.  28,  1844, p. 400.)   This
little  patient, with a fracture of the frontal  bone an inch long and de-
pressed a quarter  of an inch, caused by the  kick of a horse, and most
unequivocally pronounced, was  allowed  by this physician to pass during
the subsequent days through acute inflammation and fever, with violent
convulsions, coma, apoplectic stertor,  &c, he employing only two slight
venesections, a few leeches, and some calomel, and above all the douche
of cold water let to fall upon  the vertex from a height of two feet, to
which  dangerous experimemt (as we deem it) he attributes the cure—
aided by the recuperative powers of nature  in young  subjects !   This
truly is a fearful mode of demonstrating pathological  possibilities, and
an abuse, as it seems to us, of  the principles of conservative surgery.
   Compression.—Mr. Guthrie  (Op. cit., Injuries of the Head, &c, Lon
don, 1842, p. 40)  correctly, in our judgment, considers compression not,
with Sir C. Bell, the result of a  diminution  in the quantity of blood in
the brain, but rather of a plethoric state of  the vessels of that organ,
and of some integral change caused in the whole volume of the brain
and its functions by such compression, as from a clot of blood or depres-
sion made by a mere point of bone, &c., in fracture, the removal  of
which  immediately removes the coma, &c, while an  ounce of lead may
lie  quietly  in  the brain without causing any unpleasant symptoms.
Hence it is not so much the actual pressure, as Sir  C. Bell, Serres,
Gama, &c. think, that causes these symptoms, as it is irritation.
  Mr.  Guthrie  gives as  an  example of this  truth some cases of com-
pression he has seen, wherein the pulse was remarkably  quick (145) till
life ceased, accompanied  with  paralysis of the left  side, and the whiff-
like breathing on the right side of the mouth, convulsions, loss of speech,
&c. He was so struck with the flatness of the convolutions of the brain
on  the right side  as compared with those of  the left, that he sliced off
a portion, and immediately came to a larger coagulum of blood than  he
had ever seen without causing  immediate death.   This coagulum press-
ing from  within  outwards, was, he thinks, the undoubted cause of the
appearance  mentioned, (Op. cit., p. 47.)  Here is another proof of the
symptoms of compression caused by actual mechanical pressure.
   In those well-marked  gun-shot injuries in military service, where the
fracture, as of the parietal bones, and extravasation are  the only lesions
with the insensibility from the extravasation coming on at a considerable
interval after the infliction of the wound, the rule in surgery to remove
the bone is absolute.  So also  thinks Dr. Cormack, (Lond. and Edinb. 
TREPHINING OR OPERATION WITH THE TREPHINE.        531
Month. Jour., Oct., 1843, p. 922.)  When  these cases are complicated
with concussion and deep-seated extravasation, the diagnosis is difficult.
When  the brain  remains depressed  after  the blood has been removed
the symptoms are not mitigated.
   [Dr.  Henry J. Bigelow, of Boston, has published the particulars of a
case of recovery  after the passage of an  iron  bar through the head,
wnich is  probably unparalleled.  A crowbar, three feet and a half long,
and weighing above thirteen pounds, was driven through the brain of a
man, and carried  away a considerable portion of its substance, yet the
patient recovered !   We can only refer to this case, full details of which,
with illustrations, may be found in  the American  Journal of Medical
Sciences, July, 1850.  G. C. B.]
   Ball-wounds perforating the Brain  through and  through,  without
causing  immediate death.—It  is now deemed  an established fact in
pathological surgery, that an ounce ball or one even of larger dimensions
may perforate though and through the anterior lobes of the brain  trans-
versely, as from temple  to temple, and the  patient yet  retain all his
faculties, digestion, sleep, reason, &c, for the space of 20 or even  30
days, until inflammation and suppuration  ensue, and  thus necessarily
cause death.  A case of this kind very  recently occurred in America,
at St.  Louis, (State  of Missouri,) in a gentleman thus  wounded in a
fracas.   The particulars of another still more remarkable case are related
by M. Blaquiere,  (Journ. des  Connaiss.,  &c,  Paris, 1844,) where a
pistol ball, weighing  the seventeenth  part of a pound, passed  through
the anterior and lower part of the brain, of a child at Mexico, in 1842,
aged only four  years, each perforation being situated in the temple at
the same locality, nearly, i. c, about an inch  and a half perpendicularly
above the outer angle of the eye.   Six days transpired  of apparently
almost uninterrupted health, when inflammation  and suppuration  super-
vened, and the child died, not however until the twenty-ninth day  ! The
aperture at the entrance  of the ball was found as usual in all bones, less
than that at its exit.  The cerebral  substance between the track of the
ball and  the frontal bone, being a distance of 6 or 8 lines in extent, was
found thickened.   The substance of the brain above the track, and also
the ventricles remained  intact.  The meninges  were inflamed, and the
perforation filled with pus.
   Foreign Bodies lodged in the Cranium.—In alluding in the text to a
case of Dr. Cheesman of New-York, in which a  portion of a gun-barrel
remained clasping for a long time the neck  of the radius,  (we think)  we
arer eminded of a recent  case related by Dr. 0' Calloghan, (Dublin Med.
Press, Feb. 1845, p. 82,) wherein, from the explosion of a fowling-piece,
a  severe wound was inflicted in the forehead immediately above the nose,
in an officer of the Ceylon Rifle Brigade.   Pus, bloody serum, and frag-
ments of bone afterwards  passed through the nostrils from the wound.
The patient  recovered  and  returned to duty, but in a few months was
incommoded by a metallic substance protruding through the palate, with
an offensive discharge, which he was entirely unconscious of, as the sense
of smell had been  entirely destroyed by the  accident.  The patient
having  afterwards died  from intemperance, there was found, on  exam-
ining the head, the whole of the iron breech of a gun, with the screw
attached, lodged in the forehead, weighing three ounces ! 
532
NEW ELEMENTS OP  OPERATIVE SURGERY.
   Abscess oj the Liver from the  Fracture of the Head.—M. Blandin
(Annal. de  Thirapeut., Paris, Mars, 1845,)  considers inflammation of
the veins of the diploe followed by suppuration, and  which, it is said,
was first noticed by Bruce (See Cormack's Lond. and Edinb.  Monthly
Journal, &e., June, 1845. p.  462)  to  be  the source  of  abscess of the
liver, so frequently observed  after injuries of the head.  This must be
by means of phlebitis propagated  to the liver ;  but  why to  the liver
rather than elsewhere ?   And would not  the same phlebitis, caused by
injuries to the  vessels in  severe operations, as removal of the breast,
testicle, &c., explain  the sudden  formation of purulent  collections in
the lungs, and other organs causing death ?
   Dr. Cormack (lb., loc. cit., p. 463) doubts, we perceive, the alleged
frequency of abscesses of the liver, after  injuries of the head, from in-
flammation of the venas Santorini.
   Statistical Table of  Wounds of the Head.—MM. Lawrie and King
(Cormack's  Monthly  Journal, &c., 1844) give the following results of
their observations,  upon  a total of 234 cases  in most of which the tre-
phine was used:—
No. of		
Cases.	Cures.	Deaths
110	94	11
8	—	8
8	1	7
12	—	12
4	—	4
3	1	2
3	3	■—
5	—	5
10	6	4
19	14	5
26	7	19
14	3	11
12	2	10
234 131		98
  Out  of 77 cases of compound fracture, there  were 29 cures and 48
deaths; 26 of these 77 cases were not trephined, and of them 18 were
cured and 8 died;  51 of the 77 cases were trephined, and of them 11
were cured and 40 died.  T]

  [We copy from the Brit. Sr For. Med. Chir. Rev. Jan, 1850, the  fol-
lowing statistics  of Dr. Fritze of Nassau, founded upon the careful ob-
servation  of  301  cases.  They were  originally  published  in  Caspar's
Wochenschrift, No. 30.
Concussion, (commotion,)
Apparent concussion, but doubtful,
                 without fracture,
 Sanguineous
extravasation,

Simple fracture
    of the
   Cranium,
               < with simple fracture,
               ( with complicated do.
               ( simple fracture,   .
               < with depression,   .
               (with  "   and operation,
            compound fracture,
            with depression,   .
Compound   with depression, or comminuted,
  Fracture!   and the operation performed
   of the  1   in 24 hours after the accident,
 Cranium,   with depression, or comminuted,
              and the operation performed
              some days after the  accident.
  Hernia cerebri, .    .      ... 
           TREPHINING OR OPERATION WITH THE TREPHINE.        533

1. Results according to the nature of the injury  and mode of treatment.

   a. Fissure or fracture without primary affection  of  Cases. Reo. Died.
         brain.     ...          ...      39  34   5
                                          Cases. Rec. Died.
         No operation on the skull  .     .  29   25    4
         Removal of fragments .         .871
         Trephined.....2    2    0

                                          39   34    5
   b. Fissure or fracture with primary affection of
         brain........73  34  39
                                          Cases. Rec. Died.
         No operation  on the skull  ... 49   25  24
         Removal of fragments   ....  4    3    1
         Trephined              .... 20    6  14
44  33  11
	73 34 39
c. Fissure or fracture with depression,	without primary
affection of brain	.
	Cases. Rec. Died.
No operation on the skull .	. 22 21 1
Removal of fragments	. 9 6 3
Trephined	. 13 6 7
                                       44   33  11
d. Fissure or fracture with depression and with primary
      affection of brain      ..... 145   88  57
                                      Cases. Rec. Died.
      No operation on the skull  .    .  50   39  11
      Removal of fragments     .     .  26   14  12
      Trephined     .      .     .    .  69   35  34

                                      145  88  57
Thus there were treated without operation
    "       "     by removal or elevation of fragments .
    "       "     by the trephine .     .     ...
The trephine was employed prophylactically in .
   "     therapeutically     ....
         therapeutically in affection of brain without wounds 1
         therapeutically in affection of brain with wounds

                                                      113  52   61

  Dr. Fritze compares these results of treatment with those derived
from the  treatment  of the  cases collected  by  Blasius and Leisnig.
301	189	112
150	110	40
47	30	17
104	49	55
301	189	112
. 16	15	1
.88	34	54
ids 1	0	1
s 8	3	5
 
534            NEW ELEMENTS OP OPERATIVE SURGERY.
From the comparison, it appears that a greater porportion of recoveries
upon the  whole occurred in his series of cases than in theirs ; but that
the results in those cases where the trephine was resorted to, were much
more favorable in their cases than  in his.  This he explains by the fact
that all his  fatal cases were the subjects of medico-legal investigation,
the whole number that occurred being declared, which was probably
not the case with theirs.  An impartial  and searching criticism  of
the 112 fatal cases has led the  author to the conviction, that, in only
10  of  the  number, it was  possible that trephining, or the earlier  resort
to this, might have preserved life.   But, on the other hand, in  2 of the
fatal cases, the operation  seemed to  be the cause of death :  while  in
5 of the recoveries it was probably unnecessarily resorted to.  The fol-
lowing is the comparative view of  the cases :

blasius.                                         Cases.  Recoveries. Per cent.
    Without operation.....242      83     34.3
    Trephine.......422     270     64
                                               664     353    53.2
LEISNINO.
    Without operation.....260     118    45.4
    Trephine or removal of fragments   .    .   223     173    77.6
483     291     60
*mtze.                                           Cases. Recoveries. Per cent,
   Total cases.......301   189    62
   Without operation ...               . 150   110    73-3
   Trephine.......104     49    47-1
   Trephine and removal of fragments     .     . 151     79    52-3
2. Results according to age.
                                                           Per cent.
     Under 15 years of age.                  Cases. Recoveries. Died, of recoveries.
    Without operation    ...    37    30     7     81
    Removal of fragments ...    14    13     1     93
    Trephined.....18    11     7     61
      Adults.
Without operation
Removal of fragments  .
TreDhined  .
  Thus the injuries proved less  dangerous to the young, and operative
interference was seldomer required; but when resorted to, were  more
favorable.
  3. Results according to sex
                                      Cases.  Rec.  Died.  Per cent, of rec
    Men......264 174  100      63-5
    Women......26  13   13      50
69	54	15	
113 33 86	79 17 38	34 16 48	70 51 44
232	134	98	
 
TREPHINING  OR OPERATION  WITH THE TREPHINE.        535
  4. Results according to the seat of injury.  A statistical examination
of 291  of the  cases, leads to the result, that the minimum of danger
exists when  the frontal  region  is the seat  of injury;  then the vertex;
and next the occiput.  The  danger  is the greater, the  more extensive
the injury is, and the more  it  traverses the lateral  portions  of the
cranium, towards the basis.
  5. Results according  to the cause of the injury.  From an  analysis
of 298  cases, in which the nature  of the  injury is  stated, it  results
that it  arose from a blunt instrument in 121, from a fall in 100, from
a stone in 31, from  a pointed instrument in 12, from a kick of  a horse
in 12,  from a  cutting  instrument  in  13, and  from  fire-arms in 9.
The  following  is the proportion in which these different injuries were
recovered from, in relation to operative interference :
Cutting instruments
Pointed     "
Blunt       "
Stone  .
Falls   .
Kicks  .
Fire-arms
Treated without	Treated by
operation.	operation.
. 14	1
. 1	2.3
. 1-5	1
. 1-3	1
. 1-5	1
. 1	1
. 5	0
   Statistics thus confirm wnat theory would teach us,—that the opera-
tion of the trephine is successful in porportion as the  cause of injury
more immediately  limits its operation to the part of the  skull that is
struck, which is most so the  case  in wounds  from pointed  bodies,
and least so in those from fire arms discharged close to the head.
   In the Lond. Med. Times and Gazette, June,  1853, we find the fol-
lowing analysis of the cases of injuries of  the  head, examined  after
death, in St. George's Hospital, London, from January, 1841, to Janua-
ry, 1851, by Prescott Hewett, Assistant Surgeon to that Hospital.  In
this analysis he has included only fatal cases, in which the exact nature
of the injury has been clearly ascertained.
   Scalp  Wounds without Fracture of the  Bones.—In  this  decennium,
33  cases of scalp wounds  without fracture  of the  bone  were  ex-
amined.   In 10 of these cases death was  produced  by some other
cause.  In the  remaining 23 cases, mischief of a serious  nature  soon
followed the  injury, and ultimately  proved fatal.   Diffused cellular in-
flammation occurred in 17 cases, and in 12 this was accompanied with
erysipelas.  In  4 cases there  was  diffuse inflammation  of the neck,
which  spread down to the mediastina  in 2,  and  caused oedema of the
larynx in 2 cases.  Hemorrhage in 2 cases followed sloughing caused
by inflammation.  In 9 out of 12 cases, where  both brain and its mem-
branes were healthy, death ensued from purulent infection.  In 10 cases
inflammation had existed about the membranes of  the brain.  In 8 sup-
puration  was found between the bone and the  dura mater.   The trephine
had been applied in three cases.  Most of  the patients were persons of
intemperate habits.  Several had insisted upon leaving the hospital, but
were re-admitted with swelling of the scalp  and  other signs of inflam-
mation.  Simple acupuncture, as recommended by Sir B. Brodie, relieves 
536
NEW ELEMENTS  OP OPERATIVE SURGERY.
the cedematous swelling not uncommonly following  scalp wounds ;  but
free incisions are required when suppuration ensues.   Sloughing of the
scalp is thus usually prevented.  Separation of tho dura mater from the
bone may occur  either as a primary or as a secondary effect.  In  the
first case, the small vessels  connecting  the  dura mater to the bone are
ruptured by the  blow; in the second,  the osseous  tissue inflames and
suppurates.   Generally speaking, the suppuration between the bone and
dura mater  is circumscribed, and the extent of the mischief on tho inner
side of the bone is exactly traced by that on the outer side; but should
the suppuration occur in the parietal region, it may be much  more dif-
fuse. In this decennium there has been no single instance of the  secon-
dary puffy tumor  of the scalp described  by Pott.  It has never fallen to
the au'hor's lot to witness a case in which the application of the trephine
for the evacuation of pus within the cranium, as described  by Pott had a
successful issue.   He has  never  known the  trephine applied at  St.
George's Hospital  with the view  of evacuating matter situated either
under the dura mater or in the brain.  Matter may flow on the applica-
tion of the trephine, from  the cancellous diploe of the cranium.   Pu-
rulent infection was  observed in  fourteen  out of twenty-three  fatal
cases of scalp  wound.   This disease  is found especially  in injuries
involving the osseous system;  and  M. Chassaignac believes that  the
removal  by the  trephine  of the  contused bone,  before suppuration
has taken place in its diploe, destroys the source whence the secondary
mischief  is for the most part derived; but such an explanation cannot
be received  as a valid ono.
   Fractures of the  Bones  and Separation of the  Sutures.—In  this
decennium, 78 cases  of fractures  of the  skull  were  admitted, 18  of
which had  received other severe  injuries, of a nature likely to cause
death ; 56 were  simple fractures ; 22 were compound.   Of the  simple
fractures, 19 were accompanied by  wounds of the scalp not exposing the
bone ; extensive separation of the sutures co-existed in  14 cases.  In
47 cases the  injuries had been produced by the patients having fallen from
various heights: in 10 the blow had been inflicted by some heavy instru-
ment.  In the 56 cases of  simple  fracture, there was only one  single
instance in which the injury was confined to the spot upon which  the
blow had been struck.   Fractures of the base of the skull seldom exist
alone ; in a  large majority of  cases the  injury co-exists with  fractures
radiating from the  point  where the  blow was  struck.  In 68 cases of
fracture of the  base, six only  were confined to  this region ; and  it was
only in two cases that no trace of fracture could be detected at the
seat of the  blow.  In six cases of simple fracture, the injury was ac-
companied by depression, which  was  in  all very  slight.  In 10 cases of
compound fracture, there was  also depression of the fragments, consid-
erable in nine.   Fractures of the  skull, with  depression of  the  inner
table alone, occur but rarely.  The author divides the skull into  three
zones, to each of which injuries are often confined, fractures of the mid-
dle zone  being the most common.   Fractures involving the orbital  plates
of the frontal bone are oftentimes  accompanied with  effusion of blood
in the orbit.  Bleeding from the ear is of  not unfrequent occurrence
in severe injuries to the head, indicating fracture through the petrous
portion of the temporal bone, one of the surest is the copious  discharge 
TREPHINING  OR OPERATION WITH THE TREPHINE.        537
 of a watery fluid which may or may not be preceded by bleeding.   The
 author  believes the fluid to come from the sub-arachnoid space.   That
 such is  sometimes the case has been established by M.  Robert, in a val-
 uable paper in the Me moires de la Sociite de Chirurgie de Paris, vol. I.
 The discharge  occurred  in old  as well as  in  young  subjects.   M.
 Chassaignac  has endeavored to prove that this  fluid owes its origin to
 the filtering of the colorless part of the blood, and other surgeons have
 held that it comes from the cavity of the arachnoid.  Such cases, how-
 ever, if they do occur, must be rare. The author does not believe that
 the source of the watery  fluid in all cases is the  sub-arachnoid  space,
 but in most cases, and especially those where it is clear and  abundant
 from the commencement; and he refers to Mr. Hilton's lectures in proof
 of this statement.  Extensive separation of the sutures co-existed with
 the fractures in 14 cases;  separation of the coronal suture  occurred in
 seven cases, and of the lambdoidal in three cases ; of the sagital suture
 in four cases.   In one case, and  in one only, there was separation of a
 suture without a fracture; it occurred in the posterior part of the squamo-
•parietal suture.
    Dr. Lente published in  the New-York Journal of Medicine, January,
 1852, a statistical account of the Fractures of the Skull, treated in the
 New-York Hospital, during the twelve years elapsing between the first
 of January 1839, and the first of April, 1851.   The total number was
 128, and the injuries were nearly all of an extreme character,  depres-
 sion, laceration of the membranes or of the substance of the brain com-
 plicating the fracture.  In 45 of these cases, the operation of trephin-
 ing  was  resorted to, and of these 11, or about  one fourth  recovered.
 It was  performed prophylactically in 10, of  which 3  were cured ; thera-
 peutically in 32, of which  8 were cured.   Dr. Lente alludes to an inter-
 esting  inquiry  which was raised in a recent criminal trial in this city,
 viz. whether it is possible  for an ordinary blow upon the head, produc-
 ing fracture  of the skull, to cause immediate  death, and after an exam-
 ination of the  facts he comes to the conclusion that it is exceedingly
 improbable if  not impossible, as was  decided in the trial to which we
 have referred.  G. C. B.]

 [Depression of the Skull relieved by a  novel mode of Cupping.
   By  S. Nicolls, M. D., Surgeon to  the Longford  Union Infirmary.
   (Dublin Medical Press, Sept. 1853.)

   Some  time  ago a child, set. two  years, was brought  to  Dr.  Nicolls,
 suffering from  depression  of the  skull, consequent upon a fall  from a
 table.  The symptoms  of the compression  of the  brain were  urgent,
 and of some hours' continuance.   On examining the head he  found a
 deep narrow depression, about three inches in length, extending  from
 the lateral part of the occipital along the parietal bone, but without any
 wound in the integuments.  It occurred to him to try to elevate the de-
 pressed bone by the application of a cupping-glass, and with this end in
 view he tried several glasses of  various sizes, but owing to the form of
 the parts he could not fix any of them.   At last it occurred to him to
 surround the depressed  parts with an embankment of common glazier's
 putty, and to apply the glass upon this, when he at once succeeded, both
   Vol. II.                     68 
538
NEW elements op operative surgery.
 in fixing the  glass and in raising the depressed  bone.   The symptoms
 of compression passed off shortly  afterwards, and the child recovered,
 without any ill consequence from the accident.   G. C. B.]

                      Article.  II.—The Face.

   I have mentioned, while treating excision of the nerves and exsection
f of the jaws, the cases in which  trephining would be advantageous upon
 the face.  I shall again return to this operation, in treating of diseases
 of the  maxillary  sinus, and exostoses of the visage.   It is therefore,
 unnecessary to speak of it at present.
                          CHAPTER II.
                                                                    i
                            THE CHEST.

  After the cranium, tne thorax is the part  of the  body, upon which
the trephine has been most frequently applied.

                       Article  I.—Sternum.

  It was by means of the trephine,* that Galen removed a carious ster-
num from a young man, who was wounded  while exercising in a wrest-
ling match, and in whom he was obliged to penetrate down to the peri-
cardium, which itself was altered upon its  anterior surface.

                         § I.—Indications.

  Avenzoar, according to Freind, recommends  the employment  of  the
trephine not only  for abscesses of the mediastinum, but also for those
of the pericardium.   V.  D. Wiell performed this operation successfully,
for a large purulent collection.   Colombo, Salius Diversus, and Juncker
formally advise it; and Pauli and Solingen mention that Purmann suc-
ceeded with it in two different cases.  J. L. Petit adopted their counsel,
and the examples of  this operation are now without number.  A physi-
cian of Altorf, (Franck, Mid. Prat., t. V., p. 138,) had recourse to it
with success for a substernal abscess; as Ravaton, (Plaies d'Armes-d-
feu, p. 249,337,) also had in a similar case, and afterwards in another,
to remove some wadding, blood and a ball.   Storck, (Monro, Essai sur
VHyd., § 142, p. 306,) was enabled by this means  to remove six pounds
of blood and sanguinolent matter from the thorax.  According to Spren-
gel, Boetcher recommends that  it  should  be employed in fractures of
the sternum, in order to make a passage to allow of  our raising up the

  [* Unless the trepan is specifically alluded to by our  author, as meaning  to express an in-
strument somewhat different from the trephine, (see his remarks above,) the word now uni-
versally employed, we generally adopt the latter as the proper translation for his word tre-
pan. T.] 
TREPHINING OR  OPERATION WITH  THE TREPHINE.       539
depressed fragments.  As an evidence of its advantages in such cases,
De Lamartiniere, (Mim.  de VAcad. de Chir., t. IV.,)  mentions that a
soldier, wounded at the siege of Philipsburg in 1734, recovered perfectly
after this surgeon had removed from him four large plates of bone which
comprehended  the  entire thickness of the sternum.  Mesnier, of An-
gouleme, was no less fortunate in a young  man who had had this bone
fractured transversely.   Almost the  whole of the caries was  removed
by means of a  very  large crown, while the inequalities of the opening
were destroyed with the lenticular knife.
  Alary imitated the example of V. D. Wiell, upon a coachman of the
king's  stables, who had  been a long time affected with an  internal ab-
scess which had opened upon the neck  in the supra-sternal depression.
Sediller of Laval, treated in the same way, a girl of twenty-two  years
of age, who, in consequence of  an  abscess caused  by a blow upon the
front  part of the chest, carried a fistulous ulcer through which the me-
diastinum could be  reached without  difficulty.  The carious sternum
concealed a purulent collection, and  the patient recovered in two months.
An adult patient in whom an internal abscess had opened outwardly be-
tween  the two  first  bones of the sternum, was received into the Hos-
pital of Rouen  in the year 1754.   Lecat enlarged  the opening of the
integuments, rasped  the contour of  the bone, which had become altered
by caries, and a few days  after applied the crown of a trephine; which
enabled  him to introduce into  the cavity the substances  suitable for
cleansing its walls.  Ferrand, of Narbonne, had  no apprehension, in a
similar affection, though much more  complicated, of removing a great
portion of the same  bone  by means of the  trephine, and several of the
cartilages of the ribs, with the aid of a small saw, in a patient who ulti-
mately recovered.   Finally Auran had the same good fortune in treat-
ing a simple caries of the sternum.  It is  however certain, that in this
last case the actual cautery was several times substituted with advan-
tage for the trephine.  The  fact related by Aymar, of Grenoble, is a
conclusive  proof of  it [this use of the cautery.]   But Marchettis has
made the remark, founded on his own personal experience, that in these
cases, the cautery, by heating the  neighboring parts, may become ex-
tremely dangerous, and  that it is not  unfrequently incapable of causing
the separation  of the necrosed  bone.   In support  of  his assertion, I
could,  if it were necessary, adduce what I  have seen in one of the hos-
pitals  of Paris.  The cautery was applied; the necrosis did  not exfo-
liate, and the patient succumbed to the progress of the disease.  We
may therefore conclude with De  Lamartiniere, that the trephine is often
a precious resource  in necrosis  of  the sternum, whether  this necrosis
may or may not be caused by an external lesion, or whether it may con-
ceal a purulent collection, or may exist alone.
  M. Clot, (Compte-rendu de VEcole du  Abouzabel,  1832,) who, in
1832 gives only two  examples of it, states in 1835 (Journ. Hebd., 1835,
t. II., p. 297,)  that  he had  succeeded  eight  times  in this manner in
Egypt.   But at the present day  trephining of the sternum, like that of
the other bones, is almost always associated in practice with exsection.
(See Exsection of the Sternum,  supra.)
  [Dr. Hopton, of North  Carolina,  has reported in  the American Jour- 
540
NEW ELEMENTS OP OPERATIVE SURGERY.
 nal of the Medical Sciences, 1829, vol. Y. p. 545, a case in which he
 applied  the trephine for the removal of  a portion of a carious sternum.
                                                        G. C. B.]

                                §  II.

    The Operative Process, moreover, is subjected  to  the same  rules as
 for perforation of the cranium, whether  we resort  to the crown, perfo-
 rating trepan, Hey's saw, the rasp, &c.; except that the density of the
 bone being less, it is infinitely more easy  to penetrate into the chest
 than into the head.   The mammary artery could not be wounded unless
 the disease should oblige us to  carry the instrument beyond the  borders
 of the sternum.   In his first case, De Lamartiniere found it (the artery)
 so completely isolated that  he deemed it proper to protect it with lint
 for several weeks.  In another case  the  hemorrhage  it occasioned was
 arrested  by simple styptics.  I shall not speak here of the proposition
 made by some persons, to employ the trephine in order to arrive at the
 envelope (pericardium) of the heart in cases of pericarditis, nor of that
 which  recommends its use in order  to reach the arteria innominata,  in
 order to apply a ligature upon it;—because I have elsewhere spoken of
 the value to be attached to these suggestions.

                 Article II.—Trephining  the  Ribs.

  We have seen  above that the ancients sometimes had recourse to the
trephine to open into the chest in cases of empyema, and that at the time
of Hippocrates, some practitioners  preferred piercing in this manner a
rib, than making an incision into the soft  parts.   Though surgery at the
present day possesses more simple processes for the operation of empye-
ma, it nevertheless allows trephining of  the ribs to be useful in-certain
cases of  necrosis, or  where foreign  substances are implanted into the
body of the bone itself.  If, for example, the point of an instrument,
knife, sword or bayonet, had broken in a rib in such manner  as not to
allow of its  extraction by the forceps, the crown of the  trephine could
remove the bone and the foreign body at  the same moment.   In a case
of necrosis,  a crown of the  trephine  behind and another in front would
enable us to extract  the mortified fragment.  If  the  sequestrum were
invaginated in  a costal sheath of new formation, [see our note's  supra,
on the Formation  of Bones, Sequestra, &c. T.] the trephine would then
 still be indicated.
  It is nevertheless  true that  in all these cases the sector of the ribs,
 the osteotome of Heine, and the different  kinds of rowel saws which I
 have spoken of under the head of exsection, attain our object much bet-
 ter, so that trephining of the ribs at the present day is, or ought to be,
 almost entirely laid aside.
   To perform it,  it would be necessary, should  the skin have become
 adherent  and  degenerated,  and that an osteoform  sheath existed there
 of great volume, to lay bare the whole diseased region by means of an
 extensive elliptical incision.   Upon the supposition that the integuments
 might be separated, I  should, in place of  an incision parallel to the rib,
 prefer a T incision with its stem below, or an incision in form of  an arc, 
            TREPHINING OR OPERATION WITH  THE TREPHINE.        541

with its convexity also directed downwards.   The simple incision scarce-
ly ever allows of our isolating the diseased  parts  properly.  By means
of the  T incision,  we are enabled to turn over  in front and behind, a
triangular flap, which  gives  great  facility for the employment of the
other instruments.   The arched incision offers still greater advantages ;
for by enabling us to raise up the tissues in the form  of  a half-moon, it   ,
afterwards puts it in our power  to allow the  flap  to fall  of  itself over
the wound.
   The soft parts being thoroughly detached and raised up, the  surgeon
applies a first crown of the  trephine in front, if he is about to place on
several of them ; or upon the diseased region, or the  fistulous aperture
of the  cavity to be  opened, if only one is required.  The perforations
having been made, the section of the hard parts is completed by means
of Liston's  scissors, or any other sector, after which we  have recourse
to the forceps to extract the portion  to be removed.  The vessels to be
avoided, and the attentions required for the  dressing, are in every res-
pect the same as those I have mentioned under the head of Exsection of
the Ribs, [supra.]

                Article III.—Trephining  the Spine.

   The spinal column forming as it does a long  canal, enclosing a cord
of the  highest importance, cannot  be affected with caries, necrosis or
fracture without exposing to serious dangers.   It were to  be wished,
therefore, that we might trephine or excise it like the cranium,  sternum
or ribs.   It is an operation  which Vigaroux (Hevin,  Cours  de  Pathol.
et de Thir.  Chir., t. II., p. 207) had already proposed in the last cen-
tury, and one which  some  surgeons, in fact, appear  to have since per-
formed.   The first  attempt of the  kind is  attributed to Cline, and the
second to Tyrell.  A man who fractured the vertebral column was par-
alysed by the same blow.   Supposing that the compression of the spinal
marrow depended upon effused  blood or some fragments of depressed
bone, M. Tyrell (Bull, de Fir., t. IX., p. 173) laid bare the dorsal re-
gion of the spine at  its lower portion, and came down  upon the eleventh
dorsal vertebra.  Having directed the trephine upon  this point, he was
enabled to disengage the osseous fragments, and to raise them up.  The
patient was  relieved at first, but he died on the fifteenth  day.
   This operation, which is to be assimilated to  excision or exsection of
tne spine or of the  vertebral lamellaa,  and which was performed  by
A. Smith, with the  assistance of M. Dudley, and  which I  have  spoken
of farther back, does not deserve, as I think, to be retained in practice.
In admitting that perforation  or excision on the posterior region of the
spine might be  positively  indicated, I do not believe that the trephine
would ever become indispensable.  Pure and simple exsection, by means
of one of the osteofomes above mentioned, would be manifestly  prefera-
ble. 
542
new elements op operative  surgery.
                          CHAPTER III.

                        bones of the limbs.

   There are  scarcely any regions upon the limbs, to which tne trephine
 was not formerly applied.  At present, it is an operation more and more
 neglected, and one which the new saws will perhaps ultimately render
 completely useless.

                     Article I.—Lower Limbs.

          §  I.—Bones of the Metatarsus and Metacarpus.

  The surgeon not having at command the articulated or rowel saw, or
Liston's scissors, and  being under the necessity of excising one of the
bones of the  metacarpus  or metatarsus, might make use with advantage
of a small crown of the trephine, which he would apply  upon the con-
tinuity of the bone, after it had previously been denuded upon its dorsal
surface.  It is in this way M. Wardrop proceeded, a long time since, for
the head of one of  the bones of the metacarpus, and it is the course that
might still be adopted for the  anterior extremity of tho first bone of the
metatarsus.
                    § II.—Bones of the  Tarsus.

  Certain circumscribed  points of caries or necrosis existing upon the
cuboid bone or os calcis, might equally be removed  by the crown of a
trephine, better than  by  any other mode.  If the disease were  deep,
and the soft  parts altered only by a simple  fistula, then  the  operation
would  require a crucial incision on the dorsal region of the cuboid bone
and the plantar region of the os calcis, which, with the other precautions
indicated under the head of Exsections of these bones, (supra,) would
complete the manual.

                     § III.—Bones of the Leg.

  Trephining has often been employed for  the bones of  the leg. It has
been used upon the  tibia and fibula, and on the malleoli and near the
knee.
  A. Tibia.—The  tibia,  more than  any other part of the skeleton, is
 exposed to necrosis and caries.   I have already described in what  man-
 ner we operate upon it for those  two maladies by means of exsection.
 I will add only a word on the employment of the  trephine in such cases.
 Scultetus, (Arsen.  de Chir., Obs. 81,) who states that he trephined the
 external malleolus, on another occasion applied two* or three crowns of
 the trephine, and was thereby enabled to remove almost the whole of a
 necrosed tibia.   To Cullerier (Obs. communicated by  the author  to M.
 Champion)  we are indebted for a similar  fact.   Sequestra, of four or
 five inches extent, have been laid bare in three cases by  M. Champion,
 (communicated by the author, 1838,) by means of two or three crowns
 of the trephine.  The division of the soft  part3, and the  denudation of 
           TREPHINING OR OPERATION WITH THE TREPHINE.       543

the hypertrophied bone, are performed in both cases after the same rules.
If, after this  stage of  the  operation, the trephine  was to be  applied in
the manner of a saw or osteotome, we would first place one  of its crowns
upon the most depending fistula in the bone, then another on a line with
the one (fistula) highest up.   It might  afterwards  be advantageous to
apply several of them in the interval between the two first, in order to
isolate the sequestrum completely.   In two patients of M. Jobert, (Journ.
Hebd., 1836, p. 21,) who ultimately recovered, seven were required in
one case and four in the other.  We may, however, diminish the number
of these crowns, by evulsing the bridge left between  the first, either by
means of the crested saw, directed  from the exterior to the interior, or
by an articulated saw passed through the osseous canal to  the exterior,
or by means of the concave rowel saws, the gouge, or the chisel.
  In conclusion, if there were  true necrosed  sequestra, I  do not think
that  the trephine  would in any case here  be preferable to  the  excision
which I have described.   Upon the supposition that there were only os-
seous fistulas in the tibia, kept up  by a false mucous membrane or  by
caries, we could on the other hand,  include the morbid track of the bone
in the crown of the trephine, and  remove it by  a single stroke.  A
patient whom I saw and who was treated in this manner by M. Monod,
did very well.
  An abscess in the substance of the bone, or in the medullary canal,
which has been several times seen by M. Brodie, (Arch. Gin., 2e serie,
t. I., p. 101,)  and which I myself have once met  with in  the first bone
of the metatarsus, should equally be laid open by the trephine.  Boyer,
(Journ. des Nouv.  Decouv., 1681, t. III., p. 504,) had already proved
this in 1669.   Muralt, {Obs., etc., p. 144,) furnishes another  example
of it.  We  are indebted for a third to Meckren, (Observ. Mid.-Chir.,
exp. 72, p. 341,) and J. L. Petit, appears  to  have often  trephined the
leg with success for abscesses of the tibia.  Michel, (Journ. de  Med.,
t. LIX., p. 135, 1783,) was  not  able to  cure an ancient  caries of the
same bone until he had trephined it in several places down  to its medul-
lary canal.  A purulent cavity, which Faure, (Mem. de VAcad. de Chir.,
t. Y., p. 828, in 4to, obs. 7,) mistook for a spina ventosa, was laid bare
by him by  the  same  operation.   To Gooch, (Gaz. Salut., 1775, No.
XXYIII., p. 3,) is  attributed  the  idea of trephining the  tibia for  an
extravasation  of blood in  the interior of the canal of this  bone, and Y.
D. Wiell, (Manget, t. IY.,  2e partie, chap.  II., p. 432,) did or saw
done the same thing to relieve a contusion  in the leg.
  " When," says Pouteau, (QZuv.  Posthumes, t. II., p. 106,) " in con-
sequence  of contusion of the bones, there is concussion  with  effusion
and  serious accidents, the trephine is the only resource for giving exit
to the cause of these difficulties.   I have, on  two occasions, made this
application of the  trephine with the most perfect success.   In the first
case, the anterior surface of the tibia was sufficiently compact, (i. c,
solid,) though swollen  ; in the other 1 found it rotten, though the integu-
ments appeared sound.  I removed this rotten portion, by  means of the
rasp, and desiccated the remainder with the actual cautery ; but perceiv-
ing that- the iron  had not in any manner  assuaged the pains, I applied
on the day  after a large  crown of a trephine, and this operation imme-
diately put an end to the sufferings, [of the patient.]  In both cases the
cure was soon accomplished." 
544            NEW ELEMENTS OP OPERATIVE SURGERY
  Trephining of the internal  malleolus, like that of the inner condyle
of the tibia, is sufficiently explained by what I have said of exsection or
excision of those osseous projections.
  [The trephine is now not unfrequently  employed to relieve the pain
produced  by abscesses in  bone.  The  credit is universally given  by
British writers to Sir  Benjamin Brodie for  priority in this  operation,
but this distinguished surgeon was certainly anticipated by Mr. Hey of
Leeds, as  may easily be  proved by referring to his  Practical Observa-
tions in  Surgery, 3d. Lond. Ed. 1814, pp. 26, 36.  He there reports
three cases in which he trephined the  tibia  in the  years  1787, 1792,
and  1804, his avowed  object having been to substitute this proceeding
for  amputation.   In the  Memoirs of Dr. Nathan Smith, by his  son Dr.
Nathan R. Smith, now of Baltimore, published in 1831, p.  114, we find
it stated that it was his general practice to perforate the bone, for the
purpose of giving vent to the matter formed during the active stage of
periostitis or of inflammation of the medullary membrane of the  bone.
The  instrument  which he recommends is  " a small trephine, that cuts
out a piece about the size of a ninepenny bit," but he remarks that he
has often  succeeded by making a number of perforations through the
denuded  portion of bone, with the  perforator used in trepanning.  In
February, 1839,  the  Archives  Generates  de Medicine republished  an
article from the American Journal of the Medical Sciences, written by
another son, Dr. Morven Smith, in which are detailed  several  cases in
which his  father  had operated.   Sir Benjamin's observations, according
to  his  own  admission, (Lond. Med. Gazette, Dec. 1845,) were first
published  in 1832, therefore his claims must  yield both to those of Mr.
Hey and  Dr. Nathan Smith.   Most if not all of the  cases recorded  of
this operation, we believe, are those in which the tibia was the part invol-
ved.   After  Sir Benjamin Brodie, Mr. Liston and Messrs. Henry Lee
and Prescott Hewett, of  London, have most contributed to  advance our
knowledge on this subject.  Although this circumscribed chronic abscess
of bone is most frequently  found in the tibia, it has  been  observed in
the clavicle, lower jaw and  femur.   Cases of the latter, have been men-
tioned  by  Mr. Liston and Mr. Arnott, and we have in  our possession a
beautiful specimen of this disease in the external  condyle of the femur,
taken from a patient whose thigh we amputated some four  years  since.
Prof. Parker informs me  that a similar case has occurred in his practice.
In the case first seen by Sir Benj. Brodie in 1824, the disease was seat-
ed in the  lower end of the  tibia, " the skin  covering the swelling was
thin, tense, and closely adherent to the  periosteum, but the ankle joint
admitted of every motion and was apparently sound."  The pain was
constant, occasionally excruciating, and the disease had lasted for twelve
years.  After amputation, a cavity was  found in the centre  of the bone
as large as a chestnut, filled with dark-colored pus.  In our own  patient,
the knee joint admitted of  free motion without pain, but the pain  in the
vicinity of the joint had for a long  time  been most agonizing.  Even
had we been able to form a correct diagnosis, on account of the situation
of the disease, and the irritable, exhausted state of the patient, we could
not have  done otherwise than resort to amputation.   In some cases, it
may be a  matter of difficulty to distinguish between  this affection and
the softened  encysted  tubercle so well  described by M. Nelaton  in his 
            TREPHINING OR OPERATION WITH THE TREPHINE.       545

memoir published in 1837.  Mr. Langston Parker, of Birmingham, has
several times trophined the tibia to relieve the pain arising from an in-
flammation  of the  medullary  substance of the bone.  He was led  to
adopt this practice long since adopted, as we have seen, by Mr. Hey and
Dr. Nathan Smith, from the well  known circumstances that in some in-
stances where the  operation has  been performed with the expectation
of finding  necrosed bone and none has been found, the patients, by the
free discharge thus given  to the congested state of the medullary canal,
have been  permanently cured.  A brief analysis of Mr. Parker's valu-
able paper on this subject, we  published in the October number of the
American Journal  of the Medical Sciences, 1853.  Cases of a similar
nature, in which this operation has been advantageously performed, have
been reported by Mr. Henry Loe, of the Locke Hospital, London.  Mr.
Fergusson  prefers  the gouge  to the trephine,  as with this,  the surgeon,
at each step, may see what he is doing, and take any indications which
may present  themselves,  while the layers are removed, as to the exact
position of tho abscess.   With the trephine the abscess, which is often
very small, may bo missed altogether.   G. C. B]
  B. Fibula.—We may apply the  trephine upon the fibula, the same as
upon  the tibia, and with  so much  the more propriety, inasmuch as this
bone acquires  double and  sometimes treble its natural size when it be-
comes the seat of an invaginated necrosis.  We may also remove a por-
tion of its  continuity  by means of the crown of a trephine  as well as
with the saw,  when it becomes necessary to extirpate its lower or upper
extremity or even its middle part; but it is certain that  by using the
modern saws,  sectors and osteotomes,  we  no longer at  the  present time
have occasion in such cases for the employment  of the  trephine.  It
would  be only for certain cases of deep-seated and very circumscribed
caries of the external malleolus, that we could still feel the want of  it.
Having, therefore, indicated the circumstances where the trephine should
be preferred, in  treating of exsection of the  fibula, I will  not  recur to
that subject on the  present occasion.

                               §  IY.

  When a necrosis exists  in the centre of the  femur, and the fistulous
openings of the  new sheath are too contracted, or cannot be enlarged
by the rowel saws, the trephine may then be of some utility.  Here, al-
so, I have only to recal the rules which I  have laid down under the ar-
ticle on Exsections, in relation to what concerns the division of the soft
parts.   The semi-lunar  flap being raised  up,  we place a crown of the
trephine at an inch above or below one of the  principal osseous fistulas,
so as to penetrate into the sheath  which contains the sequestrum or the
pus.   A man,  aged 33 years, had suffered a long time in his femur;  a
crown  of the  trephine was applied by M. Lynn, (Gaz. Med., 1838, p.
778,) at four  inches below the great  trochanter; an exit being  thus
given to an abscess in the  medullary canal, and to some splinters of bone
besides, the patient recovered.  If this does not  suffice, we are to di-
vide, as I have already said of the tibia, the intervening bridge of  bone
by means of the crested  or chain-saw.  Upon  the supposition that the
sequestrum was too long or too voluminous to allow of our extracting it
  Yol. II.                    69 
546            NEW ELEMENTS  OP OPERATIVE SURGERY.
by the first opening, we must then recommence in the same manner on
another point, and break it with the osteotrite of Dupuytren, or make
use of the  gouge and  chisel to evulse the  projections which are in the
way.
  The great  trochanter and the external and  internal condyle of the
femur, should be trephined, as  has been said  in the chapter on  Exsec-
tions, should  there exist a simple point (noyau) of caries, accompanied
with necrosis or tubercles, and  that the articulation was unaffected and
the disease had extended to much greater depth than width.

                           § Y.—Pelvis.

  I have already said, under the  article of Exsections, that the ilium
has sometimes need of being perforated.   Boucher, having laid  bare
the external  iliac fossa, traversed  the bone of the ilium by means  of a
crown of the trephine, and gave egress in this manner to the pus of an
abscess which was situated in the interior of the pelvis.  If a necrosed
portion were  confined between  two plates of  new osseous formation in
this region, as in the patient of  Leaulte, and that we had ascertained its
mobility by means of a probe,  some crowns of the trephine might  also
assist in laying it bare.   A semilunar flap, with its free border  below,
and raised up to the crest of the ilium, would enable us in both cases to
come down to the  bone.   If, however, the disease in question were an
internal abscess, or some carious points of bone, without hypertrophy or
sequestrum, it would  perhaps  be  better then to confine ourselves  to a
simple crucial incision.
   Coccyx.—Sprengle states, that  in a case in which  there was an ab-
scess in the pelvic cavity, Bilguer perforated the coccyx, or point of the
sacrum, with the crown of a trephine, and  thus cured the  disease.  I
cannot, however, perceive  the utility of trephining the coccyx in such
cases ; for it  is easy to conceive that the bistoury could have reached
the collection fully  as well as the crown of the trephine, by penetrating
upon  one of  the sides of the point of the bone, from  below upwards,
from before backwards, and from without inwards.

                     Article  II.—Upper  Limbs.

  The different portions of the thoracic extremity are no less suscepti-
ble of the application of the treohine than the  corresponding regions of
the abdominal member.

                        §  I.—Fore-arm.

   What I have elsewhere said of exsection of the radius and ulna, shows
sufficiently what we may hope  from the trephine when the bones of the
fore-arm are  diseased.  The new instruments employed at  the present
time render it almost  useless in this region.  It would be moreover upon
the postero-internal side of the ulna, or the postero-external side of the
radius, and after having made the proper incisions in the soft parts,  that
we would apply this instrument, should we be  resolved upon using it.
   [With the exception of the cases of abscess in the olecranon,  treated 
            TREPHINING OR OPERATION WITH THE TREPHINE.        547

by Mr. Curling at the London Hospital, we are aware of no instance in
which the trephine has been applied in this region. Mr .C. has reported in
the London Medical Times and Gazette, for March, 1854, p. 211, two
very interesting cases, in which the affection above mentioned simulated
disease of the elbow-joint.  In  one  of these  cases, a cavity was found
in the interior of tho  ulna in which were lodged two detached pieces of
necrosed bone.  Immediate relief, however, did not follow the operation,
the disease recurring, for a few days, with almost its former violence, yet
this finally subsided and the  patient preserved the perfect motions of
the joint.   In the  second case, the  application of the trephine was fol-
lowed by  immediate relief.   G. C. B.]

                          § II.—Humerus.

   After the tibia,  the humerus is perhaps of all the long bones the one
that has been tho oftenest trephined.  Below the condyles, I would recom-
mend the  same as for the tibia, a semi-lunar and very long flap.  This
flap, by being detached from  behind  forwards, would incur the risk of
dividing only a part of  the fibres of the triceps, and could be crowded
very  far  forwards with the biceps  and vessels.   If it were the upper
fourth of the bone, the flap I speak of ought to have its free border facing
downwards.  As to what concerns, moreover, the placing and application
of the crowns of the  trephine, we should proceed  as I have described
for the tibia or the femur.

                              § III.

   The clavicle would not permit of the employment of the trephine un-
less it was enormously hypertrophied and enclosed a long sequestrum to
be extracted; and  even then  the  concave  rowel, or the chain saw, or
other species of osteotomes, would  almost always deserve the preference
to the trephine.  In using  the  instrument, moreover, we should have
nothing more to do after the flap had been cut than to raise it from
below upwards, in order to lay bare the bone, after which it is to be ap-
plied  as has been described above.

                       § IY.— The Scapula.

   It has oftener become necessary to trephine the scapula than the bones
of the ilium.  A soldier received a thrust through the shoulder from a
foil; the wound remained fistulous ; an ulcer formed in the infra-scapular
fossa,  and the pus made its  escape  therefrom but very imperfectly.
Mareschal, who decided upon the step of placing the crown of a trephine
upon the injured bone, cured his patient.  In another case, where there
was only a simple  necrosis, Else of London  also trephined the scapula,
and was no less successful.   A specimen deposited in the Anatomical
Museum of Alfort, by Flandin, and which M. Cloquet states that he has
seen; also two other similar specimens that M. Jobert professes to have
examined  in the  same collection, would go to show that the scapula may
be necrosed and  imprisoned between the two plates of a scapula of new
formation.   [See notes supra on the Formation, <fec, of Bones. T.] We 
548
NEW ELEMENTS OF OPERATIVE  SURGERY.
 may conceive now the application of the trephine under such circum-
 stances might become useful; while we may at the same time comprehend
 that the operative process cannot be traced out in a book, and that it is
 left for each surgeon to devise his own, by adapting it to the particular
 case which he has under consideration.
   I ought not, in  terminating  this article, to omit  remarking that tre-
 phining of the bones of the limbs, like that of the bones of the chest,
 is in almost  every case closely connected with what I have said of ex-
 section or excision of the same parts.   I will"repeat that the employment
 of the trephine has  lost much of its interest and  importance in these
 regions,  since the chain saw,  that of Heine, and the rowel saws, now
 recognised in the domain of surgery, have given us the power of perfor-
 ating and dividing the  bones in the depth of the tissues  with  the same
 facility that the bistoury gives us in incising and dividing the soft parts.
   Both for trephining and for exsection of the body of the bones in cases
 of chronic diseases, I have endeavored to generalize the semilunar form
 of the flap.   The convexity of the free border of this  flap, which  is
 either slight or very marked, as the case may require, gives to the surgeon
 the extreme advantage of being enabled to lay bare the parts extensively
 by means of  a single  incision, and  that of possessing  afterwards every
 facility for contracting or closing the wound.  It is a form which unites
 the advantages of the T incision, and that of the  crucial and  Y to the
 simplicity of the straight incision.  It is adapted also, as we have seen,
 to almost all the bones which are susceptible of  exsection.


                  SECTION   TWELFTH.

                              TUMORS.

   Tumors form an extensive class of surgical maladies, even after hav-
 ing deducted from them, abscesses  already treated of under the article
 on  Elementary  Incisions and Operations,  [Yol. I.,]  phlegmons  and
 every kind of tumefaction, whether acute or chronic, which is undefined
 by any well-ascertained  limits, and the principal medication of which
 consists of topical applications  and internal treatment.
  My design now is to speak only of tumors which are ordinarily treat-
 ed by mechanical means or which  are submitted to the action of instru-
 ments.
  Considered in this point of view, tumors still occupy a large  space in
 the departments of operative surgery.   They are, moreover, too diffe-
 rent in their  nature, volume, causes and situation, to make  it  possible
 to treat of them at length in a general  manner.  Taken in their ensem-
 ble,, they have been sometimes attacked with simple astringents  or styp-
 tics, sometimes by compression or caustics, by strangulation, by ligature
 of the  arteries which are distributed to them, or incision of the contour
of their  root, and sometimes by excision  or extirpation ; others have
been treated by acupuncture or the seton, vaccination, crushing, or irri-
tating injections and  scarifications.  As none of these numerous general
methods  can be suitable for all kind  of tumors, it would be useless in
this place to give their rules in detail.   Thus compression, which is use- 
TUMORS.
549
ful in some cases of erectile tumors, would manifestly be inapplicable in
cases of lipoma or exo stosis.   Crushing,  which sometimes  succeeds
with synovial, sanguineous and lymphatic tumors, cannot be applied with
advantage  to  scirrhus, elephantiasis, &c.   Cauterization, which  is  not
without efficacy in some species, would aggravate the disease in many
others.   Of what service would be a ligature upon the artery in a deep-
seated lupus ?  Who would think of treating encephaloid tumors and
neuromas by irritating injections ?   It is then in speaking of the  princi-
pal kinds of tumor in particular that I shall  have  to consider the value,
either absolute or relative, of the operations  which  are  employed for
them.   On the  other hand the  classification  of these  tumors is exceed-
ingly difficult.  If the character of some of them would serve as a point
of departure, it is not so for an infinite  number of the others.   If we
take for our guide their situation, whether in respect to the tissue or the
region of the body, we shall experience  the same embarrassment, inas-
much as there are those which are developed almost indiscriminately, in
all the organic  systems, as well as upon all the regions of the body and
at every depth  of the animal economy.
  As it is indispensable, however, to assemble them together in  certain
groupes, I shall treat successively of tumors of the integuments, (tegu-
mentaires,) those that are vascular, lymphatic, neuromatic, lypomatous,
hematic, synovial, osseous, elephantine and cancerous.
                           CHAPTER I.

                    TUMORS OF THE INTEGUMENTS.

   Having  already made some remarks on warts and corns, and certain
other vegetations of the skin, under the chapter on Elementary Opera-
tions, I shall only have to speak here of horny productions, and certain
fibrous vegetations of the tegumentary envelope.

      Article I.—Tegumentary Tumors, properly so called.

   It sometimes happens that the surface of the dermis becomes swollen
and vegetates to such degree as to  produce an actual  tumor.  So long
as this tumor does not exceed certain dimensions, it belongs to the class
of warts, and should be treated as has  been already pointed out.  If on
the contrary it acquires a certain volume, that, for example, of a small
nut, or of an  ordinary  nut, or larger  still, it should be treated by one
of the processes which I have just enumerated.  In these cases the tu-
mor presents several varieties.   If it is diffused and imperfectly circum-
scribed, and that its limits do not yet appear  to be determined, we must
not attack it either by the seton, ligature  or  extirpation.   Astringent
and refrigerant topical applications, compression, or even cauterization,
are manifestly the only suitable remedies.
  When the tumor is clearly circumscribed or, as it were, pediculated, 
550
NEW ELEMENTS OF OPERATIVE SURGERY.
these last-mentioned  remedies should be rejected, and our choice must
lie between the ligature, excision, and extirpation.

                                §1-

  The ligature does not merit the preference in any case ; as, however,
it answers the  purpose when the pedicle of the tumor has but little vo-
lume, and that its root is in no respect degenerated,  we may  make use
of it in timid subjects, or those who are badly constituted, and especial-
ly in such as dread above  everything, the  application of the bistoury.
In such cases, then, we surround the pedicle with  a  ligature of silk or
thread, and  tighten it  forcibly, and in such  manner  as  to  strangulate
completely the vessels and other living tissues of which it is composed.
The more sudden  and powerful the constriction in such cases, the less
painful is the operation, and the more rapid and complete the successful
issue.

                                §n.

  The excision of pediculated  tumors of the  skin, disembarrasses the
patient of them  immediately, and leaves  a wound which  generally
cicatrizes with promptitude.   This operation being speedy, easy, with-
out  danger, attended  with little-pain, and certain, is to be  preferred
as a general rule  to  the  ligature.   Before having recourse to it, how-
ever, we must  make   ourselves  assured that the root  of the  pedicle
is wholly sound at  the point where it is continuous with the rest of
Lhe  dermis.  Otherwise, in fact, we should  remove  only a  part of the
disease, and the  tumor would  soon  reappear.  This excision  is per-
formed almost indifferently  with any kind of cutting instrument.  The
surgeon, holding the  tumor  with one  hand by  means  of the  forceps
or  erigne, or causing it to be held by an assistant, readily cuts through
the  pedicle with  a single stroke by  means of a good pair of scissors
or  an  ordinary  bistoury.  If it  is  small, he immediately cauterizes
the  wound  with nitrate of silver, and has  afterwards  no need of any
other  dressing.  The cure is generally  complete when the eschar de-
taches itself at the expiration of  a few days.  If the wound should be
larger, we should treat it like any other simple wound, and the cicatriza-
tion would not be long delayed.

                               §111.

   Nothing, moreover, would  prevent  us in  such  cases from combining
 excision with the ligature.   The  thread being applied, the tumor could
 immediately be effectually excised outside  of it, inasmuch  as it would
 cause no additional  pain, and  the  patient  would in  this  manner be
 disembarrassed of a  mass, which, in  putrifying, continues in some per-
 sons for about the  space of a week, to be sufficiently  offensive.

                                §IY.

    Extirpation  of cutaneous  tumors,  nevertheless, is the only  proper 
TUMORS.
551
operation, when the alteration comprises the whole thickness of the skin at
the point which serves as its root.   Then it becomes important also to re-
move a certain portion of the sound tissues with the degenerated mass.
For that purpose we make on each side of it a curved incision, so as to
circumscribe a very long ellipse, the centre of which  corresponds with
the  apex of the tumor.  As it is unnecessary to penetrate deeper than
the  integuments, we stop at the sub-cutaneous tissue, and the  operation
is generally as  prompt as it  is easy.  The  wound which results from
it is then  treated by  strips of adhesive plaster  or by  the  suture, if
we wish to attempt immediate union.  In the contrary  case, we dress
it flat by means of the perforated linen and a gateau of lint.

                               §V.

  A process which has appeared to me convenient when approximation
by  the first intention is to be attempted, consists in first perforating
a fold of the skin under  the  pedicle of the tnmor, with a sufficient
number of  pins  while  the tumor is being  held  up.   These  pins
being once  adjusted in their  place, prevent us  in  nowise  from  pro-
ceeding to the excision in the manner just mentioned.   They also allow
of every facility in  closing the wound,  since nothing more is required
than to  pass a  noose  of thread   around them in order to  complete
in an instant the twisted suture.
  In these  cases, moreover, as in  others, the adhesive straps, needles
and points  of suture should  be  promptly removed,  and replaced by
emollient cataplasms, should there supervene  the  least appearance of
erysipelas, whether simple or phlegmonous; better is it in  such cases to
take fifteen  days in cicatrizing a small wound, than to incur the danger
of diffused phlegmon.

                   Article II.—Horny Tumors.

  Horny  productions have frequently been observed in man, in whom
they present a form and dimensions exceedingly variable.  There is no
region of the body which has not been the seat of them;  and the same
individual might have a very great number of  them at the same  time.
They have been  noticed, and  I  myself have  seen  them on the cranium,
forehead and mastoid regions.   They often exist upon the  nose, face and
chin, and  sometimes upon the  lips. They have been encountered upon
the neck, especially at the nape, also on the chest, belly, and sacrum,
and about the  genital organs.  The  limbs  themselves are not exempt
from them;  they have been observed upon  the shoulder, arm, elbow,
fore-arm, and different parts of the hand.  A horny excrescence resem-
bling the enormous  beak of  a parrot, was successfully removed by M.
D. Lasseree, (Cas. de Chir., etc., p. 42, fig. 5,) from the hand of a man
who was eighty  years of age.  The same productions are found  also
upon the  breech, thighs, legs  and feet.  An old man who died of an
enormous cancer of the stomach, at the Hospital of La Charite in 1837,
had  the integuments upon his limbs so completely covered with them,
that it was impossible to count them.   There had been admitted somo
time previous into my  department, (of  La  Charite,) a young  woman 
552            NEW ELEMENTS OF  OPERATIVE SURGERY.
who was precisely in the same condition, and I have collected  two or
three other analogous facts.  In all these individual the horny produc-
tions were exceedingly small;  they resembled  so many points, heads,
nails, or pins implanted in the skin.
   When these horny productions are multiplied  in this manner, there
is no mode of submitting them to the  processes  of operative surgery.
In such  cases, if anything is to be attempted for the relief of the pa-
tients, we have no other  resource but topical applications and general
treatment, external or internal.  In the  contrary case, that is to say,
when there is but one  only, or a small number  of them, when they are
so large or elongated  as to occasion inconvenieuce, and to induce the
patient  to demand their  removal, these horns are to be attacked by the
same processes  as  tumors purely cutaneous.  Nevertheless, it is rare
that they allow of our depending upon the  ligature or simple  excision.
Being almost always deeply implanted in the dermis, they  necessitate
too powerful  tractions upon them to allow of our placing a constricting
thread upon the sound tissues behind them,  [i. e., deeper or below, or
under their  root.]   The scissors or the bistoury  also [in excision, vid.
a few lines above.   T.]  would then  divide the skin flat-wise, and pro-
duce a larger and more  irregular wound, and  one, consequently, less
favorable to cicatrization, than that by extirpation.  I should add that,
in the extirpation of horny tumors, we ought, more even than in that of
cutaneous tumors properly so called, to encroach at least to the distance
of some  lines upon the sound tissues, in order to be assured with cer-
tainty against every fear  of a return.   Though  these  tumors do not
extend deeper than the skin except in some cases, they should be ope-
rated upon in the same manner in whatever regions they may exist.  It
could only be upon  the cranium or face from the superficial  position of
certain arteries, that any particular precautions would become necessary.
If they  should  penetrate to the muscles or bones, as has been seen in
the thigh, or down to the dura mater, the surgeon would reflect seriously
upon them before proceeding to their extirpation.   But it is not required
that I should describe this operation in particular, for the different re-
gions of  the body.   I shall, however, be enabled to say a word in rela-
tion to it, in speaking of the other operations which are performed ou
certain  complex organs, and there may be found in the Thesis  of M.
Dauxais, (Des Comes, in 4to, fig., Paris, 1820,) together with all the
known examples of horny vegetations in man, a very just appreciation
of the remedies which prudence authorizes us to employ in such cases.
                          CHAPTER  II.

              VASCULAR FUNGOUS OR ERECTILE TUMORS.

  A class of tumors which has excited much attention among the mod-
erns, is that which comprehends navi materni, spots, marks, birth-stains,
aneurism by anastomosis, erectile productions, and fungous sanguineous 
TUMORS.
553
tumor3.  These different names being employed to designate tho same
kind of morbid growths, have been almost universally superseded to-day
by the title of erectile tumors, as proposed by Dupuytren, although this
phrase is  itself fully as objectionable  as  the others, (Legons Or ales,
t. IY.)  We understand by this, tumors or patches  either of a reddish
or of a more or less deep brown color.  These productions, being com-
posed  of a  net-work of vessels irregularly interlaced and combined
together, present some resemblance to the tissue of the corpora caver-
nosa.  These erectile tumors, however, contain  almost always a degen-
erate structure, which essentially distinguishes them from the natural
erectile tissues, and which  predisposes them to transformations of a bad
character.   Nor is it rare also to encounter in them cerebroid or mela-
notic matter, and to feel embarrassed when called upon to decide, if the
case in question is in reality one of erectile tumor or encephaloidal fun-
gus.  It becomes requisite, therefore, to establish  several varieties of
erectile tumors.

                        Article I.—Species.

                      §  I.—Arterial Funguses.

  The most common, namely, those which are observed more especially
upon the surface of the skin, and which have been known for ages under
the name of stains, birth-marks, and n&vi materni, depend almost always
upon an unnatural dilatation of the  arterial capillaries.  So also are
they generally of a bright red tint, and liable at moments to color deep-
er and become swollen to greater or less extent.   Though erectile tu-
mors in which the arterial  capillaries  preponderate  usually occupy the
skin, they are however developed also in the interior of the limbs, and
at the centre or surface of certain particular organs.

                      § II.—Venous Funguses.

  These, which from the very beginning acquire a sufficiently large size,
and  present a violet, livid or brownish hue, are more especially  formed
of veins, and are more frequently encountered underneath the skin, and
in the  depths of  the tissues and organs, than  upon the surface of the
body.  Usually flabby and crimpled they readily shrink under pressure
or in certain positions of the patient.  To make them  tense and to in-
crease their size, we have only to incline downwards the part on which
they are situated, and to maintain them in regard to the heart, in a de-
pending position.

                      \  III.—Mixed Funguses.

  Yery frequently the arterial and venous capillaries so blend together,
that it becomes impossible  to avoid making a mixed species of such tu-
mors, or to assign them to one of the preceding classes rather than to
the other.  In these the physical characters are necessarily a mixture
of those which I have just  described.  It is thus that with fungous and
livid protuberances upon them, there are noticed also patches of bright
  Yol. II.                      70 
554
NEW ELEMENTS OF  OPERATIVE SURGERY.
 red which are hard and more homogeneous, and that by means of pres-
 sure or a  certain position, they are  in  part  flattened without having
 their color entirely effaced.

                    § IY.—Fungus Hematodes.

   So long as erectile tumors do not present other characters than those
 described, their  diagnostic  is  sufficiently easy.   But  if they  become
 blended  with tissues  of a new formation, or with a more  deep-seated
 degenerescence of their own elementary structure, we then have tumors
 which  in part  resemble encephaloid or melanotic or certain  fibro-vascu-
 lar tumors, and especially those which  English practitioners have de-
 scribed under the title of fungus hematodes.

                     Article II.—Treatment.

  Erectile  tumors are not always situated in the same anatomical tis-
 sues of the body.  At  the surface of  the body nothing prevents our at-
tacking them by an infinite variety of surgical processes.  Here we may
recur  to  topical  applications,  compression, strangulation, vaccination,
the seton, caustics, scarifications, the ligature, extirpation, &c.   Under-
neath the skin they present more difficulties ; astringents, caustics, vac-
cination, scarifications  and the ligature, can no longer be  applied  to
them, or at least with great difficulty.  Deeper still, that is to say, be-
tween  the  muscles or in the thickness of those  tissues, compression
itself, the  seton, and injections, can afford scarcely any chance of suc-
cess while incurring the risk at the  same time of real dangers.  Nothing
then is left to have recourse to but extirpation, and some other processes
 of a very questionable efficacy.   We arrive finally  to those [erectile tu-
mors] which are situated in the structure of the bones themselves, and
which leave us no other choice but the removal of the limb or a ligature
upon the principal arteries which are supplied  to it.
  These  preliminary observations were  necessary  to enable  the reader
 to understand  what I  am about to say of the boasted operations for
 erectile tumors.   I should add  before going any farther, that although
 there may  be erectile tumors which might give rise to serious  hemor-
 rhages, as is seen in the case mentioned by Turner, ([Maladies de la Peau,
 t. II., p. 242, trad. Franc.,)  there are others, as those  of infants, those
 that occupy the surface of the skin,  or which exist  from birth for exam-
 ple, which sometimes continue for a great number of years  without in-
 creasing  in extent, or  giving rise  to any inconvenience.  I have  seen
 some which have ultimately wasted  away and disappeared spontaneous-
 ly.  M. Ouvrard (Op. cit., p. 385) mentions one which became inflamed
 and was thus cured.  It becomes important, therefore,  before undertak-
 ing their treatment, to  ascertain with  certainty, if they have a tendency
 to increase in growth, or that they have become so prominent at the sur-
 face of the skin as to give the child annoyance.

            k  I.__Topical Applications and Compression.

    A.  Topical  Remedies.—-These local means made use of by M.  Cham-
T, 
TUMORS.
555
pion upon the strength of the advice of Abernethy, (Surgical Works,
Yol. II., p. 322,) proved  unsuccessful in a case where compression, if
not a ligature upon  the carotid, would have alone sufficed; and I have
scarcely any more confidence in this moans than I  have in the applica-
tion of  the hand of a corpse (la main d'un mort,) seriously recommend-
ed  by Yan Helmont, (Tumulus Pestis, etc.,) as a remedy against erec-
tile tumors, or nmvi materni.
  B. Compression.—Practitioners also are far from being agreed upon
the efficacy of compression in the treatment of erectile tumors.  Though
Pelletan, Boyer, Abernethy and  Dupuytren  have obtained some advan-
tages from it, J. Bell, M. Brodie and most other practitioners regard it
as useless or injurious.  The case cited by Boyer, of a nwvus in which
the  tenderness of the mother  effected a perfect cure  in her child by
holding  her finger during  several months, 7 or 8  times a day,  trans-
versely under  its nose, is  an exception which cannot serve for the foun-
dation of a precept.  The  case in which M. Roux believes he succeeded,
was not in reality cured, if I may rely upon the testimony of some ocu-
lar witnesses.   I have  seen a case in every respect  similar to that of M.
Roux ;  the same sex and the same situation in the disease ; I prescribed
compression, and a pelote  bandage was prepared,  but  both the  infant
and the nurse became tired of it; nothing therefore was accomplished
and things remained unchanged, (Champion.)   Randolph and M. Roux,
however, cite some other examples sufficiently conclusive in favor  of
compression.  According  to M. Recamier  (Revue Mid., Mars, 1831, p.
349) it effected  the cure of a naevus which had become cancerous, after
two ablations and cauterization had failed.   It is moreover evident that
this remedy cannot be suitable to all kinds of erectile tumors nor to all
the regions of the  body;  those  of the external surface of the  dermis
alone allow of its employment.  Every thing indicates that it would not
succeed in nmvi materni composed of the venous capillaries ; nor upon
the abdomen, cheeks, breech, shoulder or elsewhere where the cutaneous
patch cannot have a solid point d'appui, can compression be relied upon
but with very little confidence.   Should it  be made trial  of under an
opposite condition  of things, it  would be necessary to continue  it for
several months with a  perseverance which is rarely met with, nor would
it  then succeed once  in fifteen  or twenty times.  As  to the rest, the
mode of effecting it is by the ordinary compressive means, such as banda-
ges, machines, collars, apparatus  specially adapted to  this object, &c.
M. Champion  has  seen areolar or saccular  sanguineous tumors  under
compression develop themselves   to considerable extent below the skin,
and acquire an elongated  form and sometimes a very great size.
   In conclusion, it is a method  which cannot be  proposed  but  where
every other is impracticable, or in persons who cannot bear the mention
of  any operation which is really effectual.

                         § II.— Vaccination.

   A very mild remedy, but one which scarcely  deserves any more con-
fidence  than  compression, is vaccination.   Many English surgeons,
among them M. Hodgson,  the same without doubt whom a certain journal
designated under the name of Dr. Godgson, (Clin, des Hopitaux, No. 97, 
556            NEW ELEMENTS  OF OPERATIVE SURGERY.

t.  II., p. 388, 1815,) as also MM.  Earle, Dowing  [Downing?] and
Cumin, (The Lancet, 1820, Yol. II., p. 237,) were the first to extol this
process  for such  affections.   It is a method  which I have made trial
of, and recommended to  many patients.   An  examination of the facts
published in foreign journals, and those  to  which I have myself been
witness, authorizes mo at the  present  time to say, that vaccination may
cure certain erectile tumors upon the cutaneous surface, whether arterial
or venous ;  and that it even  succeeded in a child whom I saw with M.
Rayet, and  who had a tumor  of a mixed character of the size of a pul-
let's egg  occupying the lower  lip and one of the chocks.   But it is easy
to comprehend, that if the disease were situated underneath the integu-
ments, vaccination could scarcely have  any effect upon it.   It is suitable,
therefore, only to external tumors,  and to those  of the  mucous mem-
branes which can be attacked upon the surface.  The operation, then,
requires  that we  should  make  a  great number of punctures, whether
internal,  or external, upon the  entire surface of the tumor.   It is im-
portant, moreover, that these punctures should not bo over four or five
lines apart.  From the moment  when the vaccine pustules begin to dry
up, a considerable degree of  tumefaction gradually takes place in the
whole mass, which becomes heated and inflamed, and sometimes terminates
ultimately in resolution.  It would seem in such cases, that the vaccinal
process induces throughout all  the canals of the erectile tissue, an adhesive
inflammation,  which prevents  the  afflux  of fluids  to the parts from
being maintained, and definitivelv transforms the whole into a kind  of
solid and permanent cicatrix.
  It is nevertheless true that  vaccination will almost always fail against
erectile  tumors, and so much  the more so, as it has no effect, it is said,
upon  patients  who have  been  previously vaccinated, (Parral, Archiv.
Gin. de Mid., 1834, t. YL, p. 207.)
  In the  treatment of Erectile Tumors by inoculating them with Croton
oil, which we  have alluded to under those tumors, Dr. Alexander Ure,
(London Med. Gaz., March 21, 1845,) states  that he has succeeded  in
one instance where a tumor of this kind of the  size of a currant was
situated at the inner angle of  the right upper eyelid in an infant aged  3J
months.  The  oil was  introduced by  several  minute punctures on the
point of a cataract  needle—and  repeated twice.  The tumor inflamed
and rapidly withered away.   T.]

                      § III.— Cauterization.

  The necessity of  destroying naevi,  in consequence of their hemor-
rhage, or deformity, or the rapid progress which the disease sometimes
makes, besides being susceptible of  reproduction, and of becoming can-
cerous, for  what  reason is unknown, says J. Frank, (Mid.  Prat., trad.
Fran?., t. IV., p. 434, et suiv.,) in consequence of repeated cauterizations
and  irritations, nevertheless  constantly  brings  back the mind of  prac-
titioners  to the  same means.   The potential  cauterv, moreover, which
answered in  several cases cited  by Turner, (Malad. de la Peau  trad
Fran^., t. II., p. 242,) F. de Hilden,  (46 obs., 5e centurie ; trad. Franc '
p. 91,) and Muys, (Nouv. Obs. de Chir., dee. 3, Obs. Ire., p.  155, trad'
Fran^.,)  has  frequently been employed, moreover, to destroy what the
bistoury  had left. 
TUMORS.
557
   Cauterization for erectile tumors, however, notwithstanding the recom-
 mendation of it which had been given by Callisen, (Chirurgia Hodiern.,
 etc., p. 204,) and  the praises bestowed upon it also by M. Hodgson, M.
 Guthrie, (Tarral, Op. cit., p.  98,) and M. Wcller, had nevertheless been
 generally rejected from ordinary practice as a dangerous remedy.   Boyer
 (Malad. Chir., t. II., p.  39o) charges it with causing excruciating
 (atroces) pains, and  of exposing the tumor to a dangerous degeneration.
 According to M. Begin, (Diet, de Mid. et de Chir. Prat., t. VII., p. 446,)
 it can  scarcely  have  other  effect than  to hasten the development or the
 transformation of the naevus into a cancerous affection.   Wedelius (Prix
 de VAcademie de Chirurgie, t. V.,p. 124, in 12mo) relates thatanasvus
 which  existed in a girl, degenerated in  cancer through  the employment
 of nitric acid.  These objections, acknowledged by M. Maunoir, (Mim.
 sur le  Fongus Him., etc.', p.  87,) and  re-stated  by myself and  others,
 have not prevented  M. Wardrop (Gaz. Med., 1834,  p. 711) from em-
 ploying this practice, and from endeavoring  again to demonstrate  its
 advantages.  Encouraged by  the successes  of this  practitioner,  MM.
 Lawrence^ Higginbottom, Lee, Langstaff, and some  others mentioned
 by M.  Tarral, have also used  caustic, and all agree in justifying its em-
 ployment.  Defrance (These  No.  267,Paris,  1835) reports an observa-
 tion which proves that M. Roux, receding from his first opinion,  has also
 since made trial of it.  I have also used it in a considerable number of
 children, and it appears certain at the  present  day,  that the  fears of
 Boyer on the danger of  caustics, in such cases, are not well founded.
   Cauterization, nevertheless, is only suitable to those superficial tumors,
 which  are rather extended  upon  the surface than in depth.  A child five
 years of age  had a superficial and arterial tumor in the right ham.   Re-
 peated applications  of potash ultimately destroyed it in a  number  of
 points  ; but perceiving that the disease  increased in the same proportion
 upon the other  side, it was  deemed advisable to suspend the treatment.
 This child, who was subjected at a later period to a serious operation,
 died in consequence  of the reproduction of the tumor.   Another  child
 aged seven years, whom a  student of medicine exhibited to me  at the
 Hospital of La Charite,  and whose right breech  was covered  with an
 erectile tumor as  large as the spread-out hand, was also only partially
 cured by caustic potash, so that extirpation was resorted  to, which ended
 in the  death of the little patient at the expiration of  a few days.  A
 young  man who had quitted the army, was admitted into  my department,
 at the  Hospital of La Charite,  for the  remains of an erectile  tumor
 which  appeared to have occupied an extent of from five  to six inches of
cutaneous tissue, between the ischium  and fore-part of  the right thigh.
This man informed us, that while in his regiment he had been treated
by caustic potash ;  but that new patches of tumors continued to be pro-
duced upon the outside of those which has been previously  destroyed. Cer-
tain it  is, that he now had remaining one from two to  three inches long,
and about an inch and a half  wide, the  surface of which was encrusted,
and seemed to be the seat  of the commencement of a cancerous trans-
formation.  A layer  of  zinc  paste effected  its separation  ; a  regular
cicatrix of good character was  established underneath, and the cure
finally  accomplished.
   The  children whom I have treated with caustics, had erectile tumors 
558
NEW ELEMENTS  OP OPERATIVE SURGERY.
which were situated in the interval between the eye-brows, and at root
of the  nose in one, on the side of the nose in another; the ala of tho
nose in a third and fourth, and on  the fore-part of the chest in a fifth.
The largest was  not over an inch and a half in extent, and the smallest
was twice the  dimensions of a small bean.   In another child whom I saw
with M. Rayer, and who had erectile tumors in the dorsal and sacral re-
gions at the  same time as upon the face, the potash also  succeeded,
though one of these tumors was several inches in breadth.
  A. Diffused Cicatrization.  This  operative process comprises  two
modifications : in one I use a piece of potash, in the same way as nitrate
of silver.   Having previously moistened the surface to be cauterized, I
seize the fragment of potash, either with a forceps or the fingers protect-
ed  by  linen or paper, or  after  having secured it in a sort of crayon, I
rub it upon all the projecting  points and  anfractuosities of the patch  or
tumor, taking  care, it is understood, not to permit any of it to run upon
the sound skin.
  Xo dressing is afterwards necessary.   As soon  as  the incrustation
which  results  from  this has separated, that is to say, at the expiration
of from four to six or ten days,  the same process is repeated, and  so on
successively, until there  no longer remains any vestige of the morbid
tissue.   If the cicatrix should not have at the same time been formed
underneath  it, the wound  is to  be  thence dressed like any other simple
wound until the desiccation is completed.   In this way we cause scarce-
ly any pain, and four to five or six cicatrizations frequently suffice.  This
is what  I should be disposed to call cauterization en nappe, and is the
only mode I have been in the use of since 1837.
  [MM. Bonnet and Gensoul have lately proved that the chloride of
zinc may cure  the disease known as aneurism by anastomosis.   A tumor,
occupying the  summit of the head, an inch in thickness, and of rounded
surface, about half a foot in diameter (15 centimetres), consisted of an
immense number of anastomosing  arteries, pulsating with a loud  bruit
de souffle, and was nourished by seven large trunks coming from the fron-
tal, the  temporal, and the occipital region, each about the size of the
brachial artery.   Injection was inefficient and impossible ; pressure, con-
tinued for a year, failed, and the surgeons were talking of tying the two
carotid arteries.  The cauterization by the paste of the chloride of zinc
effected the separation of the tumour without any hemorrhage whatever,
from each of the nutritious arteries.  The result of the case, not yet
complete, is to be communicated at a future meeting of the society.—
Med. Times and Gazette, July 23,  1853,  p. 98.   G. C.  B.]
  B.  Scattered Cauterization.—Others have adopted a different mode.
Applying an  indefinite number  of grains of potash at certain distances
from each other, either at the same time  or successively, their object  is
to riddle the tumor, so to speak,  with small cauteries.  After  the fall of
the eschars, they  allow  each ulcer to  suppurate, these, in cicatrizing,
prevent any reproduction of the  erectile tissue beneath them.   The pot-
ash applied in this  manner by  M. Tarral upon a tumor of the size of
an olive, by M. Langstaff on smaller marks, by M. Laugier, (Tarral, Op.
cit., p. 200-205,) on a uretro-vaginal tumor as large as  a nut, by M.
Higginbottom in many other cases, and by M. Allier, (Journ. des. Conn.
Med.-Chir., 1838, p. 188,) above  the  clavicle in an infant  aged  eight 
TUMORS.
559
months, has always  succeeded in the  same way as with M. Wardrop.
If any protuberances remain  in  the interspaces, they are to be treated
in the same manner until  they  have  all disappeared.  This mode of
cauterization is not only more painful but less  convenient than the
other.   It  does not succeed  so well when the tumor is spread  out and
thin, but it merits the preference for tumors with thick and unequal ele-
vations, inasmuch  as cauterization en nappe can never be but extremely
superficial.
   C.  Other Caustics.—Perhaps, also, it would be advisable in this case,
to employ  the zinc paste, or  Yienna  caustic, in preference to potash.
But  this is a question of practice upon which time and facts do not yet
allow of our giving a definite  opinion.
   I. The fear which had so long restrained surgeons, in respect to the
dangers  imputed  to caustics,  having  been  once dissipated, they soon
had  recourse  to  trials with  other species  of cauterization.    Thus
MM.  Graefe, (Tarral, Op.  cit., p. 211,) and Guthrie,  we  see attack
and cure certain superficial erectile tumors by means of nitrate of silver.
Cauterization  with nitrate  of silver, says M. Champion, was the only
method that could be employed in a  new-born infant, in  whom the nse-
vus occupied the  left ala of  the nose, with the corresponding  part of
the lip; no  trace of the disease was left behind, while an operation
would necessarily  have produced one.  I should think indeed that naj-
vi materni, which were but little extended and superficial, would often
yield to this means.  I have  employed it on two occasions,  with entire
success  for erectile nsevi on the visage, which were only two or three
lines  in diameter.  A  young  girl of eleven years of age, who had an
irregular, slightly granulated   naevus, of five or six lines' extent, below
the great  angle of the left  eye, was cured in this manner by five appli-
cations of the nitrate of silver.   But this kind of cauterization would
inevitably be attended with no success, in cases where the patches were
somewhat large or of a certain thickness.
   II. Going from this extreme to the other, in respect to caustics, Du-
puytren  and  some other surgeons  have not hesitated  to apply the hot
iron to erectile tumors.
   Though it may not be certain that Morin and M. Maunoir, who quotes
him, had recourse to this treatment at the very first, it is at least prov-
ed that M.  Graefe has frequently made use of it, since 14 examples of
it are related in one account alone of his clinique.  In order to cure a
pulsating  tumor, of the  size  of a nut, situated on the external part of
the dorsum of the tarsus, and caused by a punctured wound  from a nail,
M. Fleury  (Archiv.  Gen. de Med.,  Mai, 1839, p. 87) was obliged to
cauterize the  base of it with red-hot  iron some time after he had freely
incised it.
  For my own part, I am satisfied that the actual cautery which has been
employed by M. Ouvrard as an auxiliary to excision, ( Observ. de Med. et
de Chir., p.  37,) would answer as well as chemical caustics ; that we
might make  trial of it, therefore, with very  considerable  prospect of
success  in  all cases of superficial  erectile tumors ;  and that  it would
have the advantage also of enabling us to destroy at once both patches
and projections, which  the potential cautery could only remove in suc-
cession. Nevertheless, it is  still a remedy which is suited only to tumors 
560
NEW ELEMENTS OF OPERATIVE SURGERY.
    upon  the surface of the body; and since it has the inconvenience of in-
    spiring  great  terror in the patient, and is far from always proving suc-
    cessful, and since M. Graefe himself states  that he has seen it fail in five
    instances, and inasmuch as we may moreover obtain almost the same re-
    sults  with  potash, or  the Yienna paste, 1 am induced to believe that it
    will not obtain an extensive adoption in practice.
      III. I cannot state  to what extent, butter of antimony, nitric acid,
    sulphuric acid, and the arsenical  pastes  might be  employed in these
    cases  ; but  there is every reason to believe, that we might obtain the
    same results from them as from potash.
      IY. Nor  would perforating the  tumor with one or many red-hot
.    needles, as recommended by M. Bushe, ( Warren on Tumors, etc., p. 418,)
    or introducing into its interior, through a  track previously made for it
    by a seton, or some other instrument, a probe heated in the same manner
    as some English surgeons, and M. Macilwaine,  (Mid-Chir.  Trans.,
    part 1st, p.  189,) among others, have done, ever  become  an effectual
    operation in such cases.   [We think our author's judgment, for want
    of experience in  the treatment with hot needles, is for once at fault, in
    the expression of the  opinion just given by him.   Experience, in this
    country, at least, has satisfactorily established the important fact, as we
    have  shown  in detail, in our notes in Yol. I. and Yol. II., infra, that
    the treatment  by red-hot  needles,  as so successfully practised by Dr.
    Mott and others, is by far the  most efficacious and radical cure which
    has ever been attempted for ordinary superficial naevi, or even for those
    of larger extent, which rise to the  elevation of half an inch or more
    above  the surface. T.]

                             § IY.— Tatooing.

      A German surgeon, M. Pauli, (Rev. Mid., 1836,  p. 253 ;  Journ. de
    Siebold, t. XY.,) has  recommended and employed a process, which, in
    a certain point of view, resembles vaccination.  This method consists
    in a species of tatooing, with carbonate  of lead.   The object  of the
    author is to change the red color of the erectile tissue, or navus  mater-
    nus, into a white spot.   It is satisfactorily established, that by punctur-
    ing the skin with needles, which have been dipped  in substances  of dif-
    ferent colors, we imprint upon it marks that are perfectly  indelible ; it
    is a fact, the  truth of  which the  people of India, and French laborers
    and soldiers, furnish daily evidence ; but nothing shows that the patient
    has been in any respect benefited by the operation, though even his red
    patch  should be superseded by  a white one, and every thing leads us to
    infer that the tatooing of M. Pauli, is incapable of  changing the  nature
    of erectile tumors.

                          \  Y.— The Ligature.

      The different  kinds of ligatures have been applied to erectile tumors
     in the same  manner as to all other  excrescences which grow upon the
     surface  of the skin.          _    t',          ,.  .  .  ,
       A  The Simple  Ligature.—When the  tumor is pediculated, we may
     effectually strangulate its root circularly by means of a circular ligature. 
TUMORS.
561
M. Walther, and M. Maunoir, and before them, A. Petit, (Observ. Clin.,
p. 364,) have frequently succeeded in this  manner.   There is every
reason to believe that the excrescences strangulated  in this mode by
Saviard, (Nouv. Obs. Chir., p. 515—516, obs. 114,)  in the daughter
of a draper, and in his own niece, were also pcdiculated erectile tumors.
They had, says Saviard, a large head and thin neck.   This form is less
rare than the statement of authors  would lead us to conclude.   A hat-
ter of Paris had  one of the size of an almond, in front of, and below
the right ear, which held only by a small pedicle of two to three  lines
in diameter, and which it would  have been easy to strangulate.  I have
seen a similar one on the neck of another  patient,  and near the pubis
in a third.  The only precaution to be taken in these cases, is to apply
the thread  solely upon the sound skin.   We operate, moreover, precisely
in the manner which  has been described in speaking of tumors purely
cutaneous.  Erectile  tumors, however, presenting themselves most fre-
quently under the form of plates, are rarely  susceptible of the applica-
tion of the simple ligature.
   B.  A ligature traversing the  Tumor.—In such cases another mode
has been adopted.   Bell (Surgical  Works, Yol. I.—Tarral, Op. cit.y
p. 13) was one of the  first who asserted that we might then pass a double    •
ligature  through the middle of the  tumor, in order  afterwards to stran-
gulate each one  of its halves separately with the corresponding thread.
This kind of ligature, which is extolled by M. Warren,  (on Tumors, &c,
p. 417,) who constricts each fourth of the tumor, and the credit of which
is given by M. Hutchinson to Allisen, (Tarral, Op. cit.,  p. 13, Callisen ?)
and which is no other than the ligature so frequently  employed by the
ancients, has found sufficiently numerous partisans in England, and even
in France.
   M.  White has used it with advantage, and M. Lawrence was indebted
to it for four successful  results in 1827.  M. Brodie (Gaz. 31id.,1835,
p. 778) and M.  Barton  (The  Lancet, 1829, t. II.,  p. 559,)  extol it as
one of the best processes that can be employed.   It appears, moreover,
that it has never been entirely laid aside by the  surgeons of the Hotel
Dieu  of  Lyon.   M.  Bajard,  (Bouchacourt,  Rev.  Med., 1838,  t.  III.,
p. 223, 234,) as well  as M. Bonnet, have obtained strikingly  successful
results from it,  and  M. Gensoul (Perrod, These  No.  109, Paris, 1829,
p. 39) had also already, in 1829, frequently succeeded with this method.
An erectile tumor which surrounded the anus, was cured by means of
numerous ligatures, by  M. B. Philips, (Lond. Med. Gaz., Fev., 1839;
Arch.  Gin. de Mid., Juin, 1839, p. 239.)   Nevertheless, according to
M. Turner, (Arch.  Gin. de' Mid.,  2e  ser., t. VI.,  p.  13, 14,)  it was
attended with accidents  sufficiently serious, and even  convulsions, in
the hands  of MM.  Lawrence and  Averil.   MM.  Syme, Carlisle, and
Guthrie,  who claim the credit of the ligature for  the hospital of West-
minster, also declare that it is an excellent process.  It  is, besides,
employed in several different modes: sometimes  the ancient processes
are followed ;  that is, the double ligature, passed behind the tumor, is
immediately doubled  again, while the erectile mass is drawn forwards
as if to detach it from the body ; a first half is then tied with  one of
the threads, in such manner as to strangulate it tightly, after which the
same is done for the other half.   As this belongs to a  general method,
   Yol. II.                    71 
562
NEW ELEMENTS OF OPERATIVE SURGERY.
      it possesses nothing special for erectile tumors.  It appears that Phys-
      ick (Warren, Op. cit., p. 419) tied erectile tumors only in portions and
      successively, at certain intervals.
        C.  Ligatures under  Pins.—Others, after the manner of M. Gensoul,
      (Perrod, These  No. 109, Paris, 1829 ;) Bouchacourt, (Riv. Med., 1838,
      t. III., p. 285,) perforate the  base of the tumor with a long needle or
      with a pin ; then pass a thread under the extremities of this pin, in or-
      der to strangulate the tissues behind, in the same way as I have described
      under varices.  There arc others, finally,  who, like  M. Brodie  and
      M. Barton, (Gaz. Med. de  Paris, 1835, p. 778,) or M. Keate, employ,
      instead  of one  pin, two pins  crossing each other as in the  process of
      M. Davat, with  the view of strangnlating  with more certainty all  the
      tissues in which it is desirable to  produce mortification by means of  the
      thread passed underneath.
        The same principle  governs all  the  modifications  of the  ligature.
      Provided tho needles  or threads pass through the sound tissues, that the
      constricting ligature  makes its pressure upon the undegnerated skin,
      that no  portion of the erectile tissue  escapes behind it, and that  the
      strangulation is sufficiently complete to arrest all circulation in the parts,
•     the operation will  be well performed.  So  that the simple ligature, or
      single pin or  two pins  crosswise, are nothing more  than  varieties
      demanded by the form  or extent of  the tumor, or the  particular fancy
      of the surgeon.
        Whatever  may be the mode employed, the ligature, in other respects
      sufficiently painful, is suitable  only, or  inapplicable except  to tumors
      which are purely cutaneous, accurately circumscribed, and little extend-
      ed in surface, and which project considerably from the skin.   More effi-
      cacious than vaccination, compression, tatooing and mild, caustics, it is
      less convenient,  more painful,  and  more  restricted  in its use, than cau-
      terization with potash, the Yienna paste, or the hot iron.

                        §  YI—Prolonged Acupuncture.

        Since  the attention  of practitioners has  been drawn to the  treatment
      of erectile tumors, it  has been proposed  to apply to them most of  the
      means which I have recommended against varices.  The facts  which
      authorized me to say, in 1830, that needles or other foreign bodies, left
      for some days through blood-vessels and aneurismal tumors, would effect
      their obliteration, have become the  point of departure  for  many new
      processes.  A certain number of pins or  needles, passed from one side
      to the other, at proximate distances and in various directions through  the
      tumor, where they may  be allowed to remain from eight to  fifteen days,
      have unquestionably effected the cure of certain ncevi materni.  M. Mo-
      nod and  myself employed them, in 1834, on a child aged eight months,
      who had an erectile tumor of a mixed character and larger than the fist
      situated  upon the cheek and the parotid  region.  Fifteen long needles
      were first  introduced and  left there ; at the expiration of some weeks
      they were replaced by fifteen small setons, and the same process was se-
      veral times repeated during the course of the  year.  The tumor, which
      up to that time  had  developed itself with so much rapidity, ceased at
      first to increase.  Beginning to diminish soon after, it ultimately became 
TUMORS.
563
so reduced  as to form only a nucleus or irregular patch in the thickness
of the cheek.   At the present time, (January, 1838,) the child remains
perfectly cured.   M. Lallemand, {Arch.  Gin.  de Mid.,  2e  serie, t.
YIIL, p. 17,) who, without doubt, was ignorant of my first experiments,
has cured an erectile tumor upon the shoulder by means of one hundred
and  twenty needles.   Forty at first, and then fourteen, passed in this
manner through the  tumor,  also  equally cured a patient  spoken of by
M. Nichet,  (Gaz.  Mid., 1836, p.  459;  Riv.  Mid.,  1838, t. III.,  p.
237.)  A large erectile tumor on the temple of an  infant, treated by
needles by M. Maclachlan, (Gaz. Mid., 1839,p. 362.) appears to have
entirely disappeared.   Nevertheless, a girl aged from ten to eleven years,
whom I saw with M. Sanson, and  who had a venous erectile tumor upon
the eye-brow, derived but very little advantage from this operation,
which also did  not succeed any  better in a child whom I saw with the
same  practitioner  at M. Rayer's.  M. Bouchacourt  also (Rev. Mid.,
1838, t. III., p. 237,) speaks of two patients  who  had submitted to it
without success, at Lyon, in 1837.   It would be wrong, in  fact, to exag-
gerate its efficacy.   Incapable of effecting the cure, except by inflaming
the canals or sinuses which  compose  the tumor, this method  exacts a
considerable  number  of needles, and that all  the tracks  traversed by
these  foreign bodies should afterwards become  effectually obliterated.
We may, therefore, conceive that, in a certain number of persons, frag-
ments of the vascular tissue  must escape in spite of all our efforts, and
would thus  continue to keep  up the disease.   Acupuncture, performed
by this mode, would not probably be attended with success, except with
tumors that  were more projecting than extended, with large meshes and
a tissue really  fungoid.  So  also  is it a method which is scarcely suita-
ble to birth-stains, or to erectile tumors that are purely  tegumentary.
An infant of fifteen months, who had erne of these tumors at the root of .
the nose, was only half cured by the passage, thrice repeated, of seven
to eight needles.   Caustic potash  was employed by me, at a later  period,
to effect the cure.   [It is gratifying to perceive that our author, so long
since  as this edition was published, (1839,) had formed a just apprecia-
tion of the general insufficiency,  in naivi, of this favorite, original, and
triumphant  process of his for varices, by transfixing with needles.   It
will be seen, by our notes below, that the practice in navi  is at the pre-
sent  time still  more  generally discredited, and yet that  it closely in-
fringed upon, and  approximated  to, and doubtless actually led to the
truly  efficacious, if not almost always radical cure,  of all nsevi of every
description,  deep-seated  or  superficial, to wit, the  application, once or
twice only (see our Yol. I.) and for a  few moments successively, of
some  half-a-dozen red-hot needles, instead of a hundred or two hundred
cold ones, during the space of a year.   T.]

                          §  YIL— Setons.

  The idea of passing a seton through erectile tumors, which is gene-
rally  ascribed  to  M. Fawcington, (The Lancet, 1831, p.  162; Tarral,
Op.  cit., p.  207,) is one which, if we are to believe M. Tarral,  (Arch.
Gen.  de Mid., 2e serie, t. VI., p. 207,) MM. Lawrence, Macilwaine, and
Langstaff, have frequently made use of (Lond. Med.  Rep., Nov. 1822) 
564
NEW ELEMENT3 OF  OPERATIVE SURGERY.
  with  apparent  success.   The  seton  had  been  employed  ten years
  before, by another English surgeon, (Gaz. Mid. de Paris, 1834,) for a
  tumor which was of the size of an egg.   Mr. Lawrence, in a case under
  his care, perceiving that the seton  caused  scarcely any  inflammation,
  withdrew it from the tumor after the expiration of a few days, in order
  to besmear it with nitrate of silver, and to re-introduce it into its primi-
  tive track.  External cauterization,  nevertheless,  became  necessary to
  complete the cure.  In  the patient of M. Macilwaine, the seton brought
  on a very violent inflammation, and a suppuration  which continued for
  thirty months.   M. Michel also states that  he has used the seton upon
  one occasion ; but every thing shows that his patient was affected with
  a fibrinous tumor at the  knee, and not an erectile tumor.  The few facts
  published on the employment of this resource, show that it never will,
  in reality, constitute the remedy to be depended upon for erectile tumors.
  The use  hitherto made of it, only proves  that these  tumors may be
  transfixed by foreign  bodies, with less  danger than had at first  been
  anticipated.

                     § VIII.—Numerous Setons.

   Setons applied to the number of several, in the manner I have said
  with pins or needles, have been attached with some advantageous results
  in six of my patients.   By means of a common and straight needle, if
  the case is one of a small external tumor, a  spear-shaped needle curved
  at its point, for tumors of a certain diameter, an ordinary curved needle
  for sub-cutaneous tumors, or those which are found in any deep excava-
  tion, I introduce three,  six, ten, fifteen or twenty threads,-through the
  tumor in all directions,  so as  to perforate it at every point.   I take care
v that each of the points of thread represents a large free noose, which
  is afterwards cut through in its middle.  The  two ends of each respective
  seton being  tied into as  many circles which  may be made to turn easily
  in the tumor, the free portion of all those rings, fixed above by means
  of adhesive plaster, is  detached  from the latter, the day after, in order
  that the surgeon may act  upon them with a movement  backwards  and
  forwards, and make each  one of them glide  through the portion of the
  tumor it has traversed.  We  repeat this each day  until the whole of the
  sanguineous mass is actively  inflamed which will  happen about the end
  of the  first or second week.   I withdraw then  all the threads, and the
  employment of topical applications at first emollient and then resolvent
  will suffice to calm the imflammatory movement they have occasioned.
  When the tumor is no longer heated or painful, or that it ceases to di-
  minish, we may, if there still remain in its interior any spongy portions
  which do not appear to be obliterated, traverse it again in every possible
  direction with another series of setons.
    It may be required thus to  renew this application four or five times.
  Each seton  having  no other effect than to transform into compact tissue
  the track which it has  passed through, we may readily conceive that it
  may  become useful to  insert an infinite  number  of them successively
  through certain erectile  tumors, and that the success of the operation
  will not be complete, so long as the threads shall have suffered to escape
  the smallest lobule  of the sanguineous production. 
TUMORS.
565
  In  conclusion, the  treatment by  numerons  setons is not suitable to
erectile tumors that are  flat  and superficial.  Those  which occupy the
lips, interior of the mouth, and different regions of the face, and the sub-
cutaneous tissue, will  find in  this resource a remedy truly efficacious, so
long as they are made up only of vascular branches that are reo-ular, or
that are of a small volume.   In the cases of tumors with larger canals,
and those that are voluminous and deeply-situated, it is better to recur
to other  methods.  In a young  lady whom I saw  with M. Marjolin, the
tumor obliged  me  at a later period  to  have recourse to extirpation.
Setons also are to be rejected where the tumors are already anfractuous,
—vid. supra,) hard and painful, or where there is  the  least appearance
of cancerous degenerescence.

                          §  IX.—Suture,

  If in place of confining  ourselves to  the form of a seton, we should
perhaps succeed  better if we were to change the  operation into a spi-
roidal suture, by means of long  threads.  Interlacing  the tumor in all
sorts of ways, this suture would  combine the action of  the seton to that
of the ligature or strangulation,  and would present thus greater chances
of cure.   It is  a method  in my opinion, which deserves a trial.

                          §  X.— Crushing.

  The idea of breaking up erectile tumors, seems  to belong to  M. Mar-
shal Hall, (Lond. Med.  Chir. Journ.,  Yol.  VII.,  p. 577 ;) but it is M.
Hening who first put it in practice.  The case was one of a tumor of
half an inch  in diameter: the surgeon plunged into it at one of its bor-
ders a cataract needle, and thus traversed it in eight or ten different di-
rections without withdrawing the needle  or touching any other  point of
the skin.  A slight compression prevented all hemorrhage, and no acci-
dent supervened.
  The cure not having been effected until at the expiration of six months,
creates in reality a doubt as to the efficacy of  this remedy, though M. Hall
asserts (Farral,  Op.  Cit., p. 211,) that  he has since effected several
other cures from it.   Wo could in fact comprehend that certain tumors
thus broken up in their interior, might be resolved, and become absorbed,
especially if compression and topical astringents were associated with the
crushing ; but it is  extremely probable also, that others might resist this
mode of treatment, be transformed into a sanguineous depot, or abscess,
and give rise under its influence  to some  serious accidents.
  For superficial tumors, then, crushing offers fewer chances of success
than cauterization.  For deep-seated tumors, it is not as good as numer-
ous setons.
   [In a late essay De la rupture ou de Vencrasement sous-cutani des
tumeurs  en general, des tumeurs sanguines en particulier, (Jour, des
Connais. Med.  Chir.  Jan. 1844) M. Velpeau has drawn more particular
attention to this proceeding.
   The value of this  principle of rupture is of course founded on the
long-recognised and well-established pathological principle of the innoc-
uousness and safety of wounds sheltered from contact with the air, and 
566            NEW ELEMENTS  OF OPERATIVE SURGERY.
its successes corroborate to the same degree the philosophy and truth of
the sub-cutaneous section of tendons, muscles, bridles, &c.  Bloody tu-
mors (des'tumeurs sanguines) are also instantaneously cured by M. Vel-
peau, by rupturing or crushing them, [i. e., without, of course, breaking
the skin.—T.,] though they may be of the size of an  egg, or  of the
wrist.   No  dressing is  required.  The steady downward and  utmost
pressure of  the thumb on a prominent point of the tumor, is all generally
that is required, the part affected being placed on a solid plane.   If this
pressure does not suffice, a  plate of wood on the tumor, and a stroke of
a mallet, &c. on this, will answer.   If any bumps remain, these are also
to be crushed. Bloody tumors in accidental cavities are more curable than
those in natural ones.   The cure requires  (M. Velpeau thinks) that  the
contents of the tumor, thus dispersed in the cellular tissue, should be
easy of assimilation.  The  synovial cyst, though the only  one which for
ages has been subjected to this treatment, is the least favorably disposed
to it of all;  for in these the walls  of the  cavity, unless compression is
used  subsequently, will not adhere,  and thus the tumor  will be repro-
duced.  T.]

                         § XL—Injections.

  If every erectile tumor consisted only of a cavernous mass, whose tis-
sues freely communicated with each other, the idea of injecting a liquid
into it, would be very natural, and might lead to a method as efficacious
as it would be simple.   We have seen, however, that the  fact is not so,
that sufficiently often these tumors are formed of large canals, [or large
varicose arterial or venous dilatations.  T.] and of grumous clots, and
sinuses, or small vessels, altogether independent of each other in their
calibres.
  A.  M. Lloyd.—Nevertheless, as the  cavernous arrangement cannot
be called in  question in some of  these tumors, the processes of injection
ought not to be rejected without examination.   M. Lloyd, (Gaz. Mid.,
October, 1836,) who  was  the first to extol  irritating injections, viz., in
1828, made  use of a mixture  of  three to six drops of nitric acid, to a
gros of water.  By several times  injecting this liquid into the tissue of
the tumor, by means of an  Anel's syringe, while compression  was estab-
lished around, in order to protect  the sound parts, he completely cured
his  patient.   M. Bell had  equally succeeded, in following the same me-
thod; but M. Toogood, and M.  Ward, in 18o4, wrote to M. Farral, that
they had mads trial of M. Lloyd's injections without success.
  [Mr. R. S. Davis (Lond. Lancet, July, 1845, p.  81,) affirms  that he
has treated several nmvi-materni with the  happiest success in the  space
of a few days, by merely injecting into them,  through several small punc-
tures, and by means of Anel's syringe, a saturated solution of alum, until
the tissues are well distended.  He trusts  the practice,  which he says
originated with the late Mr. Tyrrell, will come into favor  with the pro-
fession.   T.]
  B. The Author.—For myself I  should not hesitate in  injecting sub-
cutaneous tumors, by employing a  larger sized  syringe, and tincture of
iodine, in place of solution of nitric  acid.  If, as many facts induce me
to believe, this  tincture infiltrated through  the  tissues does not mortify 
TUMORS.
567
them like wine, it would I am sure cause the disappearance of the caver-
nous or areolar form of a good number of these erectile tumors.  Hav-
ing made a puncture with a cataract needle on one of the  points of the
circumference of the tumor, I would introduce  therein the beak of the
syringe, and then throw up the injection with a certain degree of force.
Repeating this injection as often as would be required for the liquid to
reach all these canals, I would obtain either an adhesive inflammation
or suppuration which would offer a like number of chances  of success.
There  would in fact be no reason  why, if the  tumor were  voluminous
and deep-seated, we should not make use of the trochar, and proceed
as in the operation for hydrocele.
   [We have already alluded to the recently proposed plan  of treating
erectile tumors &c., by injections of the perchloride, and lactate of iron.
The following is one of the most remarkable of the kind, that we have
found recorded.

Case  of Erectile  Tumor of the Orbit.  By Dr. Daniel Brainard,
   Professor of Surgery in Rush Medical College, Chicago, Illinois.

   On August 1st, 1851, the  patient, a farmer, first consulted Dr. Brai-
nard for a tumor of the left orbit, possessing all  the  aneurismal charac-
teristics.  He supposed it to arise from a severe kick from a  horse, frac-
turing the lower jaw.  The tying of the common carotid was proposed,
but he declined, until the 11th of November, when it was performed in
the usual manner.   Bags of pounded  ice and  salt applied  to the  orbit
relieved  the acute sensibility of the part.  The tumor gradually dimin-
ished in size, though a thrill could still be felt.
   On the 11th November, 1852, just one year from  the first operation,
he returned to me.   At  this time the entire orbit was filled, the  lower
lid was concealed by the fungous projection, the eye pressed outwards
and downwards, and at the root of the nose and inner part of the super-
ciliary ridge there was an elastic swelling, which had caused the absorp-
tion of the bone.  It was at that point that the pulsations were strongest
and the thrill  most distinct.   The small vessels of the forehead and side
of the nose were greatly enlarged, pulsated  strongly, and the latter gave
the peculiar thrill of the disease very sensibly.   His general health was
much impaired, and  he  had  been able  to  come to the city  by railroad
only with great difficulty.
   The question of the proper treatment to be employed in a case of erec-
tile tumor of the orbit, when the  ligature of one carotid has  failed to
effect a cure, is one of some difficulty.   The attention is naturally  turn-
ed to the other carotid ; but even if the  ligature of  that were likely to
succeed, the risk in  this case was too great, since it was found that com-
pression of it for a few seconds  rendered him perfectly insensible.  None
of the means resorted to for the  purpose of obliterating this vascular
tissue had ever been tried on deeply-seated  tumours, like those of the
orbit.  On carefully reviewing  them all, it was determined to try punc-
ture with hot needles.   This was done  first  on Nov. 13th, 1852; the
needle used was of the size of a common  knitting-needle, sharpened to a
triangular point and set in a handle, of bone.   After being heated in the
flame of  an alcohol lamp, it was plunged into the tumor about an inch 
568
NEW ELEMENTS OF OPERATIVE SURGERY.
from the root of the nose, in the course of the superciliary ridge, and
carried downward and backward to a depth of over  three inches ; on
withdrawing it, some bleeding followed, which was readily stopped by
slight pressure.   For two days there was little  pain or swelling; but on
the third day the inflammation was acute, the swelling extending over the
face, and presenting  an erysipelatous appearance.  On the fifth day this
began to decline, and in a week was nearly gone.  While the inflamma-
tion was at its height the tumor was  more firm and  the  thrill  less dis-
tinct, but as it subsided the elasticity  and  pulsation rapidly returned.
  Nov. 25th. I repeated  the operation, making the puncture half an inch
nearer the nose, and  carrying it to a depth  of only one inch.  The effects
corresponded with those before described, but were a little less violent.
On  the third day the sound was diminished, and the firmness of the tu-
mour very sensibly increased.   On a careful examination it was found
that the morbid tissue exteuded over the  bridge of the nose and down
to the inner canthus  of the right eye, where a thrill  could be distinctly
felt.
  Dec. 2nd. A puncture  was made on  the left side of the bridge of the
nose, the needle being carried  obliquely upward  and  to the left  side.
The inflammation resulting  from this puncture was acute, and a superfi-
cial suppuration occurred about it.  The thrill upon the right side of the
nose quite disappeared.
  The  effect of these three punctures  was  to limit the spread of the tis-
sue upon the forehead and nose ; but the inflammation, although acute and
extensive, was superficial, and the mass of the disease at the centre was
still unaffected.  It was evident that the needles cooled in  passing
through the  tissues, so  as not to cauterize much below the surface.
  It was therefore determined to change the treatment, and inject a fluid
into the centre  of the tumor  capable of effecting its obliteration.   For
this  purpose a  solution of the lactate of iron, of the strength  of  eight
grains  to one fluid drachm of distilled water, filtered through paper, was
preferred.   The reasons  for believing in the safety and efficiency of this
remedy will be  given below.
  14th. I punctured  the  tumour at its most  prominent  part with the in-
filtrating canula, carrying  it to the depth of about an inch ;  on with-
drawing the stilet arterial blood followed.   A fluid drachm of the above-
named solution was  immediately  thrown  in with a small syringe, con-
structed  for the purpose, and the canula  withdrawn.   The immediate
effect was an intense  pain in the left  temporal  region and a flushing of
the face, which latter only lasted a few seconds.  A chill followed, ac-
companied with nausea and vomiting.   Reaction took place in  an hour,
but the vomiting continued, and for twenty-four  hours all  drinks were
ejected;  pulse 63.
  15th. Vomiting still continues ; pain less;  upper lid  much swollen;
pulse 65.
  16th.  Vomiting less ;  no pain ; has slept well;  pulse 60 ;  swelling
increased, and so tender  as not to bear the slightest touch.
  23rd. For the  last six days the vomiting has gradually diminished;
the pulse is natural; the tumor is less tender, firm, and the pulsation
perceived only at the external angle; frequent lancinating  pain is felt
in the orbit. 
TUMORS.
569
   During  the whole of this  treatment, both of punctures  and infiltra-
tion, the head has been kept enveloped in bladders filled with a freezing
mixture of pounded ice and salt, which was very grateful to the patient.
He now began to complain of its being too cold.  The heat in the head
was reduced to a natural standard, and from the time of the infiltration
neither thrill nor sound has been perceived.  Tho veins of the face were
much diminished in size,  and the pulsation of the arteries reduced to its
natural state.  A  slight  pulsation was still perceptible at  the external
angle  of the eye,  for  which a puncture was made at that  point  with a
hot needle, on January 4th, 1853.
   Jan. 10th.  From the time of  the last  puncture no pulsation has been
perceived, the swelling subsiding.  At  this time an opening was found
to exist on the anterior  surface of the globe of the eye, which still re-
mains  protruded between the lids.   This was followed  by severe inflam-
mation of the  globe, which  lasted several days.  The discharge from
the opening was at first  the  humors of the eye, afterwards pus,  but no
blood.
   Feb. 5th.  Swelling  gradually subsiding; tumor firm, no pulsation ;
but little pain.  The patient slept for  the first time for  more than  a year
without some one to keep wet cloths upon the eye, dressed  himself, and
walked about the house ; health good.
   March 5th. Swelling entirely disappeared; the  globe of the eye per-
fectly  collapsed; lids closed.
   June 6th.  The patient has been pursuing his ordinary occupation for
three  months ; his health  appears perfectly restored.  The left orbit
seems  entirely excavated and free from disease.  G. C. B.]

                          §  XII.—Incisions.

   Snguineous tumors, however, which bleed upon the least  handling, or
from the slightest abrasion, have in some cases been attacked successful-
ly by large incisions.   The following  is the plan which was adopted by
an anonymous author, (Gaz. Mid., 1833, p. 321,) who communicated
his observations to one of the Journals of Berlin.   A child had a large
sized tumor  upon the temple:  the surgeon having slit up this  tumor
deeply  throughout its length, emptied  it by means  of fine pieces of
sponge of all the blood which could thereby be expelled from it;  pieces
of linen folded being then  introduced into the  wound,  allowed of mak-
ing  compression over  the whole  of  it, which  ultimately resulted in a
cure.  The author regards this method as  one that is very  effective  and
of an  easy employment, especially where the  subjacent tissues render
the compression supportable.  M. Lallemand,  (Archives  Genirales de
Medecine,  2e serie, t. VIII., p. 8,  14,) had imagined something similar
in 1835.  After having excised a slice of the tumor, or simply slit it up
at various  points,  this practitioner united the wounds  by means of  the
twisted suture, and was thus enabled to cure two of his patients.
  The  facts of this kind published up to  the present  time, prove that
there has been too much apprehension  of hemorrhage from the action
of surgical instruments on  erectile tumors, but  they do not  demonstrate
that a  simple incision suffices to cure this kind of disease.   A sacculous
   Vol.  II.                    72 
570            NEW ELEMENTS OF OPERATIVE SURGERY.
naevus (Eph. Nat. Cur., Dec. 2 au 6, p. 688,  Obs. 199;  Coll.  Acad.,
partie Etrang., t. VII., p. 476)  which was  situated in the  mouth, and
which was laid open, gave rise to a fatal  hemorrhage.   We  should  suc-
ceed better, no doubt, by multiplying  and crossing the incisions, so as
to divide the tumor on a large number  of points; but then the operation
would be more serious than  excision, properly so called, and we should
rarely obtain other results than those we might reasonably hope for from
multiplied setons  or the  suture.   No one, moreover, would probably  ven-
ture to attack in this manner voluminous erectile tumors, or those which
exist  at a  certain depth in the natural  cavities  or in the body of the
limbs.

                 § XIII.—Ligature of the  Arteries.

  As erectile tumors result  from vascular exuberance, it has suggested
the idea that the remedy above all others  for arresting  their develope-
ment and for destroying them, would be to obliterate the vessels which
go to or come from them.   From whence has arisen a method which
comprehends many modifications.  Some surgeons have limited  them-
selves to deep incisions upon the sound tissues around the tumor; others
isolate each artery in the neighborhood and immediately apply the liga-
ture to it:  there are others  again who lay bare the principal arterial
trunk of the region without troubling themselves with  those  of  the
tumor itself.
  A.  Incisions around the Contour of the Tumor.—In a patient affect-
ed  with an erectile tumor  upon the  right fore-finger, and whom M.
Hodgson had without any result subjected to a ligature  upon the radial
and ulnar  arteries, M.  Lawrence (S.  Cooper,  Diet, de  Chir., p. 170)
incised the  whole contour of the  root of the  finger, when  the tumor
disappeared.   Physick (Dorsey, Elements  of Surgery, Vol. II., p. 273)
had successfully made trial of something analogous a long time before.
If the  tumor were too large, perhaps it would  be advisable to imitate
M. Gibson, (Ibid., p. 272,) and to surround  it only  successively, that
is to say, incise at first the  third of its circumference, to do the same
at the  expiration  of eight or ten  days  on another  third, and so on till
the operation was finished.  Except,  however, upon the fingers,  and
when the tumor is large and flattened, we cannot perceive the advantages
of this method over extirpation properly so called, and every thing goes
to show also that the ligature upon the neighboring arteries would attain
the same result.   If, however, we should decide upon doing it, it would
be necessary to take care and direct the bistoury perpendicularly upon
the sound  skin, as in simple incisions, and  not to  fail  in penetrating
down to the aponeurosis ; all the  arteries should be tied successively
as they are opened, and  small rouleaux of lint afterwards placed in the
wound to hold the lips apart.  We thus perceive that it would be dan-
gerous to apply this method  elsewhere  than to erectile tumors upon the
cranium, some regions of the face and  fingers, or to the dorsum of  the
foot or hand.
  B. Ligature upon the small Arteries.—Nothing could be more rational
than the idea of destroying erectile tumors by tying the arteries which are 
TUMORS.
571
distributed to them; from  whence it happens that  this is an  operation
which  can now count a great number of trials.  Unfortunately it is one
also which has frequently resulted in failure.   A surgeon mentioned by
Bell, successively tied the temporal and angular artery, for a tumor
which  occupied  the upper  eyelid.   A cure did not take place, and Bell
was obliged to proceed to the extirpation  of the fungus.  It is also said
that in the case  of a tumor situated upon  the forehead, the ligature ap-
plied to the arteries in the  neighborhood by M. A. Cooper (The  Lancet,
1829, t. II., p. 559) did not prevent the  tumor from progressing.   M.
Brodie in a case succeeded by means of two  needles  placed  crosswise
and a strong ligature.  M. Roux tied  the labial, facial  and transverse
arteries for a fungous tumor of cheek and upper lip.   The compression
also used  at this first  operation, brought on  inflammation and a slight
degree of suppuration.   The tumor  appeared to diminish in extent, but
at a later period extirpation  had to be  resorted to.   A strong robust
tanner, aged about thirty, had  the entire upper  lip  transformed  into
erectile tissue of a vinous  or  violet color.  I applied a ligature to the
upper coronary artery, first on the left side  and four days after on the right
side.   To be more sure of letting no arterial branch escape, I had taken
the precaution to incise through the whole thickness of the lip vertically
from a line with the ala of the nose, to the vermilion border below.
Having tied the two ends  of  the artery,  I united by suture as in  hare-
lip ; I  proceeded precisely in  the same manner for the second operation
as for the  first.   During about the space of fifteen days, the lip  grew
paler, and  sensibly diminished in thickness ; but it soon become the seat
again  of pulsations, and ultimately resumed the state  which it was in
before  the operation.   Pelletan, who  after  the surgeon mentioned by
Bell, appears to have been the first who made trial of the operation in
question, in order to arrest the development  of an erectile tumor  upon
the cranium, cheek and ear, proceeded, after having  tied the temporal
artery, to apply  his ligature also upon the occipital.   Successive hemor-
rhages came on  and the patient  died on the fourteenth day.   A patient
operated upon  by Dupuytren (Hodgson, Traiti des  Mai. des Arteres,
p. 300) for a similar tumor, had also undergone without success a liga-
ture upon  the temporal, auricular  and occipital arteries.  I have  else-
where  said (vid. supra) that the ligature upon the small arteries  had
also failed in the hands of M. Brodie, M. Syme, (The Lancet, 1829,
p. 596,) and many others.  A ligature  applied by M. King (Tarral, Op.
cit., p.  24) to the temporal artery, for a nasvus on the upper eyelid, also
failed to effect a cure.                            *
   It is therefore one of the most uncertain operations ; and in fact how
are we to obliterate all the  arterial branches which arrive at the circum-
ference of  such tumors ?  Isolated ligatures clearly address themselves
only to the branches of a  certain  volume, those whose pulsations are
perceptible under the skin, or whose anatomical relations are well known.
But who does not know that an infinity of minor arteries, of the smallest
calibre, and the capillaries, must necessarily exist between the principal
branches ;  then how can we be assured that the deep-seated surface of
these tumors does not receive other arteries of sufficient size to replace
those we have just obliterated ? 
572            NEW ELEMENTS OF OPERATIVE SURGERY.
  C.  Ligature on  the  Principal  Arterial Trunks.—The  difficulties I
have  pointed out, and the failures I have related, have induced prac-
titioners to extend the ligature to the principal artery itself of the region
occupied by the disease.   Thus have the carotid  arteries been tied for
tumors of the head, the brachial  and  the arteries of the  fore-arm for
tumors of the thoracic extremity, and the femoral  for those of the ab-
dominal limb.
  I. Arteries of the  Head.—It  was in  1809, that M. Travers  tied the
primitive carotid for an  erectile tumor  upon the orbit.  M. Dalrymple,
his countryman, did the same for a tumor very similar.  The two patients
recovered.   Two'similar  operations were performed by M. Wardrop,
for erectile tumors upon the face.   One of the children died on the four-
teenth day, in  consequence of hemorrhage and suppuration ; the other
got well.  In a third case also, M. Wardrop tied  the  primitive carotid,
having obtained no  benefit from a ligature on the temporal  and frontal
arteries: the patient died.   An analogous operation, by  M. Walther,
also proved  unsuccessful.  The tumor was seated on the  temple.   In
the case of M. Davidge, the patient was seized with trismus and died at
the expiration of six weeks.  That of M. Pattison appears to have been
completely cured.  In these two cases the tumor was in the cheek.   M.
Maunoir failed entirely in his  operation;  and  the same  occurred with
M. Dalrymple  in a second trial with it.   The  case  of M. Machlachlan
was one of varicose degeneration of  the arteries of the hairy scalp, and
the  patient  died.  It would  appear  that  the patient  of M. McClellan,
who had an erectile patch  over the whole right side of the face, at least
derived some advantage from the operation, if in fact the cure has not
been entirely completed.  An  erectile tumor of the  antrum highmorianura
was cured in this manner by Dr. Hall.  So also in a patient of M. Arendt,
who had an erectile tumor  on the upper eye-lid ;  but  it is necessary to
be added here, that  the surgeon afterwauds made a crucial  incision
through the  tumor, that he successively tied twelve small arteries, that
many  hemorrhages still  took  place, and that it required four months for
the cure to be completed.   The  man operated upon by Delpech had an
erectile tissue in the  nasal fossas, and at first only appeared imperfectly
cured.  An  erectile tumor upon the temple, which  M. Williaume treated
by a ligature upon the primitive carotid, did not diminish.   The patient
operated upon successfully by M.  Busk had an erectile  tumor in the
orbit.   That of M. Roux, in which the tumor also occupied the orbitar
and temporal region, was but  imperfectly cured, when he was lost sight
of.                *
  If the persons  operated  upon by MM. Bernard, Rogers, and Busch,
were cured of their erectile tumors  by a ligature upon the carotid artery,
we find that the  operation did not succeed in the case of M. Jameson,
and that it was followed by death in those of MM. Kuhl, Mayo, Zeis,
Peyrogoff, and in that of mine, and  that it failed also in the patient in
whom M. Mussey applied  successively the ligature  upon both carotids.
As to the patient recently operated  upon at Marseilles by  M.  Martin,
(Lancette Fr., t.  XII., p. 486,) we are yet unacquainted with the benefit
he will  derive from a ligature  upon  the primitive  carotid.   (See the
Table of Ligatures upon the Carotid, supra. 
TUMORS.
573
   [Mr. Crisp (On the Blood-vessels, p. 275) has collected the statistics
of numerous cases of capillary,  and circoid  aneurism  treated by the
various methods of excision, cauterization, the ligature of the arteries
&c. &c.   In 16 of these  cases, he states that the carotid artery was
tied, and in 3 both carotids were tied.   " The ligature  alone was suc-
cessful in five cases ; in seven  operations benefit was derived from tho
tying of the vessel, and the disease was afterwards removed by pressure,
caustic, or excision.  In the  three fatal  cases, the  patients did not ap-
pear to die from the immediate effects of the  operation.   Although the
ligature of the  common carotid (when the disease is seated in the head
and face) does  not in the majority of instances, of itself effect  a  cure,
yet it is  probable  that by reducing  the  supply of blood to the tumor,
the calibre of the  artery is so diminished that excision and other means
may be employed with a better chance of success." (p. 278)
   In his recently  published work on operative ophthalmic surgery, Mr.
Haynes Walton has reported a  successful case of ligature of tho carotid
for the removal of an erectile tumor in the orbit.  A still later account
giving the subsequent favorable  progress of  the case appeared in the
Lond. Med.  Times and Gazette,  Feb. 1854, p. 185.
   In  a case of circoid  aneurism of the scalp, the late Dr. J.  Kearny
Rodgers, some  years  since, tied  the  primitive carotid of one side, and
some four years afterwards, that on  the opposite side was secured by
Dr. Van Buren.  From information derived  from the latter gentleman,
this  proceeding had not  produced any  material benefit.   Dr. Mussey,
during the past year, performed his second operation of tying both prim-
itive carotids for this affection, and we believe that the last derived more
advantage from the operation than his former patient.  In a similar case,
M. Auvert, tied the primitive carotid on one side, but the  patient died
from the effects of the  operation.   A patient, on  whom Dr. A. C. Post
secured one  carotid, was materially benefited.  We  have  already  re-
ferred to the cases of fungoid growths from the antrum, successfully treat-
ed by Dr. Mott and myself, by the ligature of both carotids.  G. C. B.]
   It results from these details that the ligature upon the carotid artery
is far from being sufficient always for the cure of erectile tumors of the
head.  It is to  be  remarked that  these tumors upon the temple and ex-
ternal part of the  head have less  frequently  disappeared  under the influ-
ence of this operation than those  of the  orbit,  eye-lids, nose, cheeks and
sinus maxillaire.   The patient  operated  upon by Delpech, and in whom
the erectile tissue  occupied the  septum nasi,  appears at the present time
to be definitively cured; for in the notice of the case of M. Martin, it
is stated that he still lives at Marseilles,  in a state of perfect health.
   I  have mentioned  that those  who were cured  by M.  Travers,  M.
Dalrymple, M. Arendt, and M.  Busk, had the tumor in tho orbit or eye-
lid ;  that in those of MM. Pattison, McClellan, and Hall, it was situated
upon the side of the face ; while in that of mine,  that of  M. Williauma,
that of Dupuytren, that of M. Walther, that of M. Machlachlan, one of
those of M. Wardrop, and some others, it was located upon the  torn pie
or cranium.  If the erectile  tumors  only of the  orbit had terminated
favorably.it might be explained perhaps, by  recalling to mind with MM.
Roux and Hervez, that the ophthalmic artery here forms  a small vascu- 
574
NEW ELEMENTS  OF OPERATIVE SURGERY.
lar system in some sort independent, whose functions would necessarily
be interrupted by a ligature upon the carotid : but the same (successful)
result having taken place upon other regions of the face, we can scarcely
attach any importance to this arrangement.
  However that may be, it would seem  that  erectile tumors upon the
head, which are to be treated  by a ligature  on  remote arteries, ought
not to be so attacked  without discrimination  by  the obliteration of the
primitive  carotid ; for myself I should prefer that those of the chin,
lower lip, and even upper lip, should be treated by a  ligature upon the
two external maxillary  arteries, and  those  of the floor of the mouth
and the tongue by a simultaneous  or separate ligature upon  the facial
and lingual arteries.  For tumors on the exterior of the  cranium  I
should tie  the carotid or the two secondary carotids  at the  same  time
with the primitive carotid.  If the disease occupied the nose  or antrum
highmorianum, I would confine  myself to the  ligature of the external
carotid, immediately below its division into the  temporal and internal
maxillary arteries.  Finally, in cases of erectile  tumors of the orbit or
eye-lids, I would tie  the  internal carotid alone, or  the  internal and
primitive carotid.  We have, moreover, seen in  the table  cited  above,
that these  operations  are sufficiently serious and sufficiently often fatal
to inspire the minds of surgeons with well-grounded fears.  We should
therefore  not decide upon them unless  the disease has acquired a great
development, menaces the life of the patient, or really  constitutes  a
deformity of a grave  character.  I will add, that we ought not to come
to this resolution, until after having made trial of topical applications,
compression,  vaccination,  tatooing, and cauterization, in  tho cases of
superficial tumors ; acupuncture, le broiement, multiplied setons, and
irritating  injections, where they are thick or deeply situated ; also that
we  should take  into  consideration whether extirpation,  supposing it
practicable, ought not even then to  have  the preference to the ligature
in question.
  II. In the Limbs.—A ligature upon the  principal arterial  trunk ap-
pears to have been but rarely followed by success in the cases of erec-
tile tumors.  I have already said, that  in tying the arteries of the fore-
arm for a tumor on the fore-finger, M. Hodgson had failed completely.
In  a  case cited  by M.  Chelius,  (Handbuch der Chir.,  t.  I., p.  884
Heidelberg and  Leipsic, 1826,) an erectile tumor upon tlie knee equal-
ly resisted a ligature  upon "the femoral artery.   The same  operation
performed  in 1819, by Dupuytren, (Breschet, trad, de Hodgson, p. 26,
ou  Repert. d'Anat.  et de Phys., etc., t.  II.;  Arch.,  t.  XIII. p. 459,)
for  a vascular degeneration at the lower extremity of the femur  was no
less unfortunate.   Nevertheless, MM. Roux, (Tarral,  Archiv. Gin.  t.
VI., p.  26, 2e serie,) Graefe, (Gaz. Med., 1835, p. 169,)  and Chelius',
appear  to have each succeeded once in curing erectile tumors of the
fore-arm or hand, by tying the neighboring artery ; and M. Lallemand
(Bull, de  Ferussac, t. XV., p. 73 ; Arch. Gin., t. XIII.,p. 544,) by ob-
literating  the crural artery, has been no less successful in a case of vas-
cular degenerescence upon the tibia.  So that under this point of view
the successes and reverses are, up to the present time, in  some sort
balanced. 
TUMORS.
575
  Be that as it may, erectile tumors upon the limbs, which occupy only
the integuments, or sub-cutaneous tissue, seem rarely disposed to yield
to the  ligature upon the principal  artery.  The branches which pene-
trate directly into the tumor should be attacked  by preference, whether
by the  circular section in one or several stages, or by the ligature, pro-
perly so called, on each small  artery.  As  to the tumors more deeply
situated, those  especially which have been noticed  in the tissue of the
bones  by Pott, Pearson, Scarpa, Rossi, Dupuytren, Roux, and Lallem-
and, of which 1 also have met with two examples, inasmuch as it could
be amputation only of the limb that we could  oppose to them, and that
they have already been sometimes observed to recede after the ligature
upon the principal arterial  trunk, I am of opinion that it would be ad-
visable to submit them to this last operation.  In such cases, though the
ligature upon the artery should offer but one chance of cure out of three
or even out of ten cases, still it ought to  be preferred.   For supposing
that it should not result in a cure, it  would  not  prevent  our proceeding
at a later period to amputation if that should  be found necessary.
  What I have said further back, however, shows that we should err in
reposing entire confidence in this kind of remedy, and that the erectile
tumors of the bones of the limbs resist, as often at least  as those of the
head, the ligature on the arteries which nourish them.   We  ought not,
therefore, to prefer this means, except where all the others I have hi-
therto  mentioned are impracticable.  The circular section for the tegu-
mentary  tumors ; the ligature of the sub-cutaneous arteries, and  as near
as  possible to the tumor, when the fungus penetrates as far as to the
fascia  superficialis; the ligature to  the principal trunk by the  method
of Anel,  where the  bones or deep-seated parts of the limb appear to be
the seat of the evil; such is the order in which this  kind of operation
should be placed in a practical point of view.

                       § XIV.—Extirpation.

  In former times, erectile, like all  other  tumors, were  fearlessly sub-
mitted to extirpation, but J. L. Petit, J. Bell, Callisen, Dupuytren, and
MM. Wardrop, Roux, and  Walther, have inspired  so  much  apprehen-
sion in regard to  the operation, that most surgeons no longer decide
upon it  except in  cases of extreme necessity.  The accident the most
formidable and the most frequent of this operation, is hemorrhage.  A
patient died thus in some sort under the knife of M. Wardrop; the same
occurred  in a patient of M. Roux.   The same practitioner, on another
occasion, was upon the point of losing a second patient, before  having
terminated the operation.   Two patients also of  M. Hervez de Chegoin,
caused in  the  mind  of that surgeon the  greatest apprehension.  M.
Bushe, after having excised an erectile tumor  from the temple in an in-
fant aged thirty months, perceiving the hemorrhage recur, was  obliged
to resort to a ligature upon  the external carotid.
  Nevertheless, these dangers rarely  take place, except  in cases where
the tumor  is badly defined, or where it is impossible  to  cut exclusively
upon the sound tissues; and experience proves that, practised  in such
manner as to remove  the erectile production entire, and in addition, a 
576            NEW ELEMENTS OF  OPERATIVE SURGERY.
breadth of unaltered integuments, extirpation is still the most sure and
the most rational of this order of remedies.  What prevents it from be-
ing proposed for all cases, is the deformity which must necessarily result
from it, when the tumor occupies a very extended surface,  or  the depth
and uncertainty of its limits, when it  is situated either in the central
portions of the limbs, or in the cavities of the head.
  F. De Hilden, who had already perceived  the importance of this op-
eration, positively recommends that in extirpating the tumor, we should
leave no vestige of it, but carefully remove  all its  roots.    Turner
(Malad. de la Peau, p. 234) mentions, on the authority of Willis, erec-
tile tumors which had been extirpated without danger in his time. War-
ner, (Obs. de  Chir., p. 68,) in operating  in  this manner upon the fore-
head, had been  no less fortunate.  Alanson, (Manuel de VAmput., p.
199,) while extirpating from the forehead of a  child of seven years of
age, an erectile tumor of more than an inch in extent, caused, by way
of precaution, compression to be applied  all around it.  We may find
also in the work  of M. Maunoir (Memoire sur le Fungus Himatode, p.
90 a 100) some  examples  where extirpation of  these tumors  was  per-
formed with entire success.  Others of the same kind will  be found  in
the memoir of Briot, Progres de la Chir. Milit., p. 298;  et  Diet, des
Sc Mid., t. XVI., p. 334.)  M. Champion extirpated one in  a  woman,
aged 25 years, which was situated upon  the upper and  anterior part of
the arm, and was of the size of a pound loaf of bread. M. Roux (Mare-
chal, Rivue Mid., 1825, p. 29) succeeded perfectly in a  case where
Dupuytren was not  willing to venture upon any remedy.  An infant,
aged  eighteen months, had upon the  outer  angle  of the right eye an
erectile tumor of the size, form and color  of a calf's kidney, M. Loreau,
(Communicated  by the author, 29th September, 1837,) having  effected
the extirpation of this tumor, employed the suture, in order to unite by
first intention, and obtained complete success. An erectile tumor, which
occupied the labium majus of the left side  of a woman aged  twenty-nine
years, was extirpated with success by M. PI. Portal, (Clin. Chir.  etc,
p. 142.)  After  having extirpated one of  these  tumors  on the fore  part
of the thigh, the same practitioner (Ibid., p. 141)  was  obliged  to  cau-
terize  the wound many times, with  the butter of antimony, the nitrate
of mercury and  the nitrate of silver.  In  an infant, fifteen months old,
and who, among other erectile  tumors, had one of an inch and a half in
diameter on the root of the forehead, between the eyebrows, the opera-
tion  of extirpation which  I had forbidden from fear of too deformed a
cicatrix, was performed with  success in  1837  by another surgeon of
Paris.   The facts of this kind, however, at the   present day are so nu-
merous that there is no necessity of making particular mention of them.
  Extirpation in these  tumors, in order that it may offer real chances
of success, exacts several  conditions;  first, that the instrument should
remove everything; secondly, that we should  have  it  in our power to
make  compression  with a certain degree of force, either at the bottom
or on the periphery of the wound as well  as upon the principal  arterial
trunk of the neighborhood ; finally that the  surrounding tissues should
be free from every kind of vascular degeneration ; when with  these it
should be  possible  to unite by first intention, without  making traction 
TUMORS.
577
upon the parts, we could desire nothing more ; but should it become ne-
cessary to dress flat, the operation might still  succeed if the other con-
ditions which I have just pointed out, were actually present.  An erec-
tile tumor, six  inches long, of the form of a calf's tongue, and which
had existed from the age of seven years on the outer and upper part of
the left leg of a female, and  which had been  unavailingly treated by
compression, and transformed by this means into a vast pouch, was ex-
tirpated with complete  success by M. .Neve, (Communicated by the au-
thor to  M. Champion,) though  he was not enabled to unite by first in-
tention.
  Moreover, I should not  confine myself to extirpation, as M. Ouvrard
recommends, (Obs. de Med. et de Chir., p. 374—379,) for the removal
of purely vascular tissue, unless cauterization, in such manner as to pre-
serve the healthy tissues which envelop the disease, should be afterwards
associated with it, as it was on one occasion successfully  by M. Bedor
(Journ. Hebd.  Univ., t. II., p.  369) for a pediculated  tumor of the cra-
nium.
 ^ In the young person whom I have spoken of in the paragraph on mul-
tiplied setons,  I was desirous of preserving the skin which was  sound.
Having freely dissected the parts, I removed the whole tumor, together
with about an inch  and a  half of the radial artery which was included
in it.   The blood flowed abundantly ;  but tamponing with small balls of
lint and compression sufficed to arrest it, after a ligature had been ap-
plied  to the two ends of the radial artery.  The wound regularly cica-
trized ;  but as I have already  said, a point on the skin, and some sub-
cutaneous  protuberances, give me  at the present moment,  (January,
1839,) some fears in respect to the return of the  disease.   I should re-
mark that the tumor in  this case was badly defined, and that a multitude
of dilated vessels were given off from it like so many rays from its circum-
ference.   M. Lallemand, (Arch. Gin. de Med., 2e serie, t. VIII., p. 5,)
in one case, effected a cure by extirpation, though the tumor  occupied
the gums,  and that he was obliged, at  the  same time, to remove the
whole breadth of the lower alveolar border.   M. Nichet (Riv. Mid.,
1838, t. III. p. 242) was no less  fortunate in a case in  which he per-
formed  the operation of cheiloplasty, after having extirpated the tumor
which was situated  upon the lower lip and a part of the cheek.  A livid
irregular, hard tumor of the size of a nut, had existed for many years
between two heads of the  metacarpal bones  on the dorsal side of the
root of  the medius,  in a girl aged eleven years.  I extirpated it without
interfering with the neighboring articulation, and the cure has remained
complete since the  month  of  July, 1838.  The operative  manual  has
nothing special in such cases, except that it  should be submitted to the
rules of incisions in  general, and  exact great precautions in relation to
the employment of provisional and even definitive hemostatic means.

                        k XV.—Amputation.

  The tendency of erectile tumors to repullulate, the dangers attending
their extirpation, the difficulty of attacking them when they have invaded
the interior of the limbs, have suggested the idea of performing ampu-
  Vol. II.                    73 
 578           NEW ELEMENTS OF OPERATIVE SURGERY.

 tation for the cure of some of these cases.   This operation, the propriety
 of which has been especially treated of by M. Maunoir and M. Hervez
 de Chegoin, is not in my opinion justifiable in any case at the outset.
 I should not  decide upon it but in the last extremity, after having vainly
 essayed all the other methods, and where the disease  actually compro-
 mised the life of the patient by the rapidity of its progress, or had per-
 manently destroyed the functions themselves of tho part where it was
 situated.
  Erectile tumors of the bones only could justify recourse to it, and not
 then even as  I have already said, should we come to this determination,
 until  after having fruitlessly made trial of  a ligature upon the principal
 arterial trunk of the region.  If with MM. Maunoir and Hervez we
 should sometimes  have recourse to amputation, it would  be solely in
 those  cases  where  melanotic,  cerebriform or scirrhous  productions
 have  become  implicated with the erectile tissue.   The question, then,
 would be of a cancerous tumor, and no longer one that was purely fun-
 gous ; and the chances of the operation whether fortunate or unfortunate,
 would have to be weighed after  the  known nature of  cancers, and not
 from what has been said of sanguineous tumors.  The cases of a return
 of the disease mentioned by M. Maunoir, M.  Fine, (Journ. Gin.  de
 Med., t. XLV.,  p. 46,)  and  M. Gerard, (Journ.   Univ. Hebd., t. II.,
 p. 413,) and  by a multitude of others, are not sufficient to authorize us
 to say with M. Hervez, (Journ.  Univ. de Mid., t. II., p. 22,) that the
 removal of accidental sanguineous fungous tumors of the  limbs, has
 never been followed by success, and that,  therefore, amputation is pre-
 ferable.  The case of M. Neve and that  of M. Champion, would  alone
 suffice to refute this proposition.
  [The pain  produced by erectile tumors on the foot or leg is sometimes
 so great as to require amputation of the affected limb.   An interesting
 case of this  kind  has  been reported by Mr. Fergusson (Lond. Lancet,
 Am. Ed. June, 1851, p. 530.)  The previous ligature  of  the femoral
 artery had proved of no benefit.  Prof. Parker  has amputated under
 similar circumstances, for a report of which, drawn up by the patient,
 himself a physician, we must refer the reader to the New-York Journal
of Medicine.  The pain in this case  was very excruciating.   G. C. B.]

               Article III.—General Appreciation.

  I have  described with  some detail the  different kinds of operations
 hitherto proposed against erectile tumors, because, though there may be
 none  of them which are suitable to all  cases, there is  not  one of them
 which ought absolutely to be rejected.  Erectile tumors present so much
 diversity in respect to their breadth, thickness, and layers, the regions
 they attack, and their nature and progress, that it is impossible to sub-
 mit all of them to the same kind of treatment.  Thus topical astringents
 styptics, and  refrigerants, applied to  tumors that are superficial, of but
 little  extent and still recent,  are calculated to procure  some  successes.
 Compression  alone, or aided by these last-named measures, if continued
 for a long time, will succeed  in some cases wherever it is possible to
 apply it conveniently.  Compression  also though less  active  and less 
TUMORS.
579
powerful than caustics, might be made trial of with astringents in casos
of sub-cutaneous, diffused and irregularly flattened tumors.  However,
it will always be found  one of the remedies  which  are the  least to be
depended  upon, and one on whose  efficacy  we must not  deceive  our-
selves.   Cauterization, by means of potash  and ulceration, having the
advantage of not  alarming the patient, and  of succeeding  sufficiently
often, should have the preference where the tumors are cutaneous, irreg-
ular, and too large to be extirpated.   [This is a very favorite and suc-
cessful remedy with Dr. Mott in such  cases, where the red-hot needles
cannot be applied, or do not succeed.  His next great reliance is extir-
pation or excision, at a suitable distance from the periphery of the dis-
ease, so as to cut into a margin of sound tissue.  T.]   In cases of flat
and  regular tumors, it is much better to recur to cauterization en nappe,
[vid. supra,] whether by means  of a fragment of caustic  potash, or
with a  pencil, slightly wetted  with nitrate acid of mercury.   If the
whole thickness  of  the  dermis should be affected, we should succeed
still  better by covering  the whole  degenerated patch, which has been
previously denuded  of its epiderm, with a layer  of zinc  paste, or the
Vienna caustic ; or by applying to it the red-hot iron.
  Vaccination  and tatooing  would not be suitable, except the first, on
some fungous masses imperfectly circumscribed ; and the second for
ncevi of the most superficial  character and  least  thickness : it  is even
doubtful  if these  methods deserve to be retained in practice, under any
consideration.
  Nor does broiement (or breaking up of the tumor) appear to possess
any  very great value ; I would not make trial of it, but for bulky tumors
of a  certain volume, and  which it would afterwards be easy to compress.
Having transformed  them, by means of the  needle,  into a sort of  san-
guineous depot, I would immediately  treat them by  topical astringents
and  compression.  It is in similar cases that irritating  injections might
be made  trial of; but, as with broiement, they ought not to have the
preference, except in  regions where it might  seem too  dangerous to
carry the cutting  instrument, or in patients who have  an excessive dread
of bloody operations.   I have said, farther back, what we may  expect
from the employment of setons and needles.   I will add, that it would
be a loss of time  to attack, in this manner, flat  and  superficial erectile
tumors, and all those, in fine, which are situated in the integuments, in
the form of a layer.
  Every  pediculated erectile tumor may be destroyed by the ligature,
in the same  way as ordinary  tumors ; we have thereby the  advantage
of not exposing the  patient to the risk of any hemorrhage, and  of ob-
taining a radical  cure, if the ligature is accurately placed upon  sound
tissues.   We would not pass a needle behind the pedicle, unless the skin
was  so  much compromised [in the degeneration] as to  induce  us to
fear  that the  thread might slip upon tissues which it  would be desirable
to remove.  Two needles, placed crosswise,  would be necessary, if the
tumor was flat or  presented a root of some considerable size.  A  double
ligature, passed behind and through the pedicle  of the tumor, possesses
the advantage of  cutting through the tissues  with a little more rapidity
than one  ligature  only, placed externally, and also that of being more 
580            new elements of operative SURGERY.
 readily  placed at the  bottom of cavities than  the ordinary ligature,
 or ligature under pins.   In all cases the ligature is desirable, where we
 have great apprehensions of hemorrhage, and in  young children.
   The  incision of the periphery of tumors cannot be of advantage but
 for ncevi, properly so called, or those that are purely cutaneous ;  also
 it would be required that the skin should be almost naked ou the bones,
 and that it is deemed of extreme importance not  to deform the diseased
 organ.   Except  upon the fingers, eye-lids,  nose,  lips, and ears, this
 operation does not deserve a preference over excision, of which it  pos-
 sesses almost all the inconvenience, without offering its advantages.  In-
 cisions, properly  so  called, whether simple,  as  they are employed in
 Prussia, or associated with partial excision, as practised by MM. Ouvrard
 and  Lallemand, would not deserve to be made trial of, except in similar
 cases, and even then it would be well to  associate  with them the employ-
 ment of setons, caustics, compression,  or  topical applications,  if the
 thing were practicable.
   A ligature upon the arteries  of the fungus itself will never be proper,
 unless wc should  see them pulsate under the  skin, and that they were
 well isolated, or the tumor  too large and too thick  to  be attacked by
 cauterization or  extirpation.  Before  deciding  upon this,  we should
 have made trial of most  of the methods which I have just described.
 It is only, moreover, upon the cranium and face that it would be advan-
 tageous to proceed in this manner.   As to the ligature upon the princi-
 pal arterial trunks, as it is of itself  a serious  operation and fails in  one
 case out of three, it should  never be thought of,  when the tumor occu-
 pies  only the dermis or the sub-cutaneous layer, unless it is one of a very
 large size, and  which  has already resisted all other means.  We should
 reserve  it, then, for those erectile tumors which  it is not  practicable to
 attack with  security  either  by caustics  or  cutting instruments, or  for
 those of the  cavities of the cranium and face, for  example, and  those
 of the osseous tissues and interior of the limbs.
   As to extirpation, though it be in reality the best method of all, when
 the tumors  are well  defined,  cutaneous, or sub-cutaneous, we  should
 not,  however, propose it to persons who dread it; above all, not  until
 after having in vain  made  trial of one of the others;  but we should
 come to it at first, if there are no personal objections  opposed to it, and
 in all cases where we would  be enabled  to unite  the wound by first in-
tention, and in all  regions where a large cicatrix can have  nothing about
it of a revolting character.   We should also, moreover, decide upon it
when the other methods have failed, especially when  it may be in our
 power to guard against  the  hemorrhage to which it  may give rise, and
in all those cases  where there is no choice left but this and amputation,
 properly so called.  I have no necessity of recurring to the limitations
 which 1 have assigned above to this last resource.

                         [Erectile Tumors.

   Treatment of Erectile Tumors, particularly N&vi Materni.—Though
we have taken occasion  in the first volume of  this work, to enforce the
necessity of adopting in every case where it may be possible, the method
now  generally  practised  in  this  country, by  Dr. Mott and others, of 
TUMORS.
581
treating  those congenital  meshes of aneurismal vessels, (chiefly venous
in most cases undoubtedly,) in infants and children, which  are known
more generally as nmvi materni, sometimes as aneurism by anastomosis,
and in France, (as improperly designated by Dupuytren,)  erectile tu-
mors, (see Vol. I.,) we must again allude to it here, which is perhaps,
its most appropriate head.
  It has often been justly remarked, and the same observation, is,  as we
perceive in the discussions in the Academies at Paris, coming more into
repute every day, that the apparent rudeness, boldness, and  severity of
the practice of veterinary surgeons, who in Europe are educated men,
and of scientific attainments and respectable rank, and who have no re-
sponsibilities or interferences to contend with, except the single aim and
end of effecting a cure of their  patients, has been of itself the providen-
tial means of paving  the way for some of the most daring and brilliant
operations in human surgery.   Take  the section of the tendo Achillis,
and the use  of the hot iron as examples, (see Vol. I;) to the latter of
which remedies, surgery, as regards the human species, has also at last,
step by step arrived in the treatment of the disease in question, one of
the most common, and also unfortunately one of the most formidable, at
least in its deformity, of all the opprobria medicorum.
  From immemorial time deemed among the number of those congenital
misfortunes  or blotches, which were beyond the reach of surgical art, no
serious effort was scarcely ever undertaken for their removal.   Finally,
without pretending to add anything to the erudition of their early his-
tory as given by the learned author of this work, M. Velpeau, we shall
proceed at once to say, that  all therapeutic means, surgical  or medical,
have it may be alleged, proved  in too many instances utterly impotent,
or what is worse, sources of aggravation to the existing malady.
  Thus, to say nothing of the occasionally radical  cure by extirpation,
the most ingenious  and efficacious of all methods up to the  time of the
method by perforation with red hot needles, or the American process,
as it may  be emphatically called, was undoubtedly that  of M. A. Berard,
or that of the application of  the Vienna Paste, or Caustic,  as modified
by him, and which undoubtedly owed also all its value to its severity and
boldness.  M. Berard, (Mim. sur le Traitement des Tumours Erectiles;
par M. A. Berard, Membre de l'Academie de Medecine, Paris;  Chirur-
gien de l'Hopital de Necker—in the Journal des Connaissances Medico-
Chirugical.es, Paris,  December, 1841,  p.  249,  et seq.,) employs the
Vienna Powder which is composed of lime and caustic potash, accord-
ing to  the mode of  preparing the same in the  Codex, by making it into
a soft  homogeneous paste, by mixing it gradually  with a little rectified
alcohol, and then spreading it in a thin layer over  all the tumor, except
within a few lines  of its circumference, that  marginal portion of the
naevus  being sufficiently impregnated with it by means of the imbibition
of the solution of the "potash in the alcohol.  The paste is to be com-
pletely washed off in the space of from five to ten minutes.
  But  although this surgeon at  the time of publishing this memoir, gave
this mode a  decided preference  over all others, and had used it, he says,
with great advantage in more than thirty cases, yet it is clear from his
description that there is much  danger from it, by tho copious hemor- 
582            NEW  ELEMENTS OF OPERATIVE SURGERY.

rhages it may produce, and  also the necessity of one or more re-appli-
cations of it on account of its not executing its office effectually, or from
the liability of a return of the disease.
  The process of M. Lallemand of Montpellier, was undoubtedly nearer
the mark  in its inception, so far as the real mode of cure, was in some
measure shadowed out by him in this first step.  He, in fact, following
out M. Velpeau's process for varicose veins, and perhaps also M. Vel-
peau's suggestion of the  hot iron to ncevi, (see  text above,) inserted in
various directions, and repeatedly through the tumor, pins, which were
left there until suppuration was effected through their track.  M. Berard
objects that they did not  in his own hands prove sufficiently exciting, on
which account he substituted ivory pins, which one,  a  priori would say,
were much  less so than  the metallic  bodies ; and to effect his object
more completely he superadded  the  complication of a  platina syphon,
with a glass canula attached, in order to inject in the tracks of the ivory
pins, the nitric acid of mercury.   But the inflammation and suppuration
here again  proved too violent, besides  causing  subsequent indurated
growths, on the part, and endangering the whole constitution, if not life,   ^
by the imbibition of so dangerous a poison as the fluid used for injection.
Finally, M. A. Berard abandoning all other modes, adopted that which
(as will be seen in the text above,) had long before been made trial of,
to wit: numerous setons, by means of which  he strangulates the tumor,
and had up to the  time he wrote, thereby succeeded in every  case in
which he had tried it.
  To all  these must now give place  in the generality of n&vial tumors,
and when  not too deeply  involving  the  subjacent tissues, the process
most in repute  in this  country, or  the American method, which as we
have stated, (Yol. I.,)  we will now repeat, consists in the rapid and
successive application of slender, delicate steel pins of from two to three,
and  four  inches in length, furnished with  firm, short,  small  wooden
handles, and kept near  by, heated to a red heat in  a small chafing dish
of coals.
  The pins are inserted one after the other transversely and horizontally,
and  as near the union of the base  of the tumor to the skin, or sub-cuta-
neous and  dermoid tissue  as possible.   They literally burn their way
through, and at the same  moment roast an eschar in  their passage,
which becomes  the new  wall to  the track they  have made.  As soon as
one pin  is inserted, it is immediately withdrawn.  This is followed by a
second, and so on, going close  to the track of the preceding, until the
whole diseased mass, and  congeries of vascular canals is actually riddled,
broken up and  converted  into  one  eschar as well  as isolated from the
healthy parts underneath by one continuous layer of the same.  A healthy,
and  most salutary action, just enough to accomplish the object in view,
and  no  more, is thus set up within, and at the base of the tumor, while
the latter  is transformed immediately into a superincumbent incrustation,
that becomes detached as soon as the new reproductive granulating pro-
cess underneath has completed the  cure.   Very little, or no suppuration,
and never any bleeding  ensues.  In fact a better hemostatic  means'
could not be devised than the operation itself, which thus  finishes up as
it goes, every thing  required, producing very little pain, and that mo- 
TUMORS.
583
mentary, and leaving no  subsequent  steps to be taken by the surgeon
himself, scarcely  even a common dressing.  Adroitness however, is re-
quired in the proper application of these red hot needles, and the ope-
ration has sometimes to be repeated.
  Dr.  M. Hall  proposed, as early as in 1831, (Lond. Med.- Chirurg.
Rev., April, 1831;  New York Medical Journ., Vol. II., No. 1, p. 184,)
to cure naavi by  introducing horizontally and eight or ten times through
the tumor  near  its base  on or in the skin a couching needle with cut-
ting edges.  He  thus cured one over  the size of a shilling.  This pro-
cess required only the red heat to the needles to give it the  perfection it
now has.  Mr.  Liston, (Cormack's Journ., Oct., 1843, p. 943; London
Lancet, April 1st, 1843, p. 27,) in 1843 removed  an erectile tumor
from  the popliteal  space in a  boy, aged 10  years, which had existed
there from the age of 2 years.   It was situated deep, and was complete-
ly covered  with the fibres of the semi-membranosus muscle, which was
the cause, no  doubt, of its presenting such obscure diagnostic marks to
the touch, being represented as doughy, fluctuating, solid, elastic, fatty,
&c.  A  seton had  been  passed through it, and a discharge established
without any benefit.   It was moveable and distinct from the bone  : when
cut into during the operation much  blood was discharged from it, and
also much in its neighborhood.   On the 16th day the boy was perfectly
well.  The tumor, Mr. Liston says, microscopically examined, was found
to be  of perfect erectile tissue.  Mr. Liston considers it  to have been
developed  in  the muscles with which it was connected, and instances a
tumor of different structure which he removed from the side of the neck,
and which he believes to have originated in the interior of the  sterno-
cleido-mastoid muscle, in  which last case there was great hemorrhage.
   Amorphous Erectile  Tumor  removed by  Dr. Mott.—In June, 1845,
at New York, Dr. Mott removed a  tumor  of  the  size of a turkey's
egg upon  the left side  of the neck of a  young man, aged about 25,
of spare make and pale  complexion, temperate  habits, and otherwise
healthy, which tumor was  completely covered by the attenuated expanded
fibres  of the  sterno-cleido-mastoid  and  omo-hyoideus muscles, and in
its lower part  complicated with the thyroid  body  and vessels.  It
lay  obliquely on the inner margin  of   the normal line  of the first
mentioned muscle, which, however, in consequence  of the growth  of
the  tumor,  had  undergone  in this  part the  distension, attenuation,
and lateral expansion mentioned.  In  dissecting down upon the tumor,
which was  of the  shape of a  long  oval, it was found, underneath its
muscular parietes, to be  covered  with  a  series of pellucid or thin
transparent dense  membranes,  like  the  fasciae  of femoral hernia, two
or three in  number, on  the division of which a formidable hemorrhage
ensued from the enlarged superior thyroid arteries and veins which tra-
versed  its substance, and which was  found to be of an amorphous char-
acter, partly erectile and partly of  thickened  semi-cartilaginous  and
hydatid encysted tissues.  In this operation the infra-maxillary artery,
which also  sent off branches  to the upper part  of the tumor, was acci-
dentally divided, the upper end of which, during a movement of deglu-
tition  or turning of  the  neck, receded  an inch or more upward, above
and within the  base of the jaw, and was not secured until after a num- 
584
NEW ELEMENTS OF  OPERATIVE SURGERY.
ber of unsuccessful attempts with the tenaculum and forceps.   This cir-
cumstance  occasioned  considerable embarrassment from the large col-
umn of blood which issued from the abnormally enlarged calibre of the
vessel;  and had  Dr. Mott not succeeded in securing it in time, it was
his intention  to  have  passed a ligature upon the common carotid, the
sheath of which  had been laid bare  by the operation.  To avoid the
danger  of  farther hemorrhage, a ligature  was passed  around the root
of the tumor and  its adjacent connections, by which means indirect com-
pression  was  thus established upon all the included vessels.   About an
inch of  the diseased parts was thus left in the wound, together with the
ends of some  dozen or more ligatures which it had been found necessa-
ry to apply during the operation.
  The  diseased tissues included in the general ligature sloughed away
completely, and the parts healed up kindly, effecting a perfect cure.
                          CHAPTER III.

                        LYMPHATIC TUMORS.

  I mean here  by lymphatic  tumors, the  tumors which are formed
by degenerate lymphatic glands, (ganglions.)  It is a  class of  tumors
of which, up  to  the  present, scarcely anything has been said in works
upon  operative  surgery.  Generally the  treatment of them has  been
confined  to topical applications and general  remedies, (medications;)
but I have long since  satisfied myself that surgical  processes are fre-
quently  their best, and  sometimes, in fact, their  only remedy.   This
is also, I believe, the  opinion of M. Warren (on Tumors, etc., p. 162.)
Those tumors which  are sometimes the result of a simple hypertrophy
of the natural  elements  of the organ, at other times  formed by the
establishment of a variable number of clots  (grumeaux) of concrete
pus, or of tuberculous matter, or of cysts or purulent abscesses (foyers)
which are disseminated  as it  were, in the parenchyma  of the hyper-
trophied  ganglionic  tissue, represent masses which are very tardy in
contracting  adhesions to  the  organic  layers which  surround them.
When they  have once  acquired  a certain degree  of hardness, and
have  continued  beyond  six months or for a year, it  is rare that they
disappear by resolution, (i.  e. resolvents.)  They then  rest  on the
tissue like so many foreign bodies, whose internal morbid action, (trav-
ail central,) usually  very slow, approaches by degrees the neighboring
ganglions, (i. e. lymphatic  glands or ganglions,) produces an indefinite
enlargement, or a fungous degeneration, or suppuration, or ulceration of
the primitive masses.  We may conceive, then, the  advantage which
would result to patients if it were possible to destroy such  tumors
surgically.   We have in practice three modes which we may resort  to in
such  cases with some chances  of success :  These are crushing, setons
and extirpation. 
TUMORS.
585
                       Article I.—Crushing.

  The crushing of engorged lymphatic ganglions, which was proposed
and  put into  practice in a certain number of cases by M. Malgaigne,
is not so irrational as might  at first view be supposed.   The tumor
broken  up (broyee), comminuted (morcelee), and reduced  into a pulp
(bouillie) underneath  the  integuments  which remain  intact,  is  then
placed in conditions  similar to those of a tumor formed by clots of ef-
fused blood.   Permanent compression succeeding to crushing, proper-
ly so called, sometimes induces  the matters thus broken up to be absorb-
ed, and  then  resolution is thereby  evidently rendered more easy ; only
that it is unfortunate  that  the inflammation  from  being chronic, often
passes in this  manner into an acute state, and to such degree as to
sometimes transform the lymphatic tumor into a true abscess, the healing
(niondification)  of which is then always  tedious and difficult.  There
are  also a great  number  of cases  in which the crushing  cannot  be
performed but  with great difficulty.  It  cannot in fact, be undertaken
but  for   tumors  which are absolutely  external, and for  those which
rest on some solid  point of support.
  M. Malgaigne, who  has employed crushing  only  for ganglions  of
the  groin, used for this  purpose the thumb  or thumbs applied  with
force and directly  from before backwards  on each tumor.  In  proceed-
ing in this manner there is sometimes need of a great degree of force,
and  most of the  tumors cannot be broken up by  this mode.  There
might also, perhaps, be dauger in this  region of doing some mischief
to the femoral artery.  In that region, as well as in the axilla, and
under the jaw, and in the  neck, I  have  found it answer better, when
the   condition of  the  parts allow  of it, to seize the  tumor between
the  fingers or  between  two smooth pieces of pliant wood, and  thus
to compress  it with  a sufficient degree  of force upon the  sides, and
successively upon  all the  points of its circumference.   Many lymphatic
ganglions, treated by this process, have, as it has appeared to me, restor-
ed themselves afterwards with  a promptitude which the long duration
of the disease  had scarcely permitted  me to  hope  for.  But I hasten
to declare that  crushing  nevertheless, is a method which is exceedingly
uncertain, and one that cannot  be attempted but in a very small number
of cases.
                        Article II.—Setons.

  M. Levanier, a  surgeon  of Toulon, asserts  that he has succeeded in
effecting the rapid  dispersion of inguinal tumors of very long standing,
by traversing them with small setons. These consist of simple threads,
which are passed  by  means of a needle  through the entire thickness
of the ganglion, in which they are left to remain  for  four, five or six
days, and then withdrawn to be replaced by new  ones  in different
directions.   One, two,  or  a greater  number of threads  are  introduced
in this  manner  at the same  operation  or after an  interval of some
days, in  the same  way nearly  as I have said in speaking of erectile
tumors.   The  suppuration which is established  in the track  of each
of these  threads soon  reduces  the engorgement of the ganglionic tissue
  Vol.  II.                    74 
586
LYMPHATIC TUMORS.
and the molecular 01 interstitial absorption of the tumor afterwards
continues to go on without interruption to the termination of the cure.
   Without conceding as much confidence to this method as  M. Le-
vanier, which moreover I have as yet employed but on two occasions,
I nevertheless believe  it worthy to be made trial of, especially for
ganglions that are of little volume, situated in regions where extirpa-
tion would  be dangerous, and existing in patients who prefer submit-
ting to all the uncertainties  of doubtful processes, rather than  recm
to the resources of a cutting instrument.

                  Article III.—Extirpation.
   Up to the present time, lymphatic ganglions have not  been sub-
jected to extirpation but by a very small number of surgeons.   The
reason of this  peculiarity is owing to two circumstances:  1, lym-
phatic ganglions scarcely ever become engorged or degenerate except
from the influence of remote causes ; so that there are almost always
a certain number  of them diseased at the same time, and  that it is
rarely possible to  remove them all; 2, considered as the result of the
disease denominated scrofulous, they have been deemed to form only
a symptom, or indication (ombre) of a general affection, so  that their
removal would remedy nothing, or the least important element only
of the malady.  In this matter we must understand ourselves cor-
rectly.  If  the lymphatic tumors are in reality imputable to a gene-
ral constitutional affection, their extirpation should not be attempted.
It is the cause which we must first attack and not this feeble symp-
tom.  Nor should we moreover extirpate them,  when, notwithstand-
ing they have been produced by an external cause, they are nume-
rous and diffused, [disseminees—i. e. existing in various regions. T.]
But if there be one  only, or if notwithstanding their number, they
are well isolated and easy of dissection, we are not to  hesitate.   If
there is reason to  suppose that the constitution is good, and that  the
interior of the sphlanchnic cavities is not  compromised, their removal
offers incontestable advantages.  Different also from cancerous  tu-
mors, degenerate  lymphatic tumors possess also this remarkable fea-
ture, that  the extirpation of those that  are  most diseased or  most
voluminous, rather  favors than prevents the diminution  (degorge-
ment), resolution or dispersion of the others.   Thus have I frequently
confined myself to the  extirpation of a single  one,  or of  a  certain
number of these  tumors, though I knew perfectly well  beforehand
that I should be obliged to leave many others.  Having thus  extir-
pated those which were ulcerated, or very salient externally, or those
which  occasioned most inconvenience  and  deformity, I have fre-
quently noticed that the others continued in the  same condition they
were before, or that they afterwards imperceptibly disappeared. More-
over,  those that  have  advanced farthest being destroyed, nothing
prevents our healing the others by the same topical applications, and
of submitting the  patient to the different courses  of general treatment
which are deemed to possess the greatest efficacy.  When we reflect
upon  the manner in which these  tumors terminate by suppuration,
and upon the character of the ulcers, burrowings (decollements) and
cicatrices which they establish in  the skin, even when they get well
without  an operation, we may well be permitted  to consider  the 
NEW ELEMENTS OF OPERATIVE SURGERY.
581
 advantages which their extirpation might procure.   The extirpation
 having been once decided upon, there is no serious preparation required
 for the patient: if the skin is not changed and the tumor be not of a
 large size, we may confine ourselves to a simple incision of the  in-
 teguments.  In the  contrary  case, we  comprise  the degenerated
 tissues in an elliptical incision more or less  elongated, as in the ex-
 tirpation of any other kind of tumors.   In the place of the T or cru-
 cial incision which are generally preferred when the tumor is of a
 large size, I am in the habit of substituting the  semilunar incision, so
 as to construct a flap which is reversed from the free border to the
 base, and which allows of every possible  facility for the rest of the
 operation.  The  incision of the integuments having been effected,
 the surgeon  proceeds to the dissection of the  tumor.  In the event
 of this being occupied by cysts or purulent or tuberculous layers, we
 should be cautious not to excise their tissue.  In whatever way we
 proceed, it is better to hook fast of the tumor with a simple or double
 erigne, which should  be then immediately consigned  to  the care of
 an assistant.  Then holding the parts asunder  by means of the fin-
 gers or forceps, the surgeon divides and detaches them with caution
 by means  of a straight bistoury.  As these tissues are only super-
 posed upon (appliques) or cling loosely around [colles—means here
 to invest, or to be loosely attached to, T.] the ganglion, it is generally
 easy to isolate them from it.  Also the enucleation [of the tumor]  by
 means of the finger or the handle of the scalpel ought in  these  cases
 to be substituted for the cutting instrument, whenever we perceive
 that there  would be any actual danger of wounding the large  sized
 vessels or nerves.  On the other hand, masses to be extirpated thai
 have no character of malignity,  do not exact that we should extirpate
 the last portions of them with the same care that we do in cases of
 cancerous  tumors.  So that in all cases during the course of the dis-
 section, the bistoury ought to be directed upon  the exact limits or
 circumference of the tumor rather than in an opposite direction.  We
 may for the same reason make use of the fingers  for the purpose of
 detaching or even tearing out the remaining roots of the diseased
 ganglion, when it is deeply situated, or is found to be implicated with
 organs which it would be dangerous to  approach with the bistoury.
 In delicate regions, and where the lymphatic tumors are composed
 of many lobes united by simple pedicles, there is no impropriety in
 detaching that which presents itself the first, in order afterwards to
 seize successively upon the others.   We thus cause less destruction
 of parts, and more easily preserve the other tissues.  Of all other  tu-
 mors moreover, the lymphatic or ganglionic  are those which the most
 frequently  require a ligature to be applied to their root when we un
dertake their extirpation.  In fact, if, after having isolated their  cuta-
neous surface or circumference,  we should have any apprehension in
separating  the root, that we might open  into large veins or arteries
which it might afterwards be difficult to reach or tie, we strangulate
these tumors as deep as possible by means of a ligature composed 01
two to five braids of thread, so as to interrupt their entire circulation
 in such manner as to cause their separation,  or to enable us to excise
them  as we have said under the  chapters on Cutaneous and Erec~
tile Tumors. 
588
LYMPHATIC TUMORS.
   Dressing.—After the  extirpation of lymphatic ganglions, the he-
 mostatic means and the dressing of the wound exact the same  pre-
 cautions as after all capital operations.   I ought to remark however,
 that except in a small  number of cases, immediate  union does not
 here succeed, and that in attempting it there are more inconveniences
 than advantages.   The wound being almost inevitably anfractuous
 and constituted of irregular cavities, necessarily presents walls which
 it is next to impossible to  bring into exact coaptation.   Their tegu-
 mentary borders are closed and agglutinated with facility; but collec-
 tions of blood, lymph or pus, which are soon established underneath,
 sooner or later compel us to re-open them, and favor the development
 of purulent  centres, and  phlegmonous erysipelas, a hundred times
 more formidiable than a wound which has  been left  to  discharge by
 second intention.  Unless, therefore, the ganglion removed should be
 smooth (unique) and the wound exhibit great regularity, I would not
 advise in these cases to attempt union by the first  intention.  I have
 now (1838) performed extirpation of lymphatic tumors on near a hun-
 dred persons, and none of those who have been dressed in the manner
 I am about to describe, have experienced serious accidents; whilst I
 have almost always found phlegmasias and  suppurations supervene in
 those in whom I have attempted the cure by immediate union.  I  first
 introduce small balls of fine lint into the bottom of all the cavities,  and
 fill up in this manner the entire wound, which I cover over with per-
 forated linen, then with plumasseaux, compresses and  a  containing
 bandage.   When the blood flows in abundance, without there being
 any large arteries to tie, I  pile up these balls in such manner that they
 may exercise a sort of compression under the bandage.   I use but a
 small number of them on  the contrary, and such as are  of the most
 pliant kind, when there is  nothing to fear in regard  to hemorrhage. In
 proceeding in this manner the dressing is prompt  and easy, and  the
 results simple.  At the end of two or three days  we may, without
inconvenience, remove the whole dressing down  to the  perforated
linen.  A day or two more gives time for the exudation from the wound
to saturate the balls which fill it, and to allow of our  removing them
without any effort and without occasioning any serious pain.  Each
day we deposit in the wound a less  quantity of these balls, and  no-
thing is so rapid as cicatrization in these cases, so much  so  in  fact
that most of the patients are cured in the space of from fifteen days to
a month.  It  is besides remarkable that out of near 100 patients ope-
rated upon by me for these kinds of tumors, there  are up to the pre-
sent time, but three who have died.  I am so much the more surprised
at this, because in a great number of them, the operation was lon<r,
laborious, painful and really serious.   Though in some  of these  pa-
tients  there   still  remained  other degenerate  lymphatic ganglions,
though in two or  three of them these new tumors continued after-
wards to undergo a great enlargement, it is certain that in the great
majority of cases, the cure was prompt and  radical, and that the gan-
glions that were left have, in the greatest number  of instances, ulti-
mately retrograded, by gradually re-assuming their  natural condition.
Up to the present time I have  performed  extirpation  of lymphatic
tumors only  in the inguinal, humeral, axillary, supra-clavicular, sub-
maxillary, "parotid and sterno-mastoid regions. 
              NEW ELEMENTS OF OPERATIVE  SURGERY.           589


                  § I.—Ganglions of the Groin.
  Lymphatic tumors of the inguinal region present three modifications)
which it is important should not be confounded: those which are con-
nected with a venereal affection ; those which depend upon some dis-
ease of the foot or leg ; and those which belong to the class of cancers.
In those cases where their origin depends upon a syphilitic infection,
we must never, however ancient they may be, attempt their extirpa-
tion before having submitted  the patient to the specific treatment of
venereal disease.  If the alteration of the lower limb which has been
the cause still exists, it is also prudent when practicable, to effect the
removal of this before every thing  else.   But  if, when these pre-
cautions have been attended  to, or are not  practicable, the  tumor is
hard, of a certain volume, and has existed more than six months, after
having  been unavailingly  attacked by topical applications and the
suitable general remedies, then is the operation indicated, and  it be-
comes proper  to perform it.  We should not nevertheless under these
circumstances, undertake it in cases of cancerous affection, or where
the chain  (chapelet)  q| lymphatic ganglions which is prolonged  into
the ili'ac fossa  was at the same time implicated in the least degree of
engorgement.   In cases of hypertrophy, however, or of simple degen-
erescence whether fungous or tuberculous, a slight degree of engorge-
ment of the supra-inguinal  ganglion would not be a  formal counter-
indication ; as the removal of the principal tumor would have the effect
in many cases to cause  it to disappear.  The extirpation of lympha-
tic  tumors in the groin is one of the  delicate  operations of surgery.
The proximity of the crural artery and vein, and their branches,  and
of the internal saphena vein, and the femoral nerve, will always render
it difficult and formidable.  The dangers it involves are  nevertheless
not the same in all cases.  So long as it is a question only of sub-cutane-
ous ganglions, it is in fact possible, with a little address and anatomical
knowledge to accomplish it without danger; but if the deep-seated gan-
glions formed the tumor, it would become necessary to renounce it, or
to decide upon tying the vessels on the side of the iliac fossa, for chance
alone would enable us to avoid them during the operation. When we
operate for the extirpation of the lymphatic glands enveloped in the sub-
cutaneous fascia, we may also find ourselves placed in two different po-
sitions.  Sometimes in fact, it is the sub-inguinal ganglions that are to
be  extirpated, while in  other patients it is  the glands in the inguinal
groove itself.
  A. Sub-Inguinal  Tumors.—:Here the tumors have no relation with
the crural vessels properly so called ; they are separated from them not
only by the fascia lata, but moreover by the internal border of the sar-
torius muscle.   It is upon the line of the saphena vein that they are situ-
ated, and not in the direction of the crural artery, unless however, they
should be prolonged as  far as to the external orifice of the crural ca-
nal above.   The patient being placed  upon his back, should have the
limb reversed  upon its outer side and moderately flexed.   An assistant
fixes it in this position, while  another looks to  and prevents the move-
ments of the pelvis.  The surgeon placed on the outside and provided
with an ordinary bistoury, divides the integuments from above down-
wards for the  right thigh, and from below upwards for the left  thigh, 
590
LYMPHATIC TUMORS.
 as has been said above.   We might in like manner place ourselves
 always on the right, in order that the incision might always be made
 from above downwards, or on the left side if we preferred perform-
 ing it from below upwards for both sides.   We may go with the first
 cut and without fear down to the  sub-cutaneous  layer.   After hav-
 ing isolated each side of the wound  from the corresponding parts of
 the tumor, we raise up the latter and give the erigne to an assistant,
 who  should carefully follow all the movements of the operator.   Af-
 ter having dissected it upon its sides to nearly as far as  its root, the
 surgeon detaches it by small cuts  from below upwards,  and in such
 manner as not to wound the internal saphena vein.  If, however, the
 situation of the  tumor, or any particular circumstances  should  have
 led to the wounding of this vein, it would suffice to compress it below,
 and afterwards to manipulate the  instrument with extensive strokes,
 in order to terminate the  operation rapidly.  Nevertheless the sur-
 geon  ought to be then aware that in this region the upper end of the
 veins sometimes gives rise to a pulsating (saccadee) hemorrhage, suf-
 ficiently obstinate to oblige him on his part to  compress  the artery,
 or even to apply the ligature to it.   However,fit rarely happens but
 in approaching their upper extremity, that it becomes advisable to
 adopt serious precautions  in relation to the arterial vessels.  Upon
 the supposition that we should have occasion here for the semilunar
 flap of which I have spoken, it would be better to turn its free border
 inwards than to  the outside; in the same manner that we should di-
 vide the inner rather than the outer lip of  the simple incision, if we
 preferred using the  T incision.  As to the  dissection of the ganglions
 themselves, prudence requires that we should perform it  on the inner
 side first,  then on the  outer  side, then from below upwards, and  to
 terminate at the inguinal extremity.  In this manner nothing would
 then prevent us, should they appear to be prolonged by means of a
 pedicle into the crural canal and to the side of the vessels, from stran-
 gulating  their root  before completing their excision.  If immediate
 union can be attempted  after extirpation of lymphatic tumors, it is
 assuredly in the region under consideration.   We  should  have re-
 course to  it if the wound is regular, if the cutting instrument has suf-
 ficed for the division of all the tissues, and  if after the ligatures are
 applied, the sanguineous exudation  has a tendency to cease of itself.
 For this purpose the limb is straightened, after which, by means of a
sufficient number of strips  of adhesive plaster, we approximate  and
keep in contact  the  two lips of the wound.   A  perforated linen a
large gateau of lint, and some turns of the roller bandage with a spica
to the groin, complete the dressing.  In the contrary case, the solution
of continuity is  filled with  small balls of lint before applying the
 other  portions of the dressing of which I have just spoken.  In either
 case, we  afterwards place the ham and the leg upon a  pillow in a
 moderate  state of flexion.
  B. Inguinal Tumors.—In the fold of the groin, lymphatic tumors are
 situated sometimes on the inner and  sometimes on the outer side, or on
 the side towards the pubis or that of the spine of the ilium, and some-
 times even on a line with the femoral artery.  This difference of situ-
 ation  as may be imagined, renders their removal either very simple
 or exceedingly difficult: In a man in whom ten months before I had 
NEW ELEMENTS OF OPERATIVE  SURGERY.
591
extirpated a cerebroid cancer from the scrotum, I was obliged to re-
move a tumor of the same nature which had developed itself in a
lymphatic ganglion external to the symphisis pubis, and which, hav-
ing acquired the volume of the first, had extended  outwardly as far as
upon a line with the femoral vein.  In another case I saw  a  purely
lymphatic tumor which occupied the entire space comprised between
the antero-superior spinous process of the ilium and the track of the
vessels.   A woman upon whom I operated in 1836 at the hospital of
La Charite, had in the fold of the groin a lymphatic fungus of the size
of an egg and which had been ulcerated for more than a year and
was situated in the front part of the crural  canal  itself.  Such facts
are not rare, and it would be easy for me  to show numerous exam-
ples of them.  To perform the operation the patient should be placed
and  held as in  the preceding case.   Nor can  any precise rule be
given here for the direction of the incision of the integuments.  If
the straight incision would answer, it  should be made in the  direction
of the fold of the  groin or of the long diameter of the tumor.   If the
curved incision should be preferred, or become necessary to be em-
 loyed, the free border of the flap must be made upon the outside and
 elow, in which direction also the outer lip of the first incision should
be divided, provided the T incision should be thought most advisable.
Internal tumors  should be dissected in the manner of sub-inguinal
tumors, first upon the  inner side,  then outwardly, and  finally from
below upwards.   The external ganglions should be dissected by a rule
directly the reverse, and this in order to reserve for the last thing the
most delicate stage of the operation, to wit, the isolation of the tumor at
the most proximate point to the vessels.  By means of these precautions
we may proceed without any very great degree of danger as high up
as to Poupart's ligament, or on a line with the apex of the fossa iliaca.
When the diseased ganglion occupies the middle of the groin, we iso-
late it successively upon its two sides up and down, in order not to lay
bare the pedicle until the last thing.  So long as the surgeon, in order
to effect this, is not obliged to divide  the aponeurosis, there is nothing
to fear, and should the tumor not be prolonged into the iliac canal, he
may cut off its root without  a previous ligature.  But should  he at
all apprehend the extension of the pedicle of the tumor to the  neigh-
borhood of the trunk of the saphena,  he will, after having reduced it
to a  small volume, surround it with a ligature and  strangulate  it with
force before excising the ganglionic  mass on the  outer side.  In the
case of  the woman I have just mentioned, I was obliged to lay bare
the saphena vein as far as its entrance into the crural vein; but by
dissecting the tumor horizontally I  was enabled to  isolate it without
any  ligature, though the artery was afterwards noticed  upon  the
inner side of the bottom of the wound.   I would not hesitate, there-
fore, to attack lymphatic tumors in this manner, even in the iliac fossa,
should they be prolonged to that part, provided they were situated ex-
ternally to the vascular trunks.   Even if it were  necessary I would
divide the  ligament of Fallopius, in order that we might by means of the
finger, tear out these tumors or enucleate them in such manner as not
to run any risk of  wounding the principal arterial branches.   But as
I  have already said, I would no longer hazard such an attempt if the
tumors were cancerous, or the vessels surrounded as it were  by the 
592
LYMPHATIC TUMORS.
tumors, and that there was ground for believing that there existed de-
generate ganglions in the neighborhood of the lumbar region.  The
dressing in the groin presents some difficulties in addition to those of
the preceding case.   The application of adhesive straps in this place
offers but a feeble resource.  The tissues of this region are less homo-
geneous, and the disposition of the skin there is very illy calculated for
primitive agglutination.  Nevertheless, if  the wound is uniform and
in the direction of the inguinal groove, a slight  flexion of the thigh
may be found sufficient to maintain the two lips of the wound in co-
aptation.  With this  exception the dressing flatwise,  by means of
small balls of lint, the  perforated linen, the gateau of lint and the
spica, appears to me to be decidedly preferable.
   [Having purposely  devoted a great deal of personal  investigation
and practice while at the Seaman's Retreat Hospital, to dressing the
ugliest kind of shelving, jagged and leaden-edged, deep, sinuous, and
irregular wounds left in the hollow of the groin in syphlitic cases, by
burrowing abscesses and discharges succeeding to buboes and mercu-
rial drugging, and where the wound penetrated sometimes to the depth
of an inch and a half  or more, and as high up as  the crural arch and
inguinal canal; I can testify to the pre-eminent advantages of tight,
forcible strapping by multiplied and very long strips of adhesive plas-
ters, decussating each other on the abdomen  and down and  across
the thigh in every direction, so as to form  a firm stellated support, or
covering, requiring only a slight inward flexion of the thigh and per-
severing use of this mode to hasten granulation from the bottom, and
a perfect coaptation of the edges with great rapidity and without the
necessity of any auxiliary means but stimulating injections every few
days this dressing is renewed.   If they succeed thus with the gene-
ral constitutional treatment in such desperate chronic anfractuous and
cavernous wounds, surely they should never be neglected in the fresh
wound left by extirpating lymphatic glands. T.]

              § II.—Lymphatic Tumors of the Arm.

  Although lymphatic tumors may become developed upon the track
of the cephalic vein  and in the deltoid region, it is nevertheless al-
most exclusively upon the inner side of the arm that these tumors
have been noticed.   Here they may be found at all  the  different
points of the track of the artery.   Nevertheless it is at an inch or
two above the inner condyle that they are most frequently met with.
To extirpate them  in this  region the arm must  be held off from
the trunk, and the fore-arm extended in supination.  A longitudinal
incision ordinarily suffices.  Commenced above  and terminated  be-
low the tumor, it almost always allows of our arriving  immediately
upon the pedicle of the latter.  It is moreover important during  the
dissection, that the  lymphatic  mass should be properly drawn out
from between the lips of the wound by an assistant provided with
an erigne, while another assistant should always stand ready to com-
press the brachial artery in the  direction  of the axilla.   The  tumor
having been detached  from the biceps in front and the triceps behind,
may afterwards be isolated upon its deep-seated face  without anv
very great difficulty,  and without the danger  of wounding anv- 
NEW ELEMENTS OF OPERATIVE SURGERY.
593
 nmig' •  the surSeon is careful to carry the point of his bistoury par-
allel with the plane of the interior surface of the arm, and to graze
with accuracy the ganglionic tissue.   The  ulnar nerve, the median
nerve, and the brachial artery, which it quite frequently touches,
would nevertheless oblige him to strangulate the pedicle of the  tumor
with a  strong ligature, should it  send off any prolongations  be-
tween them, or should it appear too difficult or dangerous to complete
its enucleation either with the fingers or the handle of the scalpel. Here
also union  of the wound by first intention, offers some prospect of suc-
cess.  Circular strips of adhesive plaster and a graduated  compress
on  each side, the perforated linen, gateau of lint, square compress,
and roller  bandage, will always offer a facility for this, unless there
should be particular difficulties in the way; we should therefore have
recourse to it in the greater number of cases. If however, the  slight-
est accident should supervene, or  the  least difficulty interfere, we
should recur immediately to the small balls of lint and the simple dress-
ing.  The  limb is then placed in semi-flexion and upon  a cushion or
pillow, until the stage of the primitive accidents has passed by.

             §  III.—Lymphatic Tumors of the Axilla.

  The hollow of the axilla is a region where the lymphatic ganglions
frequently  become engorged and degenerate.  Diseases of the breast
and all those of the thoracic limb, occasion there a sympathetic action
(retentissement), which makes the hollow of the  axilla the locale (cen-
tre  of an infinity  of tumors of different kinds,  but which almost  all
of them, have the lymphatic ganglions for their seat.   If it be true
that surgeons rarely decide upon extirpating these  kinds of tumors,
it is in part owing to their nature, which does not allow of our always
considering them as a local and independent disease, and again, be-
cause the operation is in itself of a delicate nature, and one which is in
reality serious.   The axillary vein and the branches which it receives
in the first  place  expose us to a sufficiently abundant hemorrhage
when we happen to wound them, and afterwards there is danger of
that introduction of air which appears so frightful and so difficult to
prevent in  certain  regions, (see Vol. I.)   The artery of the same name
which it may be impossible to avoid, ard the nerves of  the brachial
plexus also constitute so many circumstances to arrest the hand of the
operator.   In adding to these that the manipulations  of the bistoury
are also necessarily restricted by the  arrangement  and  relations of
the pectoral muscles in front, those of  the shoulder behind and  on
the outside, and of the chest on the  inner  side, we have  a  sufficient
explanation of the  reserve exhibited  by surgeons  in  this matter.
Having, however, frequently encountered lymphatic tumors of the
axilla which nothing  could disperse,  and which were gradually
conducting the patients to the tomb, I have thought nevertheless that
I could surmount those objections,  and  now extirpate tumors of the
axilla, after the same indications as those for the inguinal region;  it is in
fact an operation which, since the year 1837,1 have performed a great
number of  times, and under circumstances greatly diversified.   From
whence I have acquired the conviction  that this operation, as  I  am
about to show, is in fact much more frightful [effrayante, i. e., in ap-
  vol. n.                       75 
594
LYMPHATIC TUMORS.
pearance, T.] than in reality dangerous.  Many of the patients upon
whom I have performed it, had tumors of an enormous volume, which
raised up the  pectoralis major, surrounded the brachial  plexus  and
vessels, or were prolonged  at  their upper part as  high up as the
supra-clavicular depression.  Out of an aggregate of about 25 exam-
ples which I could enumerate at the present  time, there have been
only two cases of deaths;  one of which was  a young woman upon
whom I  operated  in 1828 at the clinique  of M.  Bougon.   The
tumor, which was of the size of the head of an adult, completely filled
the hollow of the axilla, ascended as  high  up as above the  cla-
vicle, and required an extremely extensive dissection.  The patient,
after having exhibited some  encouraging indications of a cure, was
seized with a pleuritic effusion  and died  at the end of three  weeks.
The second patient was a  woman nearly sixty years of age.   All the
ganglions of the axilla had to be torn out, one after the other ; an enor-
mous cavity was the  result, which, however,  was in great part filled
up when a diffused (ambulant) erysipelas supervened and carried the
patient off.  A third patient who had undergone a similar dissection,
died at the expiration of  two  months, in consequence of accidents
disconnected with the operation.  All the others operated upon re-
covered, the most  of them  very rapidly, that is to  say, within  the
space of fifteen days  to a month or six weeks.   An inconvenience
which retards the cure in  this  operation, where we are obliged to
liberate the part from its ganglions, is the interruption to the circula-
tion of the lymph, and a tendency to engorgements and infiltration of
the hand and fore-arm.  There may also result from it so great a con-
traction of the hollow of the axilla, that the movements of the shoul-
der and the separation of the arm, especially from the trunk, may be
greatly obstructed.   The manner of performing the operation, though
varying according to the size and precise situation of the tumor, is,
however, reduced to two processes:  one which consists  in penetra-
ting into the  hollow of the  axilla without dividing the  muscles;  the
other in dividing at first through the lower border of the pectoralis
major muscle, or even the whole thickness of the two pectoral mus-
cles as high up as to the neighborhood of the clavicle.
  A.  By the hollow of the  axilla.—It rarely happens that the incision
at the hollow of the axilla  does not answer for the operation in ques-
tion ; the preferable position of the patient being upon a bed, rather than
seated on a chair.   One assistant  is to draw  the arm towards  him,
while another stands ready to compress  the  subclavian artery upon
the first rib.   The surgeon, provided with a straight bistoury, makes
his  first incision which comprises the entire length of the great  diame-
ter  of the hollow of the axilla, and extends from the upper part of the
arm to below the tumor  or even to  the side of the chest.   Upon
the supposition that this  first incision will  alone answer for the whole
dissection, it is better to place it rather behind  than too near the ante-
rior border of the axilla ; in  the contrary  case, should  it become ad-
visable to divide its posterior border, it is more proper to place it al-
together in front.   Having thus divided the integuments, sub-cutane-
ous fascia and aponeurosis, we introduce  a  finger into the wound to
derve as a guide for the simple or double erigne, which is immediately
to hook up the mass to be removed.   The surgeon then dissects the 
NEW ELEMENTS OF OPERATIVE SURGERY.
595
tumor in front, and behind, and on the inner side, and finally from be-
low upwards, in proportion as the assistant draws upon it in the direc-
tion required.   Having arrived into the hollow of the axilla itself and
upon the side of the arm, I have often succeeded in detaching it com-
pletely by means of short strokes with the  bistoury, while the fore-
finger of the left hand directed backwards and deep, by raising up the
brachial plexus or the vessels, acted as a director.  This stage of the
operation, which sometimes enables us to dissect the important organs
in the hollow of the axilla in the same way as for an anatomical prepa-
ration, is too delicate and hazardous to permit  me to lay down a ge-
neral precept.  The best mode then is to tear out gently, though with
force and by means of the finger, all  the lobules of the tumor which
appear to be interspersed among the vessels or nerves, or which are
prolonged to too great  an extent in the direction of the clavicle and
the regions of the neck.  Should the  engorgement of the ganglions
be prolonged only by a pedicle above  and to the outside, it would be
still more easy to surround it with a triple thread and to  strangulate
it forcibly, in order  to excise the whole gland  immediately below it.
By means of these  precautions we remove with promptitude and
facility, tumors which do not exceed  the size  of an  egg.   We also
extirpate without danger or any very great  difficulty, those which
are too much enlarged and which present themselves under the as-
pect of bunches  of  grapes when occupying principally the thoracic
wall of the axilla.   There are no real  difficulties or dangers therefore
but for those tumors which rest against the  root of the arm or articu-
lation of the shoulder, and for those which are prolonged to above
the clavicle.   Ordinarily during the entire operation there are  but  a
small number of arteries opened.   These are the branches of the ex-
ternal  mammary artery, those of the anterior (anterieurs) thoracic
arteries, of the common scapular artery, and rarely  the internal  cir-
cumflex artery.   We might apply the ligature to them in propoi-tion
as they are  divided, but there is but little inconvenience in causing
them to be covered temporarily by the extremity of a finger, and in
waiting until the end of the operation before tying  or twisting  them.
I have no need of remarking that if unfortunately the axillary artery
should have been wounded, as in  the case mentioned by M.  Wolf,
(Graefe und Walther  Journal, t. VII., p. 261,) it would also become
necessary to apply the ligature instantly.  The hemorrhage at  this
time, which is most troublesome, is almost always furnished by the
veins ; so much the more so because in the axilla as in the groin, the
venous reflux which might under these circumstances extend back
even  to the heart, is  not  yet entirely annihilated.   This  kind  of
hemorrhage moreover which we  first arrest with the finger,  after-
wards readily yields to tamponing and compression.  The proof of
this I have  from having seen  the  axillary vein itself opened  in  an
operation of this kind.  I lay it down as  a principle not to attempt
immediate reunion  in  these cases.  For they are of those in which
the extirpation of the lymphatic tumors leaves a cavity too anfrac-
tuous and a wound  too irregular to make it possible to hope for  pri-
mitive agglutination.   I place therefore small  balls of soft lint upon
all the points of the traumatic cavity, until it is well filled with them and
that they produce a certain degree of compression, should it seem requi- 
596
LYMPHATIC TUMORS.
site to adopt  any precautions against  the flow of blood.   A perfo-
rated linen, a  gateau of lint, and one  of the ordinary bandages for
the axilla, serve to complete and to sustain the dressing.
   B.  In front of the axilla.—If owing to its absolute volume or prim-
itive situation  it should become impossible to enucleate the tumor by
the hollow of  the axilla; if, as I have seen it in attendance with MM.
A. Berard and J. Cloquet, in a young subject aged ten years, the tumor
should appear to be situated between the two pectoral muscles, or seem
agglutinated as it were upon their posterior surface, it would  be better
to divide the anterior wall of the axillary region than to operate in the
manner I have just described.  In a young girl whom I have spoken
of farther back, and  whom I operated upon  in 1828, it became ne-
cessary to divide the  tissues  obliquely from above downwards and
from before backwards, from the inner third of the  clavicle to the
lower border of the latissimus  dorsi muscle.   Another incision  par-
allel to the posterior border of the axilla thus circumscribed  four
flaps, two smaller which I reversed downwards and backwards, and
two very large which I dissected, reversing  one  of them  upon the
side of the  sternum, and the other upon the shoulder.  These two
last, comprising the entire thickness of the pectoral muscles, enabled
me to detach little by little from the front part and side of the chest,
the totality of the tumor, which it  afterwards became necessary to
isolate behind  from the  sub-scapularis muscle, from the border of
the clavicle above and in front, and from the whole  brachial plexus
on the outside, and finally to extirpate it from  the supra-clavicular
depression, where one of its roots of a sufficiently large size had been
prolonged.   We might here easily avoid the necessity of posterior
flaps by substituting  the T for the crucial incision.   The horizontal
branch of  the T being placed behind and  parallel  to the posterior
border of the axilla, would put  it in our power to fall upon it with
an incision  which  would be  vertical  or  more  or less oblique, and
which should set out from the front part of  the clavicle.   The  two
large  triangular flaps circumscribed  in  this manner, would give
every facility desirable, and would accommodate themselves in a re-
markable manner to every possible mode of dressing. If the tumor
should be more projecting in front than above, it would be practica-
ble to lay it bare with still greater ease by means of the semilunar
flap of which I have so frequently spoken.   The free border of the
half-moon  in  this  case  might be  turned downwards towards the
axilla, inwards towards the sternum, or outwards towards the arm
according to the form of the tumor or the particular indications.  It
would be necessary for the same reason to cut it out upon  a  curve
of greater or less depth, and more or less elongated.  This flap, being
raised up upon its base, would allow as readily as the others of dis-
secting out the tumor up to its termination, and would be attended
with the  advantage of reducing the operation in fact to the condition
of a simple  incision.   The section of the  fleshy fibres which  might
here interpose, presents nothing in itself serious.  What I have  said
of the division of the tendons and  muscles (see Vol. I.)  is sufficient
to show  that  misapprehension  had prevailed  in this matter.   If
Jie operation,  therefore, by this division would be made more simple
and less  dangerous, we ought not to hesitate  ; we should operate also 
              NEW ELEMENTS OF  OPERATIVE SURGERY.          597

in front rather than at the hollow of the axilla.  The dressing after
extirpaAon of tumors of the axilla by this process, enables us bet-
ter than the other to undertake immediate union.  Whatever may be
the form of the flaps, they should be brought together  and approx-
imated  in  such  manner as  to  leave  a void  only at the depending
point of the axillary cavity.   They are to be consequently replaced
in such a way as to  reconstruct, as completely as  possible, the an-
terior wall of the axilla.  But I would recommend to leave a meche
or tent, or  some  rouleaux of lint between the lips of the  lower part
of the wound, so as to provide at that place for the egress of the dis-
charges.  This mode of reunion is  effected at  the  axilla as  every
where else, by means of simple strips of adhesive plaster, aided by po-
sition or the suture.  I ought to remark before concluding, that in
operating at the  hollow  of the axilla, should the  simple incision not
answer, we might equally substitute  with advantage for the T or
crucial incision,  that of the  semilunar, taking care  in that case to
turn its free border backwards and outwards. In whatever way the
operation and dressing may have been performed, the arm should be
kept immovable and slightly raised up towards the shoulder.  After
the first dressings, it is important, however little the purulent matters
tend to stagnate, to  open a passage  for them.   It is at this period
therefore that we must prevent the too rapid union of the lower por-
tion  of the wound, separate the arm  a little from the trunk, substi-
tute emollient cataplasms for  the lint, or even have recourse to
emollient and detergent injections into the traumatic cavity.  Acting
upon these principles I have frequently removed tumors from the hol-
low  of the axilla, which many practitioners had refused to extirpate.
(Dufresse,  Journ. Hebd. 1835,  t.  IV., p. 276.)   The tumor in the
form of a  bunch of grapes, which almost equalled the size of an
adult head, and which M. Goyrand (Lancette Franc, t. II., p. 256)
successfully removed under the impression he was operating  for a
scirrhus, was probably a lymphatic tumor.  M. Lallemand (Lafosse,
Clin, de Thopital Saint Eloi, p. 4) who employed the suture to unite
the wound, and who also supposed he had extirpated  a cancerous
tumor, likewise as it appears to me  removed only degenerate lym-
phatic ganglions.  Though no one moreover up to the present time
had laid down precise rules in respect to the operative manual in the
extirpation of tumors of the axilla, it  is nevertheless true that some
surgeons occasionally had recourse to this operation.  We already
find even in F. de Hilden the rule to cut down upon them, and to draw
them towards us  and  tie  their  pedicle deep down, before  com-
pletely detaching them from the body.  It would be abusing the pa-
tience of the reader to say now that we should  proceed in the same
manner for scirrhus, colloid, encephaloid, melanotic, fibrous, fungous,
or any other form  of tumors other than those  that  are lymphatic.
The  only point which it is important not to lose sight of under such
circumstances, is this, that we should  not  undertake the extirpation
of malignant tumofs, if the least particle of them is to escape from
the action  of  the bistoury or the  ligature in mass ; while tumors
purely ganglionic or tuberculous, may be extirpated  with considera-
ble chances of success, even though we are forced to abandon some
of the engorged ganglions in the axilla or above it. 
598
LYMPHATIC  TUMORS.
             § IV.—Lymphatic Tumors of the Neck.

  There exists in the neck so great a number of lymphatic ganglions,
and these  ganglions are distributed upon  so  many different points,
that it is scarcely possible to study their extirpation separately in all
the situations in which they sometimes give rise to  the formation of
abnormal tumors.  It has happened to me on two or three occasions
to extirpate them where they were situated behind  the sterno-cleido-
mastoid muscle, and seemed to repose upon  the outer  side of the
trapezius.   In that position we may lay them bare freely by a simple
incision, directed from above downwards or a little  obliquely.   As
in this region there is no important organ to avoid, we may, after
the incision of the integuments is  made, and the tumor  is properly
secured with the hook, proceed with free and rapid strokes of the bis-
toury.  From the natural tension of the parts rendering it almost im-
possible to keep in perfect contact the walls of the  cavity which re-
sults from this operation, we have  the reason why immediate reunion
scarcely ever takes place, and that it is more prudent in fact to dress
flatwise and with small balls of lint, rather than by the exact ap-
proximation of the parts.   If, as I  have seen in two or three cases,
the tumor, which was in all situated behind the sterno-mastoid muscle,
should occupy the upper third of the neck or the neighborhood of the
occipito-mastoid region, we might proceed otherwise, and treat the
division of the integuments as an ordinary simple wound.  Between
the os hyoides and thyroid cartilage, where lymphatic tumors of the
neck are sometimes developed ; between the sternum and the thyroid
gland, where they have also been met with in some patients, they
should be treated as will be mentioned in the article upon operations
which are performed upon the neck.  But it is necessary to consider
the extirpation of lymphatic tumors separately, in  the parotid,  sub-
maxillary, carotid and supra-clavicular regions.
  A.  Parotid Tumors.—Having to treat elsewhere of the removal
of the parotid itself, when this gland is degenerated, I could only
repeat here  the details into which  I shall then be  obliged to enter,—
(see Extirpation of the Parotid, infra.)  I will say only in anticipation
that those tumors formed by the parotid gland of which so much has
been said, have all of them, or almost all of them, for their basis or
point  of departure the lymphatic ganglions properly so called.  It is
from  having frequently ascertained the truth  of this position that I
take the liberty at the present time to affirm it positively.
  B.  Sub-maxillary  Tumors.—The sub-maxillary tumors that are
most  common, are observed in the mylo-hyoid space ; but they are
met  with also directly under  the chin, quite  frequently under the
angle of the jaw, and sometimes also upon the external face of this
bone  in front of the masseter muscle.  In a young girl  aged ten
years, who had one of the size of a large nut und^er the chin, I made
an incision, which being carried from the symphisis of the jaw to the
level  of the os hyoides, while the head  of the child was held back by
an assistant, enabled me to hook fast, dissect out and completely extir-
pate the tumor with ease.  The wound which was united by first inten-
tion by means of a band of adhesive plaster passed under the jaw in the 
              NEW  ELEMENTS  OF OPERATIVE SURGERY.          599

form of a bridle, was completely closed up in less than fifteen days. In
another patient who had one of them on each side the median line, it
became necessary to make two such incisions.  As these tumors were
in part softened and as they left  quite an irregular cavity, I deemed
it advisable to dress them with small balls of lint and to treat them by
secondary reunion; the  cure nevertheless was completed at the end
of three weeks.   The lymphatic tumors which at this part are some-
times sub-cutaneous, at least situated in front of the muscles, are not
approached by any  large sized artery.  The sub-mental is  the only
one that may be wounded and require a ligature.  Nevertheless there
sometimes exudes from the wound a sufficiently considerable amount of
blood to oblige us to  give the preference to tamponing to dressing sim-
ply with adhesive plaster.  Under the angle of the jaw the ganglions
may acquire the size of a nut, egg or fist.  Being in that part situated
outside of the digastric muscle, and sub-maxillary gland, and in front
of the sterno-mastoid muscle, they approach  sufficiently near the in-
ternal jugular and the carotid arteries  to create some little apprehen-
sion in those who should desire to attempt their extirpation.  Never-
theless I have frequently removed them and always found  that the
operation was simple and sufficiently easy.   For  that purpose, the
patient being inclined a little towards the sound side, and having the
chin slightly raised  up, should  be kept in this position by assistants,
who should at the same time depress his shoulder upon the  diseased
side.   Should the tumor be of medium size,  I lay it bare by means
of a curved incision, modelled in some measure upon the curvature
of the sub-maxillary region.   If the lymphatic mass is of  a certain
volume, I give to  this incision  a very decided semilunar form, in
order to obtain a flap which may be raised upon the side of the jaw
from below upwards and from behind forwards.  Having then seized
the tumor with a hook, which an assistant is charged with making
traction upon in the proper direction, I proceed  to  the dissection.
The finger holds apart and stretches the lamellae in proportion as the
instrument divides  them, and when we reach near the  deep-seated
parts,  completes  the enucleation should there be  any organ there
which ought  not to  be exposed to the point of the bistoury.  Whether
the wound forms a semilunar flap or  a simple curved incision, it
ought not to be completely closed except in extremely simple cases.
In the aggregate  we are exposed to fewer inconveniences when we
treat it by gentle tamponing, than when we endeavor to unite by
first intention.  The tumors on the outer side of the jaw however are
sufficiently rare.  I have removed some which were situated exactly
upon the track of the facial artery.  There can be no  positive  rule
for the direction of  the incisions in such cases, and the great diame-
ter of the tumor  must serve  as  our guide for their  location.   We
must be prepared moreover to wound the external  maxillary artery,
inasmuch as it is often enveloped as it were  by the ganglions which
we have to extirpate; but this vessel is  not of sufficient importance
to create the  least uneasiness, and the surgeon has only need  of re-
collecting that it is generally advisable to tie or twist both  its lower
and upper end, in consequence of the reflux which  takes place from
the coronary  arteries or the angular artery.  The wound here being
on a fixed plane might be  closed  by primitive  agglutination, if it 
600
LYMPHATIC TUMORS.
were found in other respects under conditions which would authoi-
ize our undertaking this kind of union with reasonable chances  of
success.
   C.  Mylo-Hyoid Tumors.—The triangular  space bounded  on the
inner side by the mylo-hyoid or the hypo-glossus muscle, outwards
and upwards by the inner face of the jaw, and outwards and down-
wards by  the supra-hyoid  aponeurosis and the platysma myoides
muscle, and in which space is situated the sub-maxillary gland, also
includes a variable number of lymphatic ganglions, which  frequently
become diseased, and  sometimes enlarge to  such extent as to ac-
quire  the volume of an  egg or greater.  These tumors becoming de-
veloped in  consequence of diseases of the face or anterior region of
the cranium, or  of the interior, of the mouth or  of the  gums, fre-
quently exist  under the character of a  local affection in persons,
who in other respects, are in the enjoyment of good health, and who
have no other kind  of lymphatic engorgement.  It is in such cases
that I have most frequently  practised  extirpation  of the  glands  of
the neck, and where the operation succeeds the best.  In addition to
the examples which I have  elsewhere  published, I could at the pre-
sent time add a great  number of others.   The tumors of which 1
speak are globulous, generally ovoid, movable, hard  or elastic, and
exceedingly prominent below the jaw.  In pressing them  at the
same  time  through the mouth and at the supra-hyoid region, one
would suppose that they were isolated  (a nu) under  the mucous
membrane  and under the skin.  But this appearance should not de-
ceive  us.  Lymphatic tumors of the sub-maxillary region,  are neces-
sarily sub-aponeurotic, and the surgeon must expect to search deeply
for them, if he expects to remove every  part that is diseased.   As
for the rest, provided their surface has not undergone any degeneres-
cence, is not ulcerated, nor has contracted any unnatural adhesion
with the surrounding tissues, the removal  of the larger sized ones is
not essentially more difficult or dangerous than that of the smaller.
  I. The operative process, moreover, is sufficiently simple; and the
incision of the integuments may be performed in three ways.   1. An
incision parallel to the lower border of the jaw or to the great diam-
eter of the  tumor, ordinarily suffices; only that it  is advisable  to
place  it sufficiently low down, in  order that after the operation it
may not be drawn towards the base of the bone.   The wound being
thus reduced to a simple slit, leaves only  a linear cicatrix, which is
naturally concealed under the jaw, and is scarcely  perceptible.
  II.  If the straight incision should not give sufficient freedom, as
happens when the  tumor exceeds in volume a large sized pullet's
egg, a vertical incision upon the lower lip  of the first wound, would
procure a division in T, with two  lower flaps, which  should be dis-
sected and reversed, one to the front and the other backwards.
  III. In this case I would still give the preference to the curved in-
cision and  semilunar flap, over the T incision.  This flap, raised  up
from the neighborhood of the os hyoides to the face, would enable us
to lay bare the entire cutaneous surface of the tumor, and  would af-
terwards fall by its  own weight over the  cavity of the wound.   In
whatever way we proceed, the patient beiag placed upon the bed and
inclined as has been described above, should have the chin  raised and 
NEW ELEMENTS OF OPERATIVE SURGERY.
601
the head thrown backward.  The incision of the integuments should
be made boldly and as far as to the most projecting point of the tumor
Its anterior angle may be prolonged without apprehension of wound-
ing any important artery.  But posteriorly it is not the same; there
it  may be possible that the facial vein, or  even the external max-
illary vein has been raised up by the lymphatic tumor and  rendered
more superficial than usual.   Most frequently, however, these ves-
sels are situated rather behind and on the inner side  of  the posterior
extremity of the tumor.   It is sufficient to  say that in these cases,
the dissection of the parts should commence from above, or from be-
low, or at the anterior half of the degenerated ganglions. Being se-
cured  and  drawn  forwards and outwards by means of an erigne;
these tumors are afterwards disengaged from the bottom of the mylo-
hyoid fossa  by means of the finger  or the handle of the scalpel, as
much as by  the cuts of the bistoury.  If the  facial  artery should, as
frequently happens, be wounded, there  is no  cause to be greatly
alarmed. The ligature is to be applied immediately, or what is as well,
it is to be temporarily closed, by the finger of an assistant.  Were
we not prepared for this,  we might in fact, in a great number of in-
stances, suppose  that  we had opened it, when it is the secondary
branches only  which  enter into  the tumor at the  apex of the gan-
glions, that  have  been divided.   The disease sometimes  produces
such enlargement in these branches that we not unfrequently find
them to have acquired the  dimensions of a crow's  quill, and throw-
ing out blood with violence at the moment that they are divided by
the bistoury.  We may while dissecting  out these tumors be com-
pelled to penetrate as far posteriorly as the sides of the larynx and
in front of the carotid arteries.   I have frequently seen  pulsating
naked before the eyes of the operator, and at the bottom of the cav-
ity previously  occupied by the tumor, the lingual  artery on the inner
side, the internal carotid behind,  and the external maxillary without.
This cavity which at  first has something frightful in appearance and
which  could easily contain the fist, may be prolonged also as far as
the median line in front and the  os hyoides below.   M. P. Eve
(Southern Medical and Surgical Journal, January, 1838 ; and Gaz.
Med., 1838, p. 17)  penetrated in  this manner as far  as the outer side
of the tonsil to remove a tumor of half a pound in weight, and cured
his patient.  I assisted M. Vidal in a young  man  in  whom he re-
moved three degenerated ganglions which occupied one entire side
of the supra-hyoid region.  Unless  the tumor be uniform and small
in size we must not  attempt  to  close this  cavity by first intention.
Tamponing and the mode by second intention, offer an infinite deal
more of security and without materially retarding the cure.  It is to
be recollected, only that after the  first  eight or ten  days,  that is,
when, the balls of lint become no longer of any use, the upper lip of
the wound, drawn upon as it is by the border of the jaw, has such ten-
dency to be raised up towards the face, as to require some preventions.
It is then that a strip of adhesive  plaster, placed on the outside of and
along the lower border of the jaw, serves to retain it and crowd  it
downwards  and  prevent its  retroversion (renversement).    This
strip would  become  still more  advisable,  if in  place  of the usual
incision, we  had employed the semilunar  flap to lay bare the tumor
   vol. n.                        76 
602                    LYMPHATIC TUMORS.
By this kind of primitive secondary union we  are  protected  from
erysipelas and purulent collections, while we produce notwithstand-
ing, in the space of fifteen days  to a month, a  perfect cure, with a
cicatrix nearly linear.  This mode of extirpation, for which  no per-
son had given  the process when I pointed it out in the year 1825,
has now been performed a ^reat number of times successfully by
M. Begin at Strasbourg, (Malic Arch. Med. de Strasbourg, 1836,)
by M. Sedillot, (La Presse Med.,t. I., p. 139,) and by M. H. Larrey
at the Hospital of Val-de-Grace.  For myself, there is not a year,
that I have not had recourse  to  it, on from  ten  to fifteen patients ;
and I have not seen up to the present time any operation whose con-
sequences are less  serious.  Every thing  goes  to show that in this
region, the introduction of air into the veins is not to be apprehended,
notwithstanding some  facts which have  been related in favor of a
contrary opinion.   Unless therefore there  should be some particular
complication or counter-indication connected with the general consti-
tution of the patient, the extirpation of lymphatic tumors from the sub-
maxillary region, should be recognized in practice as a systematized
operation of surgery.
   D.  Tumors of  the Carotid Region.—After the mylo-hyoid de-
pression and  the carotid region,  the sterno-carotid groove is that on
which lymphatic tumors  are the most  frequently met with.   The
chain of ganglions which occupy this groove, is composed  of such
numerous glandules  (grains) that they are noticed on every part of
its length from the  supra-sternal fossa to the angle of the jaw.   They
are distributed, moreover, in such a manner, that some repose  directly
upon the anterior surface  of the vessels, while others lie entirely con-
cealed, either by the internal surface or by the posterior border of
the sterno-cleido-mastoid muscle.   I have, however, never found them
to be absolutely superficial, though I have sometimes met with them
all around the carotid artery or jugular vein, while  others were at
the same time prolonged under the posterior surface  of the pharynx
or oesophagus.   If in  this region the tumors  are numerous,  deep-
seated, and but little prominent, or should raise up the  sterno-mastoid
muscle, in place of projecting  towards the side of the neck or larynx,
it  is  better not to meddle with  them, or  to attack them only with
general remedies  and  local applications.   If, on the  contrary, they
present themselves under the  form of one or more movable lumps,
(bosselures,) making a projection between the sterno-mastoid muscle
and  the middle of the neck, and if their  totality constitutes a mass,
independent of the thyroid body, the carotid artery, or jugular vein,
without having any prolongation in  the  direction of the chest, it is
allowable and practicable to  undertake their extirpation.  Upon the
supposition that the tumor situated transversely,  and strangulated by
the sterno-mastoid  muscle should be bilobate, in such manner as to
present one  of its halves posteriorly, and the other  in front, there
would still be ground to attempt its removal, should the uniting bridle,
in other respects, be so thin as  to allow of our avoiding the neighboring
vessels  and nerves.   To  perform the operation, the  patient is to be
placed upon his back, taking care that his head is raised sufficiently high
upwards.   In this position the sterno-mastoid muscle being stretched
and thrown backwards, pushes the tumor forward, and in this manner 
NEW ELEMENTS OF OPERATIVE  SURGERY.
603
renders it  more superficial, while at the same time it gives it  a
greater degree of fixity.   The  surgeon making  his  incision  from
above  downwards, divides the  integuments  to  an  extent which
should  exceed the limits  of the tumor by  nearly  an inch.   As
soon as  the  front part of the tumor is  laid bare, he detaches the
lips of the  wound upon the outer and then upon the inner side.   It
is  at  this  moment  that he hooks his erigne  into it, in order that
an assistant may secure it, and hold  it aside while the dissection  is
being  proceeded with.  This dissection  has nothing about  it par-
ticularly difficult until  we  arrive near the bottom  of the  carotid
region; but setting out from there, the finger should always pre-
cede the point of  the bistoury, and no lamella of  tissue ought to be
cut without having been previously stretched by means of the fore-
finger.   By inclining the  extremity of the instrument towards the
ganglionic  surface, we avoid with certainty all the large vessels which
are situated  behind.   I have, moreover by adopting the mode  of
enucleation, several times  succeeded in detaching some more deeply
situated  lobules, which  were entangled behind the jugular  vein,  or
carotid artery, and  sometimes  between  those two vessels.  It  is,
moreover,  a  matter of little importance, whether  the  deep-seated
surface of  the tumor should be  isolated  from  above downwards,  or
from below upwards.   We must be prepared to find by this operation,
as has happened to me in quite a great number of cases, that we have
extensively denuded the carotid artery, the internal jugular vein, the
pneumo-gastric nerve, and the  great sympathetic.  It suffices  to re-
mark that  these organs might be interfered with, and that we must
be on  our  guard against wounding them.  [See case in our Vol.  II,
under the  head of the nerves, in which the pneumo-gastric imbedded
in a tumor recently removed by Dr. McClellan, of Philadelphia, had
to be completely divided, which, however, did not interfere with the
restoration of the patient. T.]  It was  in a  case of this kind that
M. Fouilloy (Ansiaux,  Clin. Chir., p. 238, 2d edit.) was compelled to
tie the carotid artery.   There is  every  reason to believe also, that
the tumor  successfully extirpated by M.  Voisin, (Gaz. Med., 1835, p.
447,) and  which obliged him to dissect upon the  carotid, was one of
the class of those of which I am speaking.  We  may conceive also,
that an opening into the  internal jugular vein,  would in  this part
endanger to a greater degree than in most other regions of the body,
the  introduction of air into the heart, and the fearful accidents
which are the consequence of it.  In a  young man in whom I had
removed one of these tumors on the right side of  the larynx, there
was heard at the moment of my dividing one of the anterior veins
of this region, near the jugular, a hissing and  gurgling sound,  which
at first gave me great uneasiness, the more so from the patient utter-
ing a piercing cry that he was dead !   There followed, however, no
serious symptom, and the consequences of the operation were ex-
ceedingly  simple.   I have already stated, (see Yol.  I.) that a woman
in whom I had been obliged to penetrate as far  as  to the posterior
 surface  of the pharynx,  was seized  to  an  extreme degree with the
 symptoms which indicate the entrance  of air into the veins,  at the
 moment when I had wounded the upper part  of the internal jugular.
 Without asserting that these facts are very conclusive in respect to the 
604
LYMPHATIC  TUMORS.
entrance of air  into the venous system; it  is proper,  nevertheless,
that we should not forget them, and that we should reflect upon the
circumstances which may produce them, when we have decided
upon the extirpation of lymphatic tumors in the carotid region.  When
some of the lobules of the tumor are situated at, and  project towards
the posterior border of the sterno-mastoid muscle, it is not uncommon
to see them have a tendency to move forwards, and conceal them-
selves to a certain extent  under the muscle, in proportion as we ex-
tirpate the  anterior lobes.   Their removal also, greatly embarrasses
the operation,  and admits  of the question, whether it would not  be
more advisable to  attack  them separately, by means of an incision,
independent of the first, and  before commencing the other part of
the operation.   Having in one case adopted this plan,  I found that
the rest of  the tumor, thus liberated from all kind  of adhesion poste-
riorly, advanced freely forward, and yielded readily to  the tractions
that it was afterwards necessary to make upon it.   In  case of still
greater complication, as for example, where  besides these two lobes,
anterior or posterior, the  tumor should  be exceedingly thick at  its
neck, I would not hesitate in order to lay it bare, to divide the sterno-
mastoid muscle, and in such  manner  as  to transform the entire
wound  into a large T incision, whose stem  should be  placed trans-
versely.  Here  also, more  than in the sub-maxillary region, the
dressing by second intention should have the preference over imme-
diate reunion.   The lamellar character of the tissues, the natural and
unavoidable mobility of many of them, and the  great number, or
the importance of the vessels which have suffered, do  not  allow in
such cases  of  our counting upon a free primitive agglutination; and
the  danger of  purulent  abscesses  in  the  direction of the chest,
either above or below, is too formidable  to incur  this  risk by at-
tempting to shut up the  wound by first intention.
  E.  Supra-Clavicular Tumors.—The  hollow, or species of cavity
which is noticed above the clavicle, also contains  lymphatic glands,
whose degeneration is  not uncommon,  and  which come under the
same considerations of pathology, therapeutics and operative surgery,
as the preceding.  Nor should i, as they are sarrounded with numerous
or important vessels and nerves, any more recommend their extirpa-
tion to be undertaken unless in a case of necessity ; the  more so, as it is
often difficult  to ascertain in the beginning, whether they are  con-
tinuous  or  not, by chains  of the same nature as far  as the axilla, or
in the direction of the chest.   A young lady who had one of these
tumors  upon the front,  and outside of the scalenus  anticus muscle,
was desirous of getting rid of it.  Before being enabled to complete
its removal, the surgeon, a celebrated practitioner at Paris, found that
it made a  prolongation  inwards, and that there was a  similar one
in front of the carotid vessels.  In his attempt to extirpate this  last,
he opened extensively into the internal jugular vein, near its junction
with the subclavian.  A copious hemorrhage followed  : the operation,
nevertheless, was finished, but symptoms of purulent infection, or
phlebitis, soon made their appearance,  and the  unfortunate  lady
perished on the eighth or ninth day, causing  to her afflicted relative
who was a physician, and  greatly attached to her, the most poignant
regrets.  I would, therefore, not extirpate lymphatic tumors in the 
NEW ELEMENTS OF OPERATIVE SURGERY.
605
supra-clavicular region, unless they were perfectly movable, isolated,
and without any ramification towards the anterior region of the neck,
or towards the axilla or thorax.  Another reason which would pre-
vent me from interfering with them except under these circumstances,
is this, that if the introduction of air into the veins is really danger-
ous any where, it ought to be so in  the supra-clavicular region more
than any where else.  Up to the present time, I have performed this
operation only  upon  five patients.  In three of them the tumor, which
did not exceed  in volume a large nut or small egg, was so well isola-
ted and movable that there was no serious difficulty to be surmounted.
The two others had  each a ganglionic mass, which was prolonged as
far as the  brachial  plexus, and subclavian vessels.   This dissection
was tedious, but no accident supervened, and the cure was completely
established.  The patient  should have the chin  slightly  raised up,
the head inclined towards the  sound side, and turned back, and the
shoulder of the  diseased side depressed, and also directed backwards.
The surgeon placed on  the same side, makes an incision  parallel to
the clavicle if the tumor exceeds the volume of an egg; and in the
contrary case,  parallel to  the axis  of the body.   In whatever way
made, this  incision should be  of sufficient extent not to embarrass the
consecutive steps of the  operation.   Supposing after the first incision
we should  be under the necessity of making another,  we would then
freely divide the upper  lip of the  wound in the first case, and the
outer or posterior lip in the other.   Perhaps, also, it would  be more
advisable, in lieu of these different modifications of the ordinary inci-
sion, to substitute a large semilunar flap, taking care  to turn its free
border  outwards  and  downwards.  The integuments being  now
held  aside or  turned  back, the surgeon  seizes the tumor with the
erigne, and hands it over to an intelligent assistant, that he may raise
up or incline the diseased mass according as it may be required during
the remainder  of the  operation.  The dissection  is  also to be per-
formed after the same  rules as in the preceding regions.  It is better
in commencing, to do this from above, then outwardly, than to begin
on its inner border or  inferior  portion, since the  internal  jugular or
subclavian vein lies on one or the other side of it..  Having ar-
rived at its deep-seated surface, we should isolate it after the same
rules  (dans le meme sens), and here still more than in any other re-
gion,  would there be occasion for strangulating its root completely
below it, if it should  appear to be too hazardous to detach it  up to its
termination by  means of the point of the bistoury, and that the finger
would not suffice for enucleating it.   This operation, which is ordina-
rily very painful, in consequence of the numerous branches of the
cervical  plexus, which are dispersed  throughout the whole extent of
the supra-clavicular  region, compels us also, in most cases, to divide
the external jugular vein ;  but this vessel  is of too little importance
to make us  hesitate  about  sacrificing it.   I Would not  hesitate,
then,  to divide it in the beginning,  and afterwards to  tie its upper
end and even  its lower, if I thought it could cause the least incon-
venience.  We should have to respect, also, and to tie  them should
they be  divided, the transverse cervical artery, the  supra-scapular,
the ascending cervical,  and even the inferior thyroid.   As to the dress-
ing, I would regard  it as exceedingly imprudent to wish to run .the 
606
LYMPHATIC  TUMORS.
risk of union by the  first intention.   In whatever way we may pro-
ceed, the internal surface of the flaps  or  lips of the wound  cannot
be applied with  the required accuracy against the bottom  of  the
solution of continuity.   Suppuration being thus rendered  unavoid-
able, and  having no issue, would expose to the risk of purulent  ab-
scesses and diffused inflammations, of which  it would be difficult to
arrest  the progress  or avert  the danger.   The  flat dressing  by
means  of  pliant balls   of lint, perforated linen and  plumasseaux,
secures us from these apprehensions, and does not perceptibly retard
the definitive cicatrization of the wound.
  Can  it be necessary now to add,  that  lymphatic  tumors may be
developed everywhere, where there naturally exist ganglions of the
same name, and  that everywhere also it would be advisable to attack
them by conforming ourselves to the rules established in the preced-
ing paragraphs ?  Until practice shall have acquired a certain exten-
sion on this point, it would be useless, as I  consider, after having laid
down the  general rules, to detain ourselves with the projection (sup-
position) and description of special processes.
  [Lymphatic Tumors or Lymphatic Cysts, those in fact called by
the French cold abscesses (abces froids),  have been treated success-
fully by Dr.  G. Capelletti,  of  Trieste, (Giornale per servire, &c,
January, 1842 ;  Arch.  Gen.  de Paris, 4e ser,. t. III., p. 346-347.) by
means of injections of nitrate of silver (2 to 3 grammes of the nitrate
to 500 grammes of water)  ; injecting  through punctures first made
in various places by the trochar in order first to evacuate the con-
tents of the tumor.   The tumor is  to be filled with the injection,
and  the action of the  latter aided by uniform and continued pres-
sure.
  One  of the most  remarkable and mysterious cases of a general
hypertrophied condition of all the lymphatic glands on the external
sub-cutaneous regions  of the body in an adult woman from one of
the provinces  of France, aged  38 and otherwise perfectly healthy,
occurred to the excellent author of this  work,  M. Velpeau, in  his
own  service  at  the  Hospital of La  Charite, at Paris,  during  the
year 1845.  These enlarged glands in the  only  account of them we
have yet met with (Annates de Therapeutique, Paris, April, 1845, in
Cormack's Lon. fy Edinb. Month. Journ., June, 1845, p. 459.) are,
it is  stated, found in this  woman in  masses,  as it were, or strung in
chaplets varying from the size of an almond to a hen's egg, in every
region externally where such glands exist, viz.: in the axilla, groins,
neck, elbows, legs and  trunk.  They roll under the finger, are with-
out pain or change of color on their surface.* They appeared  al-
most two  years  before without any  appreciable cause.   The wo-
man  had previously enjoyed excellent health ;  she is even now robust
and suffers nowhere, except  that the  tongue is a little white, and  the
digestive organs  are occasionally out  of  order.  She  says  she has
lost flesh, but she is still rather stout;  the  skin has a slightly yellow-
ish tint, but not approaching  to icterus ; she has perspired copiously
through the night for some time past.  No one of her family, so far
as she knows, has been affected in a similar way, and none of the in-
habitants of the country where  she resides have any thing similar.
Her  place of residence is well  aired,  and from her occupation  she 
              NEW  ELEMENTS  OF OPERATIVE SURGERY.          607

passed most of her time in the  open fields.  M. Velpeau  retained
her in his ward as a subject of  study;  she  was put on the extract
of walnuts for  nearly two months, but no favorable change occurred ;
the health of the patient seeming rather to decline.   This case seems
to call in question the  pathological accuracy of  the opinion that the
enlargement of  the sub-cutaneous  glands is necessarily connected
with a scrofulous temperament, and the  evolution of which temper-
ament, so far as these glands are implicated, generally takes place in
the early period of childhood.  In this woman nothing is found but
general hypertrophy of the glands; the serous membranes are in a
good  state, the osseous system exhibits  no alteration, and there are
no  knotty  cords  in the course  of the lymphatic vessels, as is the
case in some kinds of erysipelas.  It may  be termed a sort of gene-
ral ganglionitis; but it does not follow that it is true scrofula, since
there are none of its constitutional symptoms.   Nor is  there any
thing of cancerin this case, though  this  affection is by some thought
to have its origin  in chronic lymphitis. T.]
                        CHAPTER IV.

                NEUROMATIC TUMORS (Netiromes).

  Pathologists have frequently mentioned small tumors, usually sub-
cutaneous, the distinguishing feature of which is that of causing from
time to time, and upon the  slightest occasion, painful irradiations ex-
cessively acute, which yield to no remedy and are a source of tor-
ment to the patients.  These tumors,  which many persons  have
located in the nerves, with which however they must be disconnected,
if Dupuytren and M. Wood (Trans. Med. Chir. of Edinburgh, vol.
Ill,,  p. 317),  which M. Jaumes (These No. 266, Paris, 1828), ranges
among cancers, that  Boyer was desirous of considering as scirrhous,
which are bodies  sui generis, according to some others, and upon
which MM. Arronshon (These, Strasbourg, 1822),  Clerambeault
(Obs. de Med et de Chir., 1829), Wood, Descot (Affections locales
des nerfs, 1825,  p. 208 to p. 286), and Alexandre  (De tumor nerv.,
etc.,   Leyden, 1810),  have published interesting  observations, are
much more common  than would be imagined  according to  classical
authors.   Not having to decide in this place what may be their real
character, I will confine myself to saying that for the most part they
have been found on the track or in the substance itself of the nervous
cords,  and that  they have sometimes presented themselves to me
with the characters  of tuberculous masses,  and at others under the
aspect of tumors that were truly scirrhous or encephaloid in the
crude state ;  while in other cases it would  have been utterly impos-
sible  for me to have compared them to any other morbid production
or degenerate tissue.   It is incorrect to assert with Descot (Op. cit.,
p. 208,) that  their size varies from that of a grain of  wheat to that
of a  bean; for I have met with some whose  dimensions exeeeded
that  of the fist, and  we shall  see farther on that other observers 
608
NEUROMATIC  TUMORS.
have met with  similar examples.   It would be  more correct to say
that their volume varies from that of a grain of wheat to that of the
head of a new-born infant.  Descot, in his work (Ibid. p. 209,) which
was prepared in great  part under the dictation of Beclard, commits
another  error in  saying that these tumors are scarcely ever multi-
plied.  M. Wood, in fact, speaks of a patient who had three of them.
Siebold had  two of them above the  instep, and I counted nineteen
upon the same patient at  the hospital of La  Charite, in  1836.   In
giving to these  tumors the name of ganglions, under which Hippo-
crates and Galen appear to have designated them, and in the attempt
to distinguish them under  the name of nodatio  from tumors called
nodus, Jean  de Vigo  has but attempted  a  futile division; but at
the present time not  having it in our power to adopt any name to
the exclusion of others, they are still designated  under the title of
knots (noeuds) after Pare ; painful sub-cutaneous tumors as they are
called by the English practitioners  especially;  or neuromata (neu-
romes), or chondromata (chondromes), which  is the epithet used by
Odier,  and which has  been generally sanctioned by the  French
pathologists.  The accidents  they cause, the  excruciating (atroces)
pains they excite, and their usual resistance to every kind  of
remedy, induce most patients affected with these tumors to demand
of themselves to be relieved  from them by extirpation.  It is in fact
the only efficacious means that surgery has to oppose to them.   No
doubt that  by attacking them with caustic as  Siebold the father did
upon Siebold the son (Alexandre, Op. cit., p. 21) we may also some-
times succeed in curing them ; but the operation by this mode would
be longer, less certain and in reality manifestly  more painful.  Am-
putation of the part, which Louis (Encyclop. Method., partie Chir. t.
II., p. 442), Odier (Manuel de Med. Prat, cite a l'art.  Excision  des
Nerfs), and M. Warren (on Tumors, etc., p. 62), are still in  the
practice  of, would not be justifiable at the present time, unless by
means of its degeneration the tumor had effected a profound altera-
tion in  the  limb.   As to extirpation, it would always be easy and
simple, if it were true, as  the title of sub-cutaneous  tumors would
seem to indicate, that neuromas were always found immediately un-
derneath  the skin; but observation  has now  shown that  the deep-
seated  nerves as well  as the superficial, become  the seat of  these
tumors.   It  follows from this that the removal of neuromas  may
sometimes become a serious operation.  They have moreover been
encountered upon almost every region of the body.  Franco (Traite
des Hernies, p.  484.)  speaks of a woman who carried one for ten
years upon the tibia.   Another woman, mentioned  by Loyseau (Obs.
de Med. et de Chir., p. 56.) had one upon the inner part of the thigh,
and the same practitioner met with one in  another woman upon the
outer part of the same limb.  Whether the small nodule removed by
Pouteau  ((Euvres Posth., t.  I., p. 5.) was or was not a neuroma
rather than a simple modular  induration, it was  found  nevertheless,
in front of the malleolus at the place where the saphena is opened in
bleeding of the  foot.   M. A. Petit (Discours  sur  la douleur, p.  15,
an VII.) also relates that he  had met with them almost exclusively
upon the legs, though he had seen one also upon the fore-arm. In the
case mentioned  by Valsalva, as related by Morgagni, (De sedibus et 
NEW ELEMENTS  OF OPERATIVE SURGERY.
609
 causis morb., epist. 50,) the tumor was situated upon the malleolus.
 In the case  of Cheselden, (Anat. of the Human Body, p. 256, tab.
 28, fig 7,) it was seated in the ulnar nerve.  Petit (Mem.  de VAcad.
 de Chir., t. I., p. 90,) mentions another in which it  existed upon the
 arm.  In one of the female  patients of Camper (Demonstr. Anat.
 Path., lib. I., cap.  2.) it was upon the outside of the elbow ; and in
 another woman mentioned by the same author, upon the  front  part
 of the knee.  The patient amputated  by  M. Warren (on Tumors,
 fyc., p.  60) had one upon the  tibia below  the knee.  The tumor
 spoken  of by E.  Home, (Trans, for the Improvement  of Med. and
 Chir. Knowledge,  vol. II., p. 92,) and which was removed by Hun-
 ter, was also situated upon the arm: and in the patient of E. Home
 himself, the tumor  had  to be seized in the hollow of the axilla.   A.
 Dubois, (Spangenberg, Archives de Horn., t. V., p. 306,) in one case
 saw the neuroma in the neighborhood of the patella, and on the mid-
 dle of the arm in another.  The tumor  dissected by Hasselbach
 (Alexandre, p. 22) occupied the ulnar nerve, and that of Siebold (Ibid.
 p. 21) the  space between the two malleoli.  Neumann (see Siebold,
 1.1., p. 54) encountered one on the lower and middle part of the fore-
 arm.  One  of the  patients of Rieche, (Alexandre, op. cit.,) had  the
 tumor on the inner  part of the arm, and  the other  outside of  the
 condyle of the humerus. M. A. Cooper (Trans. Med. of Edinburgh,
 vol.  III., p.  640,)  and  M. Warren  (on Tumors, p.  63,)  have  met
 with them in the breast or below it.   Nicod (Descot, op. cit., p. 244,)
 mentions to have seen them  on  the chest, and M. Marjolin (Ibid., p.
 245,) on the scrotum.  In  the patient of Short, (Obs. de Med. t. IV.,
 art. 27,) the tumor was situated upon the thigh; while M. Warren,
 (on Tumors, fyc, p.  63,) saw one in a boy of sixteen years, below
 the great trochanter.  With respect to myself, I have met with them
 on the sole of the foot, on  the outer side and inner side of the leg, in
 front and on the inner and outer side of the thigh, twice even in  the
 depth of this limb,  on the right and left side of the thorax in two dif-
 ferent women, on  the right portion of the  epigastrium, near the
 wrist, and on many points  of the fore-arm ; in the body of the biceps
 muscle,  on the track of the musculo-cutaneous nerve, and in the
 depth of the carotid  region.   What I have observed, and which is
 in accordance with what is related by authors, proves, in contradic-
 tion to what Descot (op. cit., p. 210,) alleges, that these tumors are
 more frequent in adult or old age, than in children.  One of the wo-
 men whom I had an opportunity of examining was sixty years  of
 age and upwards; another  was  40,  a third 36, and the youngest
 21.  The same  has been  the case  with the men, who were 30,  40,
 and  50  years of age,  and even older.  If one of the  patients  of
Reiche was only  19, the  other was 44;  those of Morgagni  and
Petit were young  girls, and the  cases  of Camper, E. Home,  and
Louis were clearly women.  Nor were those of Dubois  and Hassel-
bach young subjects, while the  case of Neumann was  60 years of
age.   These details prove  moreover, that if M. Wood has met with
neuroma in women only,  this must be ascribed to accident only,
 since numbers of men have also been affected by it.   We  must add
that  cases  of neuroma  have  been noticed also by Bicet, Pearson,
 Broon, Newbigging, Swan,  Hall, Windsor, Laing, Walker, Hey,
  vol. ii.                       77 
610
NEUROMATIC  TUMORS.
 Simson. Gooch, Jacopi, Monteggia, Craigie, Mojon, Capel, De Haen,
 Leduc, J. Bell, W. Blizzard, Marandel, Beauchene, Richerand, and
 some others, all of which have been  collected by M. Wood in his
 Memoir (pages 324, 326, 329, 330, 334, 345, 350, 353, 354, 390) ;
 and by Descot in his  Monography (pages 252, 253, et seq.)  As
 to the efficacy of extirpation in neuromas, it is no longer at the pie-
 sent day allowable to call it in question.  The woman operated  upon
 by Franco had been for ten years in a perpetual torment.   The tu-
 mor, which was of the size of a  small nut, had scarcely been re-
 moved, when the suffering ceased forever.  In the two examples
 cited by Loyseau, the pain, which became excessive as soon as the
 patients began to get warm in bed, also disappeared immediately af-
 ter  the  operation, which  the surgeon believed he could  render
 more effectual by afterwards cauterizing the wound.  The same re-
 sult was obtained by Pouteau, though  in the case mentioned by this
 practitioner, the pains were so excessive as to  occasion convulsions
 in the  left side.  One of the most curious facts  of this kind is that of
 Short.  In fact, though epilepsy appears to  have sometimes  origin-
 ated from some small tumor of this nature, or  from a nervous  cica-
 trix, and that Lassus has been enabled to cite Hippocrates, Galen, Cel-
 sus, and Alexander of Tralles  in support of this, we find in none of
 these authors an example so conclusive as  that of the English  Phy-
 sician.  A woman affected with epilepsy for twelve years had up to
 that time had the paroxysms only once a month ; but they now be-
 gan to appear four or five times a day, and to continue for an hour or
 an hour and a half.  As they began always with a pain  at the lower
 and inner side of  the calf, Short examined the leg of the patient du-
 ring one of these  paroxysms.  Plunging in a  scalpel to about twc
 inches in depth, he felt a small body which he separated from the  mus-
 cles and excised.  It was a hard  cartilaginous mass, or sort of  gan-
 glion, of the size of a pea, situated upon a nerve which  the  surgeon
 divided with the  same stroke of the instrument.  The patient,  who
 was immediately relieved of her paroxysm, cried out that she was
 perfectly  well, and  never had an attack  afterwards.   The young
 girl mentioned by Morgagni, and in whom the pains were so acute
 that she would have cut off her foot herself had she not been pre-
 vented, was also very speedily cured by the removal  of the  tumor.
 The same occurred in the case of Petit, who also speaks of the in-
 tolerable pains.   In  the patient of Cheselden,  who experienced a
numbness only at certain times, but suffered acute pains upon the
least shock, the operation was no less fortunate; as it was also in the
two women operated upon by  Camper, the one treated  by Hunter;
and  the patients of Dubois, Siebold, M. Reiche, &c.  Surgeons of
the present day, therefore, who would decline an operation of this kind,
would  be censurable.  There is every reason to believe for example,
that a  patient who after  an amputation of the thigh, continued for
two years to suffer the most excruciating pains, which he referred to
the extremity of his foot, might have been relieved of his misery, if
the species of swelling or tumor which  had  formed above a  portion
of a branch of the sciatic nerve which had been included in the lig-
 ature of the vessels, could have possibly  been extirpated. (Portal,
Anat. Med., t. IV., p. 289.)   The  case, mentioned  by  Portal,  who 
              NEW  ELEMENTS OF  OPERATIVE SURGERY.          611

states that he saw the specimen at Montpellier  in  the  museum of
Lamorier, reminds  me of an  observation: those  nervous  sympa-
thetic pains, which occasionally persist for so long a time, and which
many who have been amputated refer to limbs which they no longer
have—are they not imputable to the fact that nervous filaments have
in reality been included in the ligature with the vessels ?  [See re-
marks on this subject in Vol. I., under Bleeding; and Vol. II., under
Nerves.~\

       Article I.—Extirpation  of  Neuromas  in  General.

   Neuromatic tumors, in relation to their cure by extirpation, present
three varieties.  Some are situated between the aponeuroses  and the
integuments,  and others are found under the aponeuroses at  a depth
which ordinarily corresponds with the track of the nerves.   If there
are some which seem to be continuous with the nervous cords, there
are others which appear to have no kind of connection with  this de-
scription of organs.

                 §  I.—Sub-Cutaneous Neuromas.

   Whether they be  continuous or not with the nervous  branches,
Eub-cutaneous neuromas  should, nevertheless, be extirpated nearly
in  the  same manner  in all  cases.    An  incision  of  sufficient
length  is first made  upon a  line with the  tumor  itself.   After
having thus divided the skin and cellular tissue, the surgeon  secures
the tumor with an erigne and causes it to be raised up by an assis-
tant while he isolates  its  sides.  With a stroke of the bistoury or
scissors, he  then immediately after detaches its  upper  portion,  then
the deep-seated surface, and then its lower extremity.   In this man-
ner he annihilates with the first cut of his bistoury, by separating the
nodule from its nervous centres, those painful irradiations sometimes
insupportable, which he would otherwise occasion before  having
terminated the operation.   Prudence would require that a layer of
cellulo-adipose tissue of sufficient thickness should be removed with
the neuroma.  Unless the tumor should have acquired an extreme
volume, that of a small melon for example, as in the patient ampu-
tated by Louis, or that of Ant. Dubois, the simple  incision ought to
be sufficient.  A neuroma which should equal the  size of a pullet's
egg, as in  the two  cases  reported by Reiche, would in almost all
cases exact nothing more.  As these  tumors  are usually sufficient
regular, their dissection generally is easy.   The tissues moreover by
which they are surrounded, being in  the normal state, are placed in
excellent conditions for immediate reunion.  It  is on such occasions
therefore, if ever, that we should  approximate as accurately as  pos-
sible the flaps or borders of the wound, and attempt  the cure  by first
intention.  Having a regular point d'appui or sort of barrier or  pro-
tecting  plane in the aponeuroses or  bones which are found under-
neath the integuments, the surgeon experiences no difficulty m effect-
ing the exact coaptation of the two opposite walls or lips of the solu-
tion of continuity.   If, however, these tumors should have required,
either in consequence of their volume, their degenerescence or some 
 612                   neuromatic tumors.

 anomaly in their form, the formation of numerous flaps, or a caver-
 nous wound,  we  must proceed  in the manner  mentioned in the
 article on Lymphatic tumors.  In other respects the wound which is
 made  by the extirpation of sub-cutaneous neuromas, is a simple
 wound, and is to be considered in no other point of view.

                  § II.—Deep-seated  Neuromas.

   Whenever it becomes necessary in order to reach the neuroma, to
 divide the  aponeuroses, the operation becomes  manifestly  more
 serious.  The limits of the tumor being  less perfectly ascertained,
 do not enable us at first to regulate the extent of the incisions with
 all the precision desirable.  To detach a sub-cutaneous neuroma we
 scarcely ever are in danger of wounding any important artery;
 some veins only can then embarrass the surgeon.  In subaponeu-
 rotic neuromas, on the contrary,  we have to guard against enormous
 vessels, and the same organs as in the case of lymphatic tumors.
 The incision of the integuments being  made, we again endeavor by
 means of the finger carried to the bottom of the opening, to identify
 the exact position and size of the tumor, in order, without arresting
 the operation, to enlarge  the external  wound should  it be deemed
 necessary.   Dividing afterwards the aponeurosis with  free cuts from
 without inwards, should there be neither large sized arteries, veins,
 or nerves in the neighborhood; but on the contrary, by puncture at
 first, and from within outwards,  and on a grooved sound, when we
 have to  proceed with caution; the surgeon then stops to  examine
 anew the precise seat of the neuroma.   While an assistant keeps the
 lips of the solution of continuity  properly held apart, he continues to
 divide the tissues with care, and layer by layer, until the tumor is laid
 bare.  He  then secures  it with  a hook and causes it to be drawn
 upon by a  second assistant, in order to facilitate him in isolating its
 two  sides either by dissection or enucleation.  Before separating it
 above or below, it is necessary  to know if it belongs to a small or
 large nerve.  In the first case, in fact, there is no necessity of our
 having  recourse  to  a minute dissection in order to  detach it, and
 to isolate it from the nervous filaments which surround it.   We may
 without danger cut freely and completely through its two extremities,
 since the interruption  of the functions of such nervous filaments,
 cannot create any very great degree  of disturbance  in the uses of
 the part which sustains  them.  If on the contrary the nerve is im-
 portant and voluminous, we should endeavor, unless the thing should
 seem wholly impossible, to disengage it from the  tumor and to dis-
 sect and isolate from it the filaments sometimes dispersed through it,
 (eparpillees,) and  do every thing in fact to preserve  its continuity
 while removing the neuroma.  If, however, as has happened in a great
 number of cases, the nerve and the tumor are perfectly confounded
 together, we should decide upon removing the part degenerated,
 taking care to commence the section at the upper part of the tumoi
 in order that the remainder of the operation may not be made  more
 painful.  In this manner it has been found practicable to remove one
 or two inches of the ulnar, radial or median nerve, without any very
•serious accidents, or permanent paralysis  resulting  therefrom.   The 
NEW ELEMENTS OF OPERATIVE SURGERY.          613
tumor being removed, whatever be the process, we must proceed to
the ligature or torsion of the arteries, the arrestation  of the hemor-
rhage by the known means, and the treatment of the wound in the
manner described under operations in general;  not forgetting that
even under  these circumstances the attempt at  immediate reunion
presents  numerous chances of success.   Nevertheless  as  we have
here the supple and lamellar cellular tissue which separates the mus-
cles, to transport inflammation and suppuration to distant points, we
should  not  be too anxious for the immediate closure  of the wound,
when we find it impracticable to keep the different portions of it in
the most exact coaptation possible.

     Article II.—Extirpation of Neuromas in Particular.

                  § I.—Superficial Neuromas.

   Whatever be the region in which they exist, sub-cutaneous neuro-
matic tumors are to  be extirpated by a  process which is the same
every where, and for which the rules above given will be found suf-
ficient.
   A. At the  sole of the  Foot.—The  limb  being  flexed  and  turned
upon its  outer side, I made an  incision opposite  the neuroma of an
inch in length and parallel to the axis of the limb; having secured
this tumor with an erigne, I glided underneath it the point of a straight
bistoury, and readily separated  it from the neighboring tissues, first
behind and then in front.  No arterial branch being  opened, I was
enabled to close the wound immediately, and to keep it thus united
by a circular strip of adhesive plaster. The cure was accomplished
at the end of a week.
   B. On the internal malleolus, and on  the whole  antero-internal
side of the leg we are to proceed, and would succeed in the same
manner.
   C. On the knee and  in the neighborhood of the patella the limb
should be extended or flexed, according as the tumor  is more or less
movable; but we must not turn it upon  its outer side.  After hav-
ing laid  bare and removed the tumor  and united the wound, the
limb should be placed also at the ham in a state of moderate flexion
upon a pillow or large cushion.
   D. For the anterior, inner, or outer side  of the thigh, we should
proceed in the  same manner, without any necessity of more serious
precautions after the operation.  If the tumor was situated upon the
outer or posterior region either  of the  leg or thigh,  the surgeon
would  find some advantage in making his patient lie  upon his belly.
Nevertheless the incision of the skin, the  excision of the  neuroma,
and the  dressing, would be as in the preceding  cases; and for the
rest we should take care not to let the limb press upon the diseased
region.                                                   ,   -
   E. Neuromas of the hand or fore-arm  are to be  removed  atter
the same rules.   In all cases the limb should be  placed so that the
tumor should present itself in front of the operator, and in all cases
also the wound could be united by means of strips of adhesive plaster
or any other  bandage.  In the case of Neumann the tumor which had 
014                   neuromatic tumors.

existed for more than thirty years, was situated upon the lower and
middle part of the fore-arm.  After having divided the skin, it be-
came necessary to tie several arterial branches, though the neuroma
was only the size of a pea, and  appeared to occupy a branch of the
cutaneous nerve.  It is  difficult, however, to  understand why Neu-
mann was  fearful of proceeding any farther, or that he should have
thought it advisable to confine  himself to narcotics  and  afterwards
caustics to complete the operation.  I have already said moreover,
that the patient, who was seventy years of age, died of apoplexy be-
fore being cured of his wound.  If, as  in  one  of the cases of Cam-
per, the neuroma should be situated  outside of the elbow, and on
the track of some of the branches of the musculo-cutaneous nerve,
we should after having separated the limb from the trunk, keep  it in
a state of moderate extension during the whole course of the opera-
tion.  It is important here  that we should guard against the synovial
capsule, and not penetrate deeper than  is indispensably necessary in
the direction of the articulation.
  F. Upon the continuity of the arm, we should  also have to  turn
the limb inwards or outwards upon its axis, according as the neuroma
was placed more on one side than the other, and we should also have
to guard against wounding the basilic or cephalic veins and the  sub-
aponeurotic organs.  The thoracic limbs moreover,  are those in which
the dressing is most simple, and where the wound would  have the
best chance of cicatrizing by the first intention.

                 §  II.—Deep-seated  Neuromas.
  A.  The Thoracic Limbs.—The  extirpation  of deep-seated neuro-
matic tumors has already been performed upon a great number of dif-
ferent regions.
  I. I do not know if it has been employed upon  the fore-arm.  In
all such cases we should have to divide the integuments  and  isolate
the tumor in this region, in the  same way as for cutting down upon
the radial, ulnar or median nerve.  In the case of Cheselden  it is
clearly perceived that the tumor occupied the middle of the ulnar
nerve; but  it is not mentioned if it  was in  the  arm or fore-arm.
Having separated the muscles apart and isolated the tumor, it would
be necessary to detach the nerve from  the artery before  completing
its  double  section.   The  median nerve being nearly at  an equal
distance from the two principal  arteries of this region, might, so far
as regards  any immediate danger  in  the manipulation,  be excised
with less apprehension.
   II.  In the arm the neuroma may occupy the radial, ulnar or median
nerve, or the cutaneous nerves,  a.  E.  Home says that the tumor ex-
tirpated by Hunter, in a woman  aged 20 years, was situated upon the
musculo-cutaneous nerve ;  having laid  bare the neuroma by a proper
incision, he excised about three inches of the nerve.   The loss of sen-
sibility, which at first showed  itself in the thumb and forefinger, did
not long continue, and the  patient was  completely re-established.  A
Woman,«ipon whom I operated in 1838 at the hospital of La Charite,
had at the middle of the left arm  in the  substance of the biceps, a
small ovoid  movable tumor with  painful irradiations,  which had
existed  for  a great number of years,  and produced the symptoms 
NEW ELEMENTS  OF OPERATIVE SURGERY.
615
which usually attend neuromas.  Having separated the arm from the
trunk, I made an incision of two inches between the lower extremity
of the deltoid and the origin of the supinator longus muscle.  Dividing
the tissues, layer by layer, I arrived at the fibres of the biceps muscle
without touching the cephalic vein, and then  reached the tumor,
which I secured with an erigne, and then excised.  The acute pain
which the woman experienced every time I touched this  neuroma,
the greyish looking stem which was prolonged above and below, and
the numbness of the entire outer side of the fore-arm afer the opera-
tion, sufficiently prove, as I think, that the tumor in reality occupied
the trunk of  the musculo-cutaneous nerve.   The wound was united
by  first intention, and except  for a diffused erysipelas which spread
from  an issue which the woman  carried in her  arm, the cure would
have been completed at the expiration of a week.
  b. Upon the  large nervous trunks the operation might be much
more dangerous.  The  neuroma  of the size of a melon, which ac-
cording to Dubois, occupied the median nerve  of the right arm, re-
quired the crucial incision, and the excision of a considerable portion
of the nerve.   The cure was accomplished, but  the  sides of the
fingers remained insensible.   It does not appear that Petit was under
the necessity of making use of a complex incision for the  removal
of that  neuromatic tumor of the size of a pullet's egg, which had
existed for seven years in the arm of  a young  girl.  As it was sus-
pended, according to the author, to a small nervous cord, we may
consider that it was situated upon one of the cutaneous  nerves.
  c. In the first case of Reiche, it was evidently situated upon the
ulnar nerve.   The surgeon, after  having taken up  a fold of the in-
teguments, divided them to the extent of five inches.  The dissection
of the tumor obliged him to divide many small branches of arteries,
without, however, occasioning any serious hemorrhage.  It became
necessary to  remove with it  about four  inches of the  nerve.  The
pains, which were very violent  at first,  afterwards diminished and
changed in their nature, and were soon followed by a numbness in the
hand. _ The wound was cicatrized in fifteen days, and nothing ensued
from  the  operation but a slight degree  of insensibility in the little
fieger.  We  should operate here, therefore, in the  same way as for
cutting  down to, and tying  the brachial artery, with this difference,
that we are guided by the tumor, and that while raising up this last
during the dissection, it. is generally easy to  reach  the nerve and to
excise it, by commencing in the direction towards its root.
  d. In the hollow of the axilla, neuromas may also have  their seat
over the aponeuroses.  E. Home, who had to cut down upon one of
this kind contiguous to the great axillary nerve, says, without designa-
ting the process  he adopted, that he effected its excision, and that the
operation caused neither any great degree of pain, nor any other un-
pleasant symptom  as  its immediate consequence; but he adds, that
a violent inflammation soon supervened in the region occupied by the
tumor, and that it occasioned the death of the patient on the eighth
day.  The arm  in  these  cases must  be held wide apart  from the
chest, and the tissues are to be divided after the rules laid  down for
a ligature  upon the axillary artery, rather than after those for the ex-
tirpation of lymphatic tumors.  Neuromas, in fact, will be found to 
616                   NEUROMATIC TUMORS.
be resting against the root of the arm, instead of tending, like degene-
rate lymphatic ganglions,  to  glue themselves against  the  thoracic
wall of  the  axilla.   The best means of avoiding the  misfortune
mentioned  by Home, in  such  cases, would  be to dress the wound
with small  balls of lint, in place of immediately attempting its union
by first intention.
  B. The Abdominal Limb.—I.  Every thing goes to show that there
is no deep-seated nerve of the leg which is exempt from neuromas.
Up to the present time, however, the  extirpation of these tumors at
the foot  and  upon the whole length of the abdominal  member, has
scarcely  been spoken of except under  the  title of sub-cutaneous
tumors.  The case of Short is  almost the  only one which would
appear to coincide  with a profound neuroma.  Here no doubt can
exist, for the  author says he plunged  in  his scalpel to  the depth of
about two inches, and that he was obliged to separate  the tumor
from the muscles before extracting it with the forceps.   We should
have to be guided, moreover, by the  precise  situation  of the tumor
and the known track of the  nerves of this region.
  II. It is not known whether the neuromas of the knee or in the neigh-
borhood  of the patella, extirpated by  Camper and A. Dubois, were
rather  sub-aponeurotic than sub-cutaneous; but the natural arrange-
ment of the tissues of this region, induces rather to the opinion that
they were in  reality superficial tumors.
  III. Though it might appear that the tumors extracted from the thigh
by Loyseau, were situated between the aponeurosis and  integuments,
it is at least certain that  in one of the patients whom I have already
spoken of, and who had them  on different parts of the body, the dis-
ease had its seat underneath (au-dessous)  the fascia lata.
  IV. This patient having died, we had an opportunity of practising
upon the dead body the operation that might  have been  performed
upon him during life.  One of the tumors which was situated upon
the antero-external lower third  of the thigh, was laid bare by an
incision two  and a half inches  long.  Having  reached  below the
aponeurosis, I jiad still to isolate  it from among  the fibres of the tri-
ceps muscle.   There it appeared to form an immense spindle-shaped
ganglion, of  the  size of a nut,  upon the continuity of one of ths
branches of the crural nerve.  A similar  tumor located in the upper
third of  the limb, was situated underneath the  sartorius, and would
have rendered necessary the division of a part of this muscle.
  V. The sciatic nerve.   The most remarkable neuroma I have seen,
was situated upon  the  posterior part of the  thigh, at four fingers'
breadth below the breech.   The tumor, which had  existed for many
years, and had developed itself without any known cause, in a lady
aged thirty years and upwards, was of the size of the head of a new-
born infant.  Assisted by M. Gorsse, the  physician of the patient, I
extirpated it in the following manner.   Being placed upon her belly,
with a pillow under  the trunk,  Mile. H. was held  in  this  position,
while the leg was kept extended  by other assistants.  Having made
an incision in the integuments parallel to the axis of the trunk, and
six  inches  in length and commencing at the outer border of the
ischium, I had to cut through the sub-cutaneous fascia, the fascia lata
and sundry adipose layers  before perceiving the tumor.  Having 
NEW ELEMBVTS OF OPERATIVE  SURGERY.
617
isolated it on its posterior surface, it was secured with a hook and
drawn backwards, while I detached it on its inner and outer side by
means of a careful and delicate dissection.   I  disengaged it in this
manner  from the long  portion of the biceps, which  was  pushed
inwards with the semi-tendinosus and semi-membranosus.  It  was
not until then that it became evident that the sciatic nerve supported
the whole of this mass, of which it formed as it were the axis.   The
fear of inducing gangrene, or at  least an incurable paralysis of the
limb, by excising a nerve of this volume, caused me to hesitate an
instant.   Seeing however that the tumor was perfectly  free at the
middle of the great cellular track, (trainee,) which extends from the
ischium to the ham, I asked myself the question, if it might not be
possible to divest it of the nervous filaments and  to remove it alone.
After having therefore detached its whole  circumference and dis-
sected the nerve, first above  and then below, as for an anatomical
preparation, I recognized that there was nearly a third of it intact,
or as it were enchased merely upon the anterior plane of the neuroma.
The two other thirds of its cords were dispersed in  the  manner of
the grill-work (rayons) of a  cage or oyster pannier upon the  two
sides of the tumor.   Encouraged by the extreme  fortitude of the
patient, I proceeded to isolate each one of those  filaments by means
of the bistoury, and succeeded in disengaging nearly the whole of
them while pushing them  towards their common  centre in front.
The neuroma thus removed left a cavity as large as the two fists,
which I first filled up with small balls of lint, and then treated by
secondary immediate reunion.  The cicatrization of the wound ap-
peared complete at the end  of five weeks.  An evident numbness
and partial paralysis of the outer half of the foot and of the neighbor-
hood of the corresponding malleolus, were the only accidents calcu-
culated to give me any uneasiness during the first week or two after
this serious operation; but these symptoms subsided by  degrees, and
the cure, which was completed at the expiration of three months,
remained permanent.  It was in 1834 that  the operation was  per-
formed.  Mademoiselle H. married, and at the  present time (Decem-
ber, 1838) is in the enjoyment of perfect health.  Messrs. Roux and
Chelius have each published a similar case, except that in the patient
of M. Roux the  tumor, which was of a cancerous nature, reappeared
and terminated in death.
  VI. I am not aware that other physicians have spoken of neuromas
in the neck ; for myself, however,  I have every  reason to believe  that
the tumor mentioned by M. Berard, senior, and which I  have spoken
of under the article on Excision of the nerves,  was one of this kind.
I will add that in a dead body dissected by M. A.  Thierry, I ascer-
tained the existence of a spindle-shaped tumor  of the size of a small
pullet's egg, and of  a reddish tint, on the middle of the continuity of
the great sympathetic nerve at its cervical portion.  It seemed as if
this tumor might be a nervous ganglion excessively hypertrophied,
and as it was  no more adherent  than normal  nervous  ganglions, it
would  have been evidently practicable to have cut down upon  and
extracted  it, had it during life caused  any serious symptoms.   Pro-
ceeding in the same manner as for a ligature upon the carotid artery,
it might have been  removed without  difficultv;  and I do not think
  vol. ii.                        78 
618
NEUROMATIC  TUMORS.
the excision of a portion of the  great sympathetic in a case of this
kind, could be followed by any very formidable disturbance in the
animal economy.
   VII.  Upon the thorax I have in four instances removed neuroma-
tic tumors.  Madame de T. for many years suffered neuralgic pains
in the right side of her chest.   A little tumor of the size and form of
an almond, which had been noticed by M.  Rayer, and which ap-
peared to be the source of her sufferings, was situated between the 10th
and 11th ribs, precisely at the place where the cincture of the gown
is  worn.  To reach it, I was obliged by means of an incision of two
inches, to divide the integuments, the sub-cutaneous fascia, some fibres
of the latissimus dorsi and obliquus externus  muscle, and afterwards
the fibro-cellular layer which covers the external intercostals. Being
hooked fast to and raised up by an erigne, the tumor  caused a vio-
lent paroxysm of pain, and as it prolonged itself in front and back-
wards by a yellowish stem, it presented  to  me completely the ap-
pearance of a nervous ganglion.  Having excised it  posteriorly  and
then in front, I found there was no artery to tie, and drew the lips of
the wound together by two strips of adhesive plaster, which I cover-
ed with a pledget of lint and body bandage.  Some slight suppura-
tion ensued, but the cure was nevertheless completed  after the expi-
ration of a short time.  In the following  year, that is, in the month
of March, 1837, I was obliged to subject Madame de T. to a similar
operation.  A new neuroma had  shown itself at an inch below  and
behind the first;  the operation and its results  were the same, and the
patient has, up to the present time,  (December, 1838,) remained free
from any new trouble from this  source.  A  young girl of 19 to 20
years of age, whom I .operated upon at the hospital of La Charite* in
1836, had at the same place, but upon the left side, a trilobate tumor
of the size of a large nut, and which also presented the characters of
neuroma.  In this case an incision of three inches was required,  and
the tumor was almost entirely sub-cutaneous.  Having dissected  and
removed it, I was nevertheless not enabled to close  the wound by
first intention, and the cure was not effected  until at  the expiration
of five weeks.  Another neuroma which I also met with on  the tho-
rax of a woman, was likewise situated at the  same height.  Are the
constriction or frictions made there by the cord of the petticoat or the
cincture of the frock, the cause in these cases 1  The case of the man
which I have already several times alluded to, and who had so many
neuromas dispersed over the chest and limbs, had one also between the
cartilaginous border of the tenth rib and the umbilical region.  In or-
der not to be incommoded by the natural depression of the side, I laid
bare the tumor in this case by means of a transverse incision slightly
convex below. It became necessary therefore to cut through the skin,
sub-cutaneous fascia and externus oblique muscle, for the tumor was
situated quite deep.   The extirpation was not in other respects  diffi-
cult, but it required a ligature upon two arterial branches and left  a
sufficiently extensive cavity underneath the integuments.  This pa-
tient, though cured of the operation, having a cancerous affection of
the bones of the  left wrist, underwent  at  a later period amputation
of the fore-arm, which terminated in death at the expiration of twenty 
NEW ELEMENTS OF OPERATIVE SURGERY.
619
days in consequence of numerous metastatic abscesses in the viscera
and an enormous effusion in the pleura.
  VIII. Recapitulation.—Neuromas as we thus perceive being ordi-
narily uniform and perfectly isolated in the midst of the other tissues,
may be extirpated without great difficulty in almost all patients.  If
they occupy small nerves it would be a useless precaution to endea-
vor to  detach them from these, rather than to excise  the nerve and
the tumor at the same stroke.   In the contrary case and especially if
the sciatic nerve were involved, we should do our utmost to detach
the nervous filaments from it, at least in part, as I succeeded  in doing
in the case mentioned farther back.   If this  separation were utterly
impossible and the accidents caused by the neuroma were really seri-
ous, we should still finish the operation, at the risk  of interrupting the
continuity of a  large nerve.  The facts which  I have related under
the article on Excision of nerves, and those which have been con-
sidered in  this  chapter,  prove  that the consequences of  such an
operation rarely compromise the life, that they do not always alter
the functions of the limb to an incurable extent,  and that very fre-
quently in fact  the phenomena of sensation and  motion which had
been believed to be permanently destroyed,  are ultimately  more or
less perfectly re-established.
                         CHAPTER V.

    LIPOMAS, OR FATTY (Graisseuses) TUMORS OR WENS (Loupes).

   Ever since surgeons, aided by the light of analysis, have sought
to distinguish tumors rather by their nature than their form, the word
wen (loupe) which was employed at first to designate all  tumors, is
scarcely ever used any longer except for  such as are composed en-
tirely of fat, which are the only  ones recognized at the present time
under  the  name of lipoma (lipome).  After the example of some
modern pathologists, therefore,  I  would  understand by  the word
loupe or lipoma, which was invented by Littre (Hist, de VAcad. des
Sc, 1709), tumors constituted of pure or degenerate fat.   This  spe-
cies of disease which belongs to the class of hypertrophies, involves
no danger in itself, and in reality incommodes only by its volume or
weight, or the deformity it produces.  Nevertheless lipomas appear to
me to be susceptible of many kinds of transformation or decomposition.
It is not impossible perhaps that they may undergo even cancerous
degeneration ; the putrescent  transmutation (la fonte putride), how-
ever, is one of their most usual terminations.  As on the other hand,
however, these tumors scarcely ever disappear by resolution, and as
their augmentation has no  determinate limit, surgery must necessa-
rily interpose its  aid and devise means of disembarrassing patients of
them.  The remedies adapted to them are  reduced to a small num-
ber, and topical  applications of whatever description  are  devoid of
efficacy.   General remedies would be more dangerous than useful. 
620
LIPOMAS, OR FATTY  TUMORS OR  WENS.
There is nothing in fact  in such cases, if we wish to do any thing
effectual, but the mechanical or chemical destruction  of the tumor
that can be resorted to; so that the entire therapeutic  of lipomas
definitively resolves itself into this principle : that is, to  destroy them
by caustics, the  ligature or the cutting instrument, or to do nothing
at all.   So long  as the lipoma possesses little volume, is imperfectly
defined, or scarcely causes any inconvenience, or is deeply situated,
we  may, if there is reason to believe that its increase  will not ulti-
mately render its destruction more  dangerous, wait and do nothing,
or confine ourselves to some hygienic precautions.  On the contrary,
whenever the lipoma is superficial, well-defined and easily accessible
to an operation, it is much better to attack them at once than to tem-
porize.  Though it  should even be unfavorably situated, we ought to
advise the patient to  get  rid of it in good season, inasmuch as the
operation, the longer  it is delayed, since  it must ultimately  become
indispensable, presents so much the less chance of success, in pro-
portion as the tumor is of older date or more voluminous.   On this
point I will take  the liberty of making a remark.
  Fatty tumors are far from being situated  always in the sub-cuta-
neous tissue, as most modern pathologists maintain.  Without men-
tioning those which are  seen in the chest, abdomen and pelvis, they
are  sufficiently often met with also, underneath the aponeuroses and
even in the  central  portion of  the limbs.   It is easy to comprehend
also  that lipomas may exist wherever the adipose cells are naturally
intermingled with the  other tissues ; so that we ought to have reason
to be astonished  rather at their absence than  their presence between
the  muscular layers and bundles (faisceaux).  There are, therefore,
under this point of view, two classes of lipomas :  the sub-cutaneous
or superficial, and the sub-aponeurotic or deep-seated, in the same
way also as there are  two  kinds of neuromas  and two orders of lym-
phatic tumors.   In  respect to regions  for which  they have a predi-
lection, it would be difficult to specify them; for fatty  tumors have
been observed upon  almost every part of the body.   I  have met
with them on the supra-hyoid region, on the cheeks and forehead and
in the supra-clavicular region, upon the shoulder, at the middle of the
arm, on the anterior border of the axilla,  in front of the sternum or
abdomen, at  the nape, on  the back, in the fold of the groin, at the
perineum and upon the  thighs  and legs.  Dupuytren (Journ. Hebd.
Universel, t. IV., p.  28.) speaks of a lipoma which occupied the lum-
bar region.   Dorsey (Elements of Surgery &c, Journ. des Progres
t. IX., p.  281.) mentions the case of  a lipoma which was situated
upon the dorsal region, where I have also seen them in two instances.
In the patient of M.  Graefe (Gaz.  Med., 1835,  p. 169.)  the tumor
was  situated  between the  muscles of the abdomen; and below the
clavicle in the case of  M. Portulapi (Bulletin de Fgrussac,  t. I., p.
240.  The Lancet,  April,  1824, p. 24.)  In a patient  mentioned by
M. Taramelli, the lipoma extended from  the groin to the perineum
(Bull, de Ferussac,  t. XVI., p. 85.); while  that extirpated by M. Tail-
lefer (Gaz. Med., 1837, p. 93.) was situated in the dorsal region.  M.
Serre (Ibid., 1838,  p.  266.) has seen one at  the posterior region of
the neck and M. Syme  (Edinb. Med. and Surg. Journ., vol. 137, p.
381.) met with a curious example of one  in the hollow of the axilla. 
NEW ELEMENTS OF OPERATIVE SURGERY.
621
Thus, as I shall  describe farther  on, I have  encountered enormous
fatty tumors in the posterior region and depth of the thigh, upon the
acromion, on the arm, at the side, under the axilla, &c.; so that there
is nothing more variable than  lipomatous  tumors,  both  as regards
their form,  depth or volume, or the region where they are situated.
We may consult on this subject,  Chopart, Louis, M. S. Cooper, Ali-
bert and M. Pautrier (These No. 6, Paris, 1834.)  There is scarcely
any other mode of curing lipomas except by the ligature or extirpa-
tion.   Though the red-hot iron or caustics, properly so called, might
be applied without any very great danger to sub-cutaneous lipomas,
it would be a different  case with  those that  are deep-seated.  It is
moreover a  kind of remedy which is not suitable to lipomas that are
greatly developed, and one which in no case deserves the preference
over the two other operations which I have just mentioned.
  The ligature  for lipomas, sometimes sufficient, rarely preferable,
and never indispensable, would not be conveniently  applicable but to
those which were pediculated or  not of large volume.   It should be
applied, moreover, with the same precautions and by the same pro-
cesses as for cutaneous and erectile tumors.   It would also be appli-
cable for  fatty tumors,  as  for  all others, to strangulate their roots
after having dissected them,  if there should be any great difficulty
experienced in avoiding the deep-seated vessels; but their extirpa-
tion is, in truth, the  best, and I might say, almost the only resource.
In cases of  sub-cutaneous lipoma, nothing is so simple as this opera-
tion.  If the tumor is but of little volume, a straight smooth (unique)
incision is first made  through the integuments, either a T, or crucial,
or semilunar, or a V, or L, or an  ellipse, or even stellated, if any advan-
tages are to result from it.  As the tumor contains no liquid, there is
no  danger  in wounding its tissue while cutting through the skin.
As these tumors do not usually contract any intimate adhesions with
the neighboring  tissues, they are generally easily isolated and  de-
tached from the surrounding cellular texture;  though even some
pelotons should be left behind, the  cure would not on that account be
materially interfered with ;  and as they receive no large-sized vessel,
they may be extirpated without  incurring the  risk of any  serious
hemorrhage.  The teguments with which they are surrounded being
scarcely ever diseased, may be preserved, reversed, and  then  ap-
proximated  in such manner, after the operation, as to be brought
into contact at  every point.   The bottom and  flaps of the  wound
being almost constantly composed of sound tissues, surprisingly facili-
tate all the efforts at immediate union  or piimitive agglutination.
  The extirpation of lipomas is thus  one of those operations which
are performed with  the  least repugnance,  and undertaken with the
greatest degree of confidence.  Nevertheless, it would be wrong to
decide  upon it on too slight grounds.  An adult man, strong,  and of
good constitution, and about fifty years of age, came to the hospital
of Saint Louis, in 1822, for the removal of a lipoma  of the size of the
two  fists,  and situated upon the  postero-superior part of the right
shoulder.  The  extirpation of  this tumor, which was performed by
M.  Richerand, presented at first  nothing peculiar.  But an erysipe-
las, which ultimately extended from the shoulder to the nape,  and
from the neck to the  cranium, soon put a period to  his life.  An old 
622           LIPOMAS, OR FATTY TUMORS OR  WENS.

man who had a lipoma, larger in volume than the head of an adult,
appended as it were  to  the posterior region of the neck, operated
upon by M. Roux,  in 1825, at the hospital of the Faculty, also per-
ished in a few days.   When,  therefore, we decide upon extirpating
lipomas, it is important to guard against the general consequences of
operations, in  the same way as in the extirpation of all other sorts
of tumors.


              Article I.—Sub-Cutaneous Lipomas.

  The arrangement of the incisions and the character of the operative
process, ought moreover, in general, to vary, according to the size,
form, and seat of the tumor.  M. Gensoul (Pautrier, These No. 6,
Paris, 1834,)  who, like MM.  Rust,  Walther  and  Textor (RusVs
Hand, der Chir., t. VI., p. 683), first plunges a long knife  through
the root of the tumor to separate it, first on one side and then on the
other, has the  advantage of terminating  the  operation rapidly; but
he runs the risk of sacrificing useful  integuments and cutting out
irregular flaps.  It is better therefore to make use of the bistoury, and
to divide the skin from without inwards, and  to prepare flaps of
suitable form and extent, to be well adapted to, and to cover over,
the wound accurately after  the removal of the tumor.   Fabre
(Observ.  de Chir.,  in-12, 1778)  after having laid them  bare by  a
longitudinal incision, and passed a ribbon  through their base in the
same direction, so as to enable him to draw them towards him, le-
commends that we should strangulate their root by a ligature, which
being tightened gradually during the dissection, has the advantage of
pushing out (chasser) the tumor and benumbing the pain; but it is
doubtful if this process, which is  not every where practicable, finds
many partisans at the present day. Complex incisions also are not
indispensable but for  lipomas  of a certain  size.  By means  of  a
straight incision I was enabled to remove from the root of the shoul-
der a lipoma of larger size than a  pullet's egg.   Nevertheless,  if the
integuments should  be too much attenuated, the tumor approach
the size of the fist or exceed it, or the skin  have undergone the least
degenerescence,  it would be preferable to have recourse  to complex
incisions, and even to sacrifice a portion of the integuments, rather
than rely upon a simple incision.

                              §1.

  A young girl  from  the country, whom  M. Rayer desired me to
operate upon in his wards, at La Charite, had in front and below the
left clavicle a trilobate  lipoma, of  the size  of the fist.  After having
first  made an incision through the tissues from  the neighborhood of
the sternum to the  root of the shoulder, I then divided the skin from
above downwards to the  extent of two inches, making thus two tri-
angular flaps, which were dissected and  reversed, the one outwards
and  the other inwards.  After the removal of the tumor these two
flaps were readily raised  up to the horizontal branch of  the T and
adapted to the bottom of the wound by means  of strips of adhesive
plaster. 
              NEW  ELEMENTS OF  OPERATIVE SURGERY.          623


   A man aged from 45 to 50 years, who had in the supra-clavicular
 depression a lipoma, which a charlatan, by means of different caus-
 tics, had transformed into a bleeding fungus, was received, in 1837,
 into the hospital of La Charite for the purpose of having his tumor
 removed.  The integuments  in this case being destroyed or degen-
 erated, I was obliged to surround the lipoma with two curved  in-
 cisions, and to remove with it an ellipse of the skin and of the cellulo-
 adipose  sub-cutaneous tissue.   An erysipelas supervened, but the
 patient, nevertheless, got well in a short time, as also did the young
 girl whom I have just spoken of.

                             § III.
   A woman  of more than usual embonpoint, had between the lowei
 border of the axilla and the side of the  thorax a badly-defined lump
 of the size of an egg, which caused  her, she said, acute  suffering.
 For the removal of this tumor, which was continuous  and without
 any line of demarcation, with the  general adipose tissue, I required,
 only a simple incision three inches in length, and parallel to the lower
 border of the pectoralis major near the chest.

                             § IV.
   Another woman from 35 to 36 years of age and whom M. Ribail
 had sent to me, had in front of the acromion and on the anterior
 surface of the right deltoid muscle, a lipoma, slightly flattened, lumpy
 (bossele), and of the volume  of a pullet's egg.   I was enabled to  re-
 move  this also by the straight incision, and the cure was not inter-
 fered with by any serious accident.  A  young girl who was sent to
 me by Doctor C. Piron, had a lipoma of the same size  as  the pre-
 ceding on the acromial side of the left  shoulder.   Here the adhesions
 were such that I considered it proper to lay it bare by means of a T
 incision, whose stem  was turned backwards and slightly outward
 This patient was also cured.

                             §  V.
   In the  case of the young  man mentioned farther back,  and who
 had a  slightly elongated fatty tumor of the size of the fist, below the
 lower  jaw, I  was equally obliged to recur to the  T incision ; nor did
 any inconvenience result  from  it, and  the patient soon recovered.
 There is  every  reason to believe, however, that a semilunar  inci-
 sion, with its  free border below, would have permitted me, by raising
 up by dissection the  flap of  soft parts thus circumscribed, to com-
 plete the operation with as much certainty and security.

                           § VI.
   Having to remove a lumpy (bosselee)  lipomatous tumor of the
size of a small egg, and of very irregular form, on the left side of the
waist of a woman who was admitted into the hospital of La Charite
in 1837, I limited  myself to a simple incision of three  inches in
length, and parallel to the direction of the neighboring  rib.  Imme-
diate  reunion  took  place, and the patient was well  in a few days,
and without any suppuration.   Recently, on the  18th of December, 
624
LIPOMAS,  OR FATTY TUMORS OR WENS.
1838, I removed a similar tumor which a student of medicine had
upon  his right side.  I made a vertical incision slightly convex pos-
teriorly, and in  five days after the  young  man was cured.  These
examples, I presume, are sufficient to point out the different modes
of extirpating superficial lipomas of moderate volume.

                          § VII.
   But if the tumor should be of a larger size, we must proceed in
another manner,  always, however, in conformity with the anatomi-
cal requirements  of the region, or of the part where they are situated.
If the ancients had given more details of their experience, we should
probably have  had evidence  of large-sized lipomas having  been
noticed by them.  That  horrible tumor of  the size of the head, and
which subsided  and increased,  and hung near the ear of a baker,
mentioned  by Felix Plater,  (Bonet,  Corps  de Med.,  t. III., p. 14,)
was  it not a fatty tumor ?  The one called steatomatous by Loti-
chius, (Bonet, t. IY., p.  322,) which was also of the size of a man's
head, and likewise situated behind the ear, evidently belonged to the
class  of lipomas.  We  see also by a case of M. Serre (Gaz. Med.,
1838, p. 266,) that fatty tumors upon the posterior region of the neck
may acquire an  enormous volume,  and a weight of at least seven
pounds.  The one I noticed in  1825, and which occupied  the same
region, was not  less voluminous  than  the  steatoma mentioned by
Lotichius or by F. Plater.  It appears that M. Miller even had extir-
pated one  of the weight  of twenty pounds, and which M. Warren
(Surg. Observ. on Tumors, p. 55,) was enabled to show entire to his
pupils.  Whatever may be the volume, lipomas of the posterior region,
of the neck or ears, are nevertheless extirpated nearly in the same man-
ner as superficial fatty tumors in general.  While almost constantly
sub-cutaneous in these  regions, they  have  scarcely much greater
breadth to their  root when very voluminous than when they are in
the condition of  small lipomas.   But ihe danger of their extirpation
lies in the depth of their root,  and in the thickness of their pedicle,
much more than in  the totality of their mass.   There is nothing  to
avoid there but the occipital artery or the auriculo-mastoidean above,
and some branches of the cervical arteries below.  The patient ope-
rated upon by M. Serre recovered perfectly well, and there is nothing
to induce  us to  think that the operation should be more dangerous
here than anywhere else.  A steatoma of the size of the head, which
was situated upon the occipital region of a child two and a half years
old, was removed by M. Seerig with perfect success, (Arch. Gen. de
Med., 3e serie, t. I., p. 115,)  while F. de Hilden, (Bonet, p. 83,)  on
the authority of a letter  of Screta, speaks also of a child two months
old, and which was  operated upon in this  manner  at the hospital
of Strasburg, for an enormous tumor which it had on its nape.

                            § VIII.
   The posterior  region of the  trunk  also has frequently presented
these enormous  lipomas.  The alleged  sarcoma of such prodigious
size which formed between the  shoulders in a woman mentioned  by
F. Plater,  (Bonet, t. III., p. 14,) and which was successfully removed,
was  probably a degenerate lipoma.   Dupuytren  removed one  of 
NEW ELEMENTS  OF OPERATIVE SURGERY.
625
 these, which was  partitioned  off with several  osseous plates, ana
 which was situated above the lumbar region, in a woman aged sixt)
 years.  Dorsey (Journ. des Progres, t, IX., p. 280,) states that he
 removed from the back of a man a lipoma which weighed twenty-five
 pounds.   The cure took place rapidly,  and the figure given by the
 author shows that this tumor held on to the trunk only by a sort of
 fold of  the  integuments.  A  friend of A.  Petit,  (Anat. Chir. de
 Palfin, t. II., p. 19,) by making use of the ligature, was enabled to
 separate from the dorsal region, a lipoma of twenty-eight pounds, and
 another of forty-eight pounds.  A patient, seen by Petit himself, had
 one upon the back, which must have weighed at least sixty pounds.
 A lipoma in the same region, of four pounds' weight, was since extir-
 pated  by M. Taillefer, (Gaz.  Med., 1837, p. 93,) who united the
 wound by suture, and  cured  his patient in fifteen days; so that en
 this plane of the trunk the extirpation of fatty tumors presents numer-
 ous chances of success, whatever may be their volume and weight.

            Article  II.—Sub-Aponeurotic Lipomas.

                       §1.
   Though lipomas may exist on the anterior region of the body, the
 remark, nevertheless, is true, that they are less frequently developed
 there than behind.  The largest sized one I have noticed on the ster-
 num did not exceed the dimensions of the fist.  There is no  proof to
 show that the tumor shaped like a ball,  of the size of a man's head,
 and which was situated in  the substance of the parietes  of the ab-
 domen, as mentioned by F. Plater (Bonet, t. III., p. 15), was a fatty
 tumor, rather than one of any other kind.

                              § II.
   That which M. Graefe (Gaz. Med., 1835, p. 169,) extirpated under
 the title of lipoma, and which was situated below the obliquus externus,
 was it  in reality a fatty tumor ?  It is readily conceivable, moreover,
 that the operation would not be sensibly more difficult in front of the
 chest than in the dorsal region.   But in the abdomen the case would
 be different  if the tumor really had its seat underneath the muscles
 or  aponeuroses.   The  risk of wounding the  epigastric,  internal
 mammary, lumbar or  intercostal arteries, would  here be among the
 least of the inconveniences to encounter from the operation.  It is
 the neighborhood of the peritoneum and the development of inflam-
 mations and of consecutive suppurations, which would then be the
 real sources of danger.

                             § III.
  The  same dangers would exist if the lipomas were  developed in
the sides or hypochondriac regions.   Lotichius (Bonet, t. IV, p. 321,)
states that he saw in the hypochondrium of a patient, a steatoma of
the size of the head, and  that the extirpation of this tumor undertaken
by a charlatan, was followed by death at the end of two days.  F.
Plater  (Ibid., t. III., p.  15,) also speaks of a tumor which had a strong
resemblance to the brain, and which existed in a  young man, on the
left side, near the back ; but no one had the courage to undertake ita
  vol.  n.                        79 
626           LIPOMAS, or fatty  tumors or  wens.

removal.  That case of a carcinoma, also, which occupied the right
hypochondrium, was of the size of a child's head, and extirpated with
success, and the history of which is given by Bartholin, (Bonet, t. IV,
p. 461,)  was it not, perhaps, a degenerated lipoma?  M.  Warren
(on Tumors,  p. 57,) has extirpated a lipomatous tumor  above  the
side and hypochondrium, and which was situated  between the ribs
and the lower portion of the serratus magnus.

                             § IV.

  Be that as it may, it is in the vicinity of the root  of the limbs and
upon the limbs themselves, or on the thorax, that the largest sized
lipomas have been noticed.   I do not speak here of the man whom
M.  Sedillot showed  me, and who had the whole circumference of his
neck surrounded by an enormous collar-shaped (bourrelet) indolent,
lumpy  [bosselCe] tumor, because I  am no more certain that this was
of a fatty character, than I am that that was in the  child mentioned
by M.  Warren, (Ibid.,  pi.  14, p. 428.)   Another patient  whom M.
Lebatard sent to me in 1838, had the whole of the neck imprisoned,
as it were, in enormous masses of a lipomatous  appearance, at  the
same time  that similar tumors existed in the axilla and  groins ; but
neither here, also, am I certain that they were legitimate lipomas.

                             § V.

  In the region of  the shoulder they have been noticed  above, in
front, behind and  outside.  The patient operated upon  successfully
in 1823, by M. Portulapi, had a lipoma of fifty-two pounds' weight,
the root of  which was situated in the subclavicular fossa.  Already
this surgeon, in 1814, had removed another lipoma weighing fourteen
pounds.  Dupuytren (Archiv. Gen. de Med., t.  V, p. 430,) removed
one  weighing six pounds, situated on  the  posterior part of  the
shoulder of a patient, who  recovered ; and  I  have, as  I  have said,
observed many others  of a certain size, which were situated also
upon the stump of the shoulder, properly so called.
  Though in the  supra-clavicular depression, lipomas rarely acquire
an extreme volume, they present here at least some particular features
in connection with their extirpation, and  dangers and  difficulties
which  it is  important not to be ignorant of.  Those which are sub-
cutaneous demand no further attention there than elsewhere.  It is
when they  are situated beneath  the  aponeurosis, that their diagnosis
and removal  may  be difficult.  The  softness of  the  neighboring
tissues, the void which the  hollow of  the axilla opens to them in
front and upon the outside, and the subscapular cavity behind, admit
of their being depressed and flattened with extreme facility, and  of
projecting or disappearing, so to speak, in the  manner of a conges-
tive abscess (abces par  congestion) or varicose tumors,  and of ap-
pearing soft like a hernia or abscess, or conveying the idea of a dis-
ease altogether different.   I had a woman for several months  at La
Charite in  1838, who carried a  lipoma of this kind in the left supra-
clavicular depression, and who in this manner became the subject of
very different opinions on the part of those who had  an opportunity
of  examining her.  Another patient whom I operated upon with M. 
NEW ELEMENTS OF OPERATIVE  SURGERY.
627
Maingault, had a tumor in the same region, whose size did not api
pear to exceed that of a  pullet's egg.   An incision extending from
the outer border  of the sterno-mastoid  muscle, to the apex of the
acromion in the  direction of the omo-hyoideus muscle, enabled  us,
after having divided through the integuments and aponeurosis, to lay
the tumor bare.   In order to isolate it, it became necessary to divide
many branches of the cervical plexus.   Having arrived below the
clavicle in  front, and upon the anterior  side of the border of the
scapula behind, we recognized that this tumor,  which seemed so ac-
curately defined at first, prolonged itself into the hollow of the ax-
illa, where it became necessary to penetrate the whole depth of my
finger to detach it by enucleation from  below upwards, from among
thenervous cords which  compose  the brachial plexus.  I removed
in this  manner, by a laborious and  tedious  dissection, a  completely
fatty mass of very irregular shape, and of the size of the fist.  We
left in its place an enormous cavity, which was filled with small balls
of lint, and which ultimately cicatrized so  perfectly and in so simple
a manner,  that the patient was  enabled   to return from  Paris  to
Rouen at the expiration of a month.

                             § VI.

   It is rare that  lipomas  acquire in the arm  or fore-arm, sufficient
size to require our attention to be called to  them as tumors  of a re-
markable character.  The thoracic limb properly so called, is in fact
one of the regions of the body where fatty tumors are the least fre-
quently observed.  Upon  the supposition that the species of steatoma
which  was situated underneath the  skin of the fore-arm in a patient
mentioned by M.  Galenzowski, (Journ. des Progres, t. VIII., p. 221,)
was a lipomatous mass, rather than a tumor of some other  description
—this at least would be an  exception ;  for I repeat  that  lipomas of
the upper extremity rarely exceed the size of an egg, and it would be
difficult if not impossible  to cite a  series of examples where they
originated  underneath  the  aponeurosis.   Fabre (Observ. de Chir.,
in-12, p. 51,) however gives a remarkable instance  of one.  The
tumor was  monstrous.   Extending  from the apex of the deltoid to
the external condyle of the  humerus, it was prolonged transversely
under  the  cephalic vein, then between the brachialis internus and
biceps  muscles, continuously with the external aponeurotic intersec-
tion of the arm.

                             §VII.

   The thigh on the contrary has often been invaded by this descrip-
tion of tumors, and it is there especially  that we encounter them of a
remarkable size.  M. Taramefli (Bulletin de Ferussac, t. XVL, p. 85)
states that he successfully  extirpated a lipoma weighing eight pounds,
which reached from the root of the fold of  the groin to the perineum.
A tumor which weighed eighteen pounds, and whose  root ascended
into the pelvis  at the  perineum, and which  M. Kohlrusch (Ibid.,
t. XII., p. 232) who describes it as a steatoma, succeeded in removing
so as to cure his patient, was evidently also of a lipomatous character.
M. Benedict, (Bull, de Ferussac, t. I., p. 239,) in  fact relates, that he 
628
LIPOMAS, OR  FATTY TUMORS  OR WENS.
extirpated from  the thigh a fatty tumor, caused by a fire-arm, and
in which he found some pieces of money !  In 1838, I removed from
the outer and lower part of the thigh, in a woman 40 years of age, a
fatty tumor of the  size of the head !   This lipoma, which had ex-
isted for years, and which might have been taken for an encephaloid
tumor, required an incision of ten inches in length in the direction of the
vastus externus  muscle,  and  another  much shorter, transversely in
the direction of the ham.   The dissection discovered to us, that this
mass, in place of  penetrating beneath the  aponeurosis in the ham, had
simply depressed the fascia lata in the direction of the gastrocnemii
muscles between  the tendons of the biceps and semi-tendinosus, and
then in the externa] supra-condyloid groove of the knee.   No  acci-
dent supervened, and the  cure, which has remained perfect up to the
present time, (January, 1838,) confirms what the dissection moreover
had authorized us to believe, that the tumor in question was a lipoma,
and not a cerebriform tumor.

                            § VIII.

  Also it is  the  same with lipomas  of the thigh and leg, as with
lipomas in every  other region  of the body; whatever may be their
volume, their extirpation is generally attended with but little danger
when they do not go beyond the depth of the sub-cutaneous layer.  It
is no longer so however, when their root  is situated  among the mus-
cles.  In such cases the patient cannot be relieved  of them but by
means of a dangerous operation; the more so as fatty tumors of this
description readily acquire a very large size.   There was one of this
kind at the hospital of Saint-Louis,  in 1837, the size of which was
equal to  two adult  heads.  In a  patient mentioned  by M.  Klein,
(Graefe und Walther Journ., vol. I. p.  112,) the lipoma reached from
the breech to the ham, and weighed near 28 pounds.  A woman who
was admitted into the hospital of La Charite  in  1836  had a similar
tumor in the same region; and in 1837 I  operated for another which
weighed 32 pounds in a man from  the country, who had also a lipo-
ma of the size of a child's head in  the  dorsal region.   Fatty tumors
therefore constitute in this region an extremely serious disease.   Ori-
ginating among the muscles, in the midst of pliant tissues, they ordi-
narily acquire great dimensions in  their vertical diameter, before
becoming prominent under the skin.  In  the woman I have spoken
of, the tumor, which descended down to between the gastrocnemii
muscles, and ascended nearly as high as the attachment of the gluteus
maximus, and had extensively separated the muscles and vessels, and
was eighteen inches long and eight to  ten in  thickness, nevertheless
weighed only from  eight to. nine  pounds.  The  one  I removed  in
1837, and which occupied precisely the same region, ascended about
five inches higher than the first and descended only to three or four
inches below the knee.  Though it weighed 32  pounds and was of
enormous volume, as the cast of it in wax which was deposited  in
the museum of the Faculty shows, yet it  had  not deformed the sub-
stance of the thigh to a much greater depth than that of which I have
just spoken.  The patient operated  upon by M. Klein and in whom the
tumor singularly resembled in its situation, nature and weight, that of 
NEW ELEMENTS OF OPERATIVE SURGERY.
629
the patient on whom I myself operated, died on the ninth  day, while
mine succumbed on the eighth.  The woman, on the contrary, whom I
have mentioned first, ultimately recovered ;  when at the end of three
months and after having experienced several  attacks of erysipelas,
she left the hospital, she continued  to walk for a  long  time in the
wards, and the wound had completely cicatrized.  When called upon
to such tumors, the surgeon ought to put to himself a number of ques-
tions.   Knowing that the patient cannot be relieved of the difficulty
without endangering loss of life, he ought first  to ask himself if it is
proper to meddle with the case.  Should the tumor incommode only
by its weight and volume, and had not undergone any degeneration,
and had developed itself very slowly and made no  further progress,
perhaps it would be more prudent to respect it especially in a person
in advanced age or dyspeptic (cacochyme.)   In the contrary case
we have no resource but extirpation of the tumor  or amputation of
the limb, as the dimensions of the pedicle no longer admit of the em-
ployment of the ligature and as caustics are inadmissible in any case.
Amputation of the thigh for  a lipoma has something in it strange
and repugnant.   It is true that in order to remove these enormous
tumors, we may be obliged to  divide a certain  number of the poste-
rior muscles of this part of the limb;  that the continuity of the femo-
ral vessels and of the sciatic nerve, run some risk of being implicated,
and that in every case we are more or less compelled to create  an
enormous wound, whose suppuration is necessarily  exceedingly dan-
gerous.  But besides that most of  the muscles, from being simply
spread out or widened apart, may if necessary be avoided, the lobes
of the lipomatous tumors are ordinarily sufficiently  movable to allow
of their being readily enucleated  from the periphery of the vessels
and nerves.  Moreover, the division of the femoral  artery or sciatic
nerve, would it necessarily result in gangrene  and  death?  It is not
to be  forgotten that amputation in  such cases is  to  be performed
either in the articulation itself or very near the great trochanter, and
that besides the  slight  prospect of success it  presents, there would
nevertheless,  even under the most favorable circumstances possible,
be thereby produced an  immense  amount  of  mutilation; while the
pure and  simple extirpation of the  tumor, which  in the aggregate
would not be more dangerous  than the extirpation of the limb, would
at least have  the advantage,  should it succeed, of  effectually curing
the patient,  I would not  therefore prefer  amputation of the thigh
to extirpation of the tumor, unless it should be found impossible to
operate without wounding at the same  time  the crural artery and
nerve  as well as the sciatic  nerve.  Of the  two  patients I opera-
ted upon, one it is  true died, but he had been exhausted by long-suf
fering and was near sixty years of age ;  the other however recovered,
though the dissection in her during the operation  had been almost as
extensive as in the other.
   The extirpation  of these lipomas, however, in this region, is more
frightful or dangerous than really difficult:  to accomplish it I adopted
two different modes.  In the first  case I  made an incision which
went  directly down to the  adipose tissue, and extended from the
tuberosity  of the ischium along the semi-tendinosus muscle as far
down as below the ham.   Transforming this first into a T incision, 1 
630
LIPOMAS,  OR FATTY TUMORS OR WEN'S.
divided the tissues outwardly as far as to the external side of the
triceps muscle.  Having reversed the two flaps of the T, I had only
to divide the two  thirds of the  long portion of the biceps.  Then
dissecting the tumor with free strokes of the instrument, I detached
it first on its outer side, then inwards  and then from above down-
wards, either by means of the bistoury, or with the fingers or the
handle of the scalpel, completing the  extirpation in less than  five
minutes.   In the second  patient  the mass was so immense, and fur-
rowed by veins so numerous and so enlarged, that I deemed it pro-
per to remove with it a large ellipse of integuments.  I was obliged
in this manner to include in the  incision a portion of the biceps
muscle, and of the semi-tendinosus, semi-membranosus and gracilis
muscles, which were broadly spread out in the manner of a mem-
brane, upon the surface of the lipoma.   Having detached this gigan-
tic tumor from the external parts of the leg and thigh, I tore out a
lobe from it from  below  the breech, and then a second from the
hollow of the  ham; but  from its having enveloped the vessels in
its extension inwards, the dissection on this part became difficult and
laborious.   The great anastomosing  artery, which I could not avoid
at the distance of two lines only from the trunk of the crural, made
me fear at first that I had wounded this last.  The isolation of the
sciatic nerve also was not  unattended with difficulty.  The opera
tion nevertheless, notwithstanding the rupture of two or three putres
cent (putrilagineuses) cavities which I had to empty as I proceeded
was neither very long nor  very laborious; it did not last over  a
quarter of an hour.  In neither  case did the approximation of the
lips of the wound present any difficulty.  But for the attacks of ery-
sipelas and some menaces of purulent infection which supervened in
the woman operated upon  in 1836, accidents  which may be devel-
oped after an operation of the least serious nature, the cure certainly
would not have required more than five or six weeks to be accom-
plished.  In the man who perished, and upon whom I did not ope-
rate until after having  taken the  advice  of MM.  Ribes,  Larrey,
Marjolin, Sanson, Laugier, Berard the elder, Berard the younger,
Monod, Robert and  all the other distinguished  surgeons of Paris,
death appeared to have been the result of defect of  reaction, and as
it were exhaustion of the vital principle.   These operations, how-
ever, up to the present time have not  been performed sufficiently
often, to  enable us to appreciate with exactitude their value or  their
danger.
                             §IX.
  I would remark in conclusion, that lipomas, like lymphatic tumors
and neuromas, are so easily detached from  the surrounding tissues,
that enucleation is applicable to them, and ought to be substituted
to the employment of the bistoury, wherever there would be danger
of  wounding the large vessels or important nerves.   Being situated
independently, and  as it were without  any organic attachment, in
the midst  of the  tissues, they may moreover be  torn out without
fear by means of the finger or any other mode.  They are  the kind
of  tumors in fine whose extirpation, all other things being equal, in-
■ volves the fewest dangers, and presents the best chances for success 
             NEW ELEMENTS OF  OPETATIVE SURGERY.          631

together with the greatest degree  of facility and  simplicity in the
operative maual.
  [Fatty Tumors.—Our countryman, Dr. Parker, a missionary in
China, has had much practical experience in a peculiar form of enor-
mous cutaneous or fatty tumors, which he has seen or operated for
successfully during  his philanthropic labors.  In a recent memoir of
his, published in Cormack's Monthly Journal of Med. Science, (June,
1846, p. 393, &c.) he mentions one in a beggar aged 35 on the right
side of his face, and which increased in ten years to two and a half
feet in circumference.   Dr. Parker extirpated it without difficulty
by two elliptical  incisions, each  eighteen inches long.  It weighed
near nine pounds, and was of glandular  structure, with a few cells
containing a yellow or dark fluid,  and was in  part  cartilaginous.
A slight paralysis only  was left from the division of the portio dura.
The patient recovered so well in three weeks  as to  perform the
duties of porter to the missionary hospital.  These excessive growths
of a lipomatous or with mixed cartilaginous  and  encysted organiza-
tion, and which in some cases have been seen by Dr. Parker (accor-
ding to the paintings  he exhibited  at  New York,) to extend  like
wings  from the whole posterior  portion of the trunk and lower limb
on one side, appear  to  be the result of the excessive indulgence or
gluttony  in the Chinese for farinaceous and other non-nitrogenized
kinds of food, that favor fatty growths and accumulations.   See note
on Mr. Mcllvalne's views on  this subject,Vol. II.]
                        CHAPTER VI.

                     ELEPHANTINE TUMORS.

  The class  of elephantine  tumors, very common in Africa, the
Indias, and many countries of Asia and America, but rare in Europe,
and especially in France, are met with only as an exception in other
than the genital organs either of men or women.   Being caused by
an hypertrophy, together  with  degenerescence of the  integuments,
or cellular tissue, and sometimes of the aponeuroses and  muscles,
they may acquire a development still more considerable than lipomas.
I have seen instances of them upon the nose, ears, feet and  hands,
and some other regions of the body.  In 1836, at the hospital of La
Charite, a woman was brought to  me, of about forty years of  age,
who had the hand, fore-arm and elbow three times  their natural  size,
in consequence  of a degenerescence of this kind, and  in whom the
upper half of the arm, as well as all the other parts  of the body were
in a perfectly sound condition ; so that the disease  had  become  sud-
denly arrested  at the distance  of two or three inches above the
humero-cubital articulation.   A man in whom I extirpated the limb
at the articulation, and to whose case I  have elsewhere alluded, had
upon his right arm a similar degenerescence, which extended from the
extremities of the  fingers to the shoulder, and ultimately became 
632
ELEPHANTINE  TUMORS.
 complicated with a cancerous or colloid transformation at the centre
 of the humerus.   I have met with many instances  of persons who
 had  in this manner the foot and the leg, either partially or wholly
 enlarged to double, triple, or even quadruple their natural size.   In
 one  of these patients the elephantine  tumor abruptly terminated in
 the  form  of an enormous lardaceous collar, at some inches below
 the knee.   In the greater part of them the disease imperceptibly dis-
 appeared  above, and in all  of them the limb truly exhibited the ap-
 pearance of the leg of an elephant.  Should the tumor be accurately
 defined,  as  in the case  of those I  have been  describing, and
 should it  have  been of long  standing  and have  resisted all  the
 means indicated  by a  judicious therapeutic,  we may,  should  the
 person be in  other respects in good health, propose its removal.  But
 in such cases it is amputation of the limb itself  only, which presents
 any  chances  of success, or that can be had recourse to.  In all cases,
 on the contrary, where the elephantine degeneration shall appear  to
 be imperfectly limited or prolonged under the form of indurated plates
 or radiations beyond the tumor  itself, properly so  called ; or com-
 plicated with plates or projections of a similar nature, on other parts
 of the body ; or we have reason to suspect the slightest alteration in the
 viscera; or that the health of the patient has  been  profoundly de-
 teriorated, we must be cautious  not to meddle with it, or confine our-
 selves  to palliatives.  I shall, however, return to these tumors  in
 speaking of operations performed on each region  of the body, in
 particular, and especially upon  the scrotum or vulva.  The tumors
 called keloid, (keloides) which I have  seen in  the  form of a firm,
 reddish-colored lardaceous plate,  four to six lines in  thickness, and
 two  inches in breadth, upon the shoulder of a  young lady, who had
 already been operated upon for it, by M. Forget; which I have met
 with also, under the angle of the scapula, in  the dorsal  region  of
 another female; and which M. Warren, (on Tumors, etc., p. 45, pi. 3,)
 who has described them,  appears  also  to have observed on the
 shoulder; should be destroyed by means of the zinc paste, or extir-
 pated with the same precautions as if they were of the character  of
 an erectile  or elephantine  tumor.  Extirpation would be applicable
 only to the eloid (eloides) tumors described by the same author (R>id.,
 p. 48, pi. 4), and which show themselves under the form of a bunch
of agglomerated  enormous-sized  leeches,  or  of a  small  intestine
 coiled up upon a cirsumscribed point of the skin.
  [M. Colson, of Noyon  (France),  describes (see Journ. des  Con-
 naiss. &c, de Paris, Mai, 1842, p. 189 et seq.) a remarkable case of
 African elephantiasis  in a woman who died at the  age of 53, aftei
 fifty  years of suffering from that  and the antecedent diseases which
 appear to have led to its production.  The privations of poverty, im-
 poverished diet and constant residence in a marshy situation (com-
 mune of Salency)  predisposed  doubtless to this  train of maladies,
 which commenced in  infancy after small pox with a large tumor on
 the right side of the vulva, which  after some years' continuance was
 destroyed by an empiric by means of caustic.  The  right side of the
 abdomen and thigh however began to swell before  her catamenia
appeared,  when another empiric  attacked these parts with the cau-
tery  and caustics, applying these remedies both above and below the 
              NEW  ELEMENTS OF  OPERATIVE SURGERY.          633

knee, the  last of which caused  erysipelas and gangrene of the leg,
and  denudation of the tibia.   This last wound partially recovered,
but  continued  an open, discharging ulcer for  many years—the hy-
pertrophy of the thigh also gradually increasing.   Worms were en-
gendered in these foul ulcers.  At the age of 38 this wound  healed,
and  ulcers were established at the malleoli.  The menses were most
of the time regular,  but the urine was occasionally suppressed, which
latter difficulty was relieved by nitrate of potash drinks, bringing on
copious evacuations of this secretion, which sometimes had a milky
appearance.   The thigh at  the  middle  part was over thirty-seven
inches in circumference, covered  on  the  posterior  part, as was also
the dorsum of the foot, with thick,  offensive incrustations, also in vari-
ous  parts  with tubercles  (as is common in tropical elephantiasis),
while the leg of the  diseased limb was also hypertrophied in its lower
part  to the dimensions  of over twenty-one inches in circumference,
having enormous  red vegetations about the ankles—the whole limb
being at least three  times the size  of the other.  It retained  to  some
extent the powers of flexion and extension.  T.
                        CHAPTER VII.

                       HEMATIC TUMORS.

   A kind of tumors whose pathology might constitute several  spe-
cies, and which had scarcely been noticed before I described them
in 1826, and afterwards in 1833, are those which are caused by  effu-
sions of blood.  These tumors which have a predilection  for the sy-
novial bursas, and which sometimes form for themselves  cysts in the
cellular tissue, are either solid, fluid, or semi-fluid, or sometimes  con-
stituted of a melange of concrete clots with matters that are altoge-
ther of a  fluid nature.  I shall, when speaking of cysts (kystes), re-
turn to those which contain rather fluid than concrete matters ; at pre-
sent I  shall  confine myself to solid hematic tumors.  These tumors
perhaps are more common than would  at first be thought.  I have
elsewhere  remarked (Traite des Contusions, Paris, 1833), that  cer-
tain polypi  of the uterus,  some tumors of the prostate, with steato-
mas of the head, breast, &c, often appeared to me to owe their ori-
gin to  an effusion of blood or  fibrinous  concretion, and numerous
facts have since confirmed me in this opinion.  This much, however,
is certain, that most of the tumors described under the title of steato-
ma or  lipoma, and which do not belong to the order of fatty tumors,
enter  into the  category  of hematic tumors.    The tumor of 188
grammes in weight, which a patient carried for the space of twenty
years  upon the right side of his head, under the denomination  of a
lipoma, and which was successfully extirpated by M. D. Lasserve
(Cas de Chir., pp. 21, 22, 23, Perigueux,  1833)  was to  all appear-
ance nothing  more than a degenerate hematic  tumor.   The same
was the case as I should think, with another tumor of the size of an
egg, situated below the mamma to the left on the thorax of a man, and
  vol.  n.                         80 
634
HEMATIC TUMORS.
 which the same  practitioner removed ; also with that which existed
 upon the shoulder and which  he  also extirpated; the same with a
 cyst filled with matter resembling boiled rice and situated upon the
 left cheek of a man;  and with  the cyst still larger, which a woman
 had on her knee, together with some other tumors, for which M. D.
 Lasserve in like manner operated.   Hematic tumors differ from lipo-
 mas in general, in this, that they are  scarcely ever pediculated ;  that
 they rarely exceed  the size of an egg, the fist or the head; that they
 are almost constantly surrounded with an irregular cyst when they
 are situated in the cellular tissue, but sufficiently regular, on the con-
 trary, when they are formed in the bursas mucosae or the synovial
 cavities; in this also, that the matter of which they are composed, is
 either clotty or fibrinous or fibrous, and of a variable color, yellowish,
 gray, sandy (rousse) or brownish;  and that serous or synovial mat-
 ter is  frequently found  mingled with  it.   Like  lipomas,  hematic
 tumors do not usually cause any pain, and incommode in reality only
 by their volume or weight.  Like  lipomas also, and  perhaps more
 frequently than them, they  appear to be susceptible of degenerating
 and undergoing transformations  of a bad character.  No topical ap-
 plication or internal medication  can  destroy them when they are of
 old date or have acquired a certain volume.   Caustics, the ligature
 and  extirpation, therefore, are the only remedies we have at  our
 command.

           Article I.—Hematic Tumors in General-.

                               § I.

   Plasters, liquids and all kinds of discutient (fondants) topical applica-
 tions, by which we  sometimes succeed in obtaining resolution of san-
 guineous deposits, have no longer any efficacy when we have under
 treatment an ancient hematic concrete  tumor.   These means, eulo-
gized by M. Champion, as irritating injections have been by M. Asselin,
 (Considerations sur les Bourses Muqueuses, Strasbourg, 1803,) pos-
 sess in reality no value except in recent hematic tumors.

                              § II.

   Caustics, besides their inconvenience of destroying integuments
 which it might be advantageous to preserve, would also be attended
 with the objection of exacting a considerable space of time, and of fail-
 ing in  the majority of cases.  A surgeon mentioned  by  Lombard,
 (Opuscules de  Chirurgie, p. 108, 1786,)  who wished  to destroy
 at every possible hazard a  tumor evidently  hematic,  in front of
 the knee, by  means of caustics, could not effect his object, but caused
 by this means  several abscesses in the  neighborhood of the  patella.
 At most, therefore, escharotics under such circumstances, could only
 be employed in association with the ligature, as was practised by F.
 Aquapendente  and has been since done by Chopart  and  Sabatier;
 or in the case of those persons who peremptorily refuse every other
 kind of operation. 
NEW ELEMENTS OF OPERATIVE  SURGERY.
635
                             § III.
  The ligature upon hematic tumors is still more uncertain than for
lipomas.   As these tumors almost always present a very large base,
and have besides a more or less distinct cyst, they are badly adapted
to constrictive  means, and do not  find in such resources their best
remedy.

                             § IV.
  It is to extirpation therefore that we must have recourse,  if we
wish to relieve  the patient.  The question might then be asked, if it
would not be sufficient to lay open and empty the cyst ?  To this
first question we may reply,  that the  simple incision,  which would
doubtless sometimes succeed, would most frequently prove unsucess-
ful, expose to more accidents than extirpation, and render the remain-
der of the operation obviously more difficult.  If Paroisse (Opuscules
de Chir. etc., p. 94, 1806,)  was enabled to extract a cyst of this kind
by a simple incision, it was because inflammation, excited in the cyst
by an irritating injection,  had previously isolated  it  from the sur-
rounding tissues.   All that we can demand in such cases is, to know
if it is indispensable to carry away the totality of the cyst with the
tumor, or limit  ourselves to the excision of the latter.   Sainct Chris-
teau, (La  Chirurgie Pratique, p. 180, 1697,) having restricted him-
self to emptying a steatoma of the size of the fist, which was situated
upon the inner  side of the thigh, found himself obliged to scarify the
internal surface of the sac, and to dress the cavity  with an exciting
digestive before he could effect its cicatrization.

                              v V.
  Excision,  properly  so  called, is of such  doubtful  efficacy, that
J. Fabrice, (GEuvr. Compl., partie 2, p. 620,) was already aware of
it, and in his time recommends  that we should divide the vessel
which nourishes the remains of the  cyst.  This mode,  however, has
been  since lauded, first by Chopart and also by Louis, or by  Percy,
(Diet, des Sc.  Med.,  t.  XXVII., p.  44, 45,) but  it is to Mosniei,
(These, Paris, an XI.) and to  Bourdet, (Essais sur les Loupes, p. 23,)
that it is  specially indebted for having been rescued from oblivion,
and been made  to assume a kind of celebrity at the commencement of
the present century.  Mosnier pretends that after this operation, the
bottom of the wound is transformed into cicatrices, and takes the place
of integuments.   The facts,  nevertheless,  advanced  by  those ob-
servers, and  which are applicable  at most to certain regions of the
body, have not been of a character to convince any one, or to be
received as laws, and  extirpation,  properly so called, has continued
to be generally  preferred.  Perhaps, however, we have gone too
far  in  this respect, and that it would  answer  the  purpose when
the posterior wall of  the cyst cannot be dissected without%too much
difficulty, that it should be left in its place and made to suppurate. We
cannot see, in fact, and practice is nearly silent on this subject, why,
after suppuration, the  walls of a wound of this kind ought to have so
much difficulty  in agglutinating.   Only in this case I would not
recommend that the integuments should be removed with the tumor; 
636
HEMATIC TUMORS.
 at least we should preserve a sufficiency of them to enable us to cover
 the  bottom of the wound.  It  is nevertheless true that this practice
 must be considered as an exception, and that unles's there are parti-
 cular objections, the extirpation of the entire hematic pouch ought to
 have the preference.   The operative process also is sufficiently sim-
 ple.   If the  tumor is very voluminous, we remove with it an ellipse
 or a star of the integuments.  In the contrary case, we lay it bare by
 means of the simple incision, that of the T, or the crucial.  Perhaps,
 in such cases, the  semilunar would be preferable.  The tumor being
 concrete, enables  us to isolate its envelopes without fear, and at the
 same time to reverse the  entire sub-cutaneous layer.  This first dis-
 section being terminated, an assistant is  charged with holding the
 flaps of the integuments apart and of making traction upon the tumor
 in the proper direction,  while the  surgeon detaches and carefully iso-
 lates it with  the strokes of  his bistoury from  the deep-seated parts.
 As the hematic tumors, which may be extirpated in this way, are
 almost always sub-cutaneous, their extirpation is scarcely ever accom-
 panied with serious hemorrhage.  There are therefore generally but
 a small number of ligatures to place or arteries to tie.  If the totality
 of the cyst has  been destroyed,  and the wound  reposes every where
 on pliant vascular tissues, and the flaps have been cut of proper shape,
 there is a prospect of success by immediate reunion, and it ought to
 be attempted.  Under opposite circumstances it is better  to dress
 at first with the balls of lint, over which the flaps are to be brought,
 and  which in their turn are  to be covered with a perforated linen,
 plumasseaux, compresses  and the simple  containing bandage, until
 the wound has  become  completely cleansed and the flaps undergone
 all their retraction.  By this means we avoid the danger of nervous
 accidents, purulent collections,  and erysipelas, but we must be pre-
 pared to find the wound cicatrize slowly, and the patient not tho-
 roughly cured until after the expiration of one or two months.

         Article II.—Hematic Tumors  in Particular.

  Hematic tumors may develop themselves upon all the regions of
 the body.  It is rare however, except in the superficial or deep-seated
 mucous bursas,  that they are distinguished, as respects the operation,
 from lymphatic tumors or  neuromas, since  everywhere else their ex
 tirpation is subjected to the same rules for the operative  process that
 those last named tumors are.

                              § I.
  Were it necessary to describe the process for extirpating hematic
 tumors in all those regions where  synovial  bursas exist, I should have
 to examine those of the  temporo-maxillary region, chin, angle  of the
jaw,  the thyroid angle, spinous  process of the seventh vertebra, the
 dorsal and,  lumbar region, that  of the ribs and sternum, the  lower
 angle of the scapula, the acromion, inner condyle of the humerus, the
 radius, ulna, metacarpo-phalangeal angles, both dorsal  and palmar,
the phalangeal articulations, the spine of the ilium, the great trochan-
ter, condyles of the  femur,  spine of the  tibia, head of the  fibula,
the malleoli, heel, tarsus, first and  fifth bones of the metatarsus, club 
NEW ELEMENTS OF OPERATIVE SURGERY.          637
feet, those with feet amputated, who are humpbacked &c.; but there
are in reality no others but that of the knee and perhaps  that of the
malleoli, which require in this respect particular mention.

                              §11.

  I have in three instances extirpated hematic tumors which were
situated in the mucous bursas of the malleoli, in that of the outer an-
kle in two cases, and in that of the inner in the third.  In such cases,
if it is the external malleolus, we must be on our guard against open-
ing into the sheath of the tendons  of the peroneus longus and brevis
muscles behind, and wounding the synovial cavity of the tibio-tarsal
articulation below.   The danger  also of purulent inflammation in a
region  of this description, ought  to deter us  here from attempting
union by the  first intention, if the state of the wound or nature of the
flaps do not appear to be favorable to it.  At  the  internal malleolus
we must be on our guard against  wounding the sheath of the tibialis
anticus muscle and the posterior tibial artery behind, and the articu-
lation and the sheath of the tibialis  anticus muscle below and in front.

               § III.—Hematic  Tumors of the Knee.

  In no place are the tumors of which I am speaking more frequent-
ly encountered than  about the knee, and especially in front of the
patella;  nor is there any  region perhaps, where their extirpation
exposes to as  much danger.   A tumor of  the  size of two  fists,
which  was situated  upon  the left knee, and which M. Hip.  Lar-
rey (Gaz.  Med., 1838, p.  712,)  gives  as an example  of hematic
tumor, was extirpated at the Hospital of Val-de-Grace.   The officer
who was the subject of it was soon  seized with  general accidents
and with delirium, followed by death on the eighth day.  Two pa-
tients operated upon for simple tumors, one by M. Roux, the other
by  myself in  1825, at the hospital of Perfectionnement,  died in the
same way and in as short a space of time.  M. Hervez  de Chegoin
(Journ. Hebd. Univ., t. III., p. 329,) who still gives the name of lipoma
to  these tumors, and who confeses that he  does not  comprehend
their character, has sometimes practised their extirpation with suc-
cess, but he is far from dissembling also the gravity of the operation.
Extirpation performed by M. Warren (on Tumors, etc. p. 40) for a can-
cerous tumor in front of the patella, was also  followed by death.  It
is sufficiently remarkable also  that death in these cases should  have
resulted from cerebral phenomena and ataxic  symptoms, which are
scarcely explicable by the local accidents occasioned by the wound
itself.   I hasten to add,  however,  that in the great majority of cases,
the operation is not followed by any unpleasant symptoms, but most
usually in fact, effects a complete and sufficiently rapid cure.   Six
of the patients whom I have treated in this manner recovered per-
fectlv.
  Operative Process.—The patient is to be placed upon his back and
his  leg maintained in a  moderate state of  extension; one assistant
takes charge of the foot and the other of the thigh.   If the tumor
has but little  volume, the surgeon  lays it  bare by means of a longi-
tudinal incision.   In the contrary case, and where the skin is to be 
638                     HEMATIC TUMORS.
preserved entire, I prefer the semilunar incision, taking care to turn
its free border  outwards.  If the simple incision has been  used, its
two lips are  dissected in succession, and reversed as far as to the
borders of the  patella.   With the semilunar  incision we  carefully
detach the flap of the integuments from without inwardly, and in
such manner as to reverse it upon its base upon the inner side of the
knee.
  If on account of any particular reasons, we should consider our-
selves obliged to give the preference  to  the crucial incision,  we must
detach and reverse its four flaps upon their base, with the same  care.
The same remark applies to the elliptical or to the stellated incision, with
this difference only, that  we should here  leave a  portion of integu-
ment  on the apex of the tumor.  In whatever manner performed,
the tegumentary envelopes  having been turned back, we proceed to
the isolation  of the  periphery and deep-seated surface of the  cyst.
All the precautions required for this dissection, have reference to the
articulation of the knee and to the diseased cyst itself, there being no
large sized artery or nerve found in the neighborhood.  We  must
therefore not forget that upon the outside, and both above and below
the patella, the  synovial cavity might be readily opened, and that the
same remark applies to the inner side ; but that directly in front there
is nothing in this respect to be apprehended.  In no other region also
do hematic tumors  exact more attention in regard to the extirpation
of their cyst.   However little there  may remain of its posterior wall
at the bottom of the wound, this  cyst retards and even prevents cica-
trization, and keeps up a suppuration whose consequences are not al-
ways devoid of danger.  A patient  whom I  found at the hospital of
Saint Antoine in 1828, and whom Beauchene had operated upon two
months before, retained a large  purulent cavity in front of the knee.
The posterior wall of the cyst left at the bottom of wound, had taken
on all the characters of fibro-mucous  lamellae of a new formation, and
exhibited  no disposition  to improve (a la mondification).  I adopted
the plan of removing it by a careful dissection, and  from that mo-
ment the wound  cicatrized regularly and without any difficulty.  It
is necessary therefore, in these extirpations, to  follow exactly the line
which separates the natural  tissues  from the  thick envelope of the
tumor.  Should some  shreds of the  cyst have at first escaped from
under the bistoury, we must immediately after seize them with a dou-
ble erigne or claw-forceps, (see Vol. I.) and extract them before ter-
minating the  operation.  The dressing also deserves some attention.
The flaps having no other support to rest upon than osseous or fibrous
planes, or tissues that are but little vascular, and being moreover usu-
ally very thin, should not be  brought over and maintained upon the
wound except  by means of a very moderate degree of traction and
compression.  All the pieces of dressing also which  are  to  cover
them, should be sufficiently pliant, and so lightly adjusted that no stran-
gulation may be produced  either in the  direction of the leg or thigh.
The leg also,  by placing  a  thin cushion under the ham, should  be
kept in a state of gentle flexion rather than  in complete extension.
At the first sign of inflammation  also, it would become imperative to
envelop the knee in compresses or emollient cataplasms, and  to cover
it with leeches  and renounce every attempt at immediate union.  At 
              NEW ELEMENTS  OF OPERATIVE SURGERY.          639

a later period, and when  the borders of the wound have become ag-
glutinated and united  to the subjacent tissue, but are at some distance
apart, it may on the other hand become useful to place the leg in ex-
tension, and to maintain it in that manner by means  of an immova-
ble dressing.  Unless that is  done, the slightest flexion of the knee
brings  the patella  between the lips of the wound in the manner  of a
wedge, and may retard the cure to an indefinite period.
                        CHAPTER VIII.

               CYSTS (Kystes) PROPERLY SO CALLED.

   Cysts form  one of the most numerous class of tumors, and  have
 among them a sufficient number of varieties.  Besides the purulent,
 hematic and synovial cysts, there are the melicerous, atheromatous,
 steatomatous and hydatid, and such as are purely serous, all of which
 sometimes reclaim the aid of surgery.

                  Article  I.—Sebaceous Cysts.

   Quite a  numerous order of cysts are those that are formed at the
 expense of  the follicles  of the skin.  The tumors which result  from
 them  and which are generally known under the name of maggots
 (tannes, or  worms)  and meliceris, receive also other  appellations
 when  they exist in the form of pimples (boutons), rugosities or simple
 tubercles.   They  are frequently observed upon the scrotum and skin
 of the penis, and not exceeding in size a pin's head, yet  susceptible
 of being made to yield  by pressure a clot of sebaceous matter.   On
 the face these little tumors  when they inflame  are called  red  pim-
 ples (couperose), causing very small abscesses, which are also relieved
 by strong pressure, after having perforated their  apex with the point
 of a pin.  But it is not with small cysts of this  description that ope-
 rative  surgery has any particular connection.  When the sebaceous
 matter is accumulated in greater quantity in the crypts, it distends and
 enlarges them to such degree as to produce tumors, whose  dimensions
 vary from that of a pea to that of a pullet's egg.   These* tumors,
 which  usually do not cause any pain, which are unattended with any
 inflammatory action  or  change  in the color of the skin, and which
 possess a great regularity in their form, are soft  (mollasses), slightly
 fungous and as it were semi-fluctuating.  The cranium, face and
 neck are their most favorite localities.  They  are noticed  also on
 other regions of the  body.   I have met with one upon the shoulder
of the  size of a pullet's egg;  and also encountered them on the legs,
thighs and fore-arms.   Even the fingers themselves  may be the seat
of these tumors.  A man in the country, whom I knew in my child-
hood,  had upon the  dorsal  surface of the middle articulation of the
left middle  finger,  one of these  tumors which was of the  size of a
very large nut, in such  manner as to  form  there an  enormous mass
which  projected posteriorly.  A patient of M. Fisher operated upon 
640
CYSTS,  PROPERLY SO CALLED.
by M. Warren (on Tumors, &c, p. 529, pi. 16.) had one of a most
singular description in front of the great trochanter.  Some patients
have several at the same time, and this peculiarity is principally seen
where the sebaceous cysts are of but little size.  It is proper how-
ever to say, that I have met  with many of the largest kind at the
same time upon the same individual
  The following case perhaps also belongs to tumors of this descrip-
tion.   An officer of health in the environs of Paris, a robust man
aged 55 years, had for many years in the right supra-hyoid and paro-
tid region, a tumor which  ascended  as  high up as upon a line with
the cheek bone and the labial  opening of the mouth on the outer side
of the jaw.  This tumor, which when I had an opportunity of observ-
ing it in the spring of 1838, had already undergone various  degrees of
transformation, so much resembled an osteo-sarcoma that many expe-
rienced practitioners of the capital had characterized it as such;  its
extension towards  the larynx  below and the pharynx behind and in
the direction of the mouth, had even precluded all idea of an opera-
tion, and confined  the recommendations  to the palliative treatment
for cancerous affections.  Under the impression that  I recognized
something fluctuating in its most  prominent lumps (bosselures), and
that there was also a certain  mobility in the tumor, and that it pre-
sented neither the positive characters of cancer or evidence of actual
adhesions with the maxillary  bone, I considered it proper to lay it
open  freely upon one  portion of it.  I was enabled thereby to ex-
tract from it several ounces of a  matter either melicerous, grumu-
lous or semi-purulent, which resembled neither  fibrine, pus nor tuber-
culous matter, nor  fat or  gelatine, nor the substance known as en-
cephaloid, colloid  or melanotic  (melanique),  and which had in a
word no analogy with any of  the substances which are usually found
in cysts.
  Sebaceous matter was the only substance  to which one could pos-
sibly in some  respects compare it, that is to say, that this substance,
unctuous in some portions of it and friable, and as it were desiccated
in others, had  for its receptacle a cavity whose walls singularly re-
sembled in their papillar (pointille) or cutaneous aspect that of  meli-
cerous cysts.  Anxious  to know what course to pursue, and wishing
moreover not  to influence his judgment, I confided a portion of this
material to  M. Donne that he might submit  it to the microscope and
certain chemical reagents, without having informed him of the inten-
tion I ha*d in view.   This physician,  at the expiration of two days in-
formed me, that he had found nothing but fatty matter and particles
(paillettes) of epiderm, in  the substance which I had transmitted to
him, and consequently it could come only from a disease of the epi-
derm or of the follicles of the  skin.  Am I then right in  concluding
that the tumor in question was in reality of the description  of that
known as a maggot (tanne) and proceeding from a sebaceous cyst ?
Adopting the  affirmative,  I will  add at the present time, that these
cysts in breaking up (se decomposant) may undergo transformation
of a bad character; for a patient whom I have since exhibited at the
Clinique  and who had a tumor of the same kind more advanced, and
in the same region, was  ultimately attacked with a legitimate cancer
of the lower jaw.   Be this as it may, melicerous cysts rebel against 
NEW ELEMENTS OF OPERATIVE SURGERY.
641
all  resources except  those of operative surgery.   When they have
acquired a  certain volume and  remain in the chronic state, we may
by  compressing them upon their sides, or by dilating the little spot or
black-colored hole (pertuis) which we generally succeed in finding on
some one of the points  of their periphery, and which is as  it were
their outlet,  empty them and effect the discharge of matter resembling
worms ;  but they are not cured by these means.   The sac soon after
fills up, and  the tumor is not long in re-acquiring its primitive volume.
It is from proceeding in this manner, that some have been induced to
believe that the disease actually consisted of worms coiled up under-
neath the skin.   The small black point which gets out first, is taken
for  the head of the worm, and the sebaceous matter which  threads
out in an undulating line  as it comes through the cutaneous aperture,
completes the illusion. This  has proceeded  to such extent, that hav-
ing presented for examination, a thread of this kind of two inches in
length which I had just extracted from  a maggot ulcerated below the
left breast of an adult man, the interne  at first and the physician af-
terwards, assured me it was an entozootic worm and were preparing
to designate its species, when  I disabused  them of their delusion.
Topical applications, whatever  be their nature, have no  influence
upon this kind of worm.   The  merely  laying them open, or exciting
inflammation in them by means  of a seton, acupuncture, or  needles
or threads passed through them, does not hinder them from being re-
produced.   Even their excision in certain cases does not always cure
the patient.   They must either  be extirpated completely, or after
having emptied them by a large opening, carefully cauterized through-
out their whole  interior.   The  director of one of our royal theatres,
had in front of  the left temple a sebaceous cyst of the size of  a large
bean.  As he did not wish to submit to any sort of bloody operation,
I confined myself at first to the evacuation of the melicerous matter
by  enlarging a little the opening of #he tumor.  The latter having re-
turned, I laid  it open with a cut of the lancet  and voided it again.
But it again returned, and  the patient  at length consented to have it
extirpated.
  A physician  who was  a member of the Royal Academy of Medi-
cine, had at  the upper and posterior part of the right orbitar angle, a se-
baceous cyst of an inch  in diameter.  It was frequently laid  open in
order to empty it, but the tumor invariably reappeared; he decided
upon having its whole cavity  cauterized, and was thus cured.   In the
patient who had one of these cysts on the top of his shoulder, I ex-
cised all the projecting portion of it and touched the remainder with
nitrate of silver.   Hardly any inflammation  ensued ; the epidermic
portion at the bottom of  the wound sloughed off at the expiration of
eight days;  the  borders of the wound were not approximated, and it
was the preserved portion of the sebaceous cavity which served the
place of the cicatrices,  and assumed the appearance  and most of
the  characters of cutaneous tissues.  In conclusion, therefore, should
the  cyst  not be of large  size, the best plan is, after having circum-
scribed it in an ellipse by two semilunar incisions, to seize it with an
erigne and extirpate it.   If the approximation of the borders of the
wound and immediate reunion should be interfered with by this mode
of excision,  we should commence with a straight incision, whose lips
  VOL. n.                         81 
642
CYSTS,  PROPERLY SO CALLED.
should then  be dissected and carefully separated on each side, leav-
ing intact the tumor, which should be secured with a hook, and after-
wards extirpated.  By this mode the operation is longer, more diffi-
cult and more painful; besides which, notwithstanding all our precau-
tions, we most usually cut into the cyst before having completed the
dissection, because  the thickness of its walls can scarcely ever be
correctly ascertained beforehand, and moreover, are frequently found
intimately blended with the skin.
  A child three years of age, had upon the right external orbitar an-
gle and in front of the  temporal fossa, a sebaceous cyst of an inch in
diameter.   As  there was  a dread of any kind  of cicatrix, I  laid it
bare  by  means of  a  simple incision.  I had  already  isolated two
thirds of it, when a movement  of the little patient caused me to cut
into it in front.  The  tractions  which I was constantly obliged to
make upon it to get it out, had soon emptied it, and I  perceived on
terminating, that there  was about a centime of it in breadth left at
the bottom of the wound.  I touched this portion of it freely with
nitrate of silver, and the cure was effected perfectly.  The  wife of a
distinguished magistrate of Paris had under  her left ear, a sebaceous
cyst, slightly elongated in shape, and of the size of a nut.  Desirous of
avoiding the slightest  trace of a wound at this part, and at  the same
time to make the operation sure and prompt,  I commenced by seizing
the tumor with an erigne, which I confided to M. Prus, the physician
ithe family, while M.  Vasseur who also acted as my assistant,  stretched
the integuments.  By means of two incisions slightly incurvated, I cir-
cumscribed a very long ellipse of integuments, which I removed with
the tumor, and which  enabled  me  readily to  enucleate the latter in
front and behind, and then from above downwards, by means of the bis-
toury.  The lips of the wound were easily approximated and the cure
completed in three days without any suppuration.   If on the contrary
the tumor should be very large, ifrwould be better to lay  it open freely,
empty it with care, and then thoroughly cauterize  its  whole cavity.
The same process also would be suitable for cysts that are less volumi-
nous,  if there were   no  great danger  of a  cicatrix slightly  de-
formed.  Finally, the excision,  or rather the  amputation of the tu-
mor, together with cauterization of its deep-seated wall, would be ap-
plicable for those which have a large base,  and which  cannot be ex-
tirpated  entire, or  which we do not wish  to submit to a  simple in-
cision aided by caustic.  Upon the whole, we cannot cure sebaceous
cysts but by extirpating  them  completely,  or after having  excised
them, making use of their deep-seated wall as a portion of integument
to serve as the cicatrix.   As these are a kind of tumors, however, de-
veloped  in the substance of the dermoid tissue, or in the appendices
and cul-de-sacs of  the  skin, the  operations  employed  for  them are
attended with very little danger,  and  rarely  compromise  the  life.
Owing to their superficial position it is next to impossible in  operating
upon them, to wound  either arteries, veins, nerves, or any important
organ.  As  these operations, except we extirpate, do not oblige us to
go  as deep as  the sub-cutaneous fascia, it must be only in very rare
cases that they can give rise to diffused phlegmon, phlegmonous ery-
sipelas, phlebitis, or purulent infection.  Erysipelas properly  so called,
angioleucite, and the  unpleasantness of a cicatrix more or less de- 
NEW ELEMENTS OF OPERATIVE SURGERY.
643
formed, together with the pain, are the only inconveniences that can
occasionally result from them.
  [In America, and especially in  the West India or tropical portion
of it, these diseased sebaceous  follicles, wherever the heat of the cli-
mate and hot sun are constantly exciting the skin, are very common,
and particularly upon  the  face from its great exposure, and in that
part most frequent upon the dorsal surface of the extremity of the
nose and upon its alas.  Their enlargement  is unquestionably first
greatly accelerated by the vulgar practice of squeezing out these so-
called  worms, so accurately described by our author.  Intemperate
persons, addicted also  to gross indulgences in indigestible food, as
crude fruits, fish, &c, and those most exposed to the hot sun in warm
climates, as seafaring persons, seem most obnoxious to this hypertrophy.
In the  remarkable case (to which  I find no parallel on record) which
I operated upon in Nassau, the capital of the  Bahama Islands in the
year 1825, and which  is inserted  below, the cure was complete, and
there was no attempt whatever made by me to save any integuments
at all, as that was in fact impossible for the great breadth of base of
each tumor, as is seen  in the accurate accompanying sketches taken
from life by myself.  The  diseased parts, however, were carefully
and thoroughly shaved off en dedolant  with the bistoury, while raised
up with the forefinger in  the  nostril,  until I reached the cartilages,
leaving them in  this  manner, in fact the whole of the  nose  from
above  the limits of the tumor,  perfectly raw.   It is in fact surprising
almost, considering the heat of the climate and weather, that gan-
grene  did not take place.   The man lived many years  with his new
and normal  shaped nose, was the object of universal remark and
reference, and ultimately died  of some other disease.

To David Hosack, M.D., F.R.S., Professor in the University of
                   the State of New York.

                                    New York, Nov. 19, 1825.
  Dear Sir,—Mr. John Russel, aged 54 years, a planter, of Abaco, one
of the  Bahama Islands, of robust short stature, and of sanguine tem-
perament, was  attacked in the year 1799 with small-pox, from which
he recovered after a severe illness.  His face remained much pitted,
and the surface of the nose was particularly rough.  Soon after, there
was a perceptible enlargement of the teguments covering the  ante-
rior and lateral cartilages of the nose, which increased the  more
rapidly, as  he imagined, from the practice of squeezing out of the
end and sides of the nose what are vulgarly called worms, but which
are well known to be the secretion of sebaceous  glands, indurated
and blackened externally  by  exposure  to the air in the orifices of
their excretory ducts.
  Sir  Astley Cooper  has expressed an opinion that encysted tumors
may arise from obstruction in  the glandular follicles of  the skin, and
this may have been the first cause of the disease.   It is not uncom-
mon in  the more remote and unfrequented, or what are called out-
islands in the Bahamas, to meet with fatty tumors of small size and
globular shape, upon the teguments of the forehead, nose, and cheek.
I have heard them attributed,  with plausibility, to the use of salt fish 
644
CYSTS, PROPERLY SO CALLED.
 and crude  vegetable food.   Nothing  however like  the gigantic
 growth of Russel's nose was  ever seen in the West Indies, or any
 where described in the annals of surgery.
   This patient came  to consult me at Nassau, island of New Provi-
 dence, about the middle of October, 1824.
   For the last twenty years the  nose had not varied materially from
 the extraordinary dimensions  and grotesque appearance which  the
 sketch presents in  Plate I.
   This enormous mass of disease  consisted  of three lobular tumors,
 having the appearance of a tribolate pendulous excrescence from the
 nose.
   On examination I found them  soft to the feel, and not only pitting,
 but exuding, on pressure,  through minute and almost imperceptible
 pores,  like those of a carbuncle, a thin,  glairy, yellowish pus.   For
 years,  he informed me,  he had been daily in  the habit, during the
 warm weather, of sqeezing out through these pores (which are doubt-
 less  the  original orifices of the diseased sebaceous follicles) a tea-
 spoonful or more  of  matter occasionally mixed with blood.  They
 were so movable  as to be easily turned  up upon the forehead,  so as
 to exhibit the openings into  the nostrils underneath, which in their
 natural position, hanging down upon the mouth, they  entirely con-
 cealed.   The middle  tumor extended down as far as the lower lip,
 upon which it rested, interfering very much with drinking and eat-
 ing,  and also with articulation.  This, the largest of the three,  was
 about two inches in breadth, and, measuring  from the anterior to the
 posterior surface, an inch and a  half in diameter: the lowest part of
 it  incurvated over the nostrils.   The shape  was spherical, as  also
 that of the two lateral tumors, which were more globate, and about
 one inch in  diameter.  Each lateral tumor was seated upon the ex-
 ternal  surface of the  ala of the nose, leaving the rim of the inferior
 part of the ala in its natural state, but closely adhering to the carti-
 lage above this by a broad base nearly co-extensive with the diame-
 ters of the tumors.  The middle lobe, however, involved the whole
 of the  tip of the nose, had a larger  base and attachment than the
 lateral lobes, and was more  firmly adherent than them to the carti-
 lages upon which  it  was  situated.   The  middle  tumor  was  also
 entirely separated  on each side  from the lateral tumors by a deep
 fissure, leaving each tumor upon a distinct base.  These fissures had
 been made deeper,  he said, by constantly handling and wiping out
 the clammy  matter secreted  between the tumors.   The teguments
 upon the diseased part were  of the same  flushed  color and rough
 appearance as upon the rest of the  face.
   The remarkable tumors upon the nose of this patient  had been
 familiarly known  for  years throughout the  Bahamas,  as well as in
 many parts of the  West India islands;  and so extraordinary and
 unique were  they considered, that  he was in his travels everywhere
 proverbially designated by the cognomen of Big-Nose Russel.  The
sneering and sarcastic observations many persons had  unfeelingly
 made upon his misfortune, had  for the  last  ten years, he told me,
 almost  prevented him  from going abroad.
  There was no  pain or irritability on handling the diseased mass,
but the weight  of  it at night was so unpleasant as to inconvenience 
NEW ELEMENTS OF OPERATIVE SURGERY.
645
 his respiration, unless lying on his back; in which posture, also, the nose
 interfering with the mouth, would cause him frequently to spring from
 bed during sleep, with a sense of strangulation.  The weight may be
 imagined from the deep wrinkles upon the forehead and around the
 eyes, occasioned  by the incessant and powerful action of the occipito-
 frontalis and adjoining muscles, in their effort to sustain the tumors.
   After having proposed the operation to the patient, and with much
 difficulty  made him understand that no serious consequences were to
 be apprehended from it, he went home to Abaco, and in a few weeks
 returned to Nassau, for the purpose of having it accomplished.
   In  the  meanwhile, the  proposition I had made became  generally
 known; and on his return to Nassau, most of his friends, and one or
 two practitioners of the place, secretly dissuaded him from it, and
 told him that an operation of such moment rendered it advisable that
 he should go to London, and consult Sir Astley Cooper or Mr. Aber-
 nethy.
   These recommendations,  the motives for which, in several of his
 advisers, it  was  by no means  difficult  to interpret, had the effect
 which was intended; so  much so that when, after he had been at
 Nassau several weeks, I again suggested the operation, he positively
 and unequivocally declined.  I had almost despaired of again bring-
 ing his mind to the  resolution of having the deformity removed, until
 at length, on Tuesday, November 23d, 1824, I succeeded in gaining
 his entire  assent.   The operation was performed about noon of that
 day, in  presence of Mr. Brydon, Assistant Surgeon of the Forces at
 Nassau, in the following  manner: passing  the scalpel first on the
 outer edge of the left lateral tumor until it was removed  smoothly
 from the cartilages to which it was attached, then  doing  the same
 with the right lateral tumor, and finishing in the same manner, with
 the middle lobe ; the whole operation being completed in five minutes.
 Several large compreeses  were then placed over the nose across the
 face, secured by a bandage round the head, to check the haemorrhage,
 which was  not more than  eight  ounces.  Openings were  made
 through the compresses to admit light to the  eyes.  In four days the
 dressings were removed, and in exactly two  weeks from the moment
 of the operation,  the  wound having (under the  carbon, bark, and
 alcohol  poultice, and tonics internally) kindly granulated by the first
 intention,  the patient, to the  astonishment of an assembled multitude,
 who thronged  after him, appeared at  the  public  vendue with a
 smooth,  handsomely formed nose.   The chagrin which this  spectacle
 occasioned to those who had endeavored to defeat the operation, may
 be much more easily imagined than described.
  On  passing an incision through  the different  tumors, they were
 found to consist  entirely  of a dense, homogeneous, adipose or  fatty
substance  of a white color, each containing  near its centre one or
more small spherical cysts of about a quarter of an inch in diameter,
filled with a thick, pappy, or a theromatous fluid of a yellow color.
  Plate  II. exhibits the appearance of the face and nose after the cure.
                              Yours, respectfully,
  Dr. Hosack.                           P. S. TOWNSEND.
  From the account of the case as published by me at New York,
 1825,  p. 1 to p. 8, inclusive.   T.] 
646
CYSTS,  PROPERLY SO  CALLED.
Fig. 1.
An exact likeness of Russell's Face and Nose, as taken by P. S. Townsend, M.D.,
        a few days before the operation, which was on Nov. 23d. 1824.
Fig. 2.
An exact likeness of Russell's Face and Nose, as taken by P. S. T.,
               three weeks after the operation. 
NEW ELEMENTS OF OPERATIVE SURGERY.
647
                 Article II.—Hematic  Cysts.

  When the unabsorbed extravasations of  blood do  not give rise to
concrete hematic tumors, they become perverted in their nature and
result in the formation of cysts which contain sometimes a melange
of fibrinous clots and of  a  more or less  yellowish-colored, red or
brown serum, and sometimes concretions which have been designated
as free (fibres, i. e.  loose) cartilages, and  as hydatid granules and
lymphatic  productions, which are found floating  in  the midst of a
more or less abundant unctuous, lactescent or diaphanous liquid;  so
that  the whole conveys the  idea of grains of barley or rice as  seen
in a  potage, or  of cartilaginous  or plastic plates  or bodies,  or
laminas or septa, sometimes free, at  other  times adherent to the
interior of the pouch.  Nor is it rare to find the whole contents of the
cysts transformed into a homogeneous liquid, sometimes of a reddish
color and  ropy (sirupeux),  sometimes milky or rose-colored and
of an unctuous feel, or at other times wholly serous or slightly lemon-
colored.

                § I.—Hematic Cysts  in  general.
  The various kinds of hematic cysts do not differ in any respect as
regards the progress, duration or consequences  of the tumor, but
render certain remedies better adapted to  some than to others.
  A. Thus cysts that are purely liquid sometimes disappear under
the use of resolvent topical applications, compresses saturated with
a solution of sal ammoniac  or iodine, frictions with mercurial  oint-
ment and that of hydriodate of  potassa.  Temporary blistering also
succeeds quite frequently.
  B. A remedy much more  powerful than  the preceding, and besides
much more simple, consists  in incising the cyst on some depending
portion of it and emptying  it completely.  This  being done, accu-
rate  methodical  compression enables us to bring its walls into imme-
diate contact and in this  manner  sometimes to obtain agglutination
by the first intention.  Otherwise  it suffices to keep the incision open
for four or five days by means  of a meche (tent), that inflammation
may  be established within  the cyst  and render its agglutination
almost  unavoidable.
  C. But the best remedy in such cases evidently consists in irrita-
ting  injections, such as are employed in hydrocele. A puncture with
the trochar empties the tumor without difficulty ; immediately inject-
ing through the  canula of this instrument  a certain quantity of tinc-
ture  of iodine, in the proportion of a third  of the tincture to  two-
thirds of water,  I obtain a moderate inflammatory action, which
causes but little  pain and almost  always  terminates in the  perfect
cure of the cyst.  Up to the present time I have  not found that the
tincture of iodine has produced any of those inflammatory accidents
and  purulent  abscesses which  some practitioners charge to vinous
injections, eulogized, and also employed successfully a long time ago
by M.  Asselin,  (These sur les Tumeurs  des  Bourses Muqueuses,
Strasbourg, 1803.)  Hematic cysts therefore that  are purely liquid,
have no need in  my opinion of excision, extirpation or  caustics, and 
648
CYSTS,  PROPERLY SO CALLED.
the most they can require after resolvent topical remedies, temporary
blisters, iodine injections and the simple incision, would be multiplied
incisions.   The cyst being well circumscribed,  allows  neither the
liquid nor the inflammation, when the latter is moderate, from be-
coming infiltrated or diffused into the neighboring cellular tissue to
such extent as to create the  least  uneasiness, while the disease may
be compared in every respect to a hydrocele.
  D.  If in place of matters purely liquid, the cyst should contain a
variety of the concrete  clots which  I have mentioned,  there might
be necessity for operations somewhat more  complicated.  Then, in
fact, it is rare that the irritating injection and puncture, or simple in-
cision, suffice.   We might, however, make  trial of one or the other
of these operations, where the cyst reposes  in every portion of it, in
the midst of soft tissues.  Emptied of the liquid matter  it contains,
the tumor, if afterwards submitted to compression and the action of
discutient applications or temporary  blisters, might possibly become
concrete and  transformed into a  nodule  that would ultimately dis-
appear by simple resolution.   In  other cases,  and  where the cyst
assumes most of the characters of synovial  tissue, it would be illu-
sory to count on the efficacy of such  means.
  E.  In such cases, massage,  also, crushing, and the sub-cutaneous
punctures, might be made trial of.   The fact is known, that sero-san-
guineous liquids, when they once become encysted or enveloped in
a sac, whether serous or fibrinous, are reabsorbed with extreme diffi-
culty ; whereas, when infiltrated into the  cellular  tissue, they in
general readily and rapidly disappear.  Every thing, therefore, goes
to show, that if by massage, or any  kind of compression whatever,
we  could  succeed in rupturing the  hematic cysts, we should have
reason to hope for a cure.  By inserting a needle under the integu-
ments, so  that it  might pass  obliquely and break up the sero-san-
guineous pouch, we should also be enabled  to force the morbid fluid
to effuse itself into the neighboring cellular tissue.  If we  should
combine with this  process, compression or temporary blistering, it
might also be frequently attended with success.  With these excep-
tions, we must come to the seton and complete incision into the cyst
or the multiplied incisions.
  F. Seton.—The  treatment of hematic cysts by the seton, is not a
new mode of cure.  Surgeons of all  ages have occasionally boasted
of its efficacy.  We  may conceive, in fact, that this means,  by the
inflammation and suppuration which result from it, might  bring about
the fusion  (fonte), evacuation,  and cleansing of the sac.   The ope-
ration, then, may  be  compared in every  respect  to the one  for
hydrocele, by the same remedy.  It is just to remark, however, that
the  clots, concretions, and  various layers, which are then degene-
rated (denaturees)  in  the  interior of the  cyst, often prevent the
seton from succeeding, and  that the inflammation  thus  produced
sometimes takes on a serious character, and but rarely progresses in
a manner favorable to the cure.
  G.  Incision.—When kept up by the presence of morbid fibrinous
concretions, hematic cysts would seem to demand, above all things,
that they should be extensively laid open in order to extract from
them  these foreign bodies.  Under  this  state  of things, we  should 
NEW ELEMENTS OF OPERATIVE SURGERY.
649
 proceed in the same way as was done in  the time of Celsus in the
 operation for hydrocele by incision; that  is to say, that after having
 freely laid open the tumor by means of a sharp-edged bistoury, we
 should empty it and thoroughly evacuate it both of its liquids and
 all kinds of concretions that might have accumulated there.  Having
 thus properly cleansed it out, it is to be filled with small balls of soft
 lint, and then covered  with the perforated linen, a plumasseau, com-
 press and containing  bandage.  When the process of suppuration
 has sufficiently saturated this first dressing, the different portions of
 it are to be daily renewed, and we proceed to the end of the treat
 ment the  same as for an  abscess,  dressed  flatwise and  largely
 opened.   This method, which  is without contradiction one of the
 best,  has,  nevertheless,  the  disadvantage of not being applicable
 without danger in every region of the  body.   In the  first place, it
 would be hazardous to think of it for cysts which  exceed the  vol-
 ume  of  the  fist, in whatever locality they might be situated.   If,
 though, of less size, the tumor should be bridled by certain tendons,
 ligaments,  muscles, vessels or important nerves, there  would be
 danger in dividing it through and through.  It  is, moreover, useless
 to do that in  the immense majority of cases.
   H. Multiplied Incisions.—It is besides  sufficient for the treatment
 of this class of cysts, to cleanse out their interior thoroughly and to
 create many openings  for the fluid which is constantly tending to
 become re-accumulated in them.   For that purpose I have been for a
 long time in  the habit of treating them by incisions of about  an  inch
 in length, and which should not be wider apart from each other than
 an inch or two, so that I make  a variable number of them according
 to the dimensions of the tumor.   The first being made by puncture,
 enables me to introduce into it my finger, which then serves as a guide
 and support for the others.  Directed through these incisions more-
 over, the finger enables us to detach and extract whatever there may
 be of a concrete or foreign nature  in the  tumor.   In  order  to  pre-
 vent their primitive agglutination I  frequently pass from one to the
 other a meche of  ravelled (effilee) linen, in form of a  seton,  and
 which I do not permanently withdraw until after the complete estab-
 lishment of the suppuration.   To  set out from this period the disease
 is to be treated like a vast abscess: emollient cataplasms, and then
 resolvents and compresses saturated with lotions of the same nature,
 are the only topical applications which can  now be  of  use.   The
 concretions which often adhere to  the  interior of the cyst in the
 form of concentric laminae, are fused and gradually decomposed, and
 imperceptibly detached  and  eliminated by the inflammation,  and
 finally escape with  the product of the suppuration.  After the  dis-
 charge of all  these foreign bodies, the pus, which assumes a better
 aspect, diminishes in quantity, and  allows the  engorgement of the
tumor gradually to  subside, while the walls of the cyst approximate,
unite together and become consolidated.   It is precisely because of
these  concrete matters formed from the  blood, that hematic cysts do
not generally heal until after having been transformed into abscesses
and submitted to the treatment most  suitable  for this  last disease.
 The seton  properly so called, and  the  simple  incision, are  of  less
value than  the multiplied  incisions, because they do not like these
  vol. n.                         82 
650
CYSTS,  PROPERLY SO CALLED.
iast permit the immediate escape of the foreign bodies and the flow
of the pus in proportion as it is formed ; from whence it results that
at a later period it becomes necessary most usually to superadd mul-
tiplied incisions to the seton and simple incision.
  I. Extirpation.—Sanguineous like all other cysts, seem sometimes
to be incurable except by extirpation.  But this operation, which is
usually long and delicate, and  sometimes difficult and dangerous, is
no longer admissible at the present day, unless  the tumor should
have  undergone some degeneration of a bad character, or some lar-
daceous or fibro-cartilaginous  transformation.'  If the diseased cyst
could be removed in its totality, it would put it in our power to re-
apply the flaps immediately  over the bottom of the wound, and
to treat the solution of continuity by first  intention.  In whatever
manner done, it is easily understood that this treatment would not
be applicable except to tumors that were not of large size  and that
were  sub-cutaneous or inter-muscular.   Multiplied incisions more
over,  which almost always succeed and which are  applicable to all
cases, do not exact much more time than extirpation to  accomplish
a radical cure.  Extirpation, as respects  the operative process, the
danger and the consequences of every description, is upon the whole
infinitely more serious, without presenting more certainty of success
than the multiplied  incisions, and apart  from some cases of excep-
tions,  I cannot see that it can scarcely ever become indispensable to
give it the preference over the latter.

§ II.—Sanguineous Cysts, according to  the  region  in  which they
                          are situated.
  Every effusion  of blood having*the power to produce an hematic
cyst,  there is reason to believe  that no  region of the body can be
exempt  from this kind of tumor.  Whether we examine them in gene-
ral  or particular, it is nevertheless  aavisable  to  distinguish  them
always  into two  great classes—cellular hematic cysts, and the mu-
cous and synovial hematic cysts.
  A.  Cellular Hematic Cysts.—The first, that is to say, those which
are formed in the midst of the  cellular tissue, or external to the mu-
cous bursas, cannot be studied separately as respects operative sur-
gery.   I will remark only in regard to them, that every effusion of
blood of this kind should be treated, for a month at least, by topical
resolvents, compression, massage, crushing, or temporary  blisters,
before coming to operations, properly so called.  Two principal rea-
sons induce me to give this counsel: the first is, that every hematic
deposit  retains a  certain tendency to resolution up to the expiration
of the first month,  and that if inflammation should not supervene,
crushing and blistering succeed quite frequently ; the second reason
is, that in opening the sac in such manner as to admit of the air pene-
trating into it from without, we thereby usually excite in it an inflam-
mation  of a  sufficiently bad character, which readily takes on the
form of erysipelas, properly so called, or angeioleucite or phlegmonous
erysipelas.   At a later period, when the hematic collection becomes
completely encysted, the chances of cure by simple means diminish
from  day to day. while the concentration  of the organic  lamellas,
which become approximated to each other in order to form the en- 
               NEW ELEMENTS OF OPERATIVE SURGERY.          651

 velope to the deposit, diminish in the same proportion the dangers oi
 the operation.   The tumor now differs scarcely in any respect from
 those which have been established  in  a previously existing cyst, or
 in a synovial sac.   As for the rest, the operations  which may be
 made trial of in such cases, are either the pure and simple incision on
 a depending part of the sac, the laying of it open completely,  or the
 multiplied incisions.  Caustics, the seton, irritating injections, or extir-
 pation, would in general be insufficient or useless in such cases.  The
 operation, moreover, will  have to be submitted to the same princi-
 ples, whatever may be the region of the body to which its application
 may be useful; and it is in anatomy alone that the surgeon  must find
 the rules  for his conduct in  hematic tumors of this species particu-
 larly.
   B. Synovial Hematic Cysts.—When the hematic cyst has  estab-
 lished itself  in a previously existing mucous bursa,  there is scarcely
 reason to  hope for its cure  by resolution after the first  three  or
 four weeks of the disease have passed by.   Should there be ever so
 few clots or concretions in the cyst,  it is almost impossible for topical
 applications,  injections and temporary blisters to succeed, and crush-
 ing would both be of little effect and extremely difficult.   In those
 cases, therefore,  the operation, properly so called, may be  proposed
 without waiting  as long  as for  hematic cysts of the cellular tissue.
 We may easily conceive that all the mucous bursas might possibly
 become the seat of similar cysts; there are, however, some  in which
 they are developed much more frequently than in others, and so to
 speak, exclusively.
   I. In the head, for example, hematic cysts have been but rarely ob-
 served in the synovial bursas.  It is not the same we shall see with the
 cellular cysts, (see Hydrocephalus.)   Upon the temporo-maxillary ar-
 ticulation,  at  the angle of the jaw or on the symphisis of the chin, the
 incision through and through would present no difficulty, might be per-
 formed as  for the opening  of  an abscess, and might be preferable to
 the simple incision, unless  we should wish to recur to puncture and
 irritating injections.
   II. The mucous bursa of the thyroid cartilage, and that of the di-
 gastric muscle, should they become the seat of a sanguineous effusion,
 are to be  treated in  the same manner, unless the tumor shall have
 acquired a great volume, or the walls of the cyst have undergone a
 great  degree of  attenuation.   In this last, the irritating injection, if
 there are no foreign bodies  to extract, and the multiplied incisions, un-
 der opposite circumstances, should be substituted to the other method.
   III.  What I have said of the thyroid angle, is applicable  in every
 respect to the mucous bursa of the seventh cervical vertebra, and
 that of the anterior surface of the sternum, and of the summit of the
 angular projections, (du sommet des gibbosites;) but when  the cyst
is  established upon the sides of the spinal column, in the lumbar re-
gion,  or on the external surface of the muscles, especially the latissi-
mus dorsi, it is rare that the total incision of the cyst should  have the
 {reference.   Supposing the tumor should consist of matters purely
 iquid, a puncture to  empty it,  and  an iodine injection to inflame it,
would almost always effect a  cure.  If grumulous products, concre-
tions and clots of degenerated blood  existed in the sac, to such extent 
652
CYSTS, PROPERLY SO CALLED.
as to render the success of the injection doubtful, we must then have
recourse to multiplied incisions  and meches  of ravelled linen, (see
above.)  Six incisions of an inch and a half each thus effected the
cure of  an hematic tumor  which had  formed between the spinal
vertebras and the upper part of the arm of a man who was admitted
into my division of La Pitie in 1832.  A young man who had a simi-
lar cyst  at the lower part of the lumbar region, was cured of it  at
the expiration of a month by four incisions  of the same kind.   A
woman, in other  respects in indifferent health, and whose  life has
since  been threatened  by a  diffused erysipelas, had for the space
nearly of a year, between the spine and the lower angle of the scapula,
a tumoivresulting from a blow, and having half the volume of an adult
head.   Having laid open this tumor freely on four opposite  points, I
afterwards passed two setons through it, which were removed at the
end of a week, and nothing  further has been required to complete
the agglutination of the walls of the sac.
  IV. The mucous bursa which covers the lower angle of the scap-
ula, is quite frequently the seat of hematic extravasations.  A young
man formerly employed in carrying a hod, presented at the hospital
of La Charite, in 1836, an instance  of  a tumor of this description
which was equal in size to two fists.  I opened it in three places, and
the cure ultimately took place; but the natural mobility of the osse-
ous angle and  of the latissimus dorsi and trapezius muscles, presents
in this part such obstacles to the obliteration of the cyst, that at the
present time I would endeavor before all  other things to produce an
inflammation in its interior by means of the iodine injection, should
it not  appear to contain too  great a proportion of concrete matters.
The simple incision, to which a preference was given in the patient
mentioned  by  Marechal, (Nouv. Bibl. Med., t. I., p. 455, 1818,) and
who had a bilobate cyst upon the shoulder, brought on a suppuration
which ended in death.
   V.  Upon the dorsal portion of the acromion, hematic cysts might
be treated as in the  general  track of the spine.  Those on the con-
trary  which form between the deltoid and the scapulo-humeral cap-
sule, would ^require  that we should confine  ourselves to the simple
incision, as I have done in two instances, or to the iodine injection.
This last remark is alike applicable to the sub-tendinous cysts of the
olecranon, the  sub-muscular cysts of the coronoid process, and sub-
bicipital cysts of the radius.  Upon the inner condyle of the humerus
they would require the same treatment as for that upon the  spinous
process of the  seventh vertebra.  The same would  be the  case foi
those on the styloid  processes  of the radius and ulna, and  for those
on the dorsum of the  metacarpo-phalangeal articulations.   But the
sub-cutaneous  mucous bursa of the olecranon, and the synovial cavi-
ties of the wrist, require in this respect some special precautions.
   VI.  Hematic Cysts of the Olecranon.—I have noticed in the sub-
cutaneous  mucous bursa at the elbow  all  the varieties of hematic
effusions.  If the effusion is in a liquid state and we are called shortly
after  the  accident, topical applications, compression and the blister
should be first  made trial of.   At a later period, if the tumor is volu-
minous and almost exclusively filled with fluid matter, puncture and
the irritating injection are almost always sufficient.  Should the mu- 
c
              NEW  ELEMENTS  OF OPERATIVE SURGERY.          653

cous cavity contain at the same time those granulations which resem-
ble rice, barley or millet seeds, and which some persons have mista-
ken  for hydatids or  cartilages, puncture and injections no  longer
have the same efficacy.  Multiplied incisions should then have the
preference.   Though exposing to  phlegmonous erysipelas, they are
less dangerous than extirpation and succeed full as well, without re-
quiring so long a time for the definitive cure.  If, in the place of this
appearance of boiled rice or barley, the matters contained in the cyst
should simply present the aspect of grumous substances, concretions
or ordinary clots of fibrine, the same treatment should still be pre-
ferred.
  VII. Hematic Cysts of the Wrist.—I do not mean under this title
either the spiroidal  (spiroides) tumors which sometimes  form  in the
sheath of  the  tendons of the thumb on the outer side of the radius,
or those bumps (bosselures) of the same nature which are sufficiently
often noticed  upon the  palmar surface of the fingers upon the track
of the flexor tendons of those organs;  but of the kind of cyst which
has for its special seat  the synovial cavity in the palm of the hand
and on the palmar surface of the wrist.   This tumor, of which some
examples  are  found in the ancient collections  of observations, but
which  nevertheless  has only attracted attention  since the time of
Pelletan and Dupuytren, has this remarkable feature, that it is divided
as it were into two parts by the anterior annular ligament of the car-
pus, in such manner that one of these portions projects from the palm
of the hand,  while the other  presents itself above  it.   Conveying
moreover the sensation of a  crepitation or friction  of granulous
bodies gliding upon each other, and a kind of fluctuation when alter-
nately compressed at  its two  extremities, it is in general easily diag-
nosticated.  Having sometimes found them filled with clots 01 blood,
which may still be recognized though comminuted (morceles)  I have
ultimately come to this conclusion, that the grains of which they are
usually composed and which are almost always found in them to the
amount of some hundreds, far  from belonging to the class of hyda-
tids, as Dupuytren believed, or to that of loose (libres)  cartilages, as
others have supposed, were in fact nothing else  than  fragments of
degenerated (denaturee) fibrine or plastic lymph.  Whatever may
be their nature,  these tumors, denominated  bisaculoted  (en bissac)
tumors of the wrist, should be  first attacked by every other kind of
remedy than  that of  the cutting instrument, especially by repeated
temporary blistering,  seeing that no actual operation can be employ-
ed for them without danger.    The irritating injection, which would
be the mildest remedy for them, if liquid  matter predominated in the
cyst, is without  efficacy in other cases.  A large seton  passed from
above downwards through the  whole length of the sac might  doubt-
less succeed ;  but inflammation so readily extends to the palm of the
hand,  the tendinous  sheaths  of the fingers  and the synovial net-
works and cellular tissue of the fore-arm, that it becomes the  source
of real dangers, and  sometimes proceeds to the  extent of compro-
mising the life of the patient, or at  least the preservation  of the
limb.
  What I say of the seton is  applicable  also to  the simple incision
on  one of the prominences of the tumor, or to multiplied incisions, 
654
CYSTS,  PROPERLY SO CALLED.
or the  laying  open of the  whole tumor, including in this  divi-
sion the anterior ligament of the carpus.   I know that F. Aquapen-
dente, Portal (Hist. Anat., t. II., p. 227),Schmucker, (Bibl. Chir. du
Nord, p. 21), Gooch (Encyclop. Meth. Chir., t. I., p. 545), and Dupuy-
tren (Gaz. Med., 1830, p. 311. no. 34,) have met with success from the
incision, and  that Warner (Obs.  Chir., obs. 15 and 1G, p. 88,;  was
enabled to divide the anterior ligament  of the carpus with impunity,
and thus effected cures ;' but  I have seen  such frightful results from
this method at the Hotel-Dieu and  Hospital of St. Louis, that I would
scarcely dare recommend it.   It is to be added also, that under the
most favorable circumstances possible, the walls of the cyst operated
upon in this manner, cannot agglutinate  without  causing such ad-
hesions  and  confusion  of the tendons, which  course through the
wrist, that a deformity of the hand  or  of  the fingers would be the
almost unavoidable result.   In this  region then, hematic cysts are a
species  of noli me tangere;  and we should be on our guard  against
meddling with them so long as the patients are not greatly incom-
moded by  them, and not until  after having made trial of all other
remedies, and forewarned the family of the possible consequences of
such an operation.
  a.  As for  the rest, when once decided  upon, the operation which
I should then advise would neither  be  the seton, nor the simple in-
cision, nor the complete laying open (la fente totale)  of the sac; I
should much prefer  three or four free (large) incisions upon the
principal projections of the  cyst, which  I would then treat  as  a
large (grand) abscess, by emollient topical  applications, local  sangui-
neous emissions, and all the different kinds of antiphlogistic remedies.
Having seen a young person  operated upon by means  of the simple
incision, by M. Richerand, on the  point of  dying from the inflamma-
tion which seized upon the whole  hand and fore-arm, and knowing
the consequences  of this kind of  treatment, as pointed out  by Du-
puytren, I should not venture upon it  but with the greatest repug-
nance.  The two patients in whom I used  multiplied incisions having
got well, encourage me, on the contrary, to commend this last mode
of operating, without,  however, presenting  it as exempt from all
danger.  I should add, that in a young  man operated upon by me at
La PitiC,  in 1832,  the hematic cyst though very ancient, contained
concretions of fibrine and clots of blood still recognizable, but without
any of those grains  of which I have spoken of above.  The  four
incisions which I made upon it above  were followed  by an inflam-
mation  sufficiently intense to give me  at  first  some degree of un-
easiness ; but  the  accidents  ultimately subsided, and the cure  was
accomplished at the expiration of the second month.
  b.  A  puncture and a small incision  aided by compression,  have
also succeeded so  well  with M. Champion, that it is  well to  have
recourse to  it  again.  M. Duval, manufacturer of cotton  fabrics,
consulted me (says this practitioner in a  letter to me,) in the  year
1810, for a ganglion of a sufficiently large size, which raised up the
skin  in  the  palmar surface  of the hand, and which was prolonged
upon the lower third of the  fore-arm, by passing under the annular
ligament of the tarsus, which  divided it  into two bellies.   Having
used the bandage of Theden for the space of six weeks,  without 
NEW ELEMENTS OF  OPERATIVE SURGERY.
655
success, I plunged a bistoury into the lower part of the tumor upon
the fore-arm, which brought out more than six ounces of liquid, to
which there succeeded soon after, about two teaspoonfuls at least, of
small foreign bodies of the size of the eggs of the carp, and of a
reddish color, and  a slight degree of hardness.   The compressive
dressing to the hand had  been reapplied before the operation, and  I
continued its application  to the cyst, and  the whole limb as high as
the axilla, by means of a bandage kept moist with oxycrat and salt,
cold.   The incision, which at first was only four lines in length, had
to be  enlarged to effect a  passage for the small  granulated bodies.
No accident  took place, and scarcely any inflammation supervened.
The dressing, or the roller bandage,  was  continued for a month, re-
stricting it soon to the surfaces which corresponded with the disease,
and the cure was complete.  I operated, says M. Champion, upon a
second and similar  case  in 1822 ; only that the  tumor was of less
size.  The incision  gave egress also to concretions, but  in smaller
quantity, and the success was the same.
  VIII. The Lower Limb.—If  the mucous bursa of the antero-supe-
rior spinous  process of  the ilium should be transformed  into an
hematic cyst, it would become necessary to attack it like that of the
olecranon.   It would be  the same with that on the outer  border of
the great trochanter, and on the outer surface of the thigh.  I have
met with one  example in front of the spine of the tibia, and which
disappeared under  the influence of  two  temporary blisters.   The       •
same  took place in  the case of an hematic cyst  at the head of the
fibula.  The sub-cutaneous hematic cysts  upon  the posterior surface
of the heel, and upon the dorsal and inner side of the scaphoid bone,
the projection of club feet, and the dorsal and inner side of the first
and other bones of the metacarpus, do not exact also other precau-
tions  than those of the corresponding regions  of the hand.  Upon
the stump of persons amputated, these tumors should not be treated
but with a certain degree of reserve, inasmuch as their suppuration,
from  their being situated on the apex of  the bone, would obviously
expose to necrosis.   Between  the great  trochanter and  the coxo-
femoral articulation, between the gluteus minimus muscle and  the
same  articulation,  between the obturator  internus muscle and  the
lesser sciatic notch, under the tendon of the iliacus internus muscle,
upon  the apex of the little trochanter, between the triceps and  the
rectus femoris, under the  ligamentum patellas and between the ten-
dons of the pes anserinus, between the os calcis and the tendo achil-
lis, where  I have  met with three  examples,  also on the plantar
surface of the foot,—hematic cysts if somewhat ancient, scarcely ever
yield  to the application of  topical resolvents, nor even to large tem-
porary blisters.  As on the other hand there is some danger of pro-
ducing suppuration, they should be treated by puncture and irritating
injections, provided  they contain a sufficiently strong proportion of
liquid matters.  In the contrary case,  I know  not in reality which
should have  the preference, whether the seton, the simple or multi-
plied  incisions, or the complete  division.
  IX. I have often  observed hematic or sero-sanguineous cysts upon
the dorsal and inner regions of the metatarso-phalangeal articulation
of the great toe.  In this place temporary blistering and  topical ap- 
656               CYSTS, PROPERLY SO CALLED.
         plications of all kinds should be made trial of before proceeding
         farther.  Supposing such means should produce no effect, we should
         not even then come to the operation, unless the tumor was in reality
         a source of serious annoyance to the patient.  These mucous bursa;
         are so near the articulation, tvlth which moreover they  sometimes
         communicate, that we should* never divide  into them or lay them
         open, nor, in a word, carry the cutting instrument upon them unless
         compelled to do so.  I have  seen two patients  upon the point of
         perishing in consequence  of such attempts, and  through means of a
         suppuration, which after having invaded the articulation  ultimately
         left therein caries which rendered amputation necessary.  Platner,
         (Coll. Acad.,partie etrang., t.  VIII., pt 43, du Discours Preliminaire ;
         also Paul, Suppl. a la Chir. d'Heister, p. 50.) speaks of a ganglion
         of the  synovial cyst of the tendo achillis,  which having acquired
         an immense size, was followed by serious accidents, though nothing
         had been done to it.   I saw, says M. Champion,  a synovial ganglion
         of the same kind eight years since, in a woman aged 36 ;  it was of
         the size of  the  fist and its form was elongated.   I recommended
         puncture and compression, and  rest  for the space of a month and
         more.  The patient more alarmed at  the period of time than the
         operation, consulted an officer of health, who  promised  he  would
         make a more speedy cure.  An incision was made ; and soon after
         a  fungus formed on the inside surface of the cyst, and acquired a
#        very considerable size, ending in the death of the patient.
           X. The mucous bursa  on  the  dorsum of the foot, which I have
         seen transformed into an hematic cyst in three instances, would re-
         quire the same precautions, though there might  perhaps  be a little
         less danger of the inflammation  prolonging itself to as great an ex-
         tent as in the preceding case.
           XI. The malleolar hematic cysts I have  met with, have all been
         treated by the multiplied incisions; but it would be prudent to at-
         tempt their cure by irritating injections if they contained a large pro-
         portion of liquid matters.  The neighborhood of the fibro-synovial
         sheath of the peronei tendons on  one  side, and of the tibialis posti-
         cus on the other, together with the character of the tibio-tarsal arti-
         culation, should  always make us avoid as much  as  possible the
         establishment of a purulent inflammation in that quarter.
           XII.  It is upon the knee that hematic cysts are the most frequent-
         ly met with.   Those which develop themselves upon  the outer or
         inner condyle of the femur, rarely acquire a large size, and may be
         treated by crushing, sub-cutaneous puncture, or irritating injections,
         when  they  have resisted both  topical resolvents and temporary
         blistering.   There will be opportunity moreover after these means, to
         attack them by a complete division or by multiplied incisions rather
         than by the seton.
           XIII.  Those  in front  of  the  patella and which are so often
         encountered  in  practice, and of which I  have seen  so great  a
         number of varieties, require especially that  I should allude a mo-
         ment to them.  In this part I  have met with  them of the form of a
         plate of little thickness, four or five inches long and from two to four
         fingers' width in breadth; at other times presenting a bi-sacculated
         appearance   or an  irregularly embossed (bosselee) mass,  or hemis- 
NEW ELEMENTS OF OPERATIVE SURGERY.         65?
 P SnCam °r takinS on the character of a transverse bourrelet [like a
 collar, T.]   I have seen them of the size of the fist, though ordina-
 rily they do  not  exceed that of a pullet's or turkey's  egg.  Some-
 times filled exclusively with liquids, either viscous, or purely serous,
 or lactescent, and of a reddish brown or simply a roseate tint, they
 very often also contain clots of a fibrinous or  reddish matter, still
 possessing most of the characters of clots of blood; sometimes sim-
 ple greyish or yellowish clots that are friable, or  as  it were, carti-
 laginous  and exceedingly variable in number ; at other times  a
 species of columns or movable  bridles that are hard  and slippery
 and of a cartilaginous aspect, and adherent by one of  their extrem-
 ities or even by both, so that in pressing them upon their exterior they
 convey a sort of crepitation which is sufficiently distinct  and alto-
 gether of a peculiar character.   The  extirpation of these  cysts,
 which MM. Pezerat (Journ. Compl. des Sc. Med., and Bibl.  Med.,
 1827, p 414) and Hervez (Journ. Hebd., t. III., p. 329,) still seem to
 prefer in adducing facts in support of it, would not become indispen-
 sable unless their walls should have acquired an extreme  degree of
 thickness, and a fibro-cartilaginous density.  In such cases we should
 proceed  in the  manner pointed out  for concrete hematic tumors.
 When the cyst is not  of a very ancient date and [its  contents] al-
 most exclusively  liquid, it is advisable to commence with topical re-
 solvents,  compresses  saturated with  ammoniacal vinegar or any
 other solution of sal ammoniac.  The temporary blister would  come
 in as a second remedy.  I have seen a  certain number of hematic
 cysts of the  knee, which  had existed  over  three weeks,  dispersed
 by employing this description of remedy.  [Our author (see Vol. I.)
 means by temporary blistering  (vesicatoire volant) the successive
 application of small blisters composed as usual of Spanish flies, com-
 binations of ammonia, &c, left  on  for a short time and changed  in
 their locality.  Vesication is not  intended, but only a phlogosis or
 commencing inflammation, redness, &c, so as strongly to  direct the
 sanguineous and other currents  to  the part.  So far however from
 this temporary or transient mode of applying blisters, and which the
 author much insists on as an extremely valuable remedy, being a
 reliable one here, we ourselves have, on the  contrary, found even  in
 these largest sub-cutaneous mucous (properly serous, see our  notes
 infra) bursas, of  old  date, i. e., a year or  more, and covering the
 whole patella of an adult, being like a large inverted cup, effectually
 cured for a length of time  by means of a continuous copious  drain
 of  suppuration kept  up on the  dermoid surface of the tumor by
 thorough, repeated and full blistering, i. e. by the ordinary mode of
 applying this remedy.  However, as I have repeated, (Vol. I.) bursce
 of the largest description, provided their contents are liquid, and
 their  walls and the neighboring tissues  are not intensely inflamed,
 are, whatever may be their date, best and most effectually and rad-
 ically cured by percussion, i. e. ecrasement or crushing, &c. T.] At a
 later period we would have but little to expect from topical applica-
tions and the blister. We must then endeavor to ascertain if it is liquid
matter, or concrete, that fills the synovial bursa.  In the  first case
iodine injections would have a decided preference over every  other
preparation.  I have made use of them .on three occasions under
   vol. n.                      83 
658
CYSTS,  PROPERLY SO CALLED.
such circumstances, and the result has been  as simple as in a case
of hydrocele.  The trochar being  plunged in  at the summit of the
tumor from  below upwards, while the leg is  in  extension, enters
into the cyst as it does into the tunica vaginalis, allows us to extract
all the liquid, and  afterwards  to inject into the cyst the medicated
compound with the greatest degree of ease.  Similar successes also
were obtained formerly by various practitioners, and in our own
time by M. Asselin, who gives two fine  examples of them ;  also by
M.  Paul Guersent, as well as by M. Laugier.
  The efficacy of irritating injections  for cysts in front of the knee,
therefore, is at the present day a point definitively adjudged.   When
the cyst, on the contrary, contains a sufficiently large proportion of
solid clots, it  is probable, though not yet demonstrated, that the in-
jection might not be successful.  The most suitable operation then,
is not that of the seton;  the pure and simple incision, with the intro-
duction of a tent into the cyst, which I have done four or five times,
is far from being always successful.  The walls of the tumor only
partially agglutinate, and the  effusion  generally is  ultimately repro-
duced.  The tumor returned in three  patients that I operated upon,
and the other cases were cured only by means  of a violent  inflam-
mation, which speedily  involved the whole anterior portion of the
knee.   It  is  necessary,  moreover,  in all cases,  that  this  incision
should be near an inch long, if we wish to have no difficulty in the
discharge and extraction  of the foreign  grumous  bodies contained
in  the  cyst.  The crucial  incision  also, which I have  sometimes
made use  of,  and which many practitioners have  sanctioned, is an
operation too serious in  its consequences, and leaves a wound of too
great length and too difficult of cicatrization to merit general adop-
tion.  The same may be said of excision, which was still employed
by Percy  or  by Laurent,  (Eloge de Percy, p.  25.)  Multiplied  in-
cisions, consequently, are those to  which  I give  the preference in
these cases.  These incisions being made of about an inch in length,
and placed one above, another  below, and one on each side, and as
near as possible to the circumference of the sac, and whose aggluti-
nation is  prevented by means  of a  meche  of ravelled  linen during
the first four or five days, enable  us  to  empty the sac completely,
and thus create an inflammation in it, which almost unavoidably re-
sults in the consolidation of its walls.  Certain it is, that the patients
treated by me in this  manner, have all been  cured in the space of
from three to six weeks.  I ought, however, to add, that in a man
operated upon in this manner in 1837, at the hospital of La Charite,
for an hematic cyst at the elbow, the disease in  consequence of an-
other fall on this part, was reproduced in  1838.   We must, more-
over, not forget that sudden movements, as well as the want  of pro-
per care in the dressings, would incur  at the knee more than  in any
other part, the risk of  angioleucitis, erysipelas, and diffused phleg-
mons of a formidable character.  I have only in three instances seen
the sub-ischiatic mucous bursa, transformed into a sanguineous cyst.
In this region the disease may  present some difficulties  in the diag-
nosis ;  but it  should be submitted to the same processes of operation
as in front of the knee, and the suppuration would be  far less dan-
gerous than in the vicinity of this latter articulation. 
NEW ELEMENTS  OF OPERATIVE SURGERr.
659
                   Article III.—Serous Cysts.

   Under the title of serous cysts, we should, strictly speaking, com-
 prehend all tumors consisting of a pouch, filled with aqueous liquid.
 We should thus designate under  this name the  greater part of he-
 matic, hydatid, and synovial  cysts, as well as all serous cysts  pro-
 perly  so  called.   Under the  title of serous cysts, however, I  shall
 speak only of those tumors  which are independent of the natural
 mucous or synovial cavities, and which are constituted of an unnatu-
 ral accumulation of diaphanous and exceedingly fluid liquid.   All that
 I shall say of them, moreover, is exactly applicable to synovial cysts
 of the mucous bursas, and to those tumors known under the name of
 hygroma.  This  description of cysts does not belong only to those
 exhalations, which sometimes take place in the midst of the cellular
 tissue, and without any appreciable  degeneration.   A lymphatic
 ganglion, or any  glandular organ whatever, or the presence of any
 foreign substances, may become the source from whence it origi-
 nates.   An enormous  cyst occupied the entire  supra-hyoid region
 from one parotid cavity to  the other; M. Malcolmson (Gaz. Med.
 1838, p. 743) excised an ellipse from it below the jaw, and the liquid
 escaped  together with a foreign body.  But a  kind  of gland  was
 noticed at the bottom of the sac;  this gland being  secured with a
 hook and excised, and, in fact, extirpated almost in its totality, had
 the  appearance of belonging to  the sub-maxillary gland.   Was it
 not, perhaps, a degenerate lymphatic ganglion ? at least the serous
 cyst was certainly dependent upon it.  Marchettis (Bonet, Corps de
 Medec, t. III., p.  239, obs. 38) speaks of a tumor of the size of a pul-
 let's egg, situated in the neighborhood of the trachea, and composed
 of two cysts full of serosity, and imbedded one within the other.   The
 author adds that  there was at the bottom of the sac an excrescence
 which it  became necessary to excise, which  authorizes us in  sug-
 gesting that a lymphatic tumor had been  the point of  departure of
 the disease.   Muralt (Ephemerides  des Cur. de la Nat., dec. 2, an.
 III.) also  speaks  of serous  cysts which  contained either  bones or
 other foreign bodies, as well  as a  pound weight of  serosity.  In
 1838, a man came to the hospital of La Charite, who had a tumor in
 the scrotum of the size of two fists, with all the characters of hydro-
 cele, from which about two glasses of a rose-colored serosity  had
 been already extracted by puncture a year before, and which was soon
 afterwards reproduced.  Suspecting that this  cyst depended upon a
 degenerate hematocele, I operated  upon  it with the  multiplied in-
 cisions.  Various accidents  supervened, and the patient died at the
 expiration of fifteen days. But this cyst, which contained more than
ten ounces of a liquid  almost entirely serous, was the result of an
encephaloid degenerescence of the testicle, which latter, however,
had only  augmented to  about  double  its natural volume.   I have,
moreover, seen cysts that were purely serous, form in the groin, under
the jaw, and in the sub-hyoid region, in consequence of previous dis-
eases in the lymphatic ganglions, or in  the thyroid gland.
  The preceding  remarks were necessary to show that serous cysts
are far from always constituting a simple disease, or from being all 
660
CYSTS,  PROPERLY SO CALLED.
of them susceptible of dispersion with the same certainty by the
action of the same remedy.   I  will add, that after contusions or
bruises which occasion infiltrations or extravasations under the  skin,
we see quite often the coagulable and coloring matter of the blood
disappear,  and  give place to a serosity or viscous or  unctuous fluid,
which is almost  in every respect analogous to  the synovial fluid.
Serous cysts, in whatever way produced,  may  acquire an enormous
volume.  According to Percy, (Diet. des. Sc. Med., t. XXVII., p. 50)
Lev ret met with one which extended from the dorsal region to the
ham.   Powel, (London Med. Jour., t. II., p. 144, 1785,) gives another
example of one which was cured by  incision,  and which descended
from  the shoulder to the spine of the  ilium.   Their ordinary size,
nevertheless, rarely exceeds that of a pullet's egg, or the head of an
infant or of an adult, [being at the same time] more or less irregularly
deformed.   The shape and size of a round loaf of bread,  as in the
case mentioned by Saucerotte, (Mel.  de Chir., t. II., p. 391,) is how-
ever by no means extraordinary.   These  cysts,  moreover, may be
developed  on almost  all the regions of the body.  All practitioners
know that  the  free border of  the lips and  eyelids are frequently the
seat of tumors of this kind, which rarely exceed the dimensions  of a
small bean, and for the speedy cure of which, all that is requisite  is to
lay them open  and cauterize them with nitrate of silver.   Jourdain,
(Malad. de la Bouche, t. II., p. 195,)  a  long time since, noticed the
presence of serous cysts in the substance of the lips.   M. PI. Portal,
(Clin. Chir., p. 289,) gives an example of one upon the lower lip.
I have met with them of the diameter of an inch or the half of an
egg, once on the anterior region, and another time on the side of the
right  parietal bone.   M. Champion,  (communicated by the author,
1838,) operated for one of the size of a small pullet's egg,  and  situ-
ated under  the left temporal  muscle.  In  Heister also (Theses de
Holler, t. V., p. 241,  French translation,) we meet with  an example
of a serous  cyst as large as an egg, which had developed itself under
the ear.  In another  patient,  whose  case M. Champion has trans-
mitted to  me, the tumor, which was  bilobate and situated  between
the muscles, occupied the left portion  of the supra-hyoid region,  and
projected at the same time within the  mouth as well as below the
jaw, where it was equal in volume to a turkey's egg.  I have also
seen, in the same situation, a similar cyst of the size of the fist, in an
infant aged twenty months.  In treating of the operations which are
performed on different regions of the  neck, I shall have to return to
the serous cysts, which are sometimes produced by affections of the
thyroid or of the salivary glands.  The surface of the thorax is suffi-
ciently often the seat of similar cysts.   Rudolphi (Jour. Analytique,
1828, No. 7, p.  103,)  mentions one under  the pectoralis major,  and
which resembled a schirrhus.  I  have  also seen  one which was of
the size of  two fists,  in  a boy aged fifteen years, and which being
situated in  front of the axilla, presented the form and other appear-
ances of a  firm and well-developed mamma.  Heister speaks  of a
cyst of this description which was situated on the side of the spinal
vertebras ; and  I have frequently met with cysts on the different re-
gions of the back, which, though of hematic origin, were nevertheless
completely  filled with serous liquid.   Though M. Basletta (BulleU 
NEW ELEMENTS OF OPERATIVE  SURGERY.
661
de Ferussac, t. X., p.  95,) was  successful in curing his patient of a
cyst of the size of an egg, filled with palish (pallacee) matter, and
situated  deep within the  abdominal walls, and communicating with
the peritoneum, it was not so with M. M'Farlane, (Encyclop. des Sc.
Med., 1836, p. 55,) whose patient died after the puncture of the cyst,
which was between the  peritoneum and muscles.   M.  Tavernier
speaks of one which was situated between the abdominal muscles,
and which, having made an opening into the belly, also caused death.
In the collection of M. Ouvrard, we also find an instance of a serous
cyst of considerable size situated upon the back.   A serous  cyst of
the size of an orange was successfully removed by M. PI. Portal from
the back of a man aged fifty years,  (Clin. Chir., p. 281.)   Serous
cysts have been noticed  upon the breech by  M. Recamier, (Gaz.
Med., t. I., p. 319, No. 35,)  and  a  great number of other  practi-
tioners.   I have myself often seen them in this region; but it is at
the fold of the groin where they are most frequently found, and where
I have met with them of the size of a child's head.
  M. Jaudard (These,  Strasbourg, 1816, p. 14,  obs. 4) states  that he
saw one at Lyons in the service of M. Bouchet, which was situated
about the middle of the inner part of the thigh.  That mentioned
by Paroisse (Journ. Gen. de Med., and Diet, des Sc. Med., t. XXII.,
p. 133,) occupied at the same time the thigh and the leg.  I have often
had occasion to meet with them on  the different regions of the arm
and fore-arm, on the body of the thigh and leg, and on the foot and
hand.  All the operations I  have described for  hematic cysts, are
applicable to those that are serous.  Leaving aside what relates to
the employment of topical applications,  compression, blisters, and
even caustics, I would remark that crushing and puncture with the
needle would not succeed, except in certain cases, and should not be
had recourse to unless it should  be impracticable to make use of irri-
tating injections.   This last means, in fact, especially if tincture of
iodine be employed, is so perfectly simple and of such unfailing effi-
cacy, that it should be preferred in every case where no particular
operation would  forbid  its  employment.   Should the cyst  not  be
very large, we should make use  of a very delicate trochar and a sy-
phon-syringe corresponding.  In other cases we  should  proceed in
the same manner as in the operation for hydrocele, and should suc-
ceed equally well.  Supposing,  however, whatever the reason may
be, that we do not wish to make trial of this remedy, an opportunity
would then present for puncture or the simple incision of the cyst:
this sometimes  suffices to bring  on inflammation, suppuration and a
definitive cure.  A woman of 45, had in the left groin a tumor with thick
walls, slightly bosselated (bosselCe*) on its surface, of the size of the
head, but without ever having caused her any pain.   This woman,
who had been addressed to me  at La Charite, had her tumor punc-
tured by M.  Vidal, who  took  from it  two  glasses of  a   limpid
serosity.  Finally, a purulent inflammation established itself in the

  * We shall venture on the coining of this word, as bosse and bossel (from whence em-
bossing in English—i. e. sort of basso relievo or fret-work in the ornamental arts), are not
translateable with precision, certainly not with elegance, by bumps, lumps,  bunches,
bumpy, &c, although they may rudely convey the idea of the ineqaulities, or elevations
and depressions meant. T. 
 662               CYSTS,  PROPERLY SO CALLED.

 sac, and the pus opened for itself an outlet through  the puncture
 which had caused it.   The tumor was reduced little by little, to the
 volume of a pullet's egg.   Seeing that the process of resolution was
 suspended, I considered it  to be proper, before  having  recourse to a
 complete division of the sac, to make trial of a large temporary
 blister.  Eight days after, the walls of the sac were found completely
 agglutinated, and the patient soon after demanded her dismissal from
 the hospital, being in a state of perfect cure.  If however puncture
 or the simple incision  should seem insufficient, we should come to
 the complete division of the tumor, should it not exceed a small egg
 in its size, or in the contrary case, insert through  it one or several
 setons, or better still, divide it on several points of its free portion by
 means of large incisions.   As to extirpation, it is neither more effica-
 cious nor more certain in its effects than the  preceding method ; and
 as it  is obviously the  most dangerous  and most  difficult, and the
 longest of all, it would be advisable in general to reject it.   Up to the
 present time I have not used the iodine injection for curing serous
 cysts, except in the boy who had one on the outer side  of his breast,
 and in the infant who had so vast a one in  the  supra-hyoid region;
 but these two examples have satisfied me that a remedy like this will
 succeed in at least fifteen cases out of twenty, and that it should be
 made trial of before all others.  Serous  cysts developing themselves
 external  to the natural organs and cavities,  cannot be examined in a
 topographical point of view.   The operative process which relates
 to them should consequently be  submitted  to simple general rules,
 whether  it be crushing,  puncture,  injection, the seton, incision, or
 multiplied divisions, or finally excision of all  its most attenuated por-
 tions, or  its extirpation, when it  is of too large  a size to allow us  to
 hope for perfect agglutination of its walls. Among serous cysts there
are some that are multilocular [i. e. having several compartments, T.]
or truly hydatid.  In such cases we should have to qualify what I
 have  said of irritating injections and the different kinds of incisions.
 It would be  next to impossible here to look for a radical cure  by
 means of the seton, the simple incision, or even the multiplied incis-
ions, unless the operation, perchance,  should include all the vesicles
 of the cyst.  To operate  then  in  such  a case  with  any chance of
 success, it would be necessary to lay open the tumor throughout all
 the compartments (locules) of which it is made up, or to extirpate it
 entire.  An  hydatid cyst which existed  in the iliac region was suc-
 cessfully extirpated by M. McFarlane (Encyclop. des Sc. Med., 1836,
 p. 54), and M. Colson (Rev. Med., 1827, t. IV., p. 33) found  one of
 this description between the bladder and the rectum.   Whether the
 tumor in this respect,  in reality contain hydatids, or  is composed
 purely of serous receptacles (vacuoles), the  indication, notwithstand-
 ing, will  be the same.  It would only  be a  loss of time to attempt
 the other operative methods  described farther back, and  which,
 besides their little efficacy, would expose to  real dangers.

       Article  IV.—Synovial Cysts  (Nodus-Ganglions).

  Tumors known under the  title of synovial cysts, were formerly
 designated by the name of  ganglions or nodus, and it is these, which 
             new elements of  operative surgery.          663

people in general call thickened, knotted or twisted sinews, [nerfs foul6s,
noues or tordus—sometimes  "weeping sinews." T.]   Developing
themselves in the neighborhood  of the joints, or upon  the track of
the tendons, these tumors rarely exceed the size of a nut or egg.
All of them  appear to consist of a sort of cul-de-sac or hernia, or
appendix to  the  natural synovial cavities, whose neck (collet) had
been obliterated from some cause unknown.  They may be divided
into  two classes : 1.  Articular synovial cysts ;  and 2. Tendinous
synovial cysts.   Nothing, however, is-  so  Variable as the develop-
ment and progress of such tumors. Moinichen mentions  having seen
them  disappear on  the  approach of  parturition, and afterwards re-
assume  their primitive volume.   M. Champion mentions  having seen
one which  shrunk for  several years  successively, every two years,
about spring-time ; but  it appears in this case, that the shrinking of
the cyst was owing to  the accumulation of the liquid  producing a
crevice.   We may conceive  that the disease then acts  similarly in
fact to a hydrocele, which has been accidentally ruptured, and is soon
after reproduced.  As synovial  cysts  do  not ordinarily cause any
pain, many patients will carry them all their lives, without applying
any remedy or  paying any attention to them.  I have seen a woman
fifty years  of age, who  had three of them about the abductor and
extensor tendons of the thumb for more than twenty-five years.  I
have seen others at the dorsal region  of the foot, about the knee, and
on the track of the different tendons of the hand, which had existed
to full  as  great  a  length of time, without the persons who  were
afflicted with them, ever having thought of applying any remedy to
them.   I should, in fact, add that many of these cysts ultimately, in
the course of time, disappear spontaneously.   They are not to be
attacked by surgical means therefore, unless by their volume or rela-
tions, they produce either deformity,  inconvenience or pain, or func-
tional disturbance to such extent as to induce the patient to incur the
risk of the operation.

                     § I.—Various Means.

  Nothing also, is more variable than the treatment for this descrip-
tion of tumors.   M. Ch. H. (Encyclop. Method., t. XIII., p. 617, col.
2, 1832,) had a ganglion of the  size of a  small nut, on the flexor
tendons  of the left ring and middle  fingers. Having, in vain, con-
sulted most of the distinguished physicians of Paris, the patient, who
put himself upon the use of the muriate of soda, of which he took from
two  to  three ounces  a  day, in this  manner effected a radical cure.
Gilibert (Rousset, These de Strasburg, 1812, p. 6,) says he has seen a
case of this kind  in which satchels of plaster, or leaves of lavender,
succeeded.  Frictions with  aromatic,  mercurial and camphorated
mixtures, laurel oil, soap and water, saliva, resolvent plasters, hard and
repeated rubbings and baths of sulphur-water, equally appear to have
been followed by some successful results.   Dupuytren, according to
M. Bouboucki,  (These, Paris,  1828, p. 25,) dispersed a  synovial
ganglion in the  ham, by means  of the  simple douche.  But  were  it
allowable to make trial of such remedies, it would be puerile to count
on their efficacy,  unless  in some very rare exceptions. 
664
CYSTS, PROPERLY  SO CALLED.
                 § II.—The  Temporary Blister,
  Or even one that is permanent, would deserve infinitely more con-
fidence.  Jasger,  (Diet,  de Chir., t.  I., p.  52G,)  who  made  use  of
them for cysts at the knee, asserts that  he obtained positive advan-
tages from them.  I have elsewhere published (Archiv. Gen. de Med.,
1826,)  the  case  of a  synovial cyst on  the  posterior region  of the
wrist, which  disappeared  under the  action  of two large blisters,
though it was of very ancient date, and of the size of half an egg.
I have  often succeeded with the same remedy since, in similar cases.
A lady, who had  one  of the size  of  a large nut, on the dorsum of
the foot, opposite the calcaneo-cuboidal  articulation, and who would
not hear to an operation, was also cured by means  of large tempo-
rary blisters  and resolvent frictions, and compression.  Though I
might cite  at least  as many  as ten  analogous facts, I ought, how-
ever, to remark that most synovial cysts will not yield to this thera-
peutic.

                         § III.—Moxa.
  Moxa, which  has  already  been  made trial  of for a cyst  of the
wrist by M. A. Severin, (Med. Efficace, p. 550, § 1998,)  and which
M. Champion also says he has used with success in a patient  who
would not submit to  any other means,  would  not  probably be any
more  effectual, and has  too many inconveniences  in itself ever  to
become the favorite remedy for this disease.

                       §  IV.—Caustics.

  Though the employment of caustics may have succeeded with  F.
de Hilden (Centurie 3, obs. 79, or p. 72 ; obs. 44 of the French trans-
lation,) in curing a synovial cyst  of the carpus, and an arsenical ap
plication have been equally successful with  Woolam, (Annal Muys-
kezas, t. III., p. 490, 1811,)  such remedies, nevertheless, have in all
epochs inspired the most vivid apprehensions.  Dalechamps  (Chir.
Fran aise, p. 158, in-4°  ; p. 910, in-8°, 1570,) relates that a patient,
with synovial cysts on  the dorsum of the  hand, who was treated
for them by caustics, did not recover  until after having experienced
very severe  inflammatory accidents.  It is moreover evident that
this kind of operation, would be exposed to  all the consequences  to
be apprehended  from a cutting instrument, without having  its ad-
vantages.   Their uncertainty and the   deformed cicatrices  which
they would necessarily produce, will  always be  sufficient to pro-
scribe their use with the generality of practitioners.

                      § V.—Compression.

  One  of the remedies against synovial  cysts which has been most
extolled is compression; the ancient authors had already noticed  it.
La Vauguyon (Traite d''Operat., p.  627,)  recommends that it  be
made with a plate of lead, and that frictions be  associated with  it.
This plate of lead, adjusted by a pelote  and circular  bandage, has
been proposed anew by  Marigues  and Testat. (Malad. Chir., 1786.)
Theden, the great admirer of compression, says that by means  of 
              NEW ELEMENTS OF OPERATIVE  SURGERY.          665

 this, with lotions of the arquebusade water, he cured a synovial ganglion
 m the space of six weeks. New facts also in favor of this remedy have
 been brought forward during the course of the present century, by
 M. Balme (Dissert, an. X., p. 39,) and M. Godele, (Rev. Med., 1831,
 t. I., p. 19.)  It is nevertheless  true that compression alone rarely
 succeeds with synovial cysts, and that in order to obtain anv cures
 from it, it would be necessary to apply it with such force and'to con-
 tinue it so long a time, that in reality it scarcely deserves to be made
 trial of except as an auxiliary to other operative methods.

                  § VI.—Crushing,  (ecrasement.)
   A more efficacious remedy, and one which surgeons have  in their
 pride erroneously associated with the practice  of vulgar people or
 charlatans who itinerate about the country, is that  of crushing the
 cyst.  This  remedy, which  at  first  sight, appears  so rude, had al-
 ready been employed in the time of Phifagrius, (Peyrilhe, Hist, de
 la Chir.,  p. 702,) Chaumete, (Enchiridion des Chirurg., ch. 3, p.
 122,  1560,) and  Forestus,  (Bonet,  Corps de Med., t. III.,  p. 60.)
 Muys  (Decad. 2, obs. 8, p.  127; Nouv. Obs. de Chir.,)  armed with
 a leaden palette, cured  in this manner  a cyst at the wrist, and sim-
 ilar successes were obtained  by  Ledran (Consult, de Chir., p. 257,)
 and by Godele  (Rev. Med.,  1831, t. I., p.  17.)  I  have, says M.
 Champion, often  crushed ganglions  in  the palms  of the hands, by
 means of the thumbs  crossed, or by a single thumb ; but there is  a
 good number of them that will not yield to  this kind of pressure.
 This practitioner, who  agrees in this with Heller that  crushing is
 very uncertain, almost  always uses a mallet and a piece of paste-
 board cut  in the form  of a  shovel.   A single  stroke properly ap-
 plied ordinarily answers in  such cases.   This  compression  [rather
 percussion, T.]  astonishes  much more  than it  does harm.   On the
 carpus  and the  tarsus  it has never, says M. Champion, failed.  A
 man who swooned away immediately after the stroke, confessed sub-
 sequently that it was from fear.  This process, which the rebouteurs
 (rebouteurs) and peasants have employed from  time immemorial to
 untie the tendons, requires  that  we  should place the limb  upon  a
 solid support while making the stroke with the mallet, and that the
 cyst should afterwards be properly compressed during some fifteen
 days.  I have often in my boyhood, seen peasants in the country
 strike the fist violently upon the  wrist, and in this manner cure sy-
novial cysts  of  the hand.  I have seen others who did the same
 thing on the foot, and I  should add, that unless there be a very con-
 siderable degree of muscular force exerted, we fail in most instances
 when we attempt to crush by the thumbs alone.  This crushing [or
 sudden  rupturing or bursting of the sac, T.] is in short an  opera-
 tion  to be made  trial of. It  is, however, exposed to two inconve-
niences ; sometimes there results from it an inflammation sufficiently
acute, and  I have seen three patients in whom it was attended with
such accidents, that a vast suppuration was established in  the limb,
and their life for a long  time kept in jeopardy.
  When every thing  goes  on naturally, the tumor retains a great
tendency to be reproduced;  more than half  of the synovial cysts
which I have treated, or caused to be treated in this manner, have
  vol. n.                       84 
666                CYSTS, PROPERLY SO CALLED.

returned at the end of some weeks, or some months.  We should,
however, render success more certain by associating with this remedy
repeated temporary blistering, resolvent frictions, and  compression
for a long time continued.
   [We refer the reader for the advocacy we have made of this in-
valuable resource  of sudden  and powerful percussion, to what we
have said above of these bursal cavities or cysts, when they contain
other than pure  synovial fluid—to which the author here confines
himself.  Also to  our remarks in Vol. I., and  also infra, on  the
same mode of treatment.  The cases in which we have used it, and
we never employed any other remedy, were of the character of sy-
novial  cysts proper, in their normal state, so far as they were  un-
changed in structure and containing their normal sero-synovial fluid,
only accumulated in abnormal quantity, therefore literally, as by the
vulgar name, a weeping ganglion.  In every case the blow made
with great  rapidity and force,  by a heavy book held  in  both  my
hands, and  at the  height of two feet above the  tumor  as  the limb
lay firmly stretched on the table, I  succeeded in perfectly and radi-
cally curing the  disease, in an instant.   The  tumor entirely disap-
pears under the  blow which crushes it, so that the deformity, as if
by magic, leaves thus  the smooth  natural plain surface of the skin.
In one of the cases at the olecranon, where it appeared somewhat
bosselated,  the disease returned partially in a few  weeks, but a
second  blow completed its extinction.   In a very recent  case, the
tumor being of the size of a small  nut and on the ulnar side of the
dorsal  surface of  the radius, about two  inches above the wrist,
(caused in a stout young Irish porter from lifting heavy  trunks,) and
resting, in fact, partly on the interosseous space,  I was  enabled, by
proper pronation, to bring the tumor on to the edge  of the radius,
and  by this means  procure a solid osseous point  d'appui.  I would
recommend  this  course of pushing the tumor where it can be done,
on to a bony plane, before the blow is struck.  This I advert to, be-
cause I believe it practicable, in most instances, on the dorsal surface
of the metacarpus,  where the tumor lies on an  interosseous space.
In one such case I  recommended it to a very bold practitioner, who
nevertheless pursued his own course, opened  the sac and  caused a
severe, if not dangerous inflammation.   In  striking the blow, it must
be done with a good deal of force and with a heavy quarto book for
example.  In the cases of our author, whenever the disease returned,
he was  perhaps  too sparing in this  respect, towards his  patients.
This beautiful illustration of sub-cutaneous  or  sub-muscular, or even
sub-aponeurotic surgery, (for I should consider a synovial tumor be-
neath an aponeurosis, provided  the tumor could be made to rest on
bone, equally curable by this mode,) excludes effectually every other
treatment, and for  myself, I never saw the  slightest accident super-
vene from  it.  Nor have I found the least degree of compression
necessary after the ecrasement. T.]

                  § VII.  Sub-cutaneous Puncture.
  Some surgeons,  having confidence in the rupture of the sac, and
experiencing some  difficulties in effecting it, have proposed to intro-
duce obliquely under the skin a cataract needle, and  thus  puncture 
NEW ELEMENTS  OF OPERATIVE SURGERY.          661
 the little synovial pouch so as to allow of expelling its contents and
 lorcing them to become infiltrated into the neighboring cellular tissue.
 M. Cumin, (Journ.  Univ. des.  Sc. Med.; Journ. Analytique, t. I., p.
 367, Nov. 1827 ;  Bull, de Ferussac, t. XIV., p. 225; Arch. Gen. de
 Med., t. XIV., p.  252,) who appears to have been one of the first to
 suggest this  operation,  recommends with reason, that  we should
 make use of compression also after having emptied the sac.  I have
 attacked in this manner a synovial cyst on the dorsum of the foot,
 another which was  situated  in front of the malleolus externus, and
 similar tumors on the back of the hand and wrist, without ever hav-
 ing obtained a single radical cure.  The tumor was emptied and  the
 sub-cutaneous layer of  the neighborhood became slightly osdema-
 tous ; but the cyst soon  filled again and the disease  reappeared as
 before, whatever M. Roberts  (Journ. des Progres, t. XII., p. 258;
 Rev. Med., 1829, t. I., p. 299) may say on this point.   To obtain
 any favorable results from this means therefore, it would be neces-
 sary to associate with it not only compression, but also  temporary
 blistering and resolvent frictions.

                         §  VII.—Seton.
   Puncture, and the abstraction of the  liquid by means of a syringe
 or gum-elastic bottle, as recommended by Monro (Ancien Journ. de
 Med., t. LXXIX., p. 138,) would be at the same time more difficult
 and also still more uncertain.   The seton, which has been employed
 by quite a great number of practitioners, and which is  mentioned
 by M. Ch. L. (Encyclop. Meth., t. XIII., p. 618,)  and also  by  M.
 Cooper, is considered by others (Journ. de Med., t. V.) as calculated
 to induce a  cancerous  degenerescence of the ganglion.  At the
 present  time  the  seton might  be made trial of under a form less
 dangerous.   One,  two, three or four simple threads passed through
 the  tumor, as has been said of Erectile Tumors and Varices, and
 withdrawn  after the lapse of  some days, would probably be suffi
 cient to  create a moderate degree of inflammation in the cyst, and
 to effect its resolution.  But how could we then avoid one of two  in-
 conveniences, a purulent inflammation which would not be unattended
 with danger, or too  slight a degree of irritation, which would pre-
 vent our succeeding ?  Without, therefore, absolutely condemning
 this remedy, we ought not to repose too much confidence in it.

                   § IX.—Irritating Injections.
   Irritating injections, though  made use of by some practitioners,
 have, however, always excited  some apprehensions when about  to
 be employed for synovial cysts.   The inflammation which it  is pro-
 posed to excite by them, has been considered dangerous, in  conse-
 quence of the  neighborhood of the articulations.  It is  true  that
 some accidents have resulted from them;  that a woman  on  whom
 they were used and who  came to the hospital of the Faculty in 1824,
 was seized with all the symptoms of a  phlegmonous erysipelas  on
 the dorsum of the  hand, where  the cyst  was situated, and on a por-
 tion of the dorsal region of the fore-arm; but, I do not think that the
 subject has been sufficiently examined.   The synovial cysts are le-
gitimate serous cavities;  [see note infra, where the propriety of thus 
668
CYSTS,  PROPERLY SO CALLED.
 giving the name serous rather  than  mucous to the various bursts, is
 well  sustained.   T.]  Every thing  leads to the conclusion  that an
 irritating liquid would produce an  adhesive inflammation there, as
 in the tunica vaginalis.   Provided this  injection was made  through
 a simple puncture, and not pushed to the extent of tearing (erailler)
 the cyst, and  of becoming infiltrated into the cellular tissue of the
 neighborhood, we cannot see what evil consequences would result
 from it.   The phlegmasia thus produced under  the skin, should  it
 extend even to  the  articulations, is not comparable to ordinary in-
 flammations, or  such as are produced by the action of some internal
 cause or  external violence.  Perhaps, also, the irritating injections
 have sometimes been followed  by unpleasant consequences, because
 of the quantity or nature of the liquid  made use of.  Certain  it is,
 that the tincture of iodine, which may be introduced in moderate
 proportions into every serous cavity, and which seems to have the
 power of infiltrating itself, at least partially, into the cellular tissue,
 without producing gangrene,  has hitherto  enabled  me  to obtain  a
 number of cures which, by their  simplicity, have  been moreover of
 the most  encouraging description.
  A man aged from 30 to 35 years, had on the dorsal surface of the
 tarsus a synovial cyst of half the bigness of an egg; I punctured it
 and drew out about two spoonfuls of a serous liquid.   Two gros of
 tincture of iodine diluted, were injected in their place,  and every
 thing went on with the same  simplicity as in the operation for hydro-
 cele.   The same operation performed twice  on  ganglions  of the
 wrist, once below the external  malleolus, and in another  instance on
 the dorsum of the hand, have been followed with the same satisfac-
 ry results.   I have seen it fail, however, in a man who had a syno-
 vial ganglion on the  dorsal surface of the foot; but here the cyst was
 filled with gelatinous matter,  and the injection caused no appearance
 of inflammation  or  reaction.  In conclusion, therefore, it  would
 seem, that  irritating injections, and especially tincture of  iodine,
 should be employed  wherever the cyst is of a certain volume, and is
 found filled with matters  purely serous.  I would remark only, that
 they should be punctured  with a small trochar, and not with the bis-
 toury, and that  a  certain quantity of the tincture of iodine injected
 should be left in their interior.

                         § X.—Incision.
  Like all other cysts,  synovial ganglions may be treated by simple
 incision.   Fabricius ab Aquapendente  had  already  obtained cures
 by this operation, which is also extolled by Portal (Hist. Anat., t. II.,
 p. 227)  and Schmucker (Bibl.  Ch. du  Nord, p. 21.)   Nevertheless,
 practitioners of the present day do not resort to it but with repugnance.
 All the dangers  imputed to irritating injections, are equally applica-
 ble to this.  It produces, in fact, one  of  two things:  either the small
 wound immediately shuts up without causing inflammation, and then
 the tumor  soon reappears, or the interior of the ganglion becomes
 inflamed and is transformed into abscesses, and in this case we have
reason to fear the extension of the  phlegmasia under the form of
 phlegmonous  erysipelas to the sub-cutaneous cellular tissue  of the
neighborhood, and even to the articulations that are situated nearest 
NEW ELEMENTS OF OPERATIVE  SURGERY.
669
to the tumor.   The force of these objections  cannot be denied, and
in this respect the incision is certainly more dangerous, without being
more efficacious, than irritating injections.  Without inflammation it
cannot succeed ; with  inflammation  it  causes pus, and purulent in-
flammation, in the vicinity of the articular synovial cavities, is always
a  formidable  phenomenon.  I would  not, therefore,  employ  this
means but for synovial cysts of a small volume, and for those which
in place of matters  purely serous, are filled with  substances of a
gelatinous  (gelatiniforme) and  semi-concrete character.  I neverthe-
less admit, that the simple incision sometimes  succeeds, and that it is
far from being always  attended  with the dangers of which  I have
just spoken.   As for the rest,  I should prefer, should I  decide upon
it, to divide the tumor through and through, rather than limit myself
to incising it only on one of its points.

                      § XI.—Extirpation.
   The remedy which has the greatest certainty, and which in every
epoch has engaged the attention of practitioners, is extirpation.  There
is no doubt in fact that it is the  most positive resource,  and which
precludes all chance of a  return of the disease when  applied to syno-
vial ganglions.   Unfortunately it is  a  remedy which alarms most
patients, one also whose employment is not always  devoid of diffi-
culties and which may involve serious dangers.  Thus to extirpate
a cyst of this description, it is  necessary to lay it bare by a  simple,
a semilunar, a T, or a crucial  incision, then to go through a delicate
dissection in order to isolate it from  the  organs which surround it,
and thus remove it entire.  The operation may in consequence be
long,  painful and sufficiently laborious.   There results from it, more-
over,  a considerably large wound, whose suppuration it is often im-
possible to prevent.  Finally, by operating in this manner we run the
risk of opening  into  the synovial and  articular capsules, and thus
paving the way for the introduction of purulent phlegmasia even
into the interior of the joints.   It is nevertheless true that the dangers
of this extirpation have been greatly exaggerated.  I  have performed
it four times on the dorsum of the foot for ganglions which were of
the dimensions of the thumb in  diameter, a French chesnut, (marron,)
a large nut or the half of an egg.   The cure  in three of my patients
was speedily accomplished.  The fourth, who was a young  girl of
nineteen years of age, continued to be threatened with a phlegmonous
erysipelas during the space  of a week ; but sanguineous emissions and
topical emollients put a term to the accidents, and the cure notwith-
standing was completed at  the expiration of three weeks.   I have
removed similar cysts from the inner as well as the outer side of the
knee.   I have extirpated one  also which was situated immediately
ab<*ve the head of the fibula.   I have treated them many times in the
same  way  on the dorsum of the carpus and metacarpus, and  out of
twelve or fifteen operations of this kind which I  could euumerate at
the present day, there is not one of them that compromised the life of
the patient. After the example of Celsus and Paul of Egina, so also
have Warner, Gooch, Eller, Schmucker, (S. Cooper, Dictionary, 1.1.,
p. 526,) and Heister, (Theses de Holler, t. V., p. 262, French translation,)
related successes obtained by means of extirpation, an operation which 
670
CYSTS, PRORERLY SO CALLED.
Chaumete, (Enchiridion, etc., p. 123,) and Friesse, (Tfieses de Halter,
t. V., p. 243, French translation,) equally eulogize.   In 1800, says M.
Champion, when I was studying medicine, I extirpated in a young co-
quettish woman, a ganglion of the size of an almond, situated on the ex-
tensor tendon of the middle finger of the left hand.   An inflammation
supervened and gave rise to three abscesses.  After the cure the young
lady retained a stiffness in the movements  of the hand, and this lesson
has taught me not to repeat the operation.  Nevertheless, a young phy-
sician of my acquaintance, adds the same  practitioner, has extirpated
one of less size, also situated on the metacarpus, and which I refused to
operate upon, preferring to wait until it should become larger that I
might burst the cyst; but  no accident followed the  operation.  Sy-
novial cysts situated  on the thumb, carpus and tarsus, have also been
removed without  danger  by M. PI. Portal, (Clinica Chir., pp. 298,
301, 303, 307.)   I would however remark, that I now regard it  su-
perfluous to dissect such tumors with so much care; that I arrive at
the same result with  infinitely less difficulty or pain to the patient by
confining myself to opening or cutting freely into the whole sac, which
I immediately fill with balls  of lint to induce it to suppurate, and af-
terwards treat it in every respect as an abscess.   The  operation is
then remarkably simple, and  I have  satisfied myself that it  will
obtain a cure as prompt and  certain as  extirpation  of the cyst, pro-
perly so called.  As  to the ligature, it is unnecessary to  repeat that
pediculated synovial  cysts only would allow of its employment, and
that it would expose  to more pain and danger than any of the ope-
rations which have been described, especially the irritating injections.
without being attended either with their advantages or  simplicity.

                     § XII.—Recapitulation.
  To sum up, therefore, synovial ganglions when it is deemed advi-
sable  to attack them seriously, should be treated  by topical  resol-
vents when they are  still recent; by temporary blisters when they
are already of ancient date; by permanent  compression where the
blister and dissolving  pomades are  without effect; by crushing with
the thumb or mallet where ordinary compression  does  not suffice;
by sub-cutaneous puncture  where  crushing is unavailing or inap-
plicable ;  by iodine  injections, by  preference wherever they are
practicable ; and by large  openings or the complete incision in cases
that are most obstinate or complicated.  So that I reject as useless or
dangerous, extirpation, simple  incision, caustics,  the ligature,  and
even vinous injections.

                  Article  V.—Osseous Cysts.

  We find in the annals of science some  cases of tumors composed
of osseous shells, in  other respects independent of the bones  and
periosteum, and containing  matters sometimes concrete, at other
times liquid.  I have  met with these tumors on the breast, scrotum
and shoulder, on the  parietes of the thorax,  certain regions of the
cranium, and on the face  and  limbs.  M. Tassery  (Annates du De-
partment  de VEure,  pp. 219, 220, 1810,) speaks of a cyst with osse-
ous walls, which  was situated on the hand, and  which contained 
NEW ELEMENTS OF OPERATIVE SURGERY.          6Yl
about two pounds of cartilaginous substance, and the exsection of
which was effectually accomplished by means of a saw. The osteo-
fibrous  tumor removed from  the cheek of a. young man by M.
D.  Lasserve (Cas de  Chir., &c, p.  27), caused  the wounding of
the canal of Stenon, and appears to have originated in the salivary
duct.   M. D. Lasserve (Ibid., p. 41, fig.  4) has also given the figure
of an osseous tumor which was as large as an egg, and  while dis-
connected with the  osseous  system,  occupied the middle of the
upper lip of a young man aged twenty-five years.   It will be how-
ever when treating of tumors of the  face  and breast, that I shall
speak of the  operations applicable to this  description  of cysts.  I
will remark here only in respect to general rules, that excision and
extirpation are the only operations applicable to such tumors; and
that we ought consequently to proceed in the same manner for their
removal as for the extirpation of a lipoma, lymphatic tumor, neuroma
or hematic tumor.  It is moreover obvious, that topical applications,
the seton, compression, injections, and excisions, properly so called,
could have no chance of success, and that before every other consid-
eration  the osseous or osteiform  plates should be removed in their
totality, if we expect to obtain a radical cure in patients who have
these osseous cysts.
   [One of the  most remarkable osseous formations but not of this
description,  occurred in an old  man aged about 75, a sailor, of tall
and robust form, and a patient at the Seamen's Retreat while I con-
ducted that  establishment.  He was of  intemperate habits, and the
result of his  indulgence in this respect  was one  of those old rum
legs or  extensive oedematous  ulcers on the calf and below, which
served as a drain to his plethoric condition.  In  a fit of depression
of mind he  threw himself from the  piazza of the third story of
the hospital,  and thus caused immediate death.   In the dissection,
besides various extravasations which it caused in the brain, every rib
on one side was fractured, and on examining the diaphragm we found
in its substance near the centre, a circular osseous plate precisely of
the size and thickness and shape of a dollar, which lay in the same
horizontal plane with the diaphragm and in the midst of its tissue,
as if inserted or sewn  into that  part.  It did not  appear during life
that this formation had in the least interfered with the respiratory
functions. T.]

              [CARTILAGINOUS AND OSSEOUS TUMORS.

   Mediastinal  Tumors—Carcinomato-cartilaginous Tumors.—An
extraordinary case of this kind, and of which the specimens are
preserved by Mr. Adams, and  were by him laid before the Patho-
logical  Society of Dublin, occurred in  the practice of Dr.  Cullen
of that  city, in 1839 (see Dublin Review, 1840),  in  a  woman aged
40, who had been married two years  but was  without children.
She had had for some time great difficulty of respiration, with vio-
lent but dry cough, and especially  paroxysms  of suffocation  at
night.   The bruits of the chest were normal.  The left  hand and
face were oedematous, and the veins of  the neck  and face livid and
distended' during the violent paroxysms of coughing.  In three or 
672
CYSTS, PROPERLY SO CALLED.
 four weeks the left arm, and then the right, and finally the  lower
 limbs also became oedematous.   Finally, she was obliged to sit up
 constantly to get breath, and the neck began to swell enormously
 and to become inflamed immediately above the sternum.  Death soon
 followed, when there was found in  the situation of the thymus, in
 the anterior mediastinum, an oval whitish tumor near three inches
 long, of a carcinomatous structure, and in some places cartilaginous
 and cerebriform ,which tumor inclined at its largest extremity to the
 left, and was adherent in part to the  trachea and arch of the  aorta.
 The inclination of the tumor to  the  left causing it  to  press on the
 vessels  of the neck and shoulder on that side, explained why the
 cedema was greatest in that region.   The  heart, aorta and pulmo-
 nary  artery were sound; also the air passages and lungs, except
 that the latter were emphysematous, no doubt  from the continued
 violent  paroxysms of coughing.  This instructive case shows the
 importance of tumors in the thorax as connected with the difficulty
 of diagnosing substernal  and thoracic  aneurisms and pulmonary
 disease.
  A still more remarkable case of tumor in the anterior mediastinum
 was published the same year as having occurred in the practice of Dr.
 J. M. Neligan,- (Edinb. Med. and Surg. Journ., April, 1840,) in a man
 aged 21, who in April, 1838, was attacked with difficulty of respira-
 tion, cough without expectoration, slight pain in the chest, &c, as in
 the above case.   Finally, a tumor showed itself above the  sternum,
 and the symptoms became aggravated, with orthopnea, swollen veins
 of the face and neck, suffocating paroxysms, and cold extremities, end-
 ing in death in less than a month from the attack.  The lungs, bronchi,
 and trachea, were, so  to  speak, perfectly sound, and also the  heart
 and its vessels, and some transparent liquid was found  in  the pleu-
 ral cavities.  We perceive the thoracic viscera were sound, notwith-
 standing the tumor had the enormous magnitude of  14 inches in
 length and A~ inches  in  breadth, and had filled the entire anterior
 mediastinum, with firm  adhesions in  front to the  posterior side of
 the  sternum, and behind to the  pleura and pericardium, while above
 it crowded the thyroid gland upwards and had even contracted firm
 adhesions also as far down as with the diaphragm below, and had
 extended laterally on each side to the  articulations of the carti-
 lages  with the  ribs.  This  case  still  more strongly points  out  the
 importance of close discrimination in diagnosing morbid structures
 in the thoracic cavity.
  Cartilaginous Tumors of the Face and Scalp.—But one of the most
 singular complications of tumors perhaps on record, is that of an un-
 married woman, aged 52, as related by Mr. Ancell (Medico-Chirur-
gical  Transactions, vol. XXV., London, 1842, 8vo.  See also  Brit-
ish  and Foreign  Medical Review, Jan. to  April, 1843, vol. XV., p.
 153, 154.)  The disease first appeared when she was 14 or  15 years
of age, and the greater part of her face  and scalp was loaded with
solid tumors of different sizes.  Those on the scalp externally  were
of a very florid color, smooth,  glassy, and denuded of hair, and va-
ried in shape from a nearly globular,  to an irregular, flattened  sphe-
roidal form; among them were a few perfectly round and of a vio-
let hue.  Some were sessile  on broad bases, others suspended by 
NEW ELEMENTS OF OPERATIVE SURGERY.
673
 short thick  peduncles.  One of these latter was removed, and when
 divided showed a smooth shining semi-transparent texture of a very
 pale pinkish hue and of a nearly cartilaginous consistence.  It ap-
 peared homogeneous except for a few vessels  ramifying through it.
 The investing skin  was much  more vascular.  Among those  on the
 face were interspersed also a number of lenticular tubercles aris-
 ing  from hypertrophy of the dermis, and some also smaller  which
 were follicular elevations.  The tumors sometimes itched and were
 painful when pinched, but were generally free from uneasiness.   At
 one  time a few were extirpated, and subsequently Mr. Bryant re-
 moved sixty at one  sitting !  They  were then not cartilaginous and
 could easily be  enucleated.  Within twelve months from the  opera-
 tion they were all  reproduced.   This most singular disease invaded
 finally the viscera, and a large tumor appeared to have formed in the
 abdomen, which was followed by ascites, anasarca of the lower ex-
 tremities, and death. On  examining the body the peritoneum  was
 found opaque, but with a shining surface.   " The parietal portion (says
 the account) and the lining of the diaphragm were studded with my-
 riads of tumors of  various sizes."   The fat of the great omentum
 was almost entirely absorbed, and its tissue sprinkled over with num-
 berless granules.  A large mass weighing almost two  pounds  was
 suspended from the anterior edge of the liver; it extended beneath
 the right lobe, displacing and depressing the gall bladder.  It was of
 ovoid and irregular  form, and  of very firm texture.  On dividing it
 the tints of the cut  surface were extremely varied, green and green-
 ish yellow predominating, while the centre was nearly white and al-
 most cartilaginous,  and exhibited radiating fibres  and lobules of an
 indistinct cystiform aspect.  Blood  oozed on pressure from a good
 many red points, but the  tumor could not be called highly vascular.
 The disease appears to have been hereditary, but was confined to the
 females of the family, who were also remarkably  prolific.  A pullu-
 lating diathesis and   tendency to fibro-cartilaginous growths appears
 to have pervaded the entire organism.
   Mr. Goodsir (Cormack's Lond. and Edinb. Monthly Journal,  &c.
 Feb.  1843,  p.  171,)  has  removed  from the  compact bone  of the
 shaft of the  humerus on its outer side, an enchondromatous tumor of
 the size of a billiard ball, which was lobulated and of compact car-
 tilaginous texture externally, and had internally  masses of exceed-
 ingly hard bone, imbedded in soft cartilage.   It be re the appearance
 of similar enchondromatous masses  found in  the phalanges of the
 fingers.  T.]

  [GANGLIONIC,  SEROUS,  AND SYNOVIAL TUMORS AND CYSTS--BURS^E
             MUCOSAE ET  SEROSA--IODINE INJECTIONS.

   Encysted  Hydropic  Tumors between the  duplicatures  of the
Peritoneum cured  by Iodine Injections.—Not only has the success-
ful treatment  by iodine injections,  as  established by M. Velpeau,
been generally adopted in Europe, for synovial  tumors  or hydro-
cele, but  also,  so long  as six  years since, was boldly  applied by
M. G. Pagani, Surgeon-in-Chief of the Hospital of Novarre in  Italy,
(see  Annali  Universali  di Medicina,  Fasci 296, Agosto,  1841,
  vol.  ii.                       85 
674                CYSTS,  PROPERLY SO CALLED.

also Journ. des Connaiss., &c, de Paris,  Fevrier, 1842, p. 84,) to
hydropic encysted collections, which apparently existed between
the duplicatures of the peritoneum in the hypogastric region.  The
case in question was that  of a man from  the country, aged about
thirty-two, in whom a rheumatic fever of short duration and accom-
panied by much dysuria, and finally a sort of dysentery, was soon
succeeded, in spite of copious bleedings, purgatives, &c, by the rapid
formation of a large encysted tumor in the hypogastric  region.  An
exploration  by the  cataract needle and trochar enabled the surgeon
to draw off a small quantity of fluid very similar to that of ganglionic
capsules,  [i. e. bursae mucosae, or  more properly bursce serosce, see
remarks  of  M. Petrequin under this head, infra, T.]  which with an
examination per anum,  and the introduction of the catheter into the
bladder,  and evacuation of its urine, led  to  the diagnosis that the
tumor was circumscribed by the enormously distended layers of peri-
toneum where it is reflected on the posterior part  of the bladder and
anterior portion of the rectum.   The surgeon accordingly,  keeping in
view the analogy of tissues to the tunica vaginalis, and  the cures he
had obtained by injection of the alcoholic tincture of iodine in hydro-
cele, introduced into the abdominal cavity  in question, by means of
the canula and syringe, through the puncture he had previously made,
twro fingers' breadth above the pubis, and  two inches to the left of the
linea alba, a diluted preparation of the same  material.   A very  mode-
rate degree of warmth and reaction was felt by the patient,  and in
five days the tumor had entirely disappeared, followed shortly after by
the cure  of the dysenteric affection and perfect restoration of health.
It would  be worth  while to ascertain how far this treatment could
be employed with utility in ordinary ascites,  ovarian dropsy, &c.  We
have already spoken of it (see Vol. I. and the present vol.)  as success-
fully employed in the mouth of the sac in reducible hernia, after the
laxis.
   M. Petrequin of Lyons,  in an article on  synovial tumors, (Journ.
des Connaiss., &c, de Paris, Juillet,  1842, p. 10, et sequ.) in pass-
ing a  compliment on the  labors  of MM.  Monro, Brodie, Ollivier,
Xienoir and Velpeau, disapproves  the phrase bursce mucosce as alto-
gether capricious and erroneous.   These tumors occupy serous, not
mucous capsules, and he has marked their whole progress, from their
inception as simple hydropical collections, through the several suc-
cessive stages of sub-acute  inflammation, hematocele, abscess, ulcera-
tion, chronic induration, &c.  M. Petrequin  reverts to a  treatise he
had published  many years  since, that on exsections of the lower ex-
tremity,  and again enforces the necessity  of early exsection  of the
great trochanter, and saving of the leg before the exfoliation caused
in that process, by inflammation and improper  treatment  or opening
of the  sub-cutaneous bursa situated over that prominence, shall have
involved the coxo-femoral articulation ; for  lesions of which last there
is reason to believe these implications of the trochanter from the dis-
ease in the superposed bursa, are too often mistaken.   The more im-
portant does this advice become, because  the affection of the trochan-
ter produced in the manner mentioned, may extend to the  joint itself.
   In ante-patellar bursas, (hygroma prerotulien,)  M. Petrequin has
seen one of four inches diameter in the direction of  the  axis of the 
              NEW  ELEMENTS  OF OPERATIVE  SURGERY.          675

 ,iT\and three inches lateralIy> which had existed two  years, and
 which  Dupuytren himself had in vain endeavored to cure.  These
 bursal  tumors often result from  traumatic contusions, and then con-
 tain bloody, grumous, and sometimes fibrinous matter, which latter
 M. Petrequin considers the original cause  (or nuclei) of foreign bodies
 about the joint, i. e.  spontaneous or amphi-articular bodies.
   These tumors, arrived at this condition, communicate, on pressing
 them, a sensation of movement,  (fremissement,) leading to the idea
 of the existence of  semi-cartilaginous corpuscles or of hydatids rub-
 bing against each other, all which can be explained by the existence
 of fibrinous concretions, or the crushing together of sanguineous clots.
 (See M. Velpeau's remarks on these bloody tumors sup. and in Vol. I.)
 He  places, erroneously, as we think, some reliance  on  resolvents,
 (such as muriate of ammonia,) and on compression, &c.; but where
 these fail,  he has found, like M. Velpeau,  a cure effected by iodine
 injections, and should the contents of the  sac be solid, an incision be-
 comes necessary.
   M. Petrequin errs also, as  we  know  from  experience,  both in
 olecranian and ante-patellar bursas, (see in this note below,  and also
 sup. and Vol. I.) in supposing that bursting them by strong percussion
 will not succeed if they have existed over a year.  It is the remedy, as
 we conceive, par  excellence, and  next to that comes iodine injections.
   He-remarks,  with great appearance of sound practical reflection,
 that such ante-patellar hygromas, when they suppurate and infiltrate
 into the neighboring tissues, might well give rise, by the tumefaction
 they produce, to the supposition of an inflammation and effusion into
 the tibio-femoral articulation.
   These sub-cutaneous, cellulous,  serous bursce, as  M. Petrequin
 properly considers synovial bursas, so called,  are found, or may in
 fact be accidentally produced over  all osseous prominences where
 there is much traction and friction of the superincumbent tissues, par-
 ticularly therefore, it might be added, near the articulations.   He has
 seen them at the inner malleolus  also,  becoming ulcerated and form-
 ing there pseudo-mucous fistulas, like those which may result from
 abscesses.   Such  are cases in point for the iodine injections.
   Besides tibial bursce, as those on  the  internal malleolus may be
 called, M.  Petrequin has seen also fibular bursas, i. e. on the outer
 malleolus.   In cases like one he saw,  and  which resulted in caries to
 the fibular extremity, he properly recommends exsection of this part,
 which can  readily  be  done  without  implicating the  joint.  These
 fibular bursas are not uncommon among  tailors, from their habitual
 position while at work making pressure on the outer ankles.
   M. Sedillot speaks of calcanean bursce (i. e. at the heel,) as new,
 or at least as hitherto undescribed by authors.  That they have long
been familiarly known,  is an  undoubted fact, but in most cases pro-
bably confounded with corns,  to which they bear a resemblance at
first.  M. Petrequin has described them  in his usual  clear and con-
densed manner.   The epiderm forms a blister or phlyctena, and the
subdermoid  tissue  is thickened  like a large flat callosity or corn, and
separated from  the  parts below.  From  this space oozes a serous
watery discharge, the parts becoming more and more inflamed and
exceedingly sore and troublesome.  He  says ulcerations and impli- 
676
CYSTS,  PROPERLY SO CALLED.
cations  of the os calcis might ensue if such cases were neglected.
Tight boots  are the common cause, and the bursa is probably then
an accidental production.
  A very similar affection, which is not uncommon, (and which  I
have several  times seen under the great toe,) explains, M.  Petrequin
remarks, the existence of a sub-metatarso-phalangeal bursa in this
part. This I treat by poulticing at first, and after the  reduction
of the  inflammation, careful excision  horizontally  of the  horny
plates down  to the sound parts, when a strap or two of adhesive
plaster firmly bound  round the toe  and foot inclusive, readily com-
pletes the cure.
  M. Petrequin has seen a bursa similarly situated under the little
toe, and considers also that a  bursa exists under the heel, also on the
lateral portion of the  metatarso-phalangeal articulation of the great
toe, where he has seen  them cause much pain and inflammation,
ending in suppuration, and passing thence  into chronic  induration
of the capsular walls, giving the appearance of an enlargement of the
extremity of the metatarsal bone.  These also, we think, are some-
times mistaken for corny callosities; though most probably a great
number of corns or callosities so called, about the  small joints of the
toes  particularly, are in  reality enlarged  bursas,  from pressure  of
tight shoes, and therefore more common in females.  The lateral bursas
at the toe go by the name  of ognons in France, (see Vol. I. and Vol.
II., under Corns, &c.) Soft Corns, so called in this country, and which
form between the toes near their commissure, and which from their
position become less frequently indurated, are also probably natural
Or accidental bursas, inflamed by tight shoes.
  M. Petrequin  has  seen  an inflamed encysted  lateral metatarso-
phalangeal bursa on  the great toe in a man, acquire the size of an
egg.  It was red and fluctuating, and seemed to involve  the natural
bursa which exists above, and the one  also below the articulation.
On opening it pus and blood were discharged, after which a cure was
effected by iodine injections.  In one case the matter  evacuated was
gelatinous.
  We  do  not wonder that  M. Malgaigne, (see  4th edition  of his
Manuel de Med. Operat., Paris, 1843, p. 113,) could  not succeed by
Sabatier's inefficient  mode of rupturing these bursas, by slow pres-
sure of one thumb over another.  Sudden and strong percussion, as
with a bound book, noticed by M. Malgaigne, is the only sure mode
of making this process successful. (See our remarks infra; also on
the same subject in Vol. I. of this work.)   Certainly this  mode could
not succeed where there  is no point d'appui, as when these tumors,
according to  M.  Malgaigne, are found, (though extremely  rare,) be-
tween the os hyoides and thyroid cartilage. Where they are met with,
however, on  the dorsal surface  of the  hand over the interosseous
space,  between  the metacarpal bones,  as  we  have  said  above,  it
would not even then be difficult, as it  appears to us, to  crowd them on
to the adjacent metacarpal bones, and burst them  in this position.
  M. Malgaigne's own process in fact is nothing more than the sub-
cutaneous  principle of M. Guerin, and  M. Goyrand of Aix,  &c. ;
i. e., he draws the bursa forcibly to one direction,  makes a small sub-
cutaneous puncture into one extremity of the sac, evacuates the sy- 
NEW ELEMENTS OF OPERATIVE  SURGERY.
677
novia or small cartilaginous bodies if they exist, and then with the
blade of the instrument sub-cutaneously breaks down effectually the
walls of the bursa, after which he makes for  10 or 15 days strong
pressure with flat pieces of agaric and thick compressions, (loc. cit.,
p. 113,  114.)  This  process  may undoubtedly answer where per-
cussion fails.
  In encysted tumors, developed in the cellular tissue, containing
collections of serosity or other liquids of greater consistency, as pus,
&c, M.  Recamier is in the practice (op. cit. Malgaigne's Manuel de
Med Operat., 4th edition, Paris, 1843, p. 113) of evacuating a portion
of the pus, &c,  little by little, and replacing this portion by injection
of warm water, until the walls collapse and adhere, in the  same
way as  he does for abscesses by congestion.
  M. P. J. Cabaret of Saint Malo, (France,) in a memoir on bursas
mucosas, (Journal des Connaissances Medico-Chirurg., Paris, Juin,
1844, p. 224—228,) after noticing the almost total neglect which had
been evinced towards them until the  time of Beclard, (Additions a
VAnatomie de Bichat, 1821,) states that these bursas form a roundish
(obronde) cavity, divided by imperfect septa, (coloisons incompletes,)
but without  any opening ; that in  their texture they appear to be
membranes, differing only from cellular tissue by being more con-
densed  and composed of large laminae (en grandes lames);  their
evident  design being [like cushions or pulleys, T.] to give  greater
ease to the movements of the bones under the skin.   For which pur-
pose their homogeneous smooth surface is slightly bedewed with an
unctuous mucilaginous liquid.  Most anatomists concur in the opinion
that they  are less  numerous in children  than in  adults, because
their  development  depends on muscular movements.  M. Velpeau
has noticed them on both sides of the  spine, on the malleoli, and on
the outer, posterior, and middle part  of  the  thigh.  I have seen
them  also in  one case (the result of syphilis)  directly over or  upon
both the great trochanters, easily movable, elastic, somewhat  pain-
ful, elliptical in shape, and thus buried deep under the muscles and
aponeuroses, as hard to the touch  as  a stone, and  of the size of a
pullet's  egg, but  totally disappearing spontaneously under the proper
internal  remedies  for  the  constitutional disease to which they ap-
peared  to owe  their origin.   They  are most usually found  acci-
dentally developed  ir.  consequence of unreduced fractures and lux-
ations, and Sir B. Brodie has seen one of great size in the case of a
girl with Talipes Equinus,  and which formed  upon  the part of the
instep upon which she walked. (Pathological and Surgical Observa-
tions on Diseases of the Joints, London, 1818.)  The excessive  se-
cretion from their internal surface may distend them into elastic  tu-
mors, truly hydropical in their character, as our author, M. Velpeau,
in a recent valuable memoir, has very properly  considered them.
(Recherches Analomiques, Physiologiques et Pathologiques  sur les
cavites  closes, naturelles  ou  accidentelles  de  l'economie animale,
1843.)   Others have on that account invented  for them the name of
Hygroma, which is  adopted by the writer,  M. Cabaret, whose  trea-
tise we  have under  consideration.   M. Cabaret remarks that these
serous bursal tumors are found in all parts of the body, but more es-
pecially at the elbow, [see notes on this subject in Vol. I. and inf.,] the 
678
CYSTS,  PROPERLY SO CALLED.
knee, [vide same  notes, T.] in front  of the patella  of individuals
who rest frequently upon this part, such as  preachers, religious  per-
sons, washerwomen, slaters, tilers, thatchers, &c, &c.  In England,
from the more rigid division of society  there for  centuries into  cer-
tain casts or permanent occupations from one generation to another,
more opportunities of course present for noting what may be  con-
sidered the accidental products or results of such professions or oc-
cupations.  Hence we hear there, and see surgical descriptions of
these enlarged bursas under the familiar names of the miner's elbow,
the housemaid's  knee, and the scriveners palm, &c.  Sir B. Brodie
has known this disease to be hereditary.
  These tumors are, as might naturally be  conceived, more or less
dense or elastic, more or less distended, and of greater or less vol-
ume, according to the greater or less pressure, constriction, motion,
&c, of the surrounding parts.  While  not  in a  state of inflamma-
tion, the contained fluid continues to be analogous to synovia; when
arising from contusions, blood may be  effused, giving a reddish or
brownish or black color to the synovia.  They then may be said to con-
stitute a natural hcematocele, the same as happens  in the cavity of the
tunica vaginalis testis, or as some  now call it peri-testis, in which
case they present the most favorable circumstances for M. Velpeau's
treatment of bloody tumors  by  percussion, [see Vol. I. supra,] or
puncture and iodine injections, more lately advocated by our author.
[See sup.]  Fibrinous clots, says M. Cabaret, or a sort of transparent
bouillie, are sometimes the result  of the alterations which the blood
undergoes in these tumors.  At other times  the liquid they contain is
mingled with a number of  movable bodies of a flattened oval form
and deep-brown color, and in appearance  resembling melon seeds.
These small masses, which are at first albuminous and  movable,
progressively acquire a great degree of hardness.
  M. Cabaret  rejects every kind of local  application, of frictions,
lotions, unguents, &c, whether iodine, mercurial, saturnine, or other-
wise, and also doubts the value  of compression and temporary  blis-
ters, which have succeeded with M. Velpeau.
  Excision of the tumor  in whole  or  in part is  also generally  pro-
scribed.  M. Velpeau has  seen two cases of death from this opera-
tion, (see Archives Gen. de  Med., Paris,) and Mr.  Keate has  seen the
disease return in a case in which he believed he had thus extirpated
it.  Sir B.  Brodie recommends it only under  certain  restrictions or
qualifications, which according to M. Cabaret are where the bursa
has become fibrous, thick, disorganized and incapable of resuming its
normal condition.
  Simple incision  is of no avail, as we all  know, against  a return,
and the  consequences, such as intense inflammation of the surround-
ing tendons, sheaths, and muscular  tissues, abscesses, phlebitis, &c.
are often of the most formidable character, which are likely, as we
consider, to be  aggravated by the former practice of introduc:ng a
seton into the cavity thus opened.   This mode of provoking aggluti-
nation of its walls we  deem too  severe, of which opinion we  find
also M. Cruveilhier.
  Puncture of the hygroma and injection of a moderately stimulating
liquid, as for example, the  iodine  injections which have proved so 
              NEW ELEMENTS  OF OPERATIVE SURGERY.          679

successful in the hands of M. Velpeau, is, according  to M. Cabaret,
deserving of adoption as a general method of cure for this disease
  M. Cabaret, in illustration of the success of this treatment, presents
five cases, four of which were bursal tumors  on the patella and one
on the olecranon, and all of which were perfectly cured by puncture
and  injections of wine  and  water,  diluted tincture of iodine, &c,
causing in a few days complete  agglutination of the walls without
any serious degree of inflammation.  We  should suppose that for the
puncture an extremely delicate trochar, not  much larger than  an
exploring needle, would  be most advisable, rather than an ordinary
trochar or bistoury.
  In conclusion, M. Cabaret says: The three last cases  (two of the
patella and one of the olecranon, and in which he injected the iodine)
which I have just given, and many others which I possess, furnish
incontestable evidence of the truth of the law laid down by M. Vel-
peau, in the following terms:  that" we should cause to be produced
in shut  cavities containing effused fluid,  an irritation which  should
be constantly adhesive  and never purulent."   These  cases, adds
M. Cabaret, will, I trust, help to make us feel the value to be derived
from the treatment of hydropsy of the sub-cutaneous synovial bursas
by iodine injections, as administered according to the method of the
learned professor of clinical surgery at the Hospital of La Charite.
  Nevertheless, as we  have before expressed  ourselves upon this
subject in various  places in the text of this work, we must with  all
due deference to the importance of the facts above adduced, and of
the unquestionable value of the treatment proposed and so success-
fully pursued by M. Velpeau, confess that we should in all cases
where it is practicable, and where there  is but  little  or no serious
pain or inconvenience in the tumor, be the tumor of what size it may,
(provided it  has  not, from its long standing,  undergone the kind of
fibrous consolidation spoken of,) prefer sudden and powerful percus-
sion, as we have described it.
  The distended, rolling bursa is then instantly  broken up into frag-
ments, if the stroke is made from  a  considerable height and with
great force  and rapidity, as by a heavy book or something similar,
held in the operator's hand, while the patient is unaware of your in-
tention  and has his head turned away, and  arm or leg firmly sup-
ported upon  a table.  Thus have I perfectly succeeded in a  large
olecranal bursa, which  had been growing for a year  or more in
H----, a healthy mulatto (part Indian and part white) of sound con-
stitution and good habits, and aged about 35.  The patient, who was
confidential porter of a distinguished mercantile firm of this city,
finding the tumor at length had attained such dimensions, being oval
shaped and of the size of a small hen's  egg and exceedingly tense,
though elastic, as to give a considerable degree of pain and annoy-
ance in  the  use  of his  arms in hoisting and  carrying boxes and
bales of goods.  He had imagined his arm would have to be ampu-
tated, and having promised, if it should be found necessary when 1
should examine it, (for I had not yet seen it,) that if so  serious  an
operation as amputation was required  it should  be performed, I
sent word to him to call upon me, and in that  event I  would give
him a note  to an eminent surgeon, who would do it at his clinique at 
680
CYSTS, PROPERLY SO  CALLED.
the University.  Immediately on looking  at it I  perceived  it was
nothing more than a bursal tumor, and as there was nothing  to pre-
vent proceeding at once to the mode of cure I  have mentioned, I
asked him to stretch his arm out in pronation firmly upon the table,
and to turn his head away.   Having at this time purposely in  my
hand  a heavy quarto  volume which I appeared to be engaged in
perusing. I suddenly came down upon the enlargement with it, hold-
ing it in both my hands, with all my force, from an elevation of three
feet, striking such  a blow upon it as dispersed in an instant  every
vestige of disease.  To the patient it naturally seemed marvellous;
and in fact would have appeared to be such in the eyes of most per-
sons out of the profession. If an operation of this kind, so instantane-
ous, so bloodless and painless too, it may be said, (for the pain is but
momentary,) and yet so radical in its total extirpation of the disease,
was known to the  school of Esculapius,  we cannot wonder why the
ignorant, marvel-loving,  superstitious multitude, before  whom  this
master spirit could have turned such skill to a valuable account,  (by
momentarily taking the patient for a few instants out of their pre-
sence,) should have deemed him  more than mortal,  and  built altars
and temples to his  honor.
   Far be  it from  the writer of this, however,  to glorify himself on
such an achievement, so long as its common utility  and  the  facility
with which any person may perform it, are so obviously sustained
on the plain principles of common sense.
   The truth and efficacy of this treatment, and its  total protection
from all return of the disease or any accident whatever, had been
made manifest to me many years since, during my residence at Nas-
sau, in the Bahama Islands, in effecting the  same results for bursal
enlargements upon the wrist.   Besides  the remarkable case  of  that
on the olecranon just  mentioned, I have since performed the same
operation on another patient,  also a laboring man, and on whom the
tumor was situated in precisely the  same locality;  but  in this  last
patient, from not having had it in my  power to strike a full  and
perfect  blow at first, I was  obliged to repeat it a few days after,
when the cure was complete, and has remained so now in both the
individuals (whom I am frequently in the habit  of seeing) for  several
years.
   In another case there  was a hemispherical  sub-cutaneous  bursal
tumor of great size on the patella, full equal in dimensions to the half
of a large orange, and completely covering the patella like a large
inverted cup.   This man, as the porter or wine-marker of  a wine
vault in the largest hotel in this city, was  in the constant necessity
of being upon his knees.  I effected a partial cure and subsidence of
the tumor for a year or more by producing, by means of common
strong ammoniacal liniment, a copious  suppurating drain over its
whole  surface for  weeks; but ultimately was  obliged, about three
years since, to come to percussion, which was performed as men-
tioned, and which  effected, as he informed me  within a few months
past, a radical and permanent cure.
   It is unnecessary, perhaps, to say more than we have already  said
in the first volume on the new mode of curing  bursal tumors by
breaking them down (as in couching the lens in cataract) at the point 
NEW ELEMENTS OF OPERATIVE SURGERY.
681
 ot a narrow tenotome, introduced sub-cutaneously at some  distance
 from the tumor.  The cures effected by this process, appear to be
 well substantiated, (vid. Vol. I.) and we have had no evidence (at
 least  no published  evidence) of its failure in any case.  A priori,
 however, it would  be deemed an operation of too great severity,
 but for these  successes, and others of a more remarkable  kind, by
 the same  process, in extracting foreign bodies  from the knee joint,
 and  the practicability of which  M. Velpeau himself has  recently
 confirmed (vid. Vol. I.) by the sub-cutaneous extraction of a ball from
 the same  articulation.
   The successful treatment of enlarged  bursce mucosce, by injec-
 tions of tincture of iodine, as some years since introduced into prac-
 tice by the learned  author of this work,  M. Velpeau, has, we  are
 gratified in perceiving, been recently verified in a most satisfactory
 manner, by experiments  performed for the same  disease in horses.
 At the sitting of the Academy of Sciences  of Paris, March 24,1845,
 (see  Gazette Medicate de Paris,  Mars 29, 1845, tome XIII., p. 204,
205,) MM. Thierry and  Leblanc  communicated  the result of their
experiments upon this subject, made in presence of MM.  Velpeau
and  Rayer.   It  is known, say  MM. Thierry and Leblanc,  that
horses are often affected  with  dropsy in the  articulations and  mu-
cous passages  (les courses muqueuses), and which are described by
veterinary surgeons under the name of wind-galls (molettes)  and
 vessigons.  Up to the present time, one remedy only has been  em-
ployed for this  affection, namely,  the red hot  iron, applied either in
the shape of the rayed  or the pointed cauteries.   But whatever
were  the means used, injurious traces of the disease always remained
behind.  It was with  the view of obviating this inconvenience, that
the authors, guided by the researches of M. Velpeau, made  experi-
ments with iodine and vinous injections as compared with the appli-
cation of the hot iron.  From the results they obtained, they believe
themselves authorized in declaring that iodine injections in  the mu-
cous bursas and synovial  sheaths,  in horses, may advantageously re-
place cauterization  by the  red hot iron, and that in a plurality of
cases, this mode of cure ought to be first employed.
  We have upon the  strength of  well-attested recorded facts, con-
sidered the discovery of  the mode of effectually curing these ancient
opprobria, by the new system of sub-cutaneous puncture, so impor-
tant and valuable, that we have been thereby in some measure com-
pelled  to  anticipate our author in the  position to which he has as-
signed this subject in the French edition of this work. As the cure of
these  bursal tumors, which have hitherto so much  annoyed, as well
as baffled, our  art, except where the patient and surgeon together,
have  had the  courage to adopt the ancient, and after all, when the
case warrants  it, the most radical process,  (we mean sudden percus-
sion,) is the most important point to be  considered in  relation to
them ; we have, in consequence, said most of what we had to add on
that subject, under  the head of sub-cutaneous surgery, in our first
volume. Though incisions and setons in these natural bursas, enlarged
morbidly into painful encysted sacs, (the most inconvenient cases of
which are those in working men, as those  familiarly known in Eng-
  vol. n.                        86 
682
CYSTS, PROPERLY SO CALLED.
land, as the maid-servant''s knee, the miner's elbow, and  the scriven-
er's  palm,) have been for the most part abandoned for the teno-
tome, several  surgeons,  nevertheless, among them our author,  M.
Velpeau, continue to adhere  to  his process.   M.  Velpeau's mode
consists in  a  simple puncture with the  trochar, to evacuate  the
hydatid corpuscules, which step is deemed indispensable to the cure,
after which he makes use of free injections of diluted tincture of
iodine, after the present received mode  of treating hydrocele, in
order to stimulate the sides of the sac to agglutination.   M. Velpeau
has met with most signal  success by this course, and obtained speedy
cures, free from all  accidents.  (Ann. de Therap., Paris, April, 1845—
also Cormack's  Lond. and Ed. Month. Journ., June, 1845, p.  460,
&c.)  M. Chassaignac (Ibid.)  in a remarkable case of one of these
tumors in the  wrist, found that  from its great size, twice that of an
egg or orange, it was compelled by the annular ligament of the wrist
to assume a bilobate form, about one half being above the ligament,
and the rest in the palm of the hand.  The large  quantity of hydatids
evacuated by the trochar were found by M. Chassaignac to be true spe-
cies of that enzootic class, possessing, as examined by the microscope,
elastic, compressible, vesicular bodies, and  not  composed of those
hard, albuminous concretions which  are mistaken, he  says,  for
them.
  M. Gherini, surgeon of the great Hospital of Milan,  (lb. and An-
nali Universali, Jan., 1845,) saw also a bilobate bursal hydatid cyst on
the posterior part of the elbow, though that has no annular ligament
to explain this form, and  cured it by incision, evacuating 52 barley-
shaped corpuscules.  The sac suppurated, but the cure was com-
plete.  Neither of the lobes of the bilobular cyst communicated with
the articulation.   We should for ourselves be adverse to the incision
in any case except  in one  of extreme necessity, as, for example,
where there was great extent of inflammation in the cyst and  neigh-
borhood, from bruises, injuries, &c, and  then  the  knife should be
withheld until general and  topical  depletion had reduced the  vio-
lence of the inflammation and attending  fever, if any, and  that the dis-
tension of the  sac by the contained synovial  or hydatid matters  had
made it necessary.   But  a mere small sub-cutaneous incision in such
cases, and sufficient to  evacuate the contents,  is a very different
thing from an  extensive dilatation of these cavities themselves, while
they are in an uninflamed state.   The incision practised in this lat-
ter state, from the exposure to the air of the peculiarly sensitive  tis-
sue of these bursas, becomes itself, by the operation, the source of
danger, whereas in  the other case, it is  to subdue inflammation, that
we have recourse to it. We think we are warranted by the pathologi-
cal discoveries of sub-cutaneous surgery, and  by the reiterated injunc-
tions so studiously enforced  by our author throughout this work on
the subject of  the dangerous accidents, such as  burrowing, destruc-
tive  suppuration, phlebitis, purulent infections, tetanus, typhus, &c,
from wounding  synovial membranes, surfaces,  passages (coulisses)
and  capsules,  to lay it down as  a precept, that  these bursal cysts
must not be thus meddled with by direct incisions, except under  the
circumstances mentioned. 
NEW ELEMENTS OF OPERATIVE SURGERY.         683
   Irrelevant  and improper  as would be the admission into a work
 eminently didactic and elemental as is  this on operative surgery by
 M.  Velpeau,  of all  matter purely controversial, unless  as in the
 academic discussions upon tenotomy (see Vol. I.) and those on fibrous
 tumors, (see this vol. infra,) new and valuable facts are thereby elicited,
 we deem it, nevertheless, an act of impartiality to state in this place,
 in reference to a subject  already treated of in the 1st vol., (the sub-
 cutaneous puncture for articular  dropsies  and foreign bodies, &c.,)
 that M. Bonnet, of Lyons, claims the merit, how  just we  cannot at
 present decide, (see his recent work, Traite des Maladies des Articu-
 lations, 2 vols. in-8° Paris, 1845, also a notice of the same in the
 Gazette Medicate de  Paris, Mai 17, 1845, t. XIII., p. 319,)  of having
 been the  first to employ, and before M. Velpeau, iodine  injections
 into the articulations.   By a curious coincidence, however, M. Bonnet
 himself, in making this reclamation over the surgeon of La Charite,
 has  in his  work just cited,  committed an act,  (Introd.,  p. xxxvi,
 and tome I.,  pp. 451, 487,)  according  to M. H. Diday, (Gaz. Med.
 loc. cit., p.  320,) of  positive injustice  towards M.  Jules Guerin in
 another matter appertaining to this subject; viz., in asserting that we
 owe to M. Goyrand, of Aix, the  credit of having  first treated the
 evacuation of articular dropsies, and the extraction of foreign bodies
 in the joints,  by the  sub-cutaneous puncture.  M. Diday contends
 (Gaz. Med., loc. cit.,  p. 320,) that at least  the germ, or original idea
 of this treatment, in  both these classes of affections, was  so specifi-
 cally and formally laid down by M. Guerin, as early as in  the years
 1840 and 1841, (see  M. Guerin's  Mem. sur les Plaies Sous-cut. des
 Artie, lu a l'Acad. des Sciences de Paris,  le  4 Mai, 1840; and the
 Essais  sur la Methode Sous-cut., Paris, 1841, pp.  84  et  113,)  that
 there can remain not  a shadow of doubt as  to his (M. Guerin's) claim
 of priority.  M.  Diday,  however, seems willing  to make a sort of
 commutation  of this  last mentioned difficulty, by admitting that M.
 Bonnet may possibly  be entitled to the  merit of having been the first
 to execute, and ivith success, the  sub-cutaneous operation for the ex-
 traction of intra-articular foreign bodies ; but that the same operation
 as applied to the evacuation of the  liquid of hydarthrosies, by making
 this fjuid  pass under  the skin, by a sub-cutaneous incision into the
 synovial  capsule, as  practised by M. Bonnet,  is not so certain  and
 efficacious a cure as the pure and  simple evacuation of the  liquid, by
 means of the  syringe,  as practised by M. Guerin ; the process of
 M. Bonnet incurring the risk of not procuring a complete evacuation,
 and of leaving a portion of the liquid, as an irritating substance, under
 the skin.
  Patellar  bursce,  or those  between the  patella and integuments,
 and familiarly known in England  as the housemaid's knee,  may, Sir
 B. Brodie is satisfied,  be reproduced after their complete extirpation,
 as he has  frequently found to be  the fact.  (London Med. Gazette,
 Mav, 1846, p.  829, from Sir.  B. Brodie's Lectures on Pathology and
 Surgery).
  Sanguineous  Tumors treated  by Ecrasement.—The process of
crushing, which we have felt it our duty to advocate in such unequi-
vocal terms, as the one  which should  always be preferred, where
practicable, for mucous bursas, has  been  applied with eminent success, 
684
CYSTS,  PROPERLY SO CALLED.
also, in sanguineous hematic tumors that are external, and favorably
situated for percussion.    M. Velpeau  reasoned very naturally,
(Traitement des Tumeurs Sanguines par ecrasement; Annates de la
Chirurgie, Aout, 1843 ; Arch. Gen. 4e, ser., t. III., pp. 217, 218, 219,)
that the extravasated blood of such tumors, if once dispersed by their
rupture, so as to become infiltrated into the surrounding cellular tissues,
must naturally from its assimilation to the  great mass of the vital
fluid, be absorbed with  yet greater facility than the serous  liquid of
synovial bursas.   He also presents as another striking argument for
the ecrasement of such tumors, the fact, that left to themselves, in their
semi-concrete and confined position, they are rarely absorbed, whereas
every  one is familiar With the fact that  every ordinary ecchymosis
or extravasation of blood from a blow or bruise, is rapidly absorbed,
and for the reason,  that in the latter case it is dispersed by the acci-
dent itself, into the  cellular tissues.   This, probably, is the source of
the correct vulgar practice  of applying pressure  and friction imme-
diately, and as soon as such bruises are  received.  The ecrasement
is performed by M.  Velpeau by  sudden pressure  upon the tumor,
with the palm of the hand or with the thenar eminence,  or with both
hands, or  it may be done with a solid body, as a  piece of money or
wood, which is to  be struck upon with a  hammer or the fist.  The
tumor is broken up immediately, leaving only some lumps (bosselures)
in the  tissues.   The tumors best adapted to it should not exceed the
fist in  size.  He very  judiciously adds, that a solid point  d'appui
must of course  exist as in ordinary serous bursas, and  before the
operation  can be thought  of.  In case  of an eschar on the tumor,
the process  may still  be applied  if the eschar is superficial, and has
not begun to be detached; in the contrary  case we should abstain.
Ecrasement is  better adapted to  the effusions in accidental, than in
normal close cavities, as the walls of these last are always thicker, and
consequently more  resistant.  M.  Velpeau furnishes numerous cases
of cures in favor of this, as it appears to us, most judicious treatment.
Surgery, it  may be said, has at  length obtained a tolerable  mastery
over external, synovial and  hematic  tumors, either by means of
ecrasement or sub-cutaneous injection of iodine, to say nothing of the
value of this last, or favorite process of the  author in normal close
cavities.
  On Close Cavities in general.—Before this chapter closes it is pro-
per to  insert in  this place, and more in  detail, the new and impor-
tant views of our author, M, Velpeau, as published by him in his work,
entitled Recherches Anatomiques, Physiologiques et Pathologiques sui-
tes Cavites Closes,  naturelles et accidentelles, de Veconomie animate.
(Par A. Velpeau,  &c, Paris, 1843,  pp.  208, see also an extended
abrege of this in the British and Foreign Med. Review,  vol. XVIIL.
July—Oct., 1844, pp. 79, 90.)  M. Velpeau maintains the new pro-
position, that serous and synovial membranes, as distinct  tissues, have
no existence, and consequently that the notion of close cavities formed
by such membranes,  is entirely devoid  of foundation.   He  bases
this proposition on the facts obtained from intra-uterine life.   From
ten embryos examined by him, and which were from fifteen to thirty
days old, he concludes that even up to the 4th week the free surfaces
present no appearances of membrane;  the  whole body consisting 
NEW ELEMENTS OF OPERATIVE  SURGERY.
685
apparently, of a homogeneous, gelatiniform and fragile substance,
none  of the cavities any where being fined with any distinct mem-
branous tissue, or laminae capable of being isolated.   The whole is
either surfaces or parenchymata, while there is nothing either in the
head, chest or abdomen, to justify the expressions cutaneous, mucous
and serous membranes, &c.  He contends that what for example
we call in extra-uterine  life  the  peritoneal or serous membranes
do not always exist, and cannot be detached as a distinct peritoneal or
serous membrane, properly so called   They are in fact only serous
surfaces continuous with, and not separable (except by a  traumatic
division) from the subjacent cellular  parenchyma of the organ, as on
the liver, uterus, ovaries, &c.  So behind the linea alba.  In proof of
this, it is to be considered that the serous membranes, properly so
called, do  not exist, and  do not become manifest until at a very ad-
vanced period of the embryonic state,  that is, prior to the organs in-
vested by them.  Pursuing  the same course of reasoning  in respect
to other cavities  than those of the  abdomen,  and which, however
ably maintained, is  too   strictly pathological  to be  properly  em-
braced  in  the text of our work, M. Velpeau comes to synovial
cavities, properly so called.   He shows that there are but few vesti-
ges to  be  found of this  supposed serous membrane.  Thus, in the
knee it is no where to be found, on the free surface of the cartilages,
or on the internal surface  of most of the ligaments.
  Accidental close cavities are divided by our author into functional
and  pathological.  The functional  consist of: 1. Serous  cavities
2. Articulations; and 3.  Cellular cavities.  The first, or  serous, are
formed by  an ovary, a noose of intestine, or a knot of epiploon or other
viscus passing through a fissure of the peritoneum and abdominal mus-
cles, so as  to fix itself under the skin.  The second  or articular, are
connected  with the articulations, and caused by a luxation or frac-
ture.   They have no lining membrane, and  are nothing more than
the polished surface of the textures which enter into  their composi-
tion.   The third  or cellular cavities, are those  usually denominated
synovial or mucous bursas, and are accidental sub-cutaneous arrange-
ments, which nature interposes over  any projecting point  or surface
of bone which is exposed to much  pressure from without, and are
evidently  designed to protect the soft parts from the hard, in the na-
ture of pulleys, or rather a sort of distended  sacs or air cushions.
Thus on the backs of porters and on the  acromion of persons who
carry burdens on the  shoulders, on the angle  of the scapula in those
who carry scuttles, &c, on the anterior part of the  sternum in join-
ers &c, on the malleoli, [and tuberosities of the ischium, T.] in tailors,
&c.  on the hump of  humpbacks, and on the salient  points of club
feet.   To these we may  specify those which in certain occupations
in England are  so common as to  have  acquired, as we have else-
where frequently noted in this work, a particular desgnation.  Thus
the bursa  over the patella, called the housemaid's knee, seen also in
the other sex and in all who have occasion to rest much on this part ;
so also the miner's elbow,  meaning the bursa at  the acromion, caused
by the position in which  the miner works.  To these  add the  scriv-
ener's palm, or bursa in the palm  and wrist  of those  who  have to
write a great deal. Our author also has seen them on the body of 
686                CYSTS, PROPERLY SO  CALLED.

the clavicle, on the posterior surface of the fore-arm, on the internal
surface of the tibia, the crest of the ilium, &c, from exposure of those
parts to friction  and pressure.   All these cavities, like normal ones
of the same character, are destitute of investing membrane.
  Pathological  close cavities comprehend every  kind of abscess,
cyst, and morbid deposit.  But  it is to  morbid sub-cutaneous close
cavities, analogous to the normal close cavities of joints and under
tendons, that he  particularly  directs attention.  These sub-cutaneous
morbid cavities  are  observed: a. In the cellular  tissue, which have
been described particularly as serous cysts, and which are surround-
ed by the condensed cellular tissue, which is mistaken for a supposed
lining membrane to the cavity ;  b. In glandular bodies, as in the thy-
roid body, breast, testicle, &c, where it  is also clear that their sur-
face is part of the tissue of the gland.   The pellicle, which may occa-
sionally be separated, has been formed there in the same way as that
which  constitutes a part of the cavity of an aneurismal sac, in which
the blood has continued to circulate.   In the ovaries,  M. Velpeau
says, the truth of his doctrine is strikingly illustrated  by the coexist-
ence of real cysts like hydatids and which can be readily detached
from the tissue of the organ, with close cavities the surface of which
is inseparable from it, and forms part of it.  c. In ganglial cavities,
as under the jaw in the region of the parotid, and  in the carotid  ca-
nals, and in  front  of the larynx, in  the supra-sternal fossa, axilla,
bend of the  arm, groin, and ham,  and in the interior of the  pelvis.
These last may  exist in  the gland, shut up, as it were, and with their
sides in contact,  or if they are towards the surface of the gland, they
then, from  having room, expand into a pouch, which, however, will
always be found to be attached in some portion of it to the glandular
mass.  The practical inference from all the above is that diseases of
close cavities or surfaces are in fact primarily nothing more than dis-
eases of the tissue, of which  these cavities constitute a part.  From
whence M. Velpeau lays it down as a law, that as the articular car-
tilages are destitute of arterial and venous circulation, and of a serous
membrane, properly so called which is distinct from their tissues, so
neither inflammation, ulcers, fungous diseases, nor transformations,
nor degenerations  of any kind, exist as a primary malady on the free
surface of those articular cartilages.  A deception may arise in this
way ;  that inflammation without the cartilages  may lead to a deposi-
tion of lymph between the  cartilages, and this deposition becoming
organized and vascular, or even blended with the  surface  of one of
the cartilages, may give rise to the supposition that the free surface
of the  cartilage  itself is the seat of the disease.  For this deposition
may constitute a real vascular movable membrane in  the articular
cavity.  Hence  fungosities and vegetations upon this membrane may
be described  as those of a synovial  membrane.  M. Velpeau admits
that in the  progress of the disease, the cartilage itself may now be-
come implicated, and thus vascularized from its circumference to its
central parts.  This however, he says, is no proof of a real synovial
membrane, as the friends of Bichat maintain, on the diarthrodial car-
tilages, or that inflammation ever originated on an isolated layer of
such cartilages.
  The opinion advanced, that  articular  cartilages are unorganized, 
NEW ELEMENTS OF  OPERATIVE SURGERY.
687
is, it must be confessed, contested by  a great number of authors.
M. Velpeau contends  that the synovial fluid is directly  produced
from  the  surface of the articular cartilage.   The salutary organic
process of adhesive inflammation,  deemed peculiar almost to cellular
tissue, and seen as the precursor or protecting interposition intended
by nature to circumscribe and to  intercept the progress of suppura-
tion, is developed also in close cavities, and with the greater rapidity
in proportion  as their parietes are  smooth and completely serous,
finally soldering them together and obliterating the cavity.  This ad-
hesive inflammation is dangerous in large cavities, as in the perito-
neum and pleura, and may in  its turn give rise to suppuration.  The
excitation therefore, where we wish to obliterate a cavity, as in hy-
drarthrosis, should, as before observed, be so controlled as to produce
always an adhesive inflammation only, and  one which shall never
become purulent.  The more the effused fluid resembles serum, the
more  easy is it to procure adhesive inflammation, and  the more it re-
sembles pus, the less chance is there of escaping purulent inflamma-
tion.   Hence  it is  an important point  to change the  contained fluid
as much as possible into the condition of serum, which our author
maintains, can in certain cases be  effected by  frequently emptying
the cavity by  puncture.  So  also  with  accumulations of blood; and
in this manner there is finally poured out instead of  blood or pus, a
purely serous, or a sero-sanguineous or sero-purulent fluid.  This re-
sult M. Velpeau has verified  in  most regions of the  body.  This
brings our author naturally to his favorite injections  with iodine, as
tested by him with such eminent success in hydrocele, &c, and the
latest information in  regard  to which will be found at length in our
notes under that head (infra).  He remarks in this work under con-
sideration, that additional importance is given  to iodine from its well-
known resolvent properties, and the beneficial influence which these
properties may have upon the infarcted condition  which is  gene-
rally  found to exist in some parenchymatous organ, in those cases in
which there is a serous effusion in a close cavity.   This applies di-
rectly to an infarcted or congested testicle accompanying hydrocele,
and where M. Velpeau has  found the true treatment  to lie in a
course  which is the  reverse  of the old practice.  Thus, therefore,
instead of endeavoring to resolve  the congested testicle before  treat-
ing the hydrocele, he begins  with both, and acts upon both at once
by his iodine injections into the hydrocele cavity ; that is, provided
the infarction is not scirrhous, encephaloid, melanotic, or tubercular,
but merely a hypertrophied condition of the testicle.  The most for-
tunate results have been obtained by M. Velpeau by the practice in
question.
   But it is unnecessary to dilate here on the advantages of these in-
 iections, as we have  given the latest details  from M. Velpeau him-
self and others, (see this volume, supra) and (infra,) as more fully
disclosed in the recent animated discussion to which this subject gave
rise in the  Paris Academy of Medicine.  It  is proper, however, to
notice  the various kinds of diseases of close cavities  in which M.
Velpeau now successfully employs this treatment:—1.  In encysted
collections of serum in the tunica vaginalis.  2.  Collections of serum
in the tunica vaginalis, which communicate with the cavity of the
» 
688
CYSTS,  PROPERLY SO CALLED.
abdomen, forming what is called congenital hydrocele.   3.  Serous
collections within a perineal sac, whether the sac be continuous with
the peritoneal cavity or otherwise.  4.  Encysted  serous collections
of the spermatic  cord.  5. Serous collections in the external genital
organs  of women, contained  in  close cavities, and  resembling the
last mentioned.  6. Serous collections in the lymphatic ganglia of
the groin and iliac fossa; and 7. Collections of purely liquid blood
in the interior of  the pelvis in women.   We wish we could subjoin
additional successful results  to the few  well-authenticated cases we
have alluded to in our first volume, in which the neck  of the sac of
several old, large, and reducible inguinal hernias, (not congenital,) has
been completely and permanently obliterated, and the hernia  radi-
cally cured by means of injections of Tincture of  Cloves,  (doubtless
suggested  by the  practice of M. Velpeau,) in the  hand  of some
young and bold practitioner of this country.  But  we are not aware
that this practice  has been followed  up, though several remarkable
cures to which both Dr. Mott and myself  were both eye-witnesses,
and the  happy results of which gave much  satisfaction to that sur-
geon, would certainly authorize new trials with it.   M. Velpeau has
succeeded with iodine injections in the cavity of a  large sanguineous
tumor, which  was diagnosed  and proved  to be such by this distin-
guished  surgeon,  and which had formed behind the  uterus and as-
cended towards the right iliac  fossa.   He also succeeded in a case of
an accidental close cavity  in the thyroid body, which  though the first
in which  he  found constitutional febrile   reaction  caused  by the
iodine, ultimately  recovered.   Finally, the same success has attended
his iodine  injections when thrown into  the cavities of the joints, to
cure articular effusions, and  he had  thus already triumphed (when
this book was published, 1843) in six  cases out of  seven of pure hy-
drarthrosis.  His experiments  on dogs go to show that iodine of more
strength than one-seventh  of the water used to dilute it, is fatal when
thrown into  the peritoneal cavity; not  however by absorption and
poisoning, but by peritonitis and enteritis.  The state  of this question
of iodine injections at the present time  will be best understood by
our notes elsewhere in this volume, (vid. infra.)
   Treatment of Tumors.—M.  Bonnet  of Lyons, with all the natural
predilections which  an  eminent surgeon like him  must possess for
the chirurgical rather than therapeutical treatment  of disease, has
in his late important work  (Traite des  Maladies des Artie, 2 vols, in
8°, Paris, 1845: see a short critique on  this work, by M. H. Diday,
in the Gazette Medicate of Paris, Mai 17, 1845, p. 316 et sequ.) in-
sisted very judiciously as  we  think upon the absolute necessity of
looking to the general diathesis of the whole system  as the frequent
if not most common source of all fungoid, serous and other growths
and diseases in the articulations.  Some of his  views upon this sub-
ject appear to be presented under an original  aspect.  The cause
of these diseases  lies, M. Bonnet says, most frequently in an arrest
of organic development, dependent on the  general condition of the
system.  Thus articular  fungosities (fungous growths or tumors)
for example, are  nothing else than plastic lymph which has  been
suspended by an internal influence ; the part which is the seat of the
disease being but a type of what is passing in the general economy; 
              NEW ELEMENTS OF OPERATIVE SURGERY.          689

but if the vital energy in the latter, now temporarily paralyzed,
should  recover  itself,  these fungosities  will be converted into
fibrous (i. e. healthy organic) tissue.  As  in the serous membranes,
so in the articulations, the fibrous transformation is the fortunate or
ealutary maximum or last term of the nisus formativus : and wher-
ever a fibrous layer  is found upon the  articular surface  of bones
denuded of their cartilage, and that we perceive this tissue expanded
into  membranes, or concentrated into fibrous bundles (faisceaux)
going  from one articular extremity to the other, we may conclude
for a certainty that there has been  one step taken towards a cure,
a vis medicatrix established by nature to  complete the evolution of
the coagulable lymph.
  M.  Bonnet makes three distinct classes in the products  of secre-
tion which are formed  in diseased articulations: 1. Those which
are systematically (regulierement) organized; 2. Those which  are
arrested in their organization ; and 3. Those which are not at all or-
ganized.
  Thus the general  diatheses, so clearly established in arthralgias,
may be characterized themselves by their tendency to favor one or
the other of these three  products: in the less  severe, as in acute  or
chronic rheumatismal diathesis, the  tendency is to the first or effu-
sions of plastic lymph; in other cases, as in the scrofulous diathesis
(where synovial fungosities are most frequently met with)  a disposi-
tion will exist to  the secretion of incomplete  organic  products; in
the diathesis which is still more aggravated, [i. e. where there is the
greatest degree of degeneration in the organism, T.] as in the tuber-
culous, purulent and gouty, there are no organic products secreted,
but depositions of tubercles, pus and uric acid, [rather lithate of soda
either  in  a fluid state  or in  crystals, which  depositions constitute
gout.  T.]
  Fungous articular tumors are  unconditionally ascribed by M.
Bonnet to the scrofulous or so called strumous diathesis, of which he
makes several species, altogether distinct from the products of the
tuberculous diathesis, as well by their external appearance as by their
peculiar characters.
  He  makes  two distinct  classes of scrofulous  persons:  1. Those
who are pale, thin  and without  any trace  of tumefaction in the ex-
ternal glands ; such have also hollow cheeks, the eyelids and lips thin,
complexion pallid, and frequently cold abscesses  (abcesfroids) with-
out tubercles.  These are individuals with the purulent  diathesis.
2. The other class have the face full, the alas of the nose, the lips and
the eyelids tumefied, and the  glands of the neck in general volumi-
nous.   They are disposed to congestions with mucous  secretion,
ophthalmias, otirrheas, &c.   These  are what  are denominated pre-
eminently scrofulous temperaments, but which  M. Bonnet proposes
to consider as laboring under a fungous diathesis, (diathese fon-
gueuse.)  In  them we frequently  meet with local  lesions, such as
those fleshy soft masses, whose tendency is to suppuration and which
are usually designated under the name of fungosities, (fongosites)—
not only in the articulations, but frequently in  the bones themselves,
under the name of spina ventosa;  also in the glands, which thence
become swollen,  and in the nose and cheeks, where they may  ulcer-
  vol. ii.                        87 
690
CYSTS,  PROPERLY SO CALLED.
ate and become the source of phagedenic eruptions  (dartres ron-
geantes), [as phagedena or cancra oris, T.] &c.
  M. Bonnet has pointed out with  much force, the injury done in
the treatment  by the common machines employed to keep the joint
in a constrained  and vicious position, whereby the disease, from a
false idea of obtaining repose for the limb, is greatly aggravated, the
synovial membrane and ligaments on one side kept in a state of ten-
sion, the osseous surfaces compressed on the other, with a permanent
tendency to an alteration in the natural relations of the bones.   He
had by  various experiments on the dead body, to determine the best
possible position for the articulations, contrived a number of kinds
of ingenious apparatus  based upon these objects: 1.  To bring the
limb into such  a position that no stress is made on the synovial mem-
brane  and ligaments, that no  danger is incurred of spontaneous
luxation, and that will allow (as in cases of anchylosis) of the easiest
exercise to the limb ; 2. To retain the part in this position during a
greater or less length of time, as may be required to  complete the
cure.
  Among other remedies  of a  local character, M. Bonnet has de-
rived great advantage in articular diseases from transcurrent caute-
rization with  the red hot-iron, frequently repeated,  eight  or ten
times for example, on the same scars—also from the moxa, for which
purpose he prefers the large Egyptian  moxa.
  Double Encysted Tumor.—Dr. W. L. Atlee, of Lancaster (Penn-
sylvania), gives a very interesting account of the successful removal,
by  him  from a healthy, robust boy aged four years, of an enormous
spherical double encysted congenital tumor on  the right side of the
trunk, which overlaid several of the lower ribs and the abdominal
muscles on that side, encroaching even upon the internal abdominal
ring.   It was  closely adherent by a broad base to the tissues men-
tioned.  On making a long incision over it in the direction of the fibres
of the external oblique muscle, he finally succeeded by a tedious dis-
section, rendered the more so by the  obliteration of the sub-cutaneous
cellular tissue, in extracting the entire mass.   This  was  found to
consist  of two  distinct hemispherical cysts, one within the other, and
both filled with serum, the intervening space between the two being
filled up by small oval hydatid-like cysts  containing pink-colored
serum and which communicated with each other by narrow necks.
Tough fibro-cellular aponeurotic bands ran over the inner surface of
the two principal cavities and connected the whole structure firmly
logether, giving it the appearance of the interior of the ventricles
of the heart.  (Amer. Journ. Med. Sciences, vol. VII., new series,
Philadelphia, 1844, p. 84-88.) T.] 
NEW ELEMENTS OF OPERATIVE  SURGERY.
691
                        CHAPTER  IX.

                       FIBROUS TUMORS.

  Among the concrete tumors which remain to be spoken  of, I
have a word to say of those which are known under the name of
fibrous tumors ;  not that I propose to treat now of polypis under this
name, (de ce nom,) but of tumors which appear to originate from a
concretion of lymph or effused blood in the tissues, or from a trans-
formation or limited  hypertrophy in some circumscribed part of the
natural tissues.   These tumors, which are ordinarily globose, (globu-
leuses,) though  more  or less bosselated, are  hard, elastic, indolent,
and  of a grayish color and of a fibrous and mammellated structure.
Some excavate for themselves a species of cyst in the tissues, the
different  layers of which latter they flatten out  (etalent) and  com-
press ;  others are blended so intimately with the surrounding tissues
that  it is impossible to separate them from  these by enucleation.  I
have seen some tumors of this kind which  had acquired the size of
the head of  an adult, and  it is rare they are found of much greater
dimensions except in the interior of the pelvis ; most usually they do
not exceed the volume of a small nut,  or that of an egg or the fist.
As  they occasion  no inconvenience  in themselves, they  may exist
during life without  any real danger to the  patient.  As they are,
moreover, wholly incurable  by any other mode than  by extirpation,
it is  imprudent  to meddle with them, unless by their volume, weight
or position they occasion some actual  trouble or disturbance in the
economy, or too great a degree of deformity.

                              §1-
  To effect their separation by a ligature would not be possible or
at least not  advisable, but  for such as  had a sufficiently narrow
pedicle  or neck at  their union with the skin.  In regard to this. I
have only to refer to what I have said of the  ligature for  tegumen-
tary tumors,  properly so called.

                              §11.
  When we  have decided upon extirpating them, we have scarcely
else  than to recall the rules for  the extirpation of  fatty, rather than
those for lymphatic tumors.  As they are generally disconnected with
any  kind of constitutional  affection, and constitute  almost  always a
disease purely local and separate from and independent of all the
natural tissues, and represent, in a word, a simple foreign body in the
midst of the organs ; a fibrous tumor may  be extirpated with every
degree of security, and without the necessity of removing with it a
large portion of  the sound parts.  Being rarely liable to return, and
leaving a wound which is pliant (souple) at  the bottom, and destitute
of any dangerous  germ, we are enabled after effecting their abla-
tion, to undertake immediate reunion with every possible  chance of
success.  What  I have just said, however, is applicable only to those 
692
FIBROUS TUMORS.
fibrous tumors which have, so to speak, dug out for themselves a cyst
in the midst of the cellular tissue.  In fact, in respect to the others,
it would be impossible to isolate, and preserve the skin which covers
them.   There  are in fact some  which, under this  point  of view,
would lead to unexpected embarrassments if we attempted to operate
upon them by the ordinary methods.   A  porter who had  upon his
nape  a  fibrous tumor  of the size  of the  fist, came  in  1831 to the
hospital of La  Pitie  to  have it removed.  This  tumor was mova-
ble, with a large base, indolent and devoid of any change of color
upon the skin.  With  the view of laying  it bare, I made  a crucial
incision upon it, but soon discovered that there was no limit between
its tissue and that of the skin.   It consequently became necessary to
cut out the four flaps in their whole extent at  the expense of its  ex-
ternal surface ; and when I had extirpated it, I was enabled to ascer-
tain that it was continuous  at  all its  points with  the tegumentary
tissue, of which it  seemed to  be  nothing more than  an  inflated
(rarefiee) layer enormeusly hypertrophied.  The operation was fol-
lowed by no serious accident; only that the  skin  in the neighbor-
hood continued hypertrophied after the cure  of the wound,  so  that
the patient remained  almost as  deformed as before the operation.  I
have since seen two instances of similar tumors, one at the nape  and
the other at the middle of the back.   A third fell under my obser-
vation in November, 1838.   A man 45 years  of age had on the  me-
dian line, or a little to the right of the anterior half of the cranium,
a tumor which at its point descended down to the forehead, and  was
prolonged upwards to a line with  the parietal protuberance.  This
tumor which had formed gradually and  without  any  appreciable
cause, and which appeared to be  situated upon an  incipient exos-
tosis, had perhaps like the preceding been  produced by the repeated
frictions  to which the diseased region  had  been subjected, and  was
moreover movable, without  any  well-defined limit, and  in every
respect indolent.  In whatever manner it was attempted to displace
it, it was always possible to recognize  in it a disc or plate of integu-
ments excessively thickened or distended, with an entire absence of
degeneration or transformation of tissues.   But for fibrous tumors be-
ing unaccompanied with this last feature, I should in fact deem those
of which I speak  a  species of flattened  elephantine tumors of very
limited extent.
  It follows from these remarks, that in.order to effect a perfect cure,
it is necessary to remove at the  same time with the tumor, every
portion of the skin which is adherent to it or constitutes a part of it.
In the three last cases threfore I have just mentioned, I refused to ope-
rate, inasmuch as extirpation is not in  my opinion  justifiable, but for
those tumors which continue to increase, or which become the source
of serious accidents.  Some other fibrous tumors, which also include
the skin in their composition, are however distinguished from the  pre-
ceding in these particulars,  viz: that well-defined limits soon become
established between them and the sound  tissues, that the  elements
of which they are constituted are no longer  in a normal state,  and
that they seem  susceptible of dangerous degenerescence and trans-
formation.   A man of about 50 years of age, and who came to  the
hospital of the faculty in  1825, had in his right groin a tumor of this 
NEW ELEMENTS  OF OPERATIVE SURGERY.
693
description, which was of half the size of the  head, and  extended
obliquely from a line with the vessels as far as to the posterior part
of the thigh below the scrotum.  It was extirpated by M. Roux, and
we found that the entire tumor was  homogeneous, and formed of a
tissue,  the section of which  presented some  analogy  to that  of
Gruyere cheese.   The  patient got well, but  in  the following year
there returned a similar tumor, which was also  extirpated; without
however preventing him  from succumbing at a later period  to the
effects of a schirrous tumor which formed on the front  part of the
pubis.   As to fibrous tumors, which are independent of the skin,
they may be  developed  upon almost all  the regions of the body and
especially in  the sub-cutaneous tissue.   In a woman operated  upon
successfully by M. D. Lasserve, (Cas de Chir., etc., p. 17, gg. 1. Per-
igueux,) he was  enabled  to extract a  fibrous tumor  of twice the
size of an egg situated upon the upper lip, in such manner from the
midst of the  tissues as to leave but very little deformity.  A patient
in whom M.  M'Farlane  (Encyclop. des  Sc. Med., 1836, p. 56,) had
removed a fibro-cartilaginous tumor which was  situated  upon the
side, between the transverse and oblique muscles, died of peritonitis
in the course  of 31 hours.   A  young lady on the contrary  who had
above the  crural arch, a  fibrous, movable tumor, of  the  size of a
small egg, recovered  perfectly from  the operation which I had  re-
commended  to her, and M.  Yvan junior has communicated to me a
similar fact.  A patient who had one of the  size of a large nut on
the dorsum of the metatarsus, came to have it extirpated, at the
hospital of La Charite in 1836. Having divided the integuments  by
a simple incision,  I seized the tumor with an erigne and proceeded
immediately  to its removal.  The  consequences of the operation
were simple,  and the tumor did not reappear.  Another patient ope-
rated upon in 1837 at the same hospital, for a tumor in every respect
similar, and which was situated two inches above the external malle-
olus, between the tendo achillis and the fibula,  was cured in the
same way.   I have  removed  from the breech of an  adult man a
fibrous tumor as large as an egg, which did not go deeper than the
aponeurosis and was never reproduced.  Another patient  whom I
operated upon in 1835, had one of the same nature between the anus
and tuberosity of the ischium.   The  cure of this also was radical.
But a woman who had  one of these tumors  on the dorsum  of the
point of the  sacrum, and which adhered throughout its deep-seated
surface to the periosteum, thus rendering its dissection  sufficiently
delicate, was  seized with an  ichorous suppuration, caries of the pel-
vis and  general accidents, which caused  her death at the expiration
of a month.   Tumors of this  description which I have met with in
the breast or  the head, will be  referred  to again in other articles.   I
will merely add  that whatever be their situation, if the skin which
covers them shall be found too much attenuated or actually degene-
rated it will  be  advisable to  remove an ellipse from it or take it
away entire at the same time  as the tumor, rather than attempt to
dissect it.   A youg girl of eleven years of age had on the radial and
dorsal side of the root of the middle finger, a hard, bosselated, black-
ish-looking tumor of the size of a large nut.  With this tumor, which
I  isolated from the hand while respecting the metacarpo-phalangeal 
694
CANCEROUS  TUMORS.
articulations and neighboring extensor tendons, I removed also a flap
of integuments one inch in length and six lines in width.  A strong
and robust man had,  from the age of 20 years, above the outer mal-
leolus, a globular  and very movable tumor  covered with attenu-
ated reddish-colored  integuments.   Having  seized this  tumor with
an erigne, I circumscribed it in an ellipse of the skin, and removed the
whole of it while dissecting its  deep-seated surface.  By this mode,
the operation is prompt and certain, and ought to have the preference
when it does not cause too great a  loss of substance.   With these
exceptions, fibrous  tumors must  be submitted in every respect to the
rules of treatment  indicated for  lipomatous tumors.
                        CHAPTER X.

                     CANCEROUS TUMORS.

  All the tumors of which I have hitherto spoken,  come within the
class  of tumors  denominated benignant  by the English surgeons.
Those on the contrary designated under the title of cancerous tumors,
have a character of malignity which has always served to distinguish
them from the others.   Their tendency to repullulate and to multiply
without end, has ever  constituted them the opprobrium of surgeons.
If they are attacked on one side, they soon reappear on the other.
Frequently the most simple operation will  be sufficient to irritate (ex-
asperer)  them  and aggravate all their  symptoms ; no method of
treatment, even at their first appearance, can promise any certainty of
effecting their radical cure.  There are a great many surgeons more-
over, who advise that  we should do nothing with them, or make  use
only of palliative  means.  Nevertheless,  upon the  supposition  that
these tumors are primarily a local affection, and admitting also their
malignant character, I lay it down as a principle  to destroy them as
soon and as effectually as possible.  To me it appears evident, that
if there is even room to hope for their cure, it must  be by means of
their mechanical or chemical destruction, and by attacking  them
before they have had time to introduce new morbific germs  into the
rest of the system.  All  the varieties of tumors however, denomina-
ted cancerous, do not  exhibit the  same  tendency to repullulate.
Those which in this respect  should be placed at the  head  are the
melanotic (melaniques) tumors; then come the encephaloid tumors;
scirrhous tumors would be placed in the third line, and the colloid at the
bottom of the scale.  These particularities, which I will discuss more
at length while speaking of the extirpation of the breast, convey an
idea of the course which the surgeon ought to pursue in regard to the
prognosis and treatment of cancerous tumors in general.

                             § I.
  Should the tumors be purely melanotic, composed of flocculi or clots
of anthracine, we should avoid performing the slightest operation 
              NEW  ELEMENTS OF  OPERATIVE SURGERY.         696

upon them, provided there existed at the same time with the principal
nucleus some spots or granulations of the same nature, either in the
neighborhood or in other regions, even though the patient should  in
other respects appear to be in excellent general health.   A man  in
other respects in good health, came in 1834  to the hospital of La
Pitie for the removal of a melanotic tumor upon the temple, of the
size of a large nut.  This  tumor,  which M. Olivier of Angers had
extirpated a year before, and which had scarcely then  the  size  of a
small nut, had reappeared only since the last three months.  All the
internal organs performed their  functions  freely.   No  other tumor
existed upon the surface of the body, and the patient, who considered
himself in other respects in perfect health,  retained also all  his  nat-
ural embonpoint.  I extirpated the tumor; the operation presented
no difficulty, and everything went  on well for about  twelve days.
The wound then became sanious, general symptoms made their ap-
pearance, and death took place six days after. The opening of the dead
body disclosed the fact that innumerable melanotic tumors existed in
the interior.   The liver especially was riddled with them; they were
found  here in hundreds, some having the size of an ordinary  pin's
head, others equalling that of a small egg, and all presenting precisely
the appearance of truffles, either  in their  crude state or reduced to
pulp.   A patient who for twenty years had had a  melanotic tumor
(grumeau) on the dorsum of the  foot, without ever having experi-
enced the slightest symptoms of general disease, desired in the month
of October, 1838, to have it removed.  The tumor, which was  only
of the size of a small nut, was readily extirpated.  Seeing that the
suture of the wound threatened to cause a phlegmonous erysipelas,
I returned to the simple dressing and union by the second intention. Up
to the present time  there is no appearance of a return of the disease.
But will this cure remain permanent ?  A woman who  had under-
gone amputation of the great toe for a similar tumor, was not yet
cured of her wound when the ganglions of the groin and iliac fossa
had already become attacked to such an  extent that in less than a
month she had in those regions enormous  black masses, which  soon
caused her death.   However slight therefore may be the grounds  for
believing that there shall exist any remote engorgement or internal
derangement, the surgeon should rank melanotic tumors in the cat-
egory of the noli me tangere.

                              §11.
   In the case of cerebroidal (cer6broides)  tumors, we must proceed
nearly in the same  way.  Nevertheless, if the disease exists in a sub-
ject who is still young and in other respects in good health, and if
the lymphatic ganglions situated above remain wholly unaffected, and
the tumor is of recent date and  perfectly well defined, the chances
of cure are assuredly greater and more numerous thaa in the case of
melanotic tumors.
                             § III.
  In a scirrhous tumor there is less tendency of  reproduction in the
midst of remote organs;  but more frequently than the two varieties
of which we have been speaking, it reappears upon the place only or 
696
CANCEROUS  TUMORS.
in the neighborhood of the part which the first tumor occupied.  It
is because this class of tumors present themselves under the form of
a degenerescence or transformation of the natural tissues, as well as
under that of abnormal productions and simple foreign bodies.  It re-
sults from this that a scirrhus is usually badly defined, and that it often
sends out to the circumference radiations or roots whose terminations
cannot be traced without difficulty.   Moreover, it is advisable when
we have decided upon operating, to remove at the same time a suffi-
ciently large proportion of sound parts, and we  should abandon the
attempt to relieve the  patient, if there existed in  the neighborhood of
the tumor, either beneath the  skin or  even  in the  substance of the
integuments, the slightest indurated plate (plaque) or  smallest larda-
ceous radicle that could not be extirpated.  In cases of melanosis and
encephaloid matter, our attention is to be directed towards the con-
dition of the remote organs; while in cases  of scirrhus on the con-
trary, it is the vicinity of the tumor which is to be specially examined.

                             §IV.
  Colloid tumors, which  besides being sufficiently rare, often attack
the bones, have this peculiarity, that they usually remain local, and well
defined like cerebroidal tumors, at the same time that they seem to
be concentrated on the organ which was their  primary seat.  It is
these, consequently, in which the operation presents  the most chances
for success.

                              §V.
  The operations proposed  for cancerous tumors  are the same as
those for the  tumors designated in the preceding articles.  It is not
my intention at this moment to speak either of internal remedies, or
of the  topical  applications purely discutient or  resolvent that have
been so much lauded by some persons; experience having  proved
that  such means  are  totally  inefficient when legitimate cancerous
tumors are under treatment.  I would say the same of compression,
if it had not found among us new advocates.   For myself, I do not
believe that  compression has  ever  radically  cured or  dispersed
tumors belonging to either of the four kinds which I  have just been
treating of.  If it should be contended that it at least has the advan-
tage of lessening  or extinguishing the engorgement, and thickening
of the  neighboring tissues, (l'empatement du voisinage,) and  of  thus
rendering the other operations more easy, I would  reply, that this is
a specious argument which cannot sustain a close examination.   In
fact, cancerous tumors are not generally accompanied but with o
very slight engorgement of the surrounding parts ; moreover, to have
any real hope of success, it is important to remove  with the tumor a
sufficiently large portion of sound tissue.  But what would compres.
sion do in a case of this kind ?  Suppose it should  have  shrunk the
tumor and diminished its volume; the instrument  might be carried
nearer to its confines,  but we should  to the same extent increase the
chances of a return.  Unless, therefore, inflammation or chronic
engorgement  of the  cellular  tissue  should  have  been   established
around the principal disease, compression must  be rejected from the
curative treatment of  cancerous affections. 
NEW ELEMENTS OF OPERATIVE SURGERY.
697
   A. Cauterization.—The destruction of cancers by means of the
hot  iron or chemical caustics  has  been eulogized  at every epoch.
In spite, however, of the successes obtained by means of their pow-
ders or pastes, they had been generally renounced by Rousselot, and
Frere Cosme, when their efficacy has been again announced by prac-
titioners in Germany, England  and  France.  Arsenical caustics and
nitrate acid of mercury, besides  being  hardly applicable  except to
superficial cancerous plates, have,  moreover, the inconvenience of
being  partially susceptible  of  absorption, and  of thus exposing  to
actual poisoning.  The zinc paste, introduced into practice by M.
Canquoin, having the property of mortifying the tissues in the man-
ner of a punch, to such depth as is desirable, would always deserve
the preference if  it would adapt itself to the anfractuosities and ine-
qualities of certain tumors, or did not exact the previous destruction
of the  epidermis.   Whenever this paste cannot be  applied with
facility we may make use of the Vienna caustic or paste, which has
the advantage of being introduced in the manner of a pulp into every
possible chink, and of moreover cauterizing with great energy ;  (see
Vol. I.)   Potash so called, butter of antimony and the concentrated
acids are, therefore, excluded  from the catalogue,  in consequence
of their tendency of fusion  into the sound tissues, and their uncer-
tainty.  But caustics, of whatever  description they may be, ought
they to have the  preference over the operation, when the question
under consideration is cancerous tumors ?   On this point it is neces-
sary that  we  should understand  ourselves; if the skin is sound and
the tumor movable, and can be cut out by a bistoury so as to leave
a wound  whose lips may be more or less  perfectly approximated,
caustics will  not  be admissible except  in  those patients who abso-
lutely  refuse  extirpation.  If the tumor  has more width than thick-
ness, includes the integuments,  is  ulcerated upon  its surface, is situ-
ated at the bottom of an ancient wound, and prolonged into some
cavity to  a great depth, and soldered (plaquee) as it were against
the bones  ; if, in a word, it is not possible to remove the cancer with-
out causing a loss of substance equal  to the integuments, then caus-
tics, and the zinc  paste, especially that of Vienna, may be made trial
of, and would in some cases even deserve, I think, the preference.
   B. As to the cutting  instrument  and the ligature, they  should be
employed here according to the rules which I have pointed  out under
other tumors, especially for fungous sanguineous tumors.  I shall,
however,  return to this subject  in detail in treating of tumors of the
breast.  This last remark renders it unnecessary for me to  treat of
cancerous tumors according to  the regions or organs they attack.   I
will  only  add that for a tumor of  the foot, which extended to  the
bones of the  tarsus, I deemed it proper to amputate the leg;  that in
a case of cerebroid tumor of the calf, I amputated the leg at the knee;
that an enormous mass of the same nature which occupied the leg of a
young sailor, induced me to  give the preference to amputation of the
thigh: that for a scirrhous tumor of the metacarpus, I amputated the
wrist; that for a colloid mass upon the radius, I amputated the fore-arm;
that  analogous tumors have induced MM. Luke, Janson, Roux, Cas-
tara  and others, to amputate the shoulder; that I have disarticulated
the arm for a disease of the same kind; and  that  as a  general  rule
  vol. h.                        88 
698
CANCEROUS  TUMORS.
 we  ought to prefer  amputation of the limb to extirpation of the
 tumor, whenever the disease penetrates to the neighborhood of the
 bones, so as to implicate a portion of the muscles, nerves, and large
 vessels.   Underneath the skin, on the contrary, and in the substance
 of the tegumentary tissue, it is advisable to treat cancers by simple
 extirpation, or by caustics.  A woman who had a cerebroid plate as
 large as the  hand  between  the umbilicus  and the epigastrium, was
 cured by  means of two applications of the  zinc paste.  Another
 woman, who had upon the thorax, below the left shoulder, an analo-
 gous plate which was hard and without ulceration, was relieved  by
 the following  process: having raised it up  a little, I glided the knife
 under it flatwise, and immediately detached its lower half, comple-
 ting its isolation with a second cut by returning the edge of the knife
 from above.   The wound, which did  well during fifteen days, having
 taken on a sanious aspect, and become covered with inequalities of a
 bad  appearance, the idea suggested itself of covering it with a layer
 of zinc paste.  After the fall of the eschar, the wound  went on
 rapidly to cicatrization.   I have met with  and destroyed plates and
 tumors of the same description upon the leg, thigh, around the knee,
 at the breech, upon the side, in front  of the chest, on  the  side of the
 neck, and  upon the cranium  and face in  an infinity of cases,  but
 without the operative process having exacted  any thing special that
 requires to be related here.   It will also be under the head of can-
 cerous tumors of the breast, that I shall have an opportunity of dis-
 cussing the advantages and inconveniences of immediate or second-
 ary reunion, and the  different kinds  of anaplasty that may be  em-
 ployed after the removal of cancers in general.

                      [cancerous tumors.]

   In thirty cases of cancerous tumors of the  breast treated by M.
 Tanchou, (see Journ. des Connaiss., &c, de  Paris, Dec, 1842,
 p. 253,) he has  obtained, he  asserts, ameliorating results, and more
 or less complete dispersion of the tumors, by means of graduated and
 methodical compression,  by compressors specially adapted  to  this
 purpose, and also by external applications of sachels containing iodate
 of potash, pulverized sponge, (eponge  en poudre—meaning, probably,
 burnt sponge, a remedy of 2000 years' standing in bronchocele,) chlor-
 hydrate of ammonia, and chlorhydrate of soda;  also other com-
 pounds  made  with the  powder of sponge, nitrate of potash,  and
 Florentine iris.  He proscribes all surgical operations.
   M. Martinet de la Creuse has ingeniously proposed, and several
 times succeeded, (see Malgaigne's Manuel de Med. Operat., 4th edi-
 tion, Paris, 1843, p. 118,) in making for the  wound, after extirpating
 scirrhous and  carcinomatous tumors, a healthy  flap of sound skin
 borrowed by the anaplastic method from the neighborhood.
   M. Ollivier, who has  otherwise written so well  on  these tumors,
 proposes  the daring expedient (op. cit.) of inoculating their centre
with hospital gangrene!
   From statistical observations obtained by M. Leroy d'Etiolles, from
every department of France, (see the result  of these researches com-
municated  by him to the Academy of  Sciences of Paris, February 
             NEW ELEMENTS OF OPERATIVE SURGERY.          699

20, 1843, in the Journ. des  Connaiss.,  &c,  of Paris,  Mai, 1843,
pp. 214, 215,) on the subject of Cancerous Diathesis and Degenera-
tion, we learn the fact that out of two thousand seven hundred and
eighty cases, communicated from  174 practitioners in those depart-
ments, there were 1192 who were not operated upon, or who died with
the disease upon them.  Of these,  18 lived more than 30 years after
the development of the disease, which, after reaching a certain point,
remained stationary  and indolent.   But out of 801  operated upon,
either  by the knife or caustics, four only lived to the same length
of time.  Of those who  lived from 20 to 30 years, we find 34 who
were not operated upon, and 14 in whom an operation was performed.
Of those who lived  from  6 to 20 years, there were 88 who were
operated upon, and 228  in whom the tumor was not extirpated.  So
that the balance in cancerous tumors, so far as the prolongation of
life is  concerned, is clearly  not in favor of the operation.
  So far as  regards a short term of existence, the difference appears
to be in favor of the operation ; thus counting from the first appear-
ance of the disease, the average  prolongation of life in those not
operated upori is, for men, five years, and for women, five years and
six months;  while in those operated upon, the  average, for men, is
five years and two months, and for women, six years.  And in these
cases, we find the average  of time that expired before the operation
was, three  years and nine months for men, and the time after the
operation, one  year  and five  months only; while for women it is
three  years and six  months before,  and  two years and six months
after the operation.
   To those who say  that the return of the disease is too often owing
to the operation for extirpation having been procrastinated, by which
time was allowed for degeneration to be  established, M.  Leroy
d'Etiolles replies, that among the numbers in this table in whom the
disease was reproduced, 61 had the tumor extirpated in less than a
year after the disease made its first  appearance ;  and that 30 patients
who were operated  upon five years  after its first development, did
not have a  return of the disease,  and that the same result occurred
in 22 others who were not operated upon until more  than ten years
after the first appearance of the disease.
   In conclusion, M.  Leroy remarks, that though it may be impossi
ble to determine beforehand, whether a tumor will remain stationary
or become cancerous, it  is worthy of investigation to ascertain if the
cancerous diathesis  does not  produce in the  subjects in  whom it
exists,  certain characters (as for example, a change in the condition
of the fluids of the economy,) by which it may be recognized.

Fibrous  Tumors (corps fibreux)  in  general—Fibrous Tumors of
             the Breast (corps fibreux de la mamelle.)
   The justly distinguished  M. Cruveilhier, in a memoir read before
the Paris Academy of Medicine, on Fibrous bodies of the Breast, (des
corps  fibreux de la mamelle,) (read Jan. 9, 1844—*see  this memoir in
the Journal des Connaissances Medico-Chirurg., Paris, March 1,
1844,  p. 8 to p. 93,)  conceives that they have not been  sufficiently
studied, that they are a very frequent disease, (lesion,) and that they
are constantly confounded  in practice with scirrhous and indurated 
700
FIBROUS TUMORS.
 cancer of these organs, and as such, subjected to extirpation.  He
 believes that  such  tumors are incapable of degeneration, that they
 never require extirpation,  that they are in some sort  functional,
 (facultative,)  that when extirpated they are never reproduced, (ne
 repullulent jamais,) in the proper sense of this word, but are a purely
 local lesion and organic production, independent of every kind of
 general infection of the economy, whether as a cause or effect.
   Neither Boyer nor Sir Astley Cooper have mentioned this disease,
 nor is it more than  obscurely alluded to by more modern writers.
   Fibrous Bodies in general.—Such growths were for the first time
 described by  Bayle as  found  existing in the uterus.  Like Bichat,
 however, who considered  that  each tissue had its own  lesions, he
 erroneously thought these bodies were confined to the uterus.  True,
 the conditions in this organ are most favorable to their production
 and  development, but they are met with in all  organs where fibrous
 tissue is found, and  are composed of two orders: 1 st. As vegetating
 fibrous bodies, growing from, or  implanted in,  (implantes,) a mem-
 branous surface in the manner of a vegetable,  like  fibrous polypi
 of the nasal fossas, formed at the expense of the periosteum ; fibrous tu-
 mors of the dura mater ; and fibrous, cartilaginous and osseous tumors,
 which grow from the  periosteum  of the bones and which may be
 called osteo-chondophyte.   2d. As non-vegetating fibrous bodies, (les
 corps  fibreux  non-implantes,)  which grow in the interior of the or-
 gans, (au milieu des organes,)  such as the fibrous bodies of the uterus,
 those of the breasts, ovaria and testicles.
   Their general characters, according to the author, (M. Cruveilhier,)
 are:  1st.  That of situation, always in the midst of the fibrous tissues.
 2d. That of form and size.   Their form is generally spheroidal, some-
 times irregular upon the surface, sometimes  mammellated,  at other
 times deeply furrowed, (sillonnee,) giving rise then to the lobular ar-
 rangement.  Their size varies from a cherry-stone, or even  a millet-
 seed, to that of the head of an adult, or even greater, their weight being
 sometimes equal  to 45  demi-kilogrammes.  3d. The characters de-
 duced from the mode of adhesion and connection of the fibrous bodies,
 with the tissues, in  the midst of  which they are developed.   Vegetal
 fibrous bodies  (above) seem to be mere prolongations of the tissue of
the organ, but all other fibrous tumors are  united to the  parts in
which they are developed,  only by means of an  exceedingly loose
cellular tissue, so that these bodies  may be enucleated with the great-
est ease by means of the finger, a blunt probe or slight traction, without
ever  requiring the aid of a cutting instrument.   In this respect these
bodies are, in their isolation or independence of organization, similai
to encysted tumors,  with which also they are sometimes confounded.
4th.  In their characters of texture, fibrous bodies or tumors are of an
extreme density, similar to cartilage, or to the unimpregnated uterus
proper.  If the fibro-cartilaginous tissues of Bichat could be sustained,
fibrous bodies would come under  them.   These bodies are, in fact,
composed of parts arranged linearly and belonging to the albugine-
ous tissue, strongly pressed against each other, interlaced togethei
in every possible direction,  and often divided  into many groups of
fibres, and pelotoned (pelotonnees) in such manner as to constitute
distinct masses or  lobules.  They  are provided with veins whose 
             NEW ELEMENTS  OF OPERATIVE SURGERY.          701

trunks are on the surface, and their minute branches distributed to
their substance.   When these tumors are lobulated, veins of greater
or less size are found in the intervals of the lobes.   These veins com-
municate  directly with the proper tissue  of the organ in which the
tumors  are.  No arterial vessel can be traced into these tumors-
injections  from the neighboring arteries will not penetrate them, and
no lymphatic vessel or nerve  has yet  been shown to exist in them.
They therefore possess no other organic element than a fibrous tis-
sue, supported (anime) by veins, and are reduced down to an obscure
nutrition sustained by a feeble oscillatory movement of venous blood.
5th.  The  evolution of fibrous bodies presents the same characters
at their first appearance as at their complete  development, whether
the tumor be only of the size of a cherry-pit, or has attained that of
the fist (poing) or head.  Facts have satisfactorily established, in the
mind of M. Cruveilhier, the conclusion that if some of these bodies are
primarily  fibrous, and  afterwards  become cartilaginous or  osseous,
a number of them will present one or other of these last mentioned
characters from  the beginning.  6th.  The consecutive pathological
characters of fibrous bodies are: a. The consecutive results produced
by fibrous bodies on  the surrounding tissues, which consist only in
the inconvenience occasioned by their weight,  being in truth nothing
more than parasitical  foreign innocuous growths, having a peculiarly
limited vitality, which causes no  other change in the  tissue in the
midst of which they are developed than some indispensable modifica-
tion of nutrition and circulation; b.  The consecutive changes which
are effected in the fibrous bodies themselves, and which are exceed-
ingly limited.   These  bodies  may indefinitely increase, or they may
remain stationary.  Many facts authorize  M. Cruveilhier to believe
that they  are susceptible of an actual diminution of volume, or a sort
of atrophy,  or  may become  encrusted  or penetrated with phosphate
of lime, or  the seat of an oedema, which dissolves the elements that
enter into their composition and makes manifest their lobular arrange-
ment.   In this case, the tumor is often impregnated with a liquid which
possesses, in appearance at  least, much analogy to that of synovia.
Fibrous bodies are incapable of cancerous degeneration. " I believe
also,"  says  M. Cruveilhier, "that  I  am sustained in saying (and this
character is of the highest importance) that  there is an incompati-
bility between fibrous production and cancerous degeneration."
   To  ascertain if these general characters apply to certain  organic
productions observed in the mammas, he invokes a great number of
clinical facts, and some from pathological anatomy.  Of all other secre-
ting organs in the animal economy, the  mammary gland,  says  M.
Cruveilhier, presents the greatest  quantity of fibrous tissue, and  has
besides adipose tissue, two essential  elements that enter into its  tex-
ture; viz., 1. A fibrous woof (charpente) or gangue;  2.  Glandular
granulations or grains, which  latter  cannot be well examined, except
in women who have died during pregnancy, and especially after par-
turition, during any period of lactation; that except under these  cir-
cumstances, mammary granulations are  but  very little developed,
which feeble development is then in correspondence with the almost
complete absence of secretion in this organ; that after the  cessation
of the menses, and especially in very old  women, the granulations 
702
FIBROUS TUMORS.
seem to disappear entirely,  leaving  the fibrous woof only remain-
ing.  The mamma, therefore, possesses in a high degree, the condi-
tions favorable to the development of fibrous bodies.
   In the mammas, the fibrous  bodies or tumors appear as small sphe-
roidal tumors, from the size of a millet-seed or cherry-pit  to a pullet's
egg, or  larger.   Their surface is sometimes uniform, or mammellated
(mamelonnee), and their hardness is extreme, or as it were, stony
(pierreuse).   Generally sub-cutaneous, they may also be developed in
the midst of the tissues  of this organ;  and are for the most part cir-
cumscribed, perfectly distinct from the tissue of the  mammary gland,
adhering to  it only by a very loose tissue, apparently perfectly inde-
pendent of this gland ; they possess the mobility of  a lymphatic gan-
glion, (i. e. gland,) and  like that roll under the finger, from whence
doubtless the name of glands, given to them in common  parlance.
   Thus are these characters precisely those that M. Cruveilhier has
given of fibrous bodies in general.
   The absence, hitherto, of all clinical and anatomical descriptions of
fibrous  bodies has caused  them  to be constantly  confounded  with
other lesions of the breast, and especially with scirrhous degenera-
tions oi" that organ—giving rise to  the same rules of treatment, and
the  same prognosis as applicable  to both.   In  respect both to fibrous
bodies and to scirrhous  degenerations, it has been asserted that such
fibrous tumors of the breast as are commonly  called glands, may ex-
ist for a long time without  undergoing  any perceptible  growth, but
that after 40, 45 and 50 years of  age, they increase  with great rapid-
ity, and  invading  the  surrounding parts, vitiate the whole animal
economy, and present  all  the characters of an incurable cancer.
Hence, as the  consequence of such ideas, was that of the necessity
of immediate extirpation—and that the sooner, therefore, this was
done after these tumors appeared, the less the  danger.  This was the
sole mode of treatment; not that practitioners asserted that such de-
generation must always ensue, but being  ignorant of any diagnostic
'marks  between cancerous tumors and those incapable  of such de-
generation,  " they preferred ten unnecessary extirpations to the omis-
sion of one  that was absolutely essential."
   Even so  little has been known  of the pathological anatomy of
mammary lesions, that  encysted  tumors themselves and  oedematous
indurations of these organs, ai'e usually confounded with cancerous tu-
mors, and often submitted like the last, to the  general law of extirpa-
tion.   " Such  also, (says M. Cruveilhier, with  great  candor, while
advocating,  distinguished  anatomist and  surgeon  as he is, humane
doctrines so honorable to him, and  so  plainly  deducible from the im-
portant truths he discloses to the  profession,) was my  rule of con-
duct fifteen years since.  I postponed the advice to  extirpate only
to obtain time to prepare the patient for this  operation,  finding him
 always  tranquil  and resigned, when  the terrible word  cancer was
 pronounced."  Doubts, however, even then arose in M. Cruveilhier's
 mind, and especially from seeing in young  girls, scarcely arrived at
 puberty, and in young women  in rosy  health, numerous cases of
 movable, rolling, circumscribed, indolent, and isolated tumors; and
 also from seeing a number of these  tumors  in  the same breast, or
 simultaneously in both breasts.   He asked himself the question if 
NEW ELEMENTS OF OPERATIVE SURGERY.
703
 such little tumors, whose discovery was so often due to chance, ought
 'n reality to be considered a cancer in its first stage.  This sugges-
 tion was strengthened by finding that many women who had refused
 to be operated  upon, or in whom he had deferred it, went on for a
 great number of years under his observation, without any perceptible
 increase of size or degeneration in such tumors, though many such
 women had become pregnant, and  suckled their children, and many
 of them had passed their critical period  of life.
   The fact of non-reproduction (defaut de repullulation) after extir-
 pating tumors of this kind, may also be adduced as a clinical  proof
 of the innocence of these tumors, and their totally foreign character
 to that of cancerous degeneration ;  for it is well known how common
 it is for true mammary cancers to grow again after their removal.
   Proofs deduced from pathological anatomy, in favor of these posi-
 tions, were soon obtained by M. Cruveilhier.  An examination of a
 great number of mammary tumors extirpated for scirrhus or incipi-
 ent cancer (a l'etat de erudite) convinced him that several of them
 exhibited the same character  of  form, density, and texture, as the
 fibrous bodies of the uterus, and offered in no respect any of those
 of cancer.   One important fact was established by this eminent ana-
 tomist, viz: that a number of  fibrous mammary tumors, which, on
 examination, appeared at first to be full (pleines, i. e. round, uniform
 and smooth) were found, to be arranged after the manner of geodes
 (geodes).   That is, on dividing them in two equal halves, each half
 could be turned inside out, upon itself, so as to form a hemispherical
 cavity, whose internal surface was then formed by the external sur-
 face of the tumor, and whose  external surface was formed by the sur-
 face  of  the incision.   But this now external surface was thick set
 (herissee) with globular vegetations or fibrous granulations, some of
 them isolated, and others that were branched after the manner of a
 polypus ; these fibrous vegetations or globules, which were superposed
 on each other (qui se modelaient les unes sur les autres) being some-
 times free, and at other times adherent to each other by means of small
 prolongations. These adjoining (juxtaposes) fibrous vegetations, knots
 or swellings, in the cases described, constituted a cavity without walls.
 In some cases, there was found in the centre  of these fibrous bodies,
 a cavity filled by a viscous fluid, analogous in appearance to synovia.
   M. Cruveilhier has  had occasion to see many oedematous fibrous
 bodies of the breast, which  had rapidly acquired a great size and
 were  speedily extirpated, and which bodies corresponded exactly with
 the fibrous bodies of the uterus, their mass being penetrated by a vis-
 cous humor, similar to synovia, and their centre here and there occupied
 by numerous geodes, without membrane or cyst, and  filled with  a
 liquid matter.  In conclusion, M. Cruveilheir remarks that he consid-
 ers himself upon the  strength  of such facts, obtained  from clinical
 observation and pathological anatomy, justified  in  adopting  these
 propositions :—1. The mammary gland  is  subject to  the develop-
 ment  of  an  organic production known under the name of fibrous bo-
dies.   2. That  the fibrous bodies (or tumors) of the mamma, which
 constitute one of the most frequent lesions to which this organ is
 liable  may be distinguished by certain signs from that kind of indu-
 ration, which succeeds to chronic inflammation, and also from can- 
704
FIBROUS TUMORS.
cerous tumors ;  the  tumor neither in chronic inflammation,  nor in
cancer, being in any manner distinct from the mammary gland itself,
at the expense of which it is formed,  and with which it is continuous
without any line of demarcation ; while the fibrous bodies are com-
pletely detached from the mammary gland and roll under the finger
in the manner  of a cyst or lymphatic gland (ganglion).   3. That as
these fibrous bodies  are incapable of cancerous degeneration, extir-
pation is not necessary, upon the supposition (en tant que) that these
bodies may endanger the life of the  patient, by the ulterior changes
which may take place in their interior.   Fibrous bodies constitute a
lesion which is essentially local; their extirpation is, so to speak, con-
tingent (facultative),  and would not  be  requisite unless from the in-
convenience caused by their weight  and size.  After fibrous  bodies
are extirpated, they never  grow  again, (repullulent) in the proper
sense of this word ; though new fibrous  bodies may be developed in
a breast which has been the seat of a previous extirpation.
   At  the  sitting of the  Paris  Academy  of Medicine,  (January  16,
1844,)  following that at which  M. Cruveilhier read his memoir, an
animated  discussion  arose  among the members upon the merits of
the new doctrines therein advanced.  As this discussion (see Journ.
des Connaissances, &c, Paris, March 1,  1844, p. 124, &c.,) was one
of a practical bearing, maintained energetically through a number of
sittings of the learned body alluded to, it will not be improper briefly
to notice the leading  points and views of some of the most eminent
surgeons  of Paris, (especially as our  author,  M.  Velpeau's own
views are also  given in the debate,) to show what conclusions also
their experience in the  rapid progress of  surgery, has led them to
form, up to the present epoch of  the history of our art.
   M. Blandin considered fibrous tumors of the breast rare  as com-
pared with the ordinary tumors  of that  organ, and especially with
its encysted tumors.  He also believed fibrous tumors capable  of de-
generating, that it  was  impossible to distinguish them  from cancer,
and that there was  no danger  in extirpating them.   M. Rochoux
had found by the microscope scirrhous matters scattered through the
interstices of these fibrous  tumors.   M. Gerdy did not always con-
sider their diagnosis  easy:  as  an example  he mentioned fibro-carti-
laginous lobular tumors, making  a crepitus under the scalpel, &c,
and having the same characters as M. Cruveilhier's tumors, and also
as Sir Astley Cooper's irritable tumors of the breast.   Though
fibrous tumors  may  possess  analogies to fibrous  tissue,  they differ
from it.   He has  found three sorts  of  tumors: benign,  malignant,
and the doubtful,  which may degenerate.  The second exhibit a
depression of the skin at the centre, when the tumor is compressed
between the hands, and  are marked by peculiar lancinating pains.
   M. Velpeau admitted that there were, in fact, mammary tumors
which did not degenerate, but he did not  consider them in reality
the same  as the fibrous tumors of M. Cruveilhier, which latter  are
susceptible of this  change.   M. Velpeau considers this peculiarity to
belong to tumors which he denominates fibrinous (fibrineuses), caused
by the extravasation of the fibrine of the blood after a blow or a
contusion.   M. Cruveilhier, as M. Velpeau thinks, has included such
tumors under his fibrous order.   The microscopic characters of fibri- 
              NEW ELEMENTS OF  OPERATIVE SURGERY.          705

nous tumors have, according to M. Velpeau, been satisfactorily as-
certained  by M. Mandl;  in fibrinous tumors, the microscope  dis-
closes nothing but fibres and  fibrilli.   But the characters during life
are not always  recognizable, and it is rare that we meet with such
tumors  except in young  people ; in other words,  we meet them
more frequently in that class of persons.   M. Velpeau does not be-
lieve  fibrinous tumors of  the breast capable of degenerating,  any
more than those of the uterus, at least such a result must be rare.
He blamed M. Cruveilhier for not having entered more into the sub-
ject of the treatment, and for confining  himself to proscribing the
operation  without pointing out some  other therapeutic means.   For
his own part, considering that both fibrous and even indolent tumors,
rarely present characters of a very satisfactory nature, and that they
are a source of perpetual disquietude to the patients, he is of opinion
that they should  always be removed (les operer)., this method having
at least the advantage  of giving confidence to the patient as well as
physician, (loc. cit. p. 125.)
  M. Cruveilhier expressed himself gratified with the remark of M.
Velpeau, that fibrous or fibrinous tumors were not susceptible of de-
generation ; with which opinion also M.  Moreau  coincided.  M.
Roux  (loc. cit., p. 125) thought the consequences would be disastrous
if the principles of M. Cruveilhier were admitted.  He apprehended
the latter had taken for his type of fibrous tumors of the breast those
that are called fibrous bodies (i. e., tumors or growths) of the uterus,
two things essentially different.  He  denied also  that one of their
characters was that of being encysted, as encysted tumors  must en-
close a liquid, and  such tumors  are  rarely fibrous.   He admitted
that many tumors did aot degenerate; a prognosis to this effect  was
a subject of immense difficulty, and  could  only be made  of young
persons.  He  himself confessed, (and where was  the surgeon who
had  not) that he had extirpated tumors as cancerous which were
not so.  He would not pretend to declare that fibrous tumors never
degenerated, but thought they did not  do so spontaneously, but might
become degenerate (i. e., cancerous  or malignant) under certain cir-
cumstances.   He opposed as dangerous,  the principle (loc.  cit., p.
126) of M. Cruveilhier, that the operation should be conditional (fa-   >
cultative;) M. Roux thinks it better to operate even under this point
of view. He notes the omission of M. Cruveilhier to give the characters
of benign tumors:  M. Roux says, in  fact, there are none  such;
they may however, in rare cases, be  absorbed  by some spontaneous
process or by means of local resolvents.  The operation  is  rarely
fatal, and  its moral effect alone is a matter of great importance,  see-
ing that the tumors do not  return.  M. Cruveilhier, in rebutting the
ideas of M. Roux, also remarked that what were called  strumous
tumors of the breast were  also confounded with the fibrous; but  that
such strumous tumors were neuromas and not scrofulous.  He went
so far as to say that the existence of fibrous tumors in the uterus  was
an immunity against cancer in that organ.  M. Amussat denied the
frequency of fibrous tumors of the breast; thus  the Dypuytren  mu-
seum, so rich in  fibrous tumors of the uterus, is exceedingly deficient
in those of the breast.  He believed they would degenerate, and was
in favor of operating always for such tumors, and even for a simple
  vol. n.                        89 
706
FIBROUS TUMORS.
lipoma (loupes).  M. Berard also took ground against the opinions
of M. Cruveilhier.   M.  Lisfranc considered fibrous tumors of the
breast exceedingly rare, as he had ascertained from having extracted
an  immense number of  tumors of the breast.   Yet such as M.
Cruveilhier describes were not uncommon.   He does not think them
exempt from degeneration: and expressed himself diametrically hos-
tile to the doctrines of M. Cruveilhier.
  M. Castel (loc. cit., p. 164) called attention to the opinion of Bichal
that the  glanduar tissue is as widely different as possible from the
fibrous tissue.  M. Cruveilhier remarked that the chief difference be-
tween him and his colleagues arose from their attaching a different
meaning from him to the phrase corps fibreux.   M. Blandin thought
(loc. cit., p. 168) the therapeutic part of this question was overlooked,
and stated that he considered it impossible to diagnose such tumors.
He thought the idea too dominant on M. Cruveilhier's mind, that cancer
was also constitutional and must return after  an operation.   M. Blan-
din maintained also, that a cancerous condition and  fibrous tumors
"were not incompatible.   These fibrous  tumors  of the breast are so
rare that some practitioners, who have  frequently removed tumors
from  the breast, declare  they have never met with  them, as MM.
Laugier and Blandin.  M. Blandin explained the non-degeneration
of fibrous  tumors of the  uterus  at  SalpCtriere,  because they were
usually old women whose constitutions were  dried up—not  young, in
whom the  natural moisture and fluids of the  parts favored such de-
generation.  He  avers that fibrous tumors of the  breast may become
the germs  of cancer ; for,  as M. Andral says, why should not the
abnormal fibrous  tissue  degenerate into cancer when it is admitted
that the normal does.   M. Blandin alluded to the tumor removed by
him from the vault of the palate and shown to the Academy, and ad-
mitted by M- Cruveilhier to be cancerous—proved so in fact, and to
be both fibrous and cancero'us by M. Mandl, who saw in it the  can-
cerous globules scattered upon a groundwork (canevas) of pelotones
of fibres—which  proof of degeneration of fibrous tumors into cancer,
is to be added to  a  similar one of Dupuytren in respect to those of
the fibrous polypi of the nose.   M. Blandin cited  two other  cases
where this cancerous degeneration became even encephaloidal, and
yet its removal was not followed by a return of the disease.   If it
be admitted, says he, that we cannot make  a  certain diagnosis of
fibrous tumors of the breast, and at the same time that we deny the
possibility  of their degeneration, then ought we also to operate upon
all indurated tumors which are not resolvable.
  M. Cruveilhier  maintained (loc. cit., p. 169)  that the tumor from the
vault of the palate mentioned by  M. Blandin, was not a fibrous body
become cancerous, but an instance of fibrous cancer, a very different
thing. The various abnormal productions always preserve their pecu-
liar characters ; they do not undergo transformation, since cancer re-
mains cancer, and tubercle continues tubercle, in the same way as
fibrous bodies continue to remain fibrous.  He acknowledges  that
encysted cancers are never  reproduced, but unlike M. Blandin, he
deems them exceedingly rare.
  M. Gerdy (loc. cit p. 212,) thought a difficulty arose in this dis-
cussion from each  one  dwelling  upon  the  peculiar  characters of 
NEW ELEMENTS OF OPERATIVE SURGERY.
707
 tumors separately, instead  of viewing them in their ensemble, when
 we should discover a certain class of tumors, which may be distin-
 guished both from scirrhus  and from degenerate tumors.   Thus, in
 considering  these characters as a whole, when  we find the simul-
 taneous existence in the two breasts, or in one  alone, of numerous
 small  tumors, which are hard,  elastic, indolent,  rolling  and clearly
 isolated, and the absence of cutaneous folds or depressions when the
 breast  is pressed between the  fingers, as is so accurately described
 by Sir Astley Cooper, we can no longer doubt  that such are fibrous
 tumors.  Difficult as the diagnosis sometimes is, there is this thin»
 certain, that we should not operate when the  tumors are clearly be-
 nign ;  in the opposite case, or if we are in doubt, we should operate.
 M. Dupuy considered that  the only  difference  between  scirrhous
 tumors that degenerated and those that did not, lay in hereditary pre-
 disposition.   M.  Lisfranc  thought the  less  frequency of uterine
 cancer, dated from  the discovery of the operation, which disclosed
 those ulcerations  that  are the  most  frequent  source of it, and by
 which we are enabled to apply a radical cure in season.   M. Amussat
 mentioned a case of cancerous tumor of the breast, which he  had
 just  removed,  and which, in the beginning,  had presented all  the
 characters assigned by M. Cruveilhier to fibrous tumors.  He contests
 the opinion of this surgeon and that of  M. Gerdy, that it is possible
 to establish a differential diagnosis between indurated (dures) tumors
 of the breast.  The true plan, he contends, is to operate  at an epoch
 as little distant as possible  from the commencement of the disease,
 which is then in most of the cases circumscribed and susceptible of
 being totally eradicated.
  M. Roux (loc. cit.  pp. 212, 213,) persisted in maintaining the diffi-
 culty of diagnosticating the benign tumors of  the breast, and urged
 with all his zeal the  necessity of operating on tumors of the breast
 in good season ; at the same time repudiating with equal energy, the
 opinion of M. Hervez de Chegoin, that we should defer operating for
 cancer to as late a period as possible.   Here this interesting discus-
 sion closed.   (Sitting of the Academy, March  26, 1844—Journal
 des Connaissances, &c, Paris, May 1, 1844, p. 213.)
  The animated discussion which has taken place at Paris on fibrous
 tumors in general, and especially those of the breast, and the difficulty
 of establishing their true character and  diagnosing them from can-
 cerous  and other tumors, has not ceased, but  promises  to incite to
 still farther and most important investigations.  The researches, in
 fact, made with the microscope, bid fair to give a still greater value to
 that instrument than it acquired  even in the time  of Lewenhoeck, or
 than has been accorded to it for years past, which is not surprising,
 when  we  consider  the mechanical  improvements which  art  has
 effected in that powerful means of interrogating the internal structure
 of every kind of organization.  (See our note on a certain  fungous
 growth of the testicle, infra.)
  M.  H.  Lebert, of  Paris,  has  communicated to the public (Gaz.
Med. de Paris, March 8, 1845, tome XIII., p. 156 et seq.,)some ob-
 servations upon the results obtained by him in examining a tumor of
the breast, which appear to us to possess a good deal of importance.
 The case which  M.  Lebert  furnishes in  illustration, was that  of a 
708
FIBROUS TUMORS.
woman perfectly healthy in every respect, aged 32, in whom a tumor
of the right breast had existed for ten years, but only latterly became
exceedingly painful and enlarged, appearing to be a general hypertro-
phy of the gland, without adhesion of the teguments, or any feeling
of isolated tumors in it, but somewhat painful on pressure.  The pain
caused by it warranted its removal by the surgeon, M. Lenoir.  The
microscope proved it to be a hypertrophied portion of the mammary
gland, its general color white, and consisting of numerous globules, and
these having throughout their interior smaller cellular globules, filled
with a reddish fluid, which oozed out whenever the knife was applied.
It had none of the characters of fibro-plastic, nor of cancerous tumors
of the breast.   The surrounding cellular tissue,  by the long continu-
ance of the disease, had also become so hypertrophied and thickened
as to give it the appearance of a cyst.   A diagnostic point elucidated
by the microscope, and  which went to show that this tumor was
nothing more than hypertrophied mammary tissue, was  the  fact that
it contained  throughout numerous large-sized nerves,  which afforded
an explanation also of the acute pains, (not, therefore, to be confounded
always with cancerous disease,) and proved its true character, for no
accidental tissues of new growth contain these or other  evidences of
high organization.  These results, moreover, confirm, as is remarked
by M. A. Berard in his recent work on tumors of the breast, the accu-
rate knowledge which Sir Astley Cooper had of this kind of tumors.
Those called cysto-sarcoma, as well as fibrous and hydatid tumors of
the breast, all belong, M. Lebert thinks, to this species.  The process of
the formation of those under consideration he thinks is as follows : a
portion  of the mammary gland or  of many of its lobes become
the seat of a sanguineous afflux or local congestion, whence a more
active nutrition and hypertrophy, both of this diseased gland and the
surrounding normal cellulo-fibrous tissue.   These lobes, as Sir A.
Cooper says,  become more prominent outwardly, and finally, are
attached to  the gland only by a mere pedicle, so as to appear some-
times  quite  distinctly separate from it.   The natural fibro-cellular
tissue which surrounds the mammary gland,  becoming dense  and
hypertrophied more rapidly  than the gland itself, is mistaken for
a fibrous tumor, and when filled with an abundance of  fibro-plastic,
or gelatinous liquid, may have  a colloidal (colloide) appearance.   Or
when this plastic fluid is deposited in  the interstices of the fibrous
tissue, it may form compartments (loges) which are ultimately trans-
formed into  small cysts, the globules of which may be  considerably
altered by imbibition.   When these cysts  exist in great numbers in
the middle of the tumor, they take on the form of mammary-hydatid,
which, however, must not be confounded with serous-hydatid tumors
of the breast, or those which  contain ecchynocoques, and which are
sometimes found in the breast.
   M.  Lebert  says,  moreover, that  those  under consideration may
acquire considerable volume;  that they are more  especially  devel-
oped in young women;  that they do not  alter  the general health;
and especially do not  contract adhesions with  the skin which  sur-
rounds them, and that they leave the nipple (mamelon) intact: in all
of which particulars it  will be perceived his views  differ in many
points from those of M. Cruveilhier. 
NEW ELEMENTS OF OPERATIVE SURGERY.
709
   M. Mandl, (loc. cit., Gaz. Med., p. 157,158,) the celebrated micro-
graphist of Paris, who also examined the tumor in question with M.
Lebert, accords with him in the existence of mammary tissue in the
portions submitted  by them to the microscope.  Nevertheless, posi-
tive as M. Lebert's opinions appear to be on its non-cancerous char-
acter,  M. Mandl  asserts that  he satisfied himself that cancerous
globules were also  present.  He states the important fact that we
must not be deceived by the usual microscopic form which the ele-
mentary globules of cancerous  tumors are known to have; for this
is sometimes not present, and  he then has been enabled by other *
physical characters, or by chemical or other means, (which he will in
due time make public,) to establish the fact that  such tumors were
nevertheless of genuine  cancerous  structure.   So of encephaloidal
(so called) tumors of the retina, though sometimes destitute of glob-
ules of the cancerous form, he has notwithstanding found them to be
unquestionably cancerous.
  Mr. Liston speaks of what he calls fibrous  tumors of the mamma,
(Lond. Lancet, Dec. 7, 1844, p. 308, &c.) which form in  the cellular
tissue between  the mammas, the latter becoming expanded and flat-
tened out in front of the tumor.
  But neither these nor Sir A. Cooper's hydatid or cysted tumors,
the cells of which latter Mr. Liston has seen sometimes filled with a
fluid as  black as printer's ink, are as frequent he  thinks  as carcino-
matous  malignant  disease of the  mamma.   These may occur, but
rarely, in women under  thirty in perfect health, with uninterrupted
catamenia.  Most generally they occur between  the  ages of forty
and fifty, and sometimes later.   They commence between the  nipple
and axilla, and sometimes in the centre of the gland, and then at-
tack the middle of the lactiferous tubes.  Sometimes the  tumor re-
mains hard and stony, with the  nipple retracted, skin puckered, &c.;
but usually it makes rapid progress in  size, becomes soft and pulpy,
or pultaceous and medullary, and throws out a fungus which may
or may not bleed profusely, depending on the constitution.   A section
of one of these tumors,  says Mr. Liston, presents a variety of dis-
eased structure: it may he fibrous-looking, that is, with white bands
running to the cellular tissue; or present the appearance of a gelati-
nous cancer, or it may be pultaceous or medullary.  Sometimes all
these heterogeneous or heterologous tissues are found in  the same
tumor;  or some portions are hard and others softened down ;  or the
vessels will give way and extravasation of blood occur.
  In mere hypertrophy of the gland, support  given to it with mode-
rate compression  may  restore it to its normal  size.  Dr. N. Arnott's
mode of pressure Mr. Liston  thinks is very ingenious, i. e. by  a sort
of wooden cup  or  bowl, made of the size of the tumor, and into
which apparatus is placed a small air-cushion,  made of very fine tex-
ture.  The cushion is inflated with air, so far  as not to be hard; this
cushion  is then put in the cup and supported by a spring like that of
a common truss.   This will answer also, Mr. Liston says, in  many .
cases of simple tumor of the breast.
  There are, he considers, some enlargements of the mamma where
the structure is altered; not a simple hypertrophy,—but where there 
710
FIBROUS  TUMORS.
 are masses of fibrine agglutinated together, and where the tumor
 will go on increasing in spite of all that can be done.
   Cystic tumors cannot be dispersed by simple compression.   Sir B.
 Brodie has described certain tumors of the breast that have yielded
 to lotions of spirits of camphor with liquor plumbi kept on till the sur-
 face is inflamed, then omitted and reapplied.
   The knife only, says  Mr. Liston, can remove the disease when
 the gland is altered in  structure  and contains a great number of
%cysts; but such tumors are not as he conceives malignant, and if the
 whole mass is extirpated there is every chance that  the disease will
 not return.  There  is no contamination of the  lymphatics, and the
 removal of the breast in those cases, may be had recourse to with
 great  propriety.
   If a patient  comes, says Mr.  Liston, with a small  tubercle in the
 breast, with some puckering and  adhesion to the integument, if it
 feels exceedingly hard and unyielding, and has all the characters of
 carcinoma, but is of recent  origin, and  you cannot trace disease to
 the lymphatic system, you may be sometimes  justified in taking the
 tumor out, but  you must  take the whole of the mamma with it.  When
 the disease is at all advanced, and there is reason to think that the
 constitution is  affected with it, it  is far better  to abstain from the
 proceeding.  At one time, adds Mr. Liston, this was the most com-
 mon  operation in surgery.   I  recollect the period when a week
 seldom passed over  without  the operation being performed two or
 three times in  our hospitals; but now it is seldom had  recourse to,
 and properly too, except in cases of non-malignant disease.
   Mr. Liston  has seen a case of carcinomatous  tumor of the breast
 in a female under 30, (see  his Lectures, London Lancet, Dec. 21,
 1844, p. 359, &c.) where the skin  covering both sides of the chest
 and all  around the  back was affected,  hard, unyielding and  exten-
 sively pervaded by  tubercles, to such extent that the motions of the
 chest  and of the upper extremities were much  impeded by the indu-
 rated state of the skin.
    Cancers of the mamma may at an early period be disposed to in-
 volve the lymphatics, the same as in  those  of the  lip.  Even in
 malignant disease, Mr. Liston has known Dr. Arnott's mode of com-
 pression, if early and well applied, to cause the tumor in great  part
 to disappear: but in  other cases it causes great suffering ;  for it cannot
 be expected to liberate the system of the constitutional  taint, which
 will then reappear in the neighboring  lymphatics and at  places far
 removed from the disease.  Thus, though the fatty matter around
 the mamma has  been absorbed by the pressure,  and  the tumor
 lies flat on the ribs, yet the  disease goes on as if nothing had been
 done.  Dissection in such cases has shown enough cancerous degen-
 eration.
    In  cystic and fibrous tumors however,  he thinks the operation
 may be undertaken  with a very fair prospect of success;  but some-
 times the disease returns, and is sure to do so if  the whole of the tu-
 mor is not taken away.
    Pseudo-Cancers.—You meet sometimes with tumors, says Mr.
 Liston, (Ibid.,  p. 359, 360, &c.)  which are not described in books, and
 which you will scarcely believe malignant, or that they can possibly 
NEW ELEMENTS OF OPERATIVE  SURGERY.
711
 return.   He describes one of this kind in a stout healthy woman, only
 a little over 30, and in whom the lymphatics were not in the slightest
 degree affected.  There was found a great deal of fatty matter around
 it, and its  interior to his surprise  consisted of a strange soft-looking
 mass, containing a great deal of coagulated blood and a quantity of
 clot without the coloring matter, but there was also curious pultace-
 ous stuff amongst it.   After this he was not surprised to find that the
 disease in a few months returned, showing itself in three or four
 fungous buds  in the cicatrix.   There  being still no  affection of the
 lymphatics nor of the axillary gland, Mr. Liston removed  these, and
 with them,  as  the patient  was so stout, an immense quantity of the
 surrounding tissue, skin, fat and even pectoral muscle, for  the tumor
 adhered, firmly to the fascia of this last and was incorporated  with
 its fibres.   The cure was complete, and remains so now, nine years
 sinse the last operation.
   In non-malignant tumors, Mr. Liston has sometimes cut below the
 mamma and left that  behind, but if there is adhesion  to it the
 whole must be sacrificed.
   In malignant tumors  when extirpated, not only the diseased mass
 must come out, but you must be  careful, he says, to cut out also
 a large portion of the apparently healthy  fatty tissue around  it, and
 keep the knife  also much  beyond and outside of the white bands
 which you will see spreading out from the  central portion  of the
 tumor into the fatty matter.  After taking out the  tumor, it is to
 be washed  and scraped, and if any indurated portions be found on
 its surface, you must proceed to  make further excisions from  the
 corresponding parts of the wound.
   It is a good rule, he thinks, to take away the fascia of the pecto-
 ral muscle ;  as  the disease  frequently has  some connexion with it,
 and will recommence in  this tissue.
   Mr. Liston thinks it an advantage in  the dressing to apply a layer
 of gold beaters'  skin to the raw surface  of the wound, to prevent this
 adhering to the lint, which is to be placed upon this intervening  tissue.
   Again, Mr. Liston disapproves of closing the edges of the wound
 tight at first with adhesive plaster, and b'y making firm pressure with
 compresses and rollers  around the chest; as this causes pain and
 oozing of the blood, and the formation of putrid clots, foetid discharges,
 &c, requiring the whole to  be removed, and perhaps more  vessels to
 be  tied.  He prefers merely the lint applied as mentioned above, wet
 for five or  six  hours, then  one or two  sutures, or more,  may  be re-
 quired,  and  to  terminate by bringing the  edges together with isin-
 glass plaster.   Thus you will probably obtain union by first intention,
 and without discharge or pain.
  The male breast  occasionally will become affected precisely, he
 says, in the same way as the female,  and require also removal, or it
 will end in internal malignant disease and death.
  M. Lesauvage of Caen, (Arch.  Gen., Fevrier, 1844, p. 178, &c.)
 disapproves of the word fibrous, and proposes, in lieu thereof, gelatino-
fibrous, to such tumors as are described by our author, M. Velpeau,
 (Diet, de Med.)  as formed of solidified  or vitalized (vivifiee) fibrine
or  albumine.   M. Lesauvage  says  they are to be  found in  those
regions that are  abundantly  supplied with cellular tissue, and that he 
712
FIBROUS TUMORS.
 has seen them in the breast, scrotum, fold of the groin, posterior part
 of the thigh, mesentery, &c.   They are always isolated, and possess
 a distinct organization within themselves of numerous cysts and blood-
 vessels, and incommode  the  neighboring parts only  by their  size,
 weight and  pressure.   In the breast they are always developed
 at the  posterior part of the  gland, which latter, when they are
 very  large,  is flattened out and covered by  them on  its  anterior
 portion.   M. Lesauvage does not describe these tumors, which he
 has seen  return after  extirpation, in seven instances, with sufficient
 clearness  to  enable us to appreciate  probably at their  just value the
 fruits of his  experience.  A  discussion which  has elicited such  pro-
 found  researches,  microscopic, pathological and otherwise, from the
 most learned surgeons and investigators of Paris, cannot  properly be
 participated in by others, unless they come duly armed  with accurate
 and new facts.
  M. S. Tanchou in a more recent work of his, (Recherches sur  le
 traitement medical des tumeurs  cancereuses du sein,  Paris, 1844,)
 boldly reassumes the prevailing popular doctrine of conservativeism
 and the substitution of medical treatment even in that most formidable
 of all surgical diseases, cancer.  He maintains that by a proper medi-
 cation  the most clearly established and unequivocal  forms of cancer-
 ous tumors of the breast, may be effectually arrested in  the economy,
 and in their  local  devastation. He  strongly censures the frequent
 resort to extirpation, where not necessary, and  for alleged cancerous
 tumors that are not in reality cancerous. From a comparative table of
 deaths by cancer, at Paris and its environs, between 1830 and 1840, but
 from which no doubt there must be a great deduction made for errors
in the true designation of this disease, as  is justly remarked by the
editors of the Archives Generates, (4e serie, t. VII., April, 1845, p. 523,)
M. Tanchou  asserts that this disease  has increased in frequency from
 1.96 in a  100 in 1830, to 2.40 in a 100 in 1840.  But  according to
 a more important table by Professor Rigoni Stern of Padua, (Arch.
 Gen., loc.  cit., p. 524,) embracing an interval of 80  years, viz., from
 1760 to 1839, the same increase of mortality from cancer has taken
place at the last mentioned city ; viz., from 48 in 1000 between 1760
and 1769,  it rose to 93 in a 1000 from 1830 to 1839 ;  but this increase
was exclusively confined to cancers of the uterus.  Whereas, M. Tan-
chou states the augmentation in Paris to  have taken place in  all the
most important organs and in proportion respectively to their greater
degree of  excitability or impressionability,  and this in their physiologi-
cal order.   He however also admits that the increase has  occurred to
 a greater extent in women. M. Tanchou imputes this increase of the
disease to  the effects of civilization, and in support of this, instances
the less degree of frequency of deaths by  cancer in  the environs of
 Paris than in the capital itself: an error  in the tables which, as is
again justly remarked by the editors  of the Archives Generates, (ib.
loc. cit., p. 524,) is to be ascribed to  the fact that the poorer class of
 patients in the suburbs most usually come for relief to  the hospitals
within the city proper.
  Fungus Hcematodes occupying the entire bladder.—Dr. E.  Bis-
sell, of Norwalk, Connecticut, (American Journ. of the Med.  Sci-
ences, new series, vol. VII.,  p. 122-124, Philad. 1844,)  relates  one 
NEW ELEMENTS  OF OPERATIVE SURGERY.
713
of the most extraordinary cases of isolated and sudden formation of
malignant disease of the bleeding fungoid description on record.  In the
short space of one year, a man aged 67, who was of temperate  habits
and up to April, 1842, had enjoyed uninterrupted health and a  sound
constitution, was seized with irritation in the bladder and constant de-
sire to urinate, followed by discharge of large quantities of blood, and
distressing pain and exhaustion, which finally ended in death. The sur-
geon, previous to this event, diagnosed through the  rectum and  above
the pubis, an enormous tumor occupying the whole bladder, and thus
dispelled the illusion of gravel and stone, for which supposed diseases
he had been for some time  under treatment by an empiric.  On
examining the body,  the diagnosis was fully confirmed.   The  tumor
was ovate, and nine inches from above downwards,  and about four and
a half inches transversely.  Its greatest  diameter  was naturally to-
wards the abdomen and perineum, from  meeting with less resistance
in those directions.  It was a true fungus haematodes, and originated
near the neck of the bladder posteriorly.  Its  texture could be torn
by the finger without much  difficulty.  The bladder was  so com-
pletely filled up by it that there was not room for the smallest  quan-
tity of urine.   The most remarkable feature is, that there was not a
vestige of disease in the kidneys or other viscera any where!
  A congenital encephaloidal tumor, or encephalocele, of an extraor-
dinary character, proving on dissection to be a true  hernia cerebri, has
been recently described by Mr. W. Lyon of Glasgow, (Lon. and Edin.
Month. Journ. of Med. Science, by J. R. Cormack, M. D., &c, Nov.,
1844, p. 983 ; and the London Medical Gazette, July 12,1844.) The
child, aged nearly one month, at the time of the  description  of the
case, exhibited  an oblong tumor, chiefly over the occiput, and extend-
ing from the vertex to the  nape,  11  inches in circumference, 9 in
length, and 7 in its lateral dimensions, partially livid or marbled in
color, fluctuating and without  pulsation; traversed anteriorly  by
small tortuous vessels, and the parts not livid covered with thin soft
hairs.  No opening could be felt under its attachment to the scalp—
the head was normal, but the forehead remarkably low, and receding
—the child well formed, but weakly.  The tumor being without pul-
sation and nearly as large as  the head, and the cranium of normal
size, were circumstances that masked its true character and  led to
the inference that it could not be connected with the brain  or com-
posed of cerebral matter.   This opinion was strengthened by the fact
that  the fontanelles remained  flaccid and could not be made tense  by
pressing on the tumor, as  if to effect its retrocession by a hernial
taxis.  Gentle compression was tried, but soon abandoned.   Finally,
the edge of an  opening into the cranium could  be felt.  The child
lived just a month, and the  tumor, on dissection, was found to con-
tain 3 oz. of bloody serum,  and its parietes to  be formed of the  scalp,
pericranium and dura mater.  Portions of the posterior lobes of the
cerebrum, about the size of a small apple, covered by the arachnoid
and  pia mater, having a film  of serum between them and  the dura
mater, projected through an opening in the inferior and middle part
of the occipital bone  into the sac, being of the size  of the point of a
finger, with rounded  edges, and situated immediately above the ten-
torium, which was imperfect.   It was bounded above by the  termi
  vol. ii.                         90 
714
TUMORS  OF THE BONES.
nation of the longitudinal  sinus, at the sides by the lateral sinuses,
and below by the incomplete tentorium. The portion of brain in the
tumor was compressed where it passed through this abnormal fora-
men, and bulged out to the size of a  small apple in the interior  of
the sac.  There was no fluid within the cranium, either beneath the
membranes or in  the ventricles.   The substance  of the  brain was
quite normal.   The impacted state of the parts about  the occipital
opening, no doubt prevented pulsation from being felt externally.
  Cases of this  description, though possibly beyond the  reach of sui-
gical aid, are rendered exceedingly valuable by the difficulties and
delusions with which a post-mortem may show the diagnosis to have
been necesssarily embarrassed.
  Even the brain itself is not exempt from the formation of scirrhous
tumors within its substance. A remarkable case of this kind is related
by M. Frestel, (Gaz. Med., de Paris, April 19, 1845, p. 253,) of an in-
fantry soldier of young and robust constitution, who was  received into
the hospital  of  Saint-L6, and who, after months of acute suffering
from pain  in the occipital region, but what is unaccountable, without,
so to speak,  any fever, or the least deviation of any of the mental or
physical functions from their normal  state, except perhaps a slight
defect at times in the articulation of words, ultimately died suddenly
without convulsions. .The organs of the different cavities  and the
cerebrum  itself was also found normal, except that there was a con-
siderable quantity of serosity in its venticles; but  on  examining the
cerebellum, its entire left portion was found disorganized, increased in
volume, and  having small but well-marked mammillary eminences
on its superior  surface.  The inferior and  posterior  part contained
a tumor of the size of a large nut, supported  on a distinct pedicle.
The right portion of the cerebellum was in  a measure healthy.  The
tumor was hard and resisting to the touch, and of a tallowy (lardace")
aspect, and when cut into  exhibited  the characters ascribed by au-
thors  to scirrhous tissue.   T.]
                        CHAPTER XL

             TUMORS OF THE BONES  (EXOSTOSES).

  Under the title of tumors of the bones, my intention here is to speak
only of the class of tumors designated by the name of exostosis.  Sur-
gical remedies are not applicable to all the varieties of exostosis.  So
long as the malady is  still the seat of an inflammatory process, and
that it presents  the slightest character of osteitis, acute or sub-acute,
there would be danger in attacking it with instruments, and the ope-
ration would  be absolutely without any result.  It is  its  cause  that
we  must extinguish, and not the exostosis, which we  have to treat.
In the  acute  state or in a state purely chronic, exostoses, developed
under the influence of syphilis, or any  other general infection, are
equally repugnant to every kind of surgical operation, so long as the 
NEW ELEMENTS OF OPERATIVE  SURGERY.
715
 germ has not been completely destroyed in the system.  Should the
 exostosis  be complicated with caries, necrosis, tubercular, sarcoma-
 tous or other degenerescence, it is  still to these last affections that
 we must address ourselves, and not  to  the  exostosis, properly so
 called.   Finally, operative surgery  ought  moreover to exclude from
 its  domain  diffused, large  or fusiform  exostoses,  and those which
 comprise the whole circumference of cylindrical bones, or the entire
 thickness of the large  bones to a  great extent.   I will add, that
 limited  exostosis, more  or  less completely pediculated, ancient and
 indolent, which  is almost the only  kind that  ought  to be  attacked,
 would not of itself justify  serious operations,  unless by its situation
 or volume, it should in reality cause a great disturbance in the exer-
 cise of some of the functions, or unless it should trouble in too serious
 a manner the regularity of the features and forms  of the part.  Ex-
 ostoses being very common, have naturally very early attracted  the
 attention  of surgeons.  Heliodorus  (Peyrilhe, Hist, de la  Chir., p.
 391,392,) who seems tb have been acquainted with eburnoid  exosto-
 sis (l'exostose eburnee), positively recommends their removal.  The
 ancient Greeks, who often employed  the hot iron in place of the cutting
 instrument in such cases, also  made use of both  these means at  the
 same  time.   J.  L.  Petit  (QZuvres Posthumes, t. II., p. 27,) who
 adopted the same method, adds that exostoses  which have  not been
 dissolved  neither by mercury or other internal remedies, ought to be
 destroyed by means of the exfoliating trephine, chisel and  mallet,
 (Maladies des  Os.)  About the same epoch Duverney (Maladies
 des Os, t. II., p.  500,) a rival of J. L. Petit, laid down the  follow-
 ing principles':  if the exostosis has not  a large  base, it  is to  be
 removed, he says,  by  means  of the rasp, chisel or saw; when  the
 exostosis, on the contrary, is large,  we ought to  give the preference
 to the exfoliating or ordinary trephine,  taking care  to  place  the
 crowns by the side of each other, in order afterwards to drive  out
 and to  remove  by means  of the strokes  of the chisel the bridges
 that remain between them.  The  red  hot iron and caustics found,
 at the  beginning of the  18th  century,  a decided antagonist  in
 Kulm  (De Exostosi, etc.,  1732;  These de Holler, t. V., p. 653.)
 Extirpation  with the knife, says the author, is the only remedy for
 exostoses, all other means being  doubtful and uncertain.  Lecat,
 wishing to reconcile the various ancient modes  of practice,  recom-
 mended in 1755, under  the anonym of Labissiere, (Prix de  VAcad.
 de Chir., t. VII.,  p. 157, in-12,) the excision of exostoses which have a
 tendency  to imposthumate or which are limited to the interruption
 of certain functions; the hot  iron against those which are compli-
 cated with  fungosities  and deep-seated caries;   delay  for those
 which  no longer make any progress and which do not cause any
 accident.  This  doctrine did not prevent  Allan (De Exostosi, §  12;
 These, 1770) from proposing the removal of exostoses in two  stages.
Having incised the integuments, scraped the periosteum, and dressed
the wound dry, Allan recommends that we should, on  the following
day, apply a sufficient number of the crowns of the  trephine; that we
should then, by means of the gouge  and mallet, drive out the osseous
bridges, and terminate by rasping the bone which sustained  the exos-
tosis.   It  is  readily conceived that this  method  could  neither  be 
716
TUMORS  OF THE BONES.
agreeable to the taste of the patient or the surgeon, and that Nicolas
(Diet,  de Chir. et  de Med. et  de Veter., t. I., p.  521,  522,) who
simply recommended to saw through the base of the exostosis, when
it is narrow, found more sympathy among practitioners.   Since then
an attempt has been made to systematize these different modes.
  B. Bell (Cours de Chir., t. V., p. 314,) and Maune (Maladies des
Os, p.  19-33-35) after him, have established, that an exostosis ought
to be attacked with the trephine, if it can be included in  the crown
of the  instrument, and with the ordinary saw when it is too large—
When  the exostosis surrounds  the whole circumference of the bone,
we  must, say these authors, exsect or amputate the  part,  whether it
exists in  the small  bones of the  feet and hands, or even  when it is
situated in the  thigh, leg, or arm.  Petit-Radel (Encyclop. Method.,
partie  Chirurgicale) in  such cases  also recommends to  exsect the
cylinder  of the  bone, rather than confine ourselves  to  the excision
of the exostosis.   Surgeons,  nevertheless, have  pursued  a more
simple  practice.  With Voigt (Plouquet, Supph, p. 53, col.  3,) the ex-
tirpation  of an exostosis succeeded very well and enabled him to
preserve  the continuity of the part.  M. A. Cooper (QZuvres Chirurg.,
translation of  Bertrand, t.  I.,  p. 306) recommends removing them
with a saw, and says that the operation, which under such circum-
stances is accompanied only with a slight pain, does not  in general
involve any danger when it has been well done.
  The ligature mentioned  by  Klein (Sprengel, Hist, de  la Med., t.
VIII., p.  341,)  does not  in  reality deserve a refutation, since  it ap-
pears so entirely foreign to the treatment of exostoses.   In conclu-
sion, it is not,  in fact, allowable to undertake the removal of these
tumors, unless it should appear practicable to reduce them by means
of the  saw, or  to destroy  them by the chisel  or the trephine.  By
means  of the cultellaire saws, the chain and rowel saws, and the im-
proved osteotomes, which  science  possesses  at the present time,
there is scarcely an exostosis, with a strangulated or pediculated base,
which  cannot  be readily extirpated.  The  operative process being
simple  or complicated, much less  from the nature or form of the exos-
tosis, than from the anatomical arrangement of the organs  which sur-
round or sustain it, cannot  be well unaerstood except when treating
of exostoses in  particular.  It is, moreover, evident that certain of
these tumors,  those  especially which are superficial and perfectly
pediculated, are generally  easily removed.    An empiric  (Guerin,
Essai  de Med., t. II., p.  276, an VI.) supposing that he was about to
lay bare  a lipoma, having perceived his error and recognizing before
him an enormous exostosis, isolated it down to  the level of the sound
bone, and succeeded in detaching it by means of a common carpen-
ter's  saw: the  patient got well

            Article I.—Exostoses of the  Trunk.

                              § I-

  On the cranium, the extirpation  of exostoses has not always been
unattended with inconveniences; it is moreover easily performed.
Having laid bare their  root by means of suitable incisions, nothing 
NEW ELEMENTS  OF OPERATIVE SURGERY.
717
 prevents our dividing them either by the ordinary saw, the  hand-
 saw, or the trephine.   Nevertheless, I  would recommend that on
 this part of the body we should not have recourse to the gouge and
 mallet, unless it were necessary, and that in order to avoid all cere-
 bral  concussion, we should confine ourselves to the employment of
 the different kind* of saws  which I have just spoken of.  Arnaud,
 (Mcrcure de France, Janvier,  1716,) speaks of an exostosis four
 inches long and two in breadth, which was situated  on the top  of the
 head of a domestic, and which was first attacked with a trephine.
 Perceiving that the tumor  was  osseous throughout its whole sub-
 stance, the surgeons deferred the operation until the next day.  Se-
 rious accidents which came on in the night, obliged further postpone-
 ment, and the patient  succumbed at the expiration of three days,
 without the autopsy throwing any light on the cause of so sudden  a
 death.  We also  find in Sauvages  (Nosologic, t. VI., p. 235,) the
 history of a patient  who had in  the auditory passage a tumor that
 was taken for a foreign body, but proved an exostosis, which was
 attempted to be extracted, but soon caused  death.  M. A. Cooper,
 ((Euvr., trans, of Bertrand, t. I., p. 310,) cites a  case of fungous
 exostosis of considerable size, which occupied the two tables of the
 frontal bone, and  which was excised, but in such a manner that the
 person  operated upon died on the sixth day.  We must not, therefore,
 undertake the ablation of exostoses of the cranium without neces-
 sity, nor resort to  this grave remedy unless the tumor has excoriated
 and ulcerated the tissues, and that it is  entirely external or threat-
 ened with some degenerescense.

                              §11.
   The bones of the  face have still more, perhaps, than the bones of
 the cranium been the seat of exostoses, and for which serious opera-
 tions  have been fearlessly undertaken.  It is to be remarked, in fact,
 that in this region  surgeons have obtained numerous successful re-
 sults.  Brutner  (Koenigsberg, 1775, observ.  premiere)  speaks of a
 patient  who, in  consequence of a fall when six  years of age, had
 on the jaw an exostosis which was extirpated eleven  years after-
 wards, and which then  weighed six ounces.  Reisinger, (Bull, de
 Ferussac, t. XL, p. 361,)  states that he  successfully removed from
 the upper jaw, an exostosis of certain volume by means of Thaster's
 saw, when all other  processes had failed.  Should the exostosis oc-
 cupy the lower jaw, it  must be destroyed  in  the same  manner.
 Jourdain, (Maladies de la Bouche, t.  II., p. 123,) in order to remove
 one which was situated  on  the outside of the jaw, incised and dis-
 sected the gum around it, to detach  it by means of a flat slightly
 curved chisel with a sharp  edge.  The  actual cautery was after-
 wards found necessary, to  destroy  a purulent exudation from the
 traumatic  surface, and the  patient  recovered in  34 days.   This
 method,  recommended by Blicke, has  been favorably received by
 M. A. Cooper, who, in a case analogous to  that of Jourdain, de-
 tached the  exostosis by  means  of  the bistoury,  and afterwards
 deemed it necessary to  apply the cautery  to the bottom of the
wound.   Other cases of exostoses of the jaws destroyed by the in-
strument or by the  hot iron, have also been reported by Harrison, 
718
TUMORS  OF THE BONES.
 (Sprengel, t. VIII., p. 366, 1832,) Mosque, (Ancwn Jou-n. de Med.,
 t. LXXI., p. 506,) and Verduin,  (Theses de Haller, t. V., p.  69.)
 One of the most curious examples of exostosis of the face, success-
 fully removed, is that related by Vigarous (Opuscules sur la regentr
 des Os, p. 170.)  The tumor occupied the  vault  of the palate, and
 extended  from the neighborhood of the anterior palatine foramen,
 as "far nearly as  the uvula.  Its  largest diameter was  ten lines.
 The surgeon having assured  himself that it was only soldered as
 it were against the bones, attempted to detach it without penetrating
 into the nasal fossas.  There remained  around the cavity where it
 was situated an  osseous  border, which afterwards  came  away in
 fragments, and did not prevent the cure from being accomplished in
 the space  of a month.   Should the exostosis be situated in the vi-
 cinity  of one of the alveolar borders,  the  cutting pliers,  which I
 mentioned under the article of exsection of the jaws, would render
 its  excision one of the easiest things imaginable  ; Liston's scissors
 would be equally applicable to it, should it be dilated, while present-
 ing at  the same time a root that was slender and of sufficient length.
 Wounds of the face, moreover, reunite with so much facility  that
 incisions should not be spared  in this region, should it appear  that
 they would render the  destruction of the  exostosis more easy and
 more certain.

                             § III.
  In exostosis of the sternum, I  have met with but  one instance in
 which  its form  and character would admit of extirpation.  The tu-
 mor was  of the  size of a pullet's egg, and its root one-half less in
 diameter than in its dilated portion.   It was laid bare by two curved
 incisions, which detached  an ellipse of  the skin in front; its section
 was afterwards made by means of two cuts of the crested saw, di-
 rected first  from right to left, then from left to right, and as near as
 possible to  the anterior plane of the bone.   The  borders of the
 wound were then gently brought together and the operation was un-
 attended with any serious  consequences.

                             § IV.
  I have also, in two instances, met with exostoses on the apex of the
spinous processes of the vertebral column, and which I might have
extirpated,  in one case, on a level with the  projecting vertebra, and
in the other, in the lumbar region.  But nothing was done to remedy
this deformity.

                             § V.
  The bones of the pelvis sufficiently often present these kinds of
exostoses.   A patient had  one of very large size on the pubes, which
caused him a good deal of suffering.  M. A. Cooper (GSuvr., transl.
of Bertrand, t. I., p. 320,)  effected  its removal, using Machel's  saw
to begin with, and  finishing with  that of Hey.   The  cure was com-
pleted in a  month.   I  have met  with a young man who had  on the
outside of the spine of the ilium,  on the left side,  an exostosis a  half
an inch in thickness, half a foot  long,  and near twenty lines in
breadth, which was situated transversely, and caused, moreover, no 
NEW ELEMENTS OF OPERATIVE  SURGERY.
719
 pain, and had, according to the patient, been developed  in less than
 two years.   The young man was not willing to submit to any opera-
 tion for his relief.   I have met with exostoses in the same situation in
 three other persons; but in these  cases they were of such  inconsid-
 erable size that I  have not thought it necessary to recur to surgical
 means.  Exostoses in the interior of  the pelvis, are among the  most
 frequent that we meet with, the  proof  of which I have given else-
 where, (Traite d'accouchements,  Vices de conformation, Accouche-
 ments contre nature,  etc., 2d edition;)  but as they are beyond the
 reach of operative surgery, it is useless  at this time to examine them.
   Plessman, who  asserts that he  destroyed one on the anterior sur-
 face of the sacrum, by means of the actual cautery, has not been re-
 lied upon by any one,  and  has left it to be inferred, that the tumor he
 refers to, was one of an altogether different description.

                     Article  II.—The Hand.

                           § I.—Hand.

   In the limbs especially,  exostoses  require  all the attention of the
 surgeon.  Covillard (Obs. iatro Chirurg., p. 97, obs. 36, 1739,) extir-
 pated one under the name  of a wen, (loupe,) of a cellular texture, of
 the size of a pullet's egg, and transparent as a crystal, and which ex-
 tended from  the phalangeal articulation  of the little finger to the mid-
 dle of the hand.   The incision of the  soft parts having been effected,
 Covillard made use of a shoemaker's knife to complete the operation,
 and his patient recovered.   An exostosis of considerable size, which
 was situated upon the same finger, and which incommoded only by its
 size, was also at a later period  successfully removed by Bidloo (Ex-
 ercit. Anat. Chir. 9, De Exostosis.)   It  must be that these  exostoses
 of the little finger  are quite common,  for M. Champion, also, gives
 two examples of them:  in the  first  case  (communicated  by the
 author) a bosselated transparent tumor,  of the size of a goose's egg,
 was situated upon the inner side of the first phalanx of this finger.
 Having operated in the manner I have described in speaking of ex-
 ostosis of the sternum, the surgeon  made use of a solid scalpel to
 force out (faire sauter) the  exostosis,  and afterwards  had recourse to
 the  gouge, to  remove everything from the phalanx, that had the
 appearance  of being expanded (rarefie), fungous (carnifie), or dis-
 eased. In the second case (These No. 11, Paris, 1815,  p. 61  ; obs. 10)
 the tumor was situated upon the outer side of the forefinger, towards
 the middle of the first phalanx.   It was  of the size of a nut,  and other
 practitioners  had proposed  to destroy it by amputating the  finger.
 An osseous  tumor of  three inches and a half circumference, devel-
 oped itself upon the second phalanx of the forefinger;  Vigarous
 (CEuvr. Chir., p. 458,) made an  incision, which included the entire
 base of the exostosis, and enabled him to detach it  in two successive
 stages, by means of a  fine  saw, by removing half  the corresponding
metacarpal bone, and  then the  forefinger itself.    The same  practi-
tioner, also, had to remove from the outer  side of the right  middle
 finger, what he called an osseous loupe, and  which kept the two fin-
gers six inches apart.  This tumor, which was seven  or eight times 
720
TUMORS OF THE  BONES.
 larger than the bone which sustained it, and which formed a kind of
 shell to it, was filled with matter resembling tallow or honey.  Vigarous
 (Opusc.  sur  la  Regen.,  &c, p. 172,) removed the  first  phalanx
 of the diseased finger, together with the second bone of the metacar-
 pus, and cured his patient in the space of six weeks.  M. A. Cooper,
 also, speaks of an exostosis which occupied the second  phalanx of
 one  of the fingers.   The first ablation was  followed by a return, but
 the second  effected a  radical cure.   In another case, Vigarous en-
 countered an osseoes  loupe*  on the first bone of  the metacarpus.
 This tumor, which  was thirteen inches and  a half in circumference,
 at its dilated portion, and  nine inches at its root, appeared to have
 been developed at the  expense of the second and third bones of the
 metacarpus, as well as of the first.

                              §11.
   I have seen exostoses on the fore-arm, which were in some instances
 globular, and at other times styloidal.   But the patients experienced
 so little inconvenience  from them, that they never thought of having
 them removed.
                              $  III.
   The humerus occasionally presents on its outer side  and near the
 shoulder, an osseous tumor, the extirpation of which has  already  been
 several times attempted.   The first example  of the kind  which
 has  been  spoken of among  us,  belongs  to Ant. Dubois.  I   have
 heard this surgeon relate that the exostosis, which was concealed un-
 derneath  the  deltoid muscle, was situated nearly two inches below
 the articulation; that it was of the  size of a large pullet's egg, and
 that  it became necessary to cut through the  muscular fibres, in  order
 to lay it  bare, after which he made use of the ordinary saw, gouge
 and  mallet to complete its extirpation.  In another case which I  have
 seen, the  tumor  was  situated precisely in the same region, and
 presented nearly the  same  volume.  M. Roux, who performed the
 operation, being desirous  of saving the deltoid  muscle, made a long
 incision on each side of it, so as to leave a kind of musculo-cutaneous
 bridge between them.   The blade of a common saw, detached and
 passed under this bridge, and afterwards re-inserted into  its handle,
 served to  make the section below the pedicle of the tumor.  As this
 saw  could not be worked  in a direction parallel with the axis of the
 humerus, it was necessary to make use  of it a second time, and then
 to have recourse to a sort of file to equalize the surface of the bone.
 An abundant suppuration  and accidents  of quite a grave character
 supervened, but the cure ultimately was completely established.   At
 the present time we should have to choose between three  processes:
 One  would consist in  laying bare the tumor by cutting a large tri-
 angular or V flap, which  should  be  raised up upon  its  base.  After
 having applied pieces of pasteboard or linen to protect and depress
 the borders of the  wound, the exostosis could be readily extirpated
  * The word loupe literally and anciently means a wen ; and afterwards it became sy-
 nonymous with lipoma, from whence it is probably derived.  (See on Lipomatous Tumors,
supra.) its use in the case mentioned here and farther back, shows that it was applied
to the reverse of wens and fatty tumors, viz., to those of an osseous, and also transparent
texture. T. 
NEW ELEMENTS OF OPERATIVE SURGERY.          721
 by means of the ordinary saw, which it would be more advisable to
 work from  below upwards than  from above  downwards.   By  a
 second process we might confine ourselves to cutting down upon the
 tumor itself, through the  whole thickness  of the tissues,  from the
 apex of the acromion to the point of the deltoid, and then push back
 the  lips  of  the wound to  the right and to the left, to enable us to
 apply the saw upon the pedicle of the exostosis; but this process
 would not  be  applicable  but  to exostoses which make a very con-
 siderable projection, and which are elongated  and have a narrow
 pedicle.  The third, which is no other than the process of M. Jeffray,
 for the exsection of  the elbow, and which M. Roux has proposed to
 put in practice, should at the present time be performed in the follow-
 ing manner: the two lateral incisions  being made, we should care-
 fully isolate the bridge and soft parts from the contour of the tumor.
 The cultellaire saw.or one of the other  hand-saws somewhat narrow,
 or even the  osteotome of M. Charriere, would  readily divide, either
 from one side  to the other or from above downwards, the  pedicle
 of the exostosis.  No doubt also the articulated saw would answer
 the purpose equally well.   All that would now remain, would be to
 thrust out and extract the foreign body through one of the openings
 destined  for the passage of the instrument.  But at the present day
 when we know,how harmless is the division of muscular fibres, who
 would expose himself to  the  difficulties  of this process, when that
 which I have pointed out above, renders the operation so easy and so
 simple ?  Exostoses are sometimes found  also upon the shoulder.   I
 have already mentioned, in speaking of exsection, or extirpation of
 the clavicle, that the history of a tumor of this kind which had two
 feet in circumference, and which weighed five pounds, and was a foot
 in length, had been given by Kulm.  The tumor was removed, with-
 out, however, his mentioning very clearly whether the clavicle had
 to come away along with it at the  same time.

                             § IV.
   Lobstein (Compte-Rendu du Musee de Strasbourg, 1834, p. 64,
 no. 79,) says that an exostoses  which was situated upon the scapula
 of a young man, was  extirpated, and  that the cure was effected in
 two months and a half.  A child thirteen years of age, had upon the
 lower angle of the right shoulder blade, an exostosis of the size of a
 large egg, one half of which projected  outwardly, and the other in-
 wardly.  The surgeon, M. W. Beaumont, (Gaz. Med.,  1838, p. 778,)
 by excising  with the saw or Liston's cutting pliers the angle of the
 scapula, which he caused to project between the latissimus dorsi and
 serratus magnus muscles, while raising  up the arm of the patient, in
 this manner removed the tumor, and succeeded in obtaining  a perfect
 cure.        ,

                        § V.—The Foot.

  Exostoses of the feet are met with especially upon the phalanges
of the toes.  Andre (Observations sur  les Maladies de VUret.,
p. 410,) speaks of an exostosis of the size of a  large cherry, which
was situated upon the great toe, and which he was unable to remove
until after having cauterized it several times with eau mercurielle.
  VOL.  n.                       91 
^•oo
TUMORS  OF THE BONES.
Having elsewhere spoken (see Vol. I.) of sub-ungueal exostoses of
the different  toes, described in a  particular  manner by Dupuytren
and M. Liston, (Bull, de Ferussac, t. XIV., p. 255,) who with myself
prefer  in such  cases amputation  of the last phalanx to  excision of
the exostoses, I will refer the reader to those remarks.   There have
been met with  on some  of the bones of the  metatarsus, exostoses
which require a little further attention.  It was in an instance of this
kind that B. Bell (tome V., pp.  314, 315,)  decided on  extirpating
completely one of these bones for  an exostosis, which occupied its
entire circumference.  M. Herpin (Constitution Medicate d' Indre-et-
Loire, p. 15,  ler  trim.  1818,) speaks of an exostosis  of three inches
in circumference, which  was situated  upon  the  first  bone of the
metatarsus, and which he removed in the spring of 1806, by means
of a small saw, after having laid  bare its root by an elliptical inci-
sion.  The bottom of the  wound  was cauterized with red hot iron,
and the patient radically cured.  There is frequently found upon the
dorsal surface of the great toe, near its anterior extremity, a conical
shaped exostosis, which it may become  advisable to extirpate.   A
straight incision and one cut with the pliers, are generally all that is
required for  it.   As, however, there is a mucous bursa there, which
is sometimes continuous with  the neighboring joint, it is advisable
not to operate there without some degree of caution.

                             §  VI.
  In the leg, exostoses are found upon the fibula, tibia, and patella.  M.
A. Cooper relates that he  saw a cartilaginous exostosis of the size of
a chesnut, underneath  the  periosteum, an inch and a half below the
head of the fibula.   The  extirpation of this  tumor  was performed
by M. Leving,  (A. Cooper, GZuvr. Chir., transl. of Bertrand, t. I.,
p. 519,) who had recourse to  the crucial incision, and divided  the
fibular nerve before removing the  tumor with Hey's saw.  The cure
was effected  in a month.  A  patient operated upon by V. Moreau,
(communicated by M. Champion, who witnessed the fact.) was  less
fortunate.  In a  peasant  girl, there  was an exostosis of an  ebur-
noid character (de nature  eburnee) and large base, situated upon the
antero-external side of the body of the tibia.  This  tumor was  laid
bare by means  of a quadrilateral flap, and then removed by the aid
of the gouge, chisel and  mallet.    This was in 1794; accidents su-
pervened, and the patient  died.   In another case, a boy of fifteen or
sixteen years of age, the  exostosis, which was seated upon the spine
of the  tibia, had  acquired  the size of a Saint-Jean pear.  The  dis-
section  of a  triangular flap allowed of rasping  the bone and em-
bracing the  exostosis  in the aperture of a piece of tin plate,  and
thus exsecting it,  without injuring  the soft  parts.  The  wound was
united  by  first intention, and the cure, according to.Bourqueneau,
(Annul, de la Soc. de  Med. Prat, de Montpellier, t. VII., p. 424,)
was completed in the space of fifteen days.   Finally, M. A. Cooper
gives a case of exostosis with narrow base, situated underneath the
periosteum at the antero-superior part of the tibia, and which, af-
ter having made an elliptical incision in the soft parts, was suc-
cessfully removed by  means of an amputating saw, directed from
above downwards, and then from  below upwards.  A  slight exfo* 
               NEW  ELEMENTS  OF OPERATIVE SURGERY.          723

 liation, which took place subsequently, did not prevent a radical cure
 from being accomplished.

                       § VII.—The Patella.
   Vigarous,  (QHuvr.  Chir.  Prat, obs.  112, p. 557,) who has gath-
 ered in  his work so many extraordinary observations, speaks of an
 exostosis or osseous steatoma, which grew on the anterior surface of
 the patella, and which was 25  inches in its circumference and was
 covered with four ulcers.   Amputation  of  the  thigh had been pro-
 posed, but Vigarous undertook to  remove  the  tumor without inter-
 fering with the articulation.   He effected this  by means of several
 incisions and  by sundry cuts of the saw.  Some osseous laminae exfo-
 liated at a later period, but the operation, which consumed only fif-
 teen minutes, was followed  by complete success.   As for the rest,
 it would appear from  the  description which this author gives of it,
 that this tumor, which was filled with soft  matter, and osseous only
 upon its exterior, belonged rather to the class of degenerated hema-
 tic tumors than to that of exostoses properly so called.

                             § VIII.
   The lower third of  the femur is  perhaps the  region of the osseous
 system where  pediculated exostoses acquire the greatest volume,
 and are most  frequently met with.   I have  seen them sometimes on
 the  inner and sometimes on  the outer  condyle of  this bone, and
 near the ham, and either acuminated or  globular, and of the dimen-
 sions of half an inch to an inch in  height.  Those which more par-
 ticularly require the attention of the surgeon, are such as have a ten-
 dency to develop themselves above the inner condyle, sometimes in
 front and sometimes behind.   This is a kind of exostosis which is
 scarcely mentioned in authors, and which has this remarkable^har-
 acter, that the tumor is almost always found with the same feMires,
 and  in the same place.  M. A.  Cooper, (Giluvr.  Chir., transl. of Ber-
 trand, t. L, or translation of Chassaignac, p. 608,)  who relates  two
 examples, says, that in one of his patients the exostosis, which he de-
 nominates cartilaginous, was situated underneath the periosteum, a lit-
 tle above the inner condyle of the femur, and that it occasioned quite a
 considerable degree of pain.   The  exsection was made without im-
 plicating the muscles, by means of a saw which it was found neces-
 sary to  fix by hooks, requiring afterwards the removal of some os-
 seous asperities by means of cutting pincers.  In the other case, the
 tumor, which was situated in  the same  place, and occasioned some
 inconvenience in the movements, was laid bare by an incision, which
 had  to include some fibres of the  sartorius muscle, through which
 the exostosis was extracted after Machel's  saw, directed by the in-
 ventor himself, had divided its neck.  I have already met, in six or
 seven instances, with the species of exostosis I  have just described.
 In the first case it  seemed as  if the tuberosity of the inner  con-
 dyle had been  transformed into a long and strong cqronoid process.
 The patient, who had been in this state for fifteen years, had become
 so habituated to it, that he would not hear anything said on the sub-
ject of an operation for his  relief.
  In the second case the tumor existed in a young man accustomed 
724
TUMORS  OF THE BONES.
to make voyages.  It had the form and size of a small melon, and
was situated underneath the vastus  internus muscle, two or three
inches above  the  articulation.   The idea of an  operation, and the
apprehension of danger, have hitherto deterred the patient, who, how
ever, suffers from it in no respect whatever.
   The third  case is that of a servant,  seventeen  years of age, who
came in April, 1835, to the public consultation of the hospital of La
Charite.   The exostosis in  him was precisely similar to that of the
preceding patient, both in situation, form and volume.
   In  a fourth example, which I saw in 1836, the patient was forty-
five years of age, and could not indicate the origin of his exostosis,
which was also  situated upon the inner side of the femur, at some
inches above the knee.
   It was in November,  1838, that I met with the fifth case.  This
last case was a man of about sixty years of age, who states that he has
had it about thirty years, and that he attributes it to a badly-treated
fracture of the thigh.   There is every reason to believe,  however,
that there is nothing very authentic in  this history.  The abdominal
limb in fact has no shortening, and the  bone, in other respects, is per-
fectly regular.   The tumor, which projects two inches and  a half on
the inside of the femur, which is three inches in diameter at its largest
part,  quite strongly bosselated, and situated  at the union of the mid-
dle with the lower third of the thigh,  exhibits at its root a contraction
(etranglement) sufficiently marked to forbid the idea of imputing it
to a morbid (vicieux) callus.  A young boy, twelve years of age, had
one of the size of a pullet's egg, a little  lower down, which gave him
no trouble, and for which he did nothing.   The same was the case in
a patient whom M. Macgloghlin took me to see in 1837.
  It is a matter of surprise that we should so often meet with tumors
of thk description in such a region.  None of the patients I saw were
in any other respect annoyed except by the size, weight  or defor-
mity of the tumor.  Thus  there were  no  sufferings, no lancinating
pains, no excoriations nor inflammations, nor adhesions of the skin or
other tissues.   So also did these patients, when I pointed  out to them
some of the dangers they might  incur in undergoing an operation,
come to the determination to retain their infirmity, and recoil from the
operation, and perhaps they acted wisely. Ought we, however, on that
account to say that supra-condyloid exostosis of the femur is absolutely
incurable ?  No, certainly ; but to remove it we have to resort to ah
operation, sometimes  difficult, and almost always dangerous, whilst
the disease in itself does not usually compromise the functions of the
limb or the general health of the individual,  and may remain station-
ary for an indefinite number of years, when  it has once arrived at a
certain period of its growth.  The conclusion, therefore, in my own
mind is, that I would not decide upon the removal of tumors of this
description, unless, notwithstanding my representations, the patients
should find themselves so much incommoded or annoyed as to make
an urgent demand for relief, or unless such tumors should threaten to
acquire too large a volume, or to undergo degeneration, or cause, in
fine, actual pain, or serious functional derangement in the part.   As
for the rest, there is no other treatment for them but excision or ex-
tirpation, in which event many processes may be employed.   Should 
NEW ELEMENTS OF oftlRATIVE  SURGERY.          725
 the exostosis be flattened and of small diameter, we lay it bare by
 means of a simple incision, commenced above and terminating below,
 and which ought to penetrate down to the bone.   The cutting pliers,
 Liston's scissors, or one of the exsection saws, will then suffice for ex-
 cising it from the femur.   When it does not appear practicable to iso-
 late the whole contour of the tumor by means of a straight incision,
 we may then choose between the crucial incision, that of the T, the
 double vertical  incision  of Jeffray, or the semilunar.   The  crucial
 incision would have no  other inconvenience than that of completely
 dividing, and in two opposite directions,  all  the fibres of  the vastus
 internus muscle.  Nevertheless this difficulty ought not, at the pre-
 sent day, to deter us, if by that means we should render the operation
 more easy, inasmuch  as the section of the muscular layers involves
 in  reality but very slight inconvenience   The T incision might be
 made  in  such manner that  its horizontal branch could  be placed in
 front or behind the tumor, almost indifferently.  I should, however,
 prefer to place it in front, in order that its vertical branch might be
 made  to fall  upon the inner border of the ham, and permit the two
 flaps which it circumscribed  to be  reversed, the one downwards and
 the other upwards and  backwards.   The incision with two parallel
 branches, one situated  in front and the other behind, so as to circum-
 scribe a bridge of soft  parts upon  the exostosis, has in this region
 still greater   inconveniences than for sub-deltoidal tumors  of  the
 humerus.  M. Roux, who made trial of it in the young servant whom
 I have mentioned farther back, was obliged to divide the soft parts
 transversely  through their middle, transforming it in this manner into
 two quadrangular flaps.  Besides creating in this manner embarrass-
 ment in the  section of the tumor, we expose ourselves  moreover to
 the risk of not being able afterwards to disengage it from among the
 muscles, and effect its complete extraction.  It is therefore more pru-
 dent to resort at first to the semilunar incision.  This incision, whose
 free border should be turned inwards, would circumscribe a flap, which
 should  be  reversed  from behind forwards, and would  lay bare the
 whole  of the exostosis.   An assistant drawing this flap upon its base
 and outwards, while another assistant would  hold apart  the inner lip
 of  the wound backwards and inwards, and while the limb was held
 in semi-flexion, and lying on its outer side, would enable the surgeon
 to  carry any saw whatever  very near the femur, and to divide the
 neck of the exostosis.  If there should remain any asperities or osse-
 ous inequalities at the bottom of the wound, nothing, would be more
 easy than to  remove them by means of the chisel, gouge and mallet,
 or  by  the  aid of the rasp or the concave rowel  saw of M. Martin.
 We might also confine ourselves to a straight incision, placed on one
 of the  sides  of  the tumor,  and which should be  sufficiently long to
 enable us to  separate  its borders  wide apart.    The osteotome of
 M.  Heine, or the saw of M. Charriere, or  even that of Aitken, intro-
 duced  by this means upon the pedicle of the tumor, would evidently
 enable us to detach it in the greater number of patients; and every-
 thing shows that by giving the incision a certain extent, it would give
 free egress to the foreign body.  It is perceived,  moreover,  that the
 process in these cases ought  to vary according to the size, form and
actual  seat of the tumor, or the particular taste and practice of the 
726
THE LIGAt-URE IN MASS.
surgeon.   I would only remark, however, that in general tne semi-
lunar incision is the one that should be adopted by preference.  Up
to the present time, this operation has not been performed sufficiently
often to enable us to appreciate exactly either its dangers or harm-
lessness.   The  two patients  of M. A. Cooper, did not recover with-
out  causing some uneasiness; and that of M. Roux, who, though he
was young, of excellent constitution, and in perfect health, ultimately
perished.  The surgeon, being obliged to penetrate down to the bone,
necessarily arrives beneath the  fascia lata.  Being unable to detach
the  exostosis without more or less contusing the neighboring tissues,
and without making a wound whose bottom is hard and more or less
rugated, he can scarcely count on immediate  reunion.  But if the
inflammation and suppuration, which in such cases would almost in-
evitably supervene,  should take on a  diffused character and extend
downwards towards the ham,  and upwards into the body of the
thigh, they would soon constitute one of those forms of phlegmonous
erysipelas, or diffused phlegmons, which are the most formidable that
can be imagined.  I would therefore lay it down as a precept, when-
ever immediate reunion, and without suppuration, cannot succeed, that
we  should not attempt the cure of the wound by  first intention, but
confine ourselves to keeping  it slightly open by means of small balls
of lint, until it is perfectly cleansed, and that there has been formed
the  pyogenic membrane and  cellulo-vascular vermilion surface.
                       CHAPTER  XII.

                    THE LIGATURE IN MASS.

  We have already seen in the preceding volumes under how many
forms the ligature is employed in surgery.   Useful  for  uniting cer-
tain wounds, almost indispensable around vessels, to  arrest the blood
in amputations, for wounds of arteries, aneurisms, and most bloody
operations, it is, so to speak, called for as often as we take  the bistoury
in our hands.  But in such cases the ligature includes and constricts
only the vascular canal, whose orifice  or calibre we wish to close.
But there are a class of operations in which we apply the ligature in
a different way.   In these we no longer apply it on a distinct vessel
at the bottom  of  any wound, nor is it now designed to  repress  the
effusion  of blood; its object here is,'by strangulating the parts, to
mortify, sometimes, quite a considerable portion o£ them left out-
side of it.  It  is to this last kind of  constriction that the title, in our
times, is given of  ligature in mass.  It is thus that polypus has been
treated at every  epoch, whether situated in the nose, the womb, or
rectum, or even in the ear.  Most pediculated tumors have also been
treated at every  period of science  by the ligature in mass.  Even
amputation of the limbs has been sometimes  performed  in  this  man-
ner.   I have related several examples of this kind under the chapter
on Amputations in general. When castration is performed, it is allow-
able  to embrace the whole of the testicular cord in a ligature, and to 
NEW ELEMENTS OF OPERATIVE SURGERY.
727
 strangulate it in mass.  The ligature for fistula in ano, so frequently
 employed in the last century, was nothisg more than the ligature in
 mass.  We  see by these examples under  what circumstances the
 strangulation of the parts ought in reality to receive the name of liga-
 ture in mass, and to how many and to what kind of operations this
 description of remedy is  applicable.  To effect it the  surgeon may
 make use of all the different kinds of ligatures  imaginable; those of
 silk, thread, linen packthread, cord, fibres of plants, lead,  silver, gold,
 platina,  and  maillechort, rendered flexible  by the various means
 known in the arts, furnish  the same resources for the ligature in
 mass as for the simple ligature of vessels or for sutures.   Neverthe-
 less, we cannot indifferently employ any one of these substances in
 preference to another.   Should we require a ligature somewhat
 small in size, and which should be at the same  time very supple and
 strong, the silk ought to be preferred.   If it is required to effect a
 firm constriction of a  soft tissue with a root somewhat large, a liga-
 ture of hemp, made by twisting three, four or five strands of simple
 thread, presents the most advantages.   Packthread,  which  might
 be  substituted for it, has the inconvenience of adapting itself with
 less facility to the  bottom  of  the parts, and  of untying itself too
 easily.   It is advisable, moreover, in place of besmearing them with
 soap, as some persons have recommended, to rub the strands of
 the thread or packthread with wax, which  prevents,  or at  least
 diminishes, its tendency to  slip.   Tissues of plants  or  ligatures of
 linen ought not  to be employed  unless  none better can be obtained.
 As to metallic  ligatures, however pliant some may consider them,
 they never possess  the flexibility of thread, and cannot obtain the
 same generalization in practice.  They consequently ought not to be
 preferred, unless there is necessity of  a very great degree of con-
 striction, or to put ourselves on our guard against the  dissolution,
 putrefaction, or  physical alterations of the ligature.  There are also
 some cases where substances, which would be susceptible of solution
 and absorption by the living organs, might have an advantage.  Thus
 to strangulate an intestine, either transversely or on  its side, and in
 such manner as to return it immediately afterwards into  the belly, it
 would be a precious advantage to have  the use of ligatures  which,
 as soon as they  were applied, would cease to act as a foreign body.
 For this purpose there has been used  silk in its natural or raw state,
 deerskin, chamois leather, gold beaters' skin,  catgut,  &c.  But in
 addition to the fact that ligatures or threads fabricated  out of these
 substances, are deficient in solidity, they have moreover the inconve-
 nience of not being absorbed, except in  a few cases, without exciting
 inflammation or suppuration.  The ligature in mass is not applied in
 all cases in the same manner. If in some cases we limit ourselves to
 encircling the part  by placing  the  ligature  immediately upon the
 skin without  any previous incision, we on other occasions  com-
 mence by dividing the integuments upon the same circle  which is to
 receive the ligature.  These two  modifications of  the  ligature in
 mass were known at a very ancient period.   In the  method known
 as M.  Mayor's,  and which, since  the time of Hippocrates, all sur-
geons occasionally employ, we commence by laying bare and dis-
secting the parts which it is our intention to destroy, and it is  nol 
728
THE LIGATURE IN MASS.
  until after we have isolated them nearly down to their root, that we
  surround them  with  the  ligature and strangulate them.   This last
  method  is daily applied, as it has been for ages past, for *he extirpa-
  tion of  tumors  of the axilla after the removal of cancers of the
  breast, also in the ligature of the spermatic cord, etc.  The various
  modifications of the jfgature in  mass are nevertheless all classified
  under two general methods, viz: the ligature without previous dis-
  section of the integuments, and the ligature after the dissection of
  the tumor.

            Article I.—Ligature  without  Dissection.

    The ligature  in mass, without previous dissection, comprises three
  varieties:  the thread or ligature is applied on the integuments with-
  out any other precaution, or after a circular incision of the skin, and
  sometimes also  after having cut through the tissues behind the root
  of the body which is to be destroyed.  The ligature upon the integ-
  uments, whether they are  cutaneous or mucous, is effected by means
  of all  the different kinds  mentioned above.   Some surgeons  of
  former times, and some practitioners of the ancient academy of sur-
  gery,  had proposed in such cases to saturate the ligature with some
  caustic  matter,  in order,  they said, that it might more  rapidly cut
  through the tissues.   This precaution, which rendered the operation
  obviously  more painful, augmented the inflammation, and did not
  sensibly hasten the fall of the ligature, and which moreover rendered
  it  more brittle, is no  longer  employed in our time.   It  is  by a
  mechanical action, and not by its chemical properties that the liga-
  ture, thus applied, is to produce its effects.   This description of liga-
  ture, which  is  applicable to cutaneous tumors, whether they are
  fibrous,  vascular or horny, when they have  a  narrow root and are
  easily raised up,  is equally applicable to bodies that are fibrous,
  mucous, or of any other character, which  are  found in  the interior
  of the mucous  cavities.  To accomplish  it we require a ligature
  properly prepared, and of a strength, breadth and thickness pro-
• portioned  to the volume of the tumor, or the degree of constriction
  to be  used.  The ligature being arranged, the surgeon  causes the
  tumor to be  raised up in such manner as to surround its root a little
  behind it, and upon the sound tissues.  If the pedicle of this tumor is
  purely cutaneous, there is no danger in strangulating it.   When it is
  rather more cylindrical or conical than dilated (renflee), we may
  limit  ourselves to  applying the  ligature upon  its neck without
  making the least traction  upon it; on the contrary it may be advan-
  tageous to raise it up with a certain degree of force while we are
  applying the ligature, if we do  not wish to incur the risk of leaving
  behind a certain portion of the degenerated tissues.
    It sometimes happens, that, in order to prevent the  ligature  from
  slipping, from the integuments towards to the tumor, we are obliged
  to give it certain points d'appui on the confines of the diseased region.
  It is in this manner that an  erigne, a tenaculum, or a hook  forceps
  with very convex teeth, sometimes becomes  necessary.   The tumor
  being  drawn upon by an  instrument of this  description, obliges  the
  ligature  to glide backwards, in proportion  as it is tightened.  As it is 
NEW ELEMENTS OF OPERATIVE SURGERY.
729
 sometimes necessary  that this  last precaution  should  be rendered
 permanent, it has been proposed to pass, at first, a simple metallic
 stem, or two similar stems crosswise, under the root of the tumor, in
 the manner I proceed, and as M. Davat has done, for the  ligature in
 mass, on varices.  These stems, having transfixed the tissues firmly,
 retain the ligature, which is placed behind them ; in this manner we
 strangulate without any great  degree of difficulty,  and  circularly
 non-pediculated tumors.  I have mentioned farther  back, what  has
 been obtained from this description of ligature, in the  treatment of
 erectile tumors.   As it is difficult to strangulate the parts completely
 when  they have a considerable degree of thickness, it was  readily
 suggested, that we  should embrace a portion  only of the base of
 large sized tumors with each ligature, to pass two, three or four lig-
 atures in order afterwards to mortify separately each of the parts,
 or  one of the  four triangles of the pedicle, when the threads  have
 perforated it crosswise.  Should it be desired to apply a double liga-
 ture, we take a long waxed thread, with a needle, pierced near its
 point, and having a handle, or a long common needle  slightly curved,
 or a probe, inserted in a canula which a trochar had  previously  ena-
 bled us to  plunge through the tumor.  We  pass  the thread behind
 the root of this last.  Having immediately cut it near the needle, or
 disengage^it from the eye  which conducted it, the thread  is instantly
 un-doubled;  we then seize hold of one  of its halves which is  tied
 into a knot on one side, and then do the same with the other, on the
 opposite  side, taking  care to tighten them in a  proper  manner.   In
 this  way, the ligature  strangles  only a portion  of the mass.  As it
 acts, moreover, from within  outwards, it  produces as much effect as
 if the tumor  was  only half the size that it is.  If, as M. Warren  (on
 Tumors, etc., p. 418) appears to have ofterf done, we should  incline
 to divide the tumor into four parts, by means  of threads, it would be
 advisable to  insert the four ligatures in succession, and to give  the
 preference to the needle of J.  L. Petit.   Each thread would thus
 circumscribe a  quarter of a circle, and the entire circumference of
 the tumor would finally become strangulated.  Finally, it  would  also
 be practicable to imitate Somme, who, wishing to divide  the bridle
 of a pseudarthrosis, plunged in his ligature, and brought it out by the
 same opening, after having passed it around the tissues to  be divided,
 a method, which, as I have elsewhere said, appears to have also been
 made trial of for varices.  We should, therefore, insert by puncture,
 and  sub-cutaneously, by means of a needle slightly curved,  or  any
 other instrument, a ligature upon the contour of one of  the halves
 of the  mass.   Brought again, by a second puncture, to the opposite
 extremity of  the great diameter of the tumor, the ligature would be
 conducted in the same manner upon the other side, and brought out
 at its point of departure.  We should, in this way, procure a circular
 constriction, which would  in  no respect  interfere with the integu-
 ments, and perform an operation entirely under the skin.   A  last
 mode of strangulation, without  previous  dissection, and  which  has
 already been  employed by  some  surgeons, by  M.  Manec  among
others, consists  in introducing as far as the centre of the tumor, four
metallic stems, each armed with a hook, which, darting through it in
the manner of a spring, afterwards divides the tissues from the cen-
  vol.  n.                       02 
730
THE LIGATURE  IN  MASS.
 tre to the circumference by means of a quick screw adjusted to their
 free extremity.

        Article II.—Ligature in Mass, with Dissection.

   The surgeon has often a  good deal  of embarrassment when com-
 pleting the separation of tumors that are deeply situated, or organs
 whose pedicle is nourished by numerous vessels, which cannot be
 seized without difficulty, or that are of large  size.   This is seen in
 the  extirpation of the tongue, the  removal of cancerous tonsils, the
 thyroid body when degenerated, and in most of the tumors of the
 neck, axilla, groin, &c.  It is easy to be conceived, that the surgeon,
 who has to extirpate  a cancerous  tonsil or tongue, must necessarily
 be intimidated with the hemorrhage which may result from such an
 operation.  All extirpations of goitre have also been  considered  for-
 midable from the same danger.  M. Mayor, (Essai sur la Ligature,
 etc.,  Lausanne,  1821  ; Essai sur la Lig. en Masse, Paris, 1826,) in
 giving more importance than any other person to this inconvenience
 in bloody  operations, has  suggested that a ligature which would
 embrace the  root of the tumor, would enable us to penetrate deeper
 down than with the bistoury, while offering, at the same time, to the
 operator all  the security desirable.  So that the ligatuflfe in  mass,
 with previous dissection, and which was  formerly but  seldom had
 recourse to, is now in sufficiently general use.   It is effected, more-
 over, with  the same  substances, and by the same  processes, as the
 preceding method.  Thus, in order to accomplish this, we may make
 use of threads, of silk, hemp or flax, ligatures of linen, packthread,
 or cord, wires of lead, silver, or other flexible metal or the different
 kinds obtained from animal tissues.  In the same way as for the  lig-
 ature in mass, externally, we might imbue the thread  with caustic or
 medicated  material, or apply it without any other precaution, upon
 the root of the tumor, and prevent its slipping by the various means
 employed to  arrest the knot in the ligature upon an artery.  If the
 body to be strangulated is voluminous, it is advisable, at first, to
 perforate it with a double ligature, the two portions of which  are
 afterwards separated, in order to  form a distinct circle, applied to
 each half of the pedicle we wish  to mortify.   Nothing, moreover,
 would prevent our dividing  the root of the tumor into four portions,
 by means of four separate  ligatures ; but the ligature in mass, with
metallic wires, would  be applicable after dissection only, to tumors
whose entire  contour  and root passed beyond the level of the integu-
ments.  If, however, in order to effect its strangulation  in a proper
manner, it should be thought advisable to insert the metallic stems
crosswise,  through its root, it would still be practicable to recur  to
this, provided we took care to  withdraw them  shortly after, that is
to say, as soon as the  ligature  had cut sufficiently deep  into the tis-
sues to prevent it from any longer having a disposition to slip.

Article III.—Manner of  effecting Strangulation by the Mass.

  The object here is  to interrupt all  kind of circulation and phy-
siological action in the mass  whose  pedicle is constricted.   The 
new elements of operative  surgery.
731
 better way would then appear to be, to  strangulate the parts at first
 as powerfully as possible.  Nevertheless, the ligature in mass  is
 sometimes employed in such manner as to cut or strangulate only by
 degrees, the organs which it embraces.  If the ligature has but little
 volume and acts insensibly, it may happen that the first organic layers
 cut by it do not mortify, but even reunite external to it, so as to im-
 prison it, before  its  action has been brought to bear upon the tissues
 which' are  deeper situated.   M. Mirault noticed this in a case of
 strangulation of the tongue ;  what I myself have also seen, and what
 J. L. Petit had already noticed after a ligature in mass upon the tes-
 ticular cord ; which  result I  have witnessed also in the case of a
 child who had  strangulated  the penis with  a  simple thread.   This
 species of constriction, therefore, is for the most part very uncer-
 tain.   Nevertheless, there might be cases where it would be advisa-
 ble, provided that by thus cutting through the tissues by degrees
 without mortifying them,  some prospect might be obtained of effect-
 ing a radical change (modifier  profondement,)  in their morbid con-
 dition.  We shall find, in  fact, in speaking of operations performed
 upon the tongue, that the patient treated in this manner by M. Mi-
 rault, ultimately recovered of his cancer.   If, however, the strangu-
 lation  at first is sufficiently  powerful to arrest the passage of the
 fluids, the tumor, which is immediately deprived of its vitality, first
 becomes blue and livid, and then softens, shrinks and loses its volume.
 From  this it  happens that the  ligature is  no sooner sufficiently
 tightened, than it slips and is displaced, and no longer makes any
 constriction.  In this point of view, practitioners  in my judgment
 appear to have examined  but one of the points of the question.   If
 the ligature changes place before the entire physiological circulation
 in the  tumor has been suspended, it is clear that life may be re-estab-
 lished  and  that  our  object will be  defeated.  If, however, this dis-
 placement does not take place until at the expiration of 24 hours, or
 in consequence  of the shrinking of the  tissues, our purpose, never-
 theless will be attained.   After this first result, however, the conse-
 quences will be the same, whether the ligature remains or is removed.
 Every thing existing external to the ligature is effectually mortified,
 represents  an eschar, and acts  in  the same way as a foreign body
 which must necessarily come  away through  the eliminating powers
 of the system.   We  see in these cases a line of demarcation estab-
 lished between the living and dead  parts, while a process takes place
 in every respect analogous to that which detaches the eschars from
 a burn.  For which reasons,  my rule is to remove the ligature at
 the end of one or two days,  when  it incommodes, or when it is not
 my design  to increase its  constriction from  day to day.  As to the
manner of performing this strangulation, it presents a certain num-
ber of modifications.

                  §  I.—Simple Strangulation.
  Whether the ligature to be applied is to be external or deep-seated,
 we nevertheless frequently confine ourselves to strangulating the pe-
dicle of the tumor by a double or even a single knot, in the same way
 as in tying an artery. Nevertheless, as it is almost always necessary
to constrict the parts as strongly as  possible, the first knot requires to 
732
the ligature  in mass.
 be firmly secured while we are adjusting the other.  To effect this
 we have three resources:  1.  An assistant holds the extremity of
 one of his fingers accurately placed upon the crossing of the threads,
 while the surgeon prepares the second knot of the ligature ; 2. should
 the finger be found too large for this purpose, we substitute for it the
 blunt extremity of any metallic instrument whatever; 3. or what is
 still more secure, we firmly embrace the  first knot with the point of
 a forceps.  Still another means consists after the first knot is made,
 in carrying the two portions of the ligature again around the tumor,
 in order to knot and tighten them  in the  same manner upon the op-
 posite side.   Whatever mode is adopted, it is  advisable to cut one
 or both of the free portions of the ligature near the knot.  We cut
 both, should nothing prevent our seizing hold of, and dividing the
 knot  at its place, when we judge proper.  We leave  one, on the
 contrary, when we  consider  it advisable that  we  should  have a
 guide to remove the ligature at a proper time.   If the ligature is in-
 tended  to be temporary, we might, after having tightened it, adjust
 its first knot by a simple  rosette  (bow-knot).   By  this means we
 may readily withdraw the ligature at the end of one, two, three, or
 four days, and disembarrass the parts without dividing anything.

                              § II.
  In place of this sudden strangulation, we sometimes have recourse
 to a graduated constriction, a constriction which, notwithstanding
 the shrinking and withering of the divided parts, shall  act in such
 manner that the strangulation of those which remain, is not at all
 relaxed, but continued up  to the time of  their complete separation.
 For this purpose, quite a number of different  modes  have been de-
 vised.  One of them  is so ingeniously arranged that the ligature
 tightens itself in proportion as the tissues recede.  To accomplish this
 M. Pelletan has  contrived an instrument more ingenious than those
 of Levret, and which is represented by a stem with a double canal,
 having at its  free extremity a sufficiently  powerful spring, which re-
 ceives the extremities of the ligature which  have been  previously
•passed around the tumor,  and which constantly tends to make trac-
 tion upon them, (les  entrainer).   Others  have  invented ligatures
 whose constriction  may be augmented or diminished at pleasure.
 All the kinds of knot-tighteners (serre-nceuds) nearly, belong to this
 description.  Whether, in fact, we make use of the serre-noeud of Lev-
 ret, that of Deschamps, Desault, Dubois, or even the simple bow-knot,
 we may, nevertheless, renew at pleasure  the degree of strangulation
 we have at first produced.  When we have  surrounded the tumor
 with a metallic thread, it will be sufficient to twist the two free  por-
 tions in a spiral manner around each other, if we wish to make daily
 increase of the  constriction.  The most ingenious instruments we
 possess of this kind are those of M. Bouchet, M. Mayor, M. Graefe,
 and Dupuytren.
   The  knot-tightener of  M. Bouchet is  a sort of rundlet  traversed
 by the two threads, and around which  they are attached in order to
 be shortened to the degree  desired.  M. Mayor, reviving an  idea
 formerly thrown out by Roderic, has proposed to pass the two united
 extremities of the noose of the ligature which surrounds the tumor, 
NEW ELEMENTS OF OPERATIVE SURGERY.          733
 through a series of beads  or small balls of wood, ivory, horn, bone,
  f?r Sr any other substance'in  the manner of stringing  the beads
 ot the Paternoster.   The first of these beads being pierced with two
 holes, allows of tightening the two halves of the  ligature strongly
 upon the last, and of forcing the  other in a proper manner against
 the tumor.   To do this with still  greater ease, we may replace the
 outer half  of this  chain  of beads by a metallic or ivory tube, and
 make use of  a small  winch (treuil) to receive the extremities of the
 ligature.   We have, by this means, a ligature which terminates in a
 flexible stem, which adapts itself with facility to the parts, and inter-
 poses no obstacle  to the gradual strangulation of the tissues.  The
 knot-tightener of M. Graefe, as modified by Dupuytren, receives by
 one of its extremities the double  thread of the  ligature.  This liga-
 ture is then attached by several turns to a small lateral nut, (ecrou,)
 which is separated from or approximated to the wings or  outer ex-
 tremity of the instrument at  pleasure,  by means  of a quick-screw,
 (vis de rappel.)  (See article, infra, on Polypi of the nose, uterus,
 &c.)

                   Article IV.—Appreciation.

   The ligature  in mass, applied exclusively and alone, and adjusted
 by a common knot as near as  possible to the root of the tumor, more
 frequently answers the purpose than is generally supposed.  It is in
 fact, in most cases, not at all necessary, as some think, to renew the
 constriction  and tighten the ligature daily.  I have seen enormous
 tumors yield to this kind  of  constriction kept up  for twenty-four
 hours, or even  in some cases for  only  twelve hours.  An  immense
 polypus  of the  pharynx and  nasal fossae  thus  strangulated for the
 space of some days, and divested of its  ligature a long  time before it
 had been completely  cut through, nevertheless separated at its root.
 How often have we not  seen polypi of the uterus, treated by the
 ligature, detach themselves beyond the point which had been touched
 (touche) by the thread, and although the constriction had been actually
 maintained  only for the space of a few hours!  Nevertheless, this
 species of strangulation is  not as suitable as  the  others,  when we
 have to include  a great mass of tissue.   It is in  such cases that par-
 tial  or progressive strangulation  merits the preference.    Partial
 strangulation by means of threads passed  through the tumor, acts
 more promptly  and with  more certainty than  the  simple  ligature ;
 but it is applicable only to external tumors, and would not be adapted
 to those whose pedicle includes voluminous vascular trunks, or large
 sized nerves.   Here, therefore,  we should make  use of gradual
 strangulation.   Underneath the skin  this last mode would, at first,
 present great difficulties, and would not probably succeed until after
 having transformed the tumor  into a vast abscess, at the same time
 without giving  assurance that the integuments would be preserved.
 The process  of M. Manec is, undoubtedly, the most difficult and
 most embarrassing, and the least certain of all.  By means of knot-
 tighteners, should we use  that  of M. Pelletan, the  results we would
 produce could only be imperfect and incomplete.   The instrument
of M.  Graefe, when a straight and inflexible stem, is  not  attended 
734
FOREIGN BODIES.
with any serious  inconvenience;  or on the contrary, the  chaplet of
Roderic, as improved by M. Mayor, may enable us to dispense with
the others, and presents all the requirements of force and simplicity
desirable.  As for the rest, it is not to be forgotten, that  the opera-
tion is practicable with all these  instruments and by all  these pro-
ceses;  which, nevertheless, does not exempt me  from adding that
the ligature in mass never should be the method of election, when it
is  practicable to  employ  the cutting instrument  without manifest
danger.  The ligature in mass, used in the manner I have  described,
causes  the separation of the tissues at the expiration  of a period of
time, which  varies between three or four days  and  two or three
weeks.
  During all  this  period  the  tumor passes into a state of putrefac-
tion, is decomposed, and emits an odor which is usually offensive,
together  with discharges  which  possess  a certain degree of acri-
mony.   Hence the  extremely  unpleasant consequences, both  to
the patient and those who approach him; and hence the real dangers
which may result from this state of things by means of resorption,
infection or  poisoning.  I have, therefore, been in the habit, when
I have  employed  this operation, of excising from a half an inch to
an inch of all that portion  of the  ligature which was  found  outside,
as  soon as the circulation appeared to me  to have been sufficiently
destroyed in the centre of the tumor.   I remove the ligature itself at
the end of four or five days, when  this first excision convinces me
that there no longer remains any degree of vitality in the  circle  of
the constriction.   The patients are thus relieved from an actual pes-
tilential ulcer, (foyer,) and they have  nothing more to undergo  than
the eliminative process from all the different  points, similar to that
which  detaches the eschars from  a  burn,  contusion,  or  gangrene.
It  is nevertheless true, however, that with the exception of a small
number of cases, the  ligature in  mass will always  be the  favorite
operation with surgeons who have but  little experience with the
knife, or not much confidence in their anatomical knowledge, or the
steadiness (surete) of their  hand.  No  one, however, as  I think,
would undertake to contend, that an operation finished in a few  min-
utes, and which leaves a fresh and living wound, can be where all other
things are equal, less advantageous than an operation which cannot
be completed in less than from eight to fifteen days, which is accom-
panied  with all the phenomena of gangrene, and the wound made by
which does not begin to  become cleansed, until  at a period when
that of the other may  be perfectly cicatrized.
                     CHAPTER  XIII.

                       FOREIGN BODIES.

  Numerous foreign substances, and of different kinds, may exist in
the human body, and require the intervention of surgery.  Some- 
NEW ELEMENTS OF OPERATIVE  SURGERY.          735
 times these substances come from without, and at other times form in
 the midst of the parts themselves.  The sequestra of bones, eschars
 within the soft parts, certain accidental productions, different sorts
 ot calculous concretions, the decomposed  products  of fecundation,
 whether uterine  or extra-uterine, &c. &c, belong to the last-named
 class.   Substances derived from  three kingdoms of nature, and
 which, having once entered into the living cavities or tissues, are
 arrested there as anomalous, and remain there as morbific causes, are
 to be enumerated under the first class.  The organs most exposed
 to these kinds of accidents, are the ear, frontal sinus, eye, nares,
 mouth,  maxillary sinus,  the air passages, oesophagus, urethra and
 bladder, vagina and womb, and  the rectum and intestines in general.
 It will be while  examining the  operations required  for the diseases
 of these different organs or regions (appareils) that the occasion will
 present of speaking,  also, of the foreign bodies which  are found in
 them.   I  do not therefore intend, at this moment, to treat of other
 foreign bodies than those that are attached to, or formed upon other
 regions of the animal economy.

                       Article I.—Trunk.

                         § I.—The Head.
   In this series we shall find foreign bodies in the head,  face, chest
 and abdomen.  Projectiles thrown by powder, as powder itself, lead,
 and especially balls, langridge (mitraille) discharges  from bombs, or
 howitzers, biscayans, and even small bullets,  are frequently found
 there.   Then come pieces (tiges)  and fragments of metal, wood,
 wadding, clothing, flints, portions of glass, &c.  There are no regions
 where these different foreign bodies have not sometimes been encoun-
 tered.   A  ball which was found near the gullet,  (Transact. Phil.,
 1738, p. 449, art. 6,) had entered there bypassing through the lower
 jaw and tongue a year before.  A dice (de) entered from the pharynx
 of a child into the pterygoid fossa, (Parrish, Encyclogr. des Sc. Med.,
 1836, p. 321.)  I have removed, through the mouth,  a ball  which a
 boy, aged fifteen years,  had driven by the discharge of a pistol into
 the body of the fourth cervical vertebra.  Marchettis (Bonet, Corps
 de Medeci&e, t. III., part 2, obs. 25, p. 230,) speaks of the fragment
 of a fan, which having  been  introduced through the orbit into the
 upper maxillary bone, made its  way out, and was extracted in part
 externally, and partly through the palate, at the expiration  of three
 months.   A man, fifty years of age, whose case is given by Muys,
 (Planque, Bibl., t. I., p. 43, in 4°.) had in an abscess below the ear,
 a portion of pipe which he had forced  into his throat six months be-
 fore.  Percy  (Manuel du Chirurgien d'Armee, p.  109,) relates a
 great number of  cases where various foreign bodies had in this way
 become lodged in the head.  A  patient mentioned by De La Motte,
 (Tr. Compl., 1.1., p. 718, ob. 205,) received a sword  thrust between
 the gum and nose, and the weapon breaking, perforated near the ear
 and remained of  the  thickness of a farthing external to its place of
of'entrance.   The wound cicatrized over it, suppuration took place
near the ear, and no attempt was made to extract the foreign body.
A man, in despair from being paralyzed, discharged a pistol into his 
736
FOREIGN BODIES.
mouth.  The following day he told me he had felt the ball descending
into the stomach, and he was no longer paralyzed !   Watching the
symptoms, I noticed, on the  eighth day.  a slight degree of emphy-
sema  over the left eye.   I cut down and extracted the ball, which
had shattered and  contused  the  orbitar arch.   This  patient was
cured both of his  wound and paralysis.   In the case of a wound,
related by Donnadieu, (Anc.  Journ. de Med., t. VIII., p. 549,) the
point  of a copper spindle remained for thirteen months fixed in the
cheek and one of the  jaws.  At  first its presence was not noticed.
A sinuous  ulcer finally  disclosed it, when the metallic point was ex-
tracted, and  the cure  took place.   Courgeolles (lb., p. 551,) makes
mention of a  fragment of wood,  which having become implanted
or imprisoned in the bone  near the supra-orbitar notch for the space of
fourteen years, had produced no other result than a warty excrescence,
which  successively disappeared and returned  without the patient
taking any farther notice  of  it.  In F.  de. Hilden, (Bonet,  Corps de
Med., p. 160,) we find the history of a ball which  had remained for six
months between the cranium and dura mater.  A patient of Morand,
(Opusc. de Chir.,  p. 159, Ire partie,) who died at the expiration  of
nine  months, presented a similar fact.  Analogous cases have been
related by a great number of surgeons, and especially by M. Larrey,
who also speaks of ram-rods traversing the cranium without causing
immediate death.   An example of this kind has just been published
by M. Zedleg, (Gaz. Med., 1838, p. 379.)   A ball had been retained
for eighteen  years  above the orbit, in the substance of the frontal
bone on the right side,  and  the patient, who in other respects had
been in quite good health up to that time, died of  apoplexy.  Tho-
massin,  (Extraction des Corps etrangers, etc., p. 16,) in the case  of
a child aged twelve years, saw an arrow forced  through and through
the  apex of the cranium, but which, however,  was extracted, with
a successful result.   A patient who had carried  for the space of four
months  a  similar body in the brain, was cured by M. Majault, the
father, (Mem. de VAcad. de la Chir., t. I.,  p. 316, in 4°.) but Majault,
the  son, operating  at  the expiration of eleven years for a similar
lesion, lost his patient on the third day,  (Journ. de Med., t. XLI.,
p. 82.)  Solingius  (V.  D. Wiel, cent. 11,) was  more fortunate, and
succeeded in extracting from the cranium a portion of th^ blade  of
a sword, which had broken there after having entered by the  great
angle of the eye.   The point of a poignard, which had broken in the
cranium, and which at first could not be extracted, became detached
almost of  itself at a later period, (Bartholin, cent. 4.)   A portion  of
the  stock  of a musket, which had been for two months in the brain
without causing any accidents, after being extracted, was followed
by death,  (Journ. de Med., t. I., p. 242, obs. 8.)  [See remarkable
and recent  cases of these injuries  in our notes under  Trephining,
Vol. II.]

                         § II.—Thorax.
  If we pass from the head to the  chest, we shall find that an ear of
wheat, (A. Pare, liv. 25, chap. 16,—Bally,  Revue Med. Franc, et
etrang., etc.)  and needles and pins swallowed by  accident,  have
made  their way through the lungs, and finally, after having produced 
              NEW ELEMENTS OF OPERATIVE  SURGERY.          737

 an abscess there,  and sometimes even without any previous morbid
 changes, have finally shown themselves under the skin.  Every body
 knows the case related by Gerard of a knife blade which had become
 fixed in a  rib in such manner as to project into the interior of the
 thorax more than  from the outside of the rib.  Bidloo,  Bagieu, Des-
 port  and M. Terrin, mention cases-where they had to extract balls
 from between the  ribs, where they had either entered or were mak-
 ing their egress.   Wherter, (Journ. Gen. de Med., t. LXIX., p. 423,)
 on the  authority  of the military surgeon  Hunter,  mentions  a bis-
 cayan of three ounces which, after having  fractured  the ribs, lost
 itself at the depth  of five  inches in the lungs.   The fragments of
 broken bones were exsected, the foreign  body extracted, and the
 patient cured;  but this account is  so problematical that  we may
 place it by  the side of that which mentions a ball of seven pounds'
 weight which had travelled into  the haunch !  Broussais (Histoire
 des Phlegmasies Chroniques, 2e edit.) speaks of a soldier who died
 at the expiration of  fifteen or twenty years, with a ball in the lungs,
 without any person having suspected it;  and  Thomassin  (op. cit.,
 p. 96,) relates that  he found a ball in the  right lung of a man who
 died at the expiration of three weeks from wounds disconnected with
 this last.  Briot (Hist, de la Chir. Milit., p. 97,) cites a case  where
 a ball, after having passed  through the scapula, became wedged in
 between two ribs.
   Having dilated  the wounds and glided the beak of a spatula be-
 hind the foreign body, its extraction was  effected while the patient
 made a strong  inspiration.   In the memoirs of M. Larrey,  (Ibid., t.
 IV., p. 259,) we find the case of a ball, weighing ten drachms (gros),
 which had perforated the thorax between the eighth and ninth ribs.
 The surgeon could not effect its extraction until after having notch-
 ed out, by means of a blunt-pointed bistoury, the whole breadth of
 the lower rib, down to within two lines above its arterial border, to
 such extent  that the patient, in a sudden flexion of the trunk, frac-
 tured the rest of this bone, wounded the intercostal artery and pro-
 duced a hemorrhage, which was  finally restrained,  but not without
 difficulty, by means  of the  process of Desault.   The same  surgeon
 had, moreover, some time  previously, extracted a ball weighing six
 drachms without previous  exsection of the bones.   A girl  who re-
 ceived the discharge of a pistol  in her back,  died on the twentieth
 day.  The ball which lacerated (rompu) says F. Plater (Thomassin,
 op. cit.) the spinal marrow had implanted itself into the body of the
 ninth vertebra.  M. Burnes (Archiv.  Gen.  de Med., t.  XXVIIL, p.
 411) speaks of a fork which was extracted from  the back of a pa-
 tient without its being known how it had  entered there.   Foreign
 bodies of another  description also, have quite frequently been found
 in  the body  (epaisseur) of the chest.  I will relate here two  singular
cases.  A convict died of a visceral affection at the hospital of Roche-
fort (Guillon, Presse Medicate, t. I., p. 151.)   In this man a. foil (fleu-
ret) was found in the chest which had transfixed it completely, one of
the extremities being in the substance of one of the ribs, and the other
in the body of a vertebra, while the middle portion, covered with sta-
lactites, was enclosed in the body of the lungs.   It was ascertained
that the wound had been made fifteen years before,  and no one sus-
  vol. ii.                      93 
738
FOREIGN BODIES.
pected that a foreign body of such a character existed in the thorax
of the patient.  A case not less remarkable, but in which the conse-
quences were more disastrous, was presented at La Charite, in 1836.
While on exercise, an officer of the National Guards, of Paris, received
in his back a musket ram-rod of large calibre.   This rod penetrated
to the depth of fifteen inches, taking an oblique direction from the left
dorsal region to the right breast.   Tractions made by a number of
surgeons, and men of great strength, near Sceaux, where the accident
happened, could not in the least degree move the foreign body.  I
was enabled in the evening to examine this patient at the hospital,
whither he had been removed.  After  the facts communicated to
me, and  after comparative measurements of the remaining portion
of the ram-rod and the  musket, with another  ram-rod of similar
•calibre;  and after  having struck  several times upon the metallic
point, which projected about five  inches from the dorsal  region,  I
had no doubt that it had perforated through and through the thorax.
No serious accident had  yet occurred, and the  patient suffered  but
little.  What in such a case was to be done ?   The removal of the
rod might give rise to a  hemorrhage and effusion  of blood which
might  suddenly prove mortal; there was room for  apprehending
that the aorta, vena cava, or even the  heart might have been trans-
fixed (embroches)—[this conjecture scarcely seems supportable,  T.]
—and that in removing from  them the  species of plug which  had
shut up their perforation, the  sources of life  would have  been in-
stantly extinguished.  But by leaving it in its place could we, on the
other hand, hope  that the wounded man would  survive ?  For how
could we conceive that a rod  like  this, traversing organs so impor-
tant, would not  soon give  birth to accidents that would prove
speedily fatal.  The case of M. Guillon was not then known to  me,
and  if it had been it would  have strengthened me  in the step  I
deemed it proper to take,  which was that of delay.
  This course, moreover, was one of necessity.  Our surgical resour-
ces, rich as they already are, have nothing which would enable us to
extract a body of this description.  I hoped that the process of sup-
puration taking place around the foreign body, would soon render it
movable, and allow of its being removed,  at the same time that it
would obliterate  the  vessels,  if any had, in reality, been  wound-
ed.   At all events, I caused to be constructed, by  the  ingenious
artist, Charriere,  an instrument which would have carried  out my
views, had not the patient, in  spite of the most rigid  antiphlogistic
treatment, succumbed at the expiration of four days, almost suddenly,
without having given  any positive  evidences of pneumonia  or effu-
sions in the chest.  The opening of the  dead body disclosed to us,
that the  rod  had traversed one of the  dorsal vertebras, at a line in
front of  the  spinal  canal; that afterwards, grazing  the vena cava
ascendens, and passing under the  base  of the  heart, it had passed
through the lung to arrive between the ribs  under the right breast,
where it still remained.  The larger vessels and the heart were intact.
The lung, though slightly engorged, was not inflamed ; it would ap-
pear that death had been caused by the effusion of a certain  quan-
tity of blood into the bronchial tubes, (les bronches,) laid  open in
the track of the rod.  I then made an essay with the instrument of 
NEW ELEMENTS OF OPERATIVE SURGERY.
739
M. Charriere, and we found that it would have perfectly fulfilled the
indication.  This instrument is composed of a large metallic plate,
which was intended to have its support upon the back, after having
allowed the projecting portion of the rod to pass through it.  This
last being admitted into a solid tunnel, or  sort of socket, itself sus-
tained upon the  plate mentioned,  furnished support to  a  nut, by
which the action would have been made upon the foreign body with-
out any unsteadiness, and in a gentle manner, after  the manner  of a
quick screw from before backwards, permitting all  the force requi-
site to be used, and that without exposing to any kind of concussion.
If this instrument,  which could not be completed until the day the
patient died, had been accessible at the first, perhaps I should have
had recourse to it: would the patient, in that  case, have  survived ?
This is precisely the  question which will always  cause the  greater
number of surgeons to hesitate under such circumstances.   I  will
nevertheless add, that hereafter, notwithstanding the  case published
by M. Guillon,  and  the defence of it  by M. Larrey, I would adopt
the resolution of extracting the foreign body, rather  than abandon its
dislodgement to the resources of the organism.
   [The difficulty in having at our disposal the ingenious contrivance
mentioned, is that such accidents are too rare to have these appara-
tus on hand, already  fabricated.  The principle, however, could be
very readily adapted, we should think, in a few minutes, to a tempo-
rary construction.  This case vividly calls  to mind  the unparalleled
one in our notes, Vol. II., under Trephining, of a long sharp chisel,
implanted  deep into  and through the vertebral  column, and which,
by herculean efforts,  was extracted on the  spot, the  proper course
undoubtedly. T.]

                        § III.—Abdomen.
   Foreign bodies in  the  abdomen, like  those of the thorax, arrive
into this cavity sometimes directly from the exterior, sometimes after
having passed through the mouth and oesophagus.   A boy (Planque,
Bibl. de Med., 1.1., p. 46,) thirteen years of age, having swallowed an
ear of barley,  discharged it three weeks after, by an abscess which
was formed in the left hypochondrium.  The same accident was fol-
lowed by the same result, in a little girl in  Silesia, (Journ. des Sa-
vants, October, 1688.)  When balls, lead or other projectiles strike
the abdomen, they enter into  the peritoneum, or  are  arrested in
the thickness of  the soft parts.  In the last case, the foreign body
should be  extracted  without  hesitation, by the ordinary processes.
Should the ball have  dragged in with it in  such manner as  to have
pushed ahead of it, and  become wrapped up (de maniere a en res-
ter coiffee) at the bottom of the passage, in  a portion  of the clothes
of the patient, nothing more would be required than to  make  ac-
tion upon this last, in  order to remove  the whole.  It  is what I did
successfully in two  of the wounded in 1830, and each of whom had
received  a ball, one below and to the right of the umbilicus, and the
other  to  the outside and left of the same point.  Supposing, on the
contrary, the projectile had fallen into the peritoneal cavity, and that
there  was no means  of  ascertaining  precisely its exact situation,
every attempt at  extraction would be fruitless, and  in fact extreme-* 
740
FOREIGN BODIES.
 ly imprudent.  It is difficult to conceive, therefore, how the contrary
 rule should have been reproduced in a recent treatise upon wounds
 from fire-arms, and that a surgeon should not  hesitate to advise that
 the abdomen should be freely laid open, and that we should perform
 a sort of gastrotomy, to go  in search of balls that  have wandered
 among the convolutions of the intestines.  Once in the belly, the ball
 may cause there various disorders.   In a man who had received the
 discharge of a pistol, and whom I  saw with  Bogros, the ball had
 opened the hypogastric vessels, and speedily caused death.  A simi-
 lar fact has been published by M. Gibson.  It is known that  Carrel
 died of a wound of the intestines, and that the ball in him remained
 in the  belly.  Though in such a case we should even succeed in with-
 drawing the projectile, what would  thereby be gained ?  It  is the
 wounds it has caused, and not its presence, which is the source of
 the  danger.   Who, moreover, does not know, that  balls, lead, and
 buck-shot, left in the midst of the tissues, become encysted, and fre-
 quently remain  there a considerable length of time without materi-
 ally disturbing the functions ?  Does not M. Larrey  (Clin. Chir., t.
 II., p.  521,) inform us that balls which had traversed  the pelvis, rec-
 tum and bladder, have nevertheless not prevented the wounded from
 recovery 1  If the projectile  was still in the tissues, we should even
 take care, while  trying to extract it, that we do not cause it to fall
 into the belly or pelvis, as happened to that practitioner mentioned
 by Theden, (Thomassin, op.  cit., p. 31.)  As to foreign bodies that
 have arrived through the digestive passages, they have given rise to
 certain results, exceedingly curious.  Legendre (Biblioth. de Planque,
 t. III., p. 560, in-40,)  speaks  of an  individual  who, after  a certain
 lapse  of time, discharged per  anum  a  fork which  he  had  swal-
 lowed.  Who is not familiar  with the  history given  by Habicot, of
 the poor boy who, to protect them from robbers, decided upon swal-
 lowing his ten pistoles of gold, and who after being on the point of
 being  suffocated, discharged  them piece by piece,  through the anus,
 during the space of fifteen days ? A curious  history of this kind is
 that of Pierre Yvens, related in the Journal of Blegny (Nouv. De-
 couv., Mai, 1679, p.  188;  et Bibl.  de Planque, t. I., p.  51.)  This
 man, who was an extravagant character, swallowed the steel (affilior)
 of a hog-killer, and retained  it thus during five or six  months.  Not
 until then did an abscess form in the right hypochondrium, and allow
 the unfortunate  porker to recover his instrument, which  he had  be-
 lieved lost forever.    Some  time after, this foolish  sort of  fellow
 swallowed in the same way the leg of a porridge-pot, which he
 voided by an abscess  in the left  hypochondrium.  Attaching no im-
 portance to these abscesses, Pierre Yvens took it in his head  also to
 swallow a pocket-knife with  its handle, (gaine,) which at a  subse-
 quent  period came out above and by the side of the lumbar verte-
 bras.   A. Pare also relates (Traite des Monstres,  liv. 25, chap.  16,
 p. 772,) upon the authority of Cabrolle, the history of a shepherd who
 was compelled by some robbers to swallow a knife half a foot long,
 and which remained in his body during the space of six months.  An
 abscess having formed below the groin, allowed of this foreign body
 being  extracted from it.  Besides the other analogous  facts related by
' Pare,  there is also mention made of the operation of gastrotomy per- 
NEW ELEMENTS  OF OPERATIVE  SURGERY.
741
 formed upon A. Grunheide, (Bibl. de  Planque, t.  I., p. 54,) for the
 purpose of extracting a knife which had entered his stomach through
 the mouth.
   Quite a great number of cases of gastrotomy to remove a knife
 directly from  the  stomach, have now been  related.   M  Larrey
 (Clin. Chir., t. II., p. 269-369) says that Grager had  recourse to
 this operation in  1613, and that Frisac  also at Toul employed it with
 success.  Beckher (Arch. Gen. de Med., t. XV., p. 274,) who, in the
 seventeenth  century, makes  mention  of a similar operation  and
 Bernes, or Barnes (Ibid.,) who, according to M. Marion (Thes >,, No.
 294, Paris, 1831,) had occasion for it,—do  they refer  to  the  same
 fact, or did each one have a case of gastrotomy?  What prevents
 our rejecting such examples as  manifestly  apocryphal, is the fact
 that they are occasionally, in our own  time,  recurring in such a way
 as to  dispel every kind of doubt.  Caiyroche (Bull, de la  Fac. de
 Med., t. VI., p. 451) gives  a  case  of gastrotomy  successfully per-
 formed upon a lady, who, for a long time previous, had bad a fork
 in her stomach, and Valentin (Ibid., 1807) relates a simila, case of a
 silver spoon.   At Paris, in fact, A. Dubois (Ibid., t. VI., j.  517) was
 seen to take  from an abscess in the iliac fossa, the blade  if a knife
 which the patient had swallowed a long time  previous.  A misan-
 thrope made an attempt upon his life and did not  succeed; he then
 swallowed a tea-spoon.  Nine months  after, a tumor, which suppu-
 rated, appeared at the  epigastrium.  M. Otto (Bull, de Therapeut.,
 t. XV., p. 320) perceived it, and through this exit  removed  the for-
 eign body, which was yet but little changed.  The cure look  place
 rapidly.  [See notes under Special Operations, infra.   T.]
   [Instances of a similar character of swallowing jackknives, table
 and pocket-knives, bits  of broken wine-glasses and tumblers, which
 had been first chewed up in the mouth; also of brass buttons, &c,
 have been very frequent in the United States  for the  last half
 century.  These feats have been usually performed by reckless and
 intemperate persons, in  high as well as low life, on  banters, bets, &c.
 In some cases they have proved fatal, in others they have passed off,
 per anum, harmlessly, or after having  caused considerable visceral
 disturbance.   The  jugglers of Hindostan, some of whom  have ex-
 hibited in America, fearlessly insert, and that several times daily, a
 smooth narrow sword of  one to two feet in length and  near an inch
 broad, through the mouth and oesophagus,  as  far down as to the
 pyloric orifice,  without the slightest injury to the parts.   T.]

                 § IV.—The Urinary Passages.
   The emigrations of foreign bodies,  which have been introduced
 through the digestive passages, have at every epoch attracted the
 attention of observers.  A woman, tormented with attacks of colic,
 was not cured, according  to Van der Wiel, until  after  she had dis-
 charged through the urinary passages a ball  she had swallowed.
 Among the examples of calculi of the bladder, which have exhibited
 for their nucleus, a pin, needle, point of a spindle, ear of wheat, ball,
&c, it is probable that many of these reached there by this emigra-
ting process.   These substances  having arrived in the stomach or
intestines, get entangled in  some of the folds of the mucous mem- 
742
FOREIGN BODIES.
brane, and gradually escaping outside  of them, continue to march
in this or that direction, according to  the disposition of the parts.
Pins, needles, and very slender bodies, may in this  way course
to long  distances  without giving  rise  to symptoms  of inflamma-
tion.   Thus an infinity of cases are related where needles, which
had  previously been swallowed, had finally made their appearance
under the skin.  Should  such bodies, in traversing through the cel-
lular partitions and layers,  ultimately reach the bladder, they might,
as will be readily conceived, become there the nucleus of a calculus.
Might it not be possible, also, that in becoming arrested in the ureter,
after having pierced through the intestine, they would descend with-
out difficulty into the reservoir of the urine ?   And could we not, in
this manner, explain how worms, nuts,  kernels of fruit, and beans,
have been expelled through the urine ?  In the case of the soldier,
mentioned in  the Journal of France, (Bibl. de Planque, t. I., p. 48,)
and who had  a pin in the ureter;  would he not,  at a later period,
have been affected with a calculus ?   A  man about 30 years of age
came into.the Hospital of La Pitie, for a considerable  contraction
of the rectum. At the opening of the dead body we found in the
pelvis  a sub-peritoneal induration, which almost  completely closed
the rectum.  A purulent passage extended beyond this as far nearly
as the liver.   A calculus of the dimensions of an inch, with a pin for
its nucleus, was  found between the ureter and ascending colon,  at
two inches below the kidney.   The pin was situated in such way
that  its head  still projected  into the intestine, while its point was
directed into the ureter.  Is not this one of the cases, where  nature
leaves herself  in some sort, to be guided by the state of the circum-
stances (prendre sur le fait) ?  Does not  all  this show, that but for
the lithic concretion, the pin, escaped from the intestine, would have
ultimately descended into the bladder.

                        § V.—Operation.
  It  is unnecessary to remark, that the  presence of such foreign
bodies does  not in itself  call for any surgical operation, so long  as
they do not, by any special manifestation, show  themselves exter-
nally.  When, therefore, they have  been swallowed, we must con-
fine ourselves  to  the conservative  treatment of the organism, and
wait until they make  their way out themselves,  or indicate their
presence upon the exterior of the  body by some  particular symp-
toms.  Under  these circumstances, whether an abscess is established,
or by the touch we distinguish the  projection of the foreign body,
we must no  longer hesitate, but extract it as  soon as possible.  The
rules  to follow in such instances are subordinate  to the particular
circumstances of  each case.  Thus, should there be an abscess, it is
to be opened freely, in order to give exit to the pus, after which, by
means of a forceps, we  seize hold of the foreign body to be extracted,
and take it away  with caution.  Should  the skin  be sound, we first
incise it to the proper extent, after  which, the foreign body having
been secured,  we should  proceed to the required dilatation  and en-
largement of  the track which is to serve for its  passage.   As the
outer surface of the stomach or of the intestines will almost necessa-
rily have contracted adhesions with the corresponding portion of the 
NEW ELEMENTS OF OPERATIVE SURGERY.
743
abdominal  wall, we may enlarge the perforation of these organs
without necessarily opening into the  peritoneal cavity.   Neverthe-
less, these  adhesions being  sometimes  irregular or very circum-
scribed, there would be danger in  enlarging too  liberally in one
direction, and an indication presented of having  recourse to multi-
plied  incisions.  It is, moreover, a remarkable fact, that after these
operations  the wounds generally close up quite rapidly, even after
the digestive  cavities have  been largely laid open.   Experience
having established that the cure is not so prompt  and certain where
ulceration exists as where  the  organs are merely divided, it is evi-
dently much better to operate in good season than to wait for the
tedious processes of nature.

                    Article  II.—The Limbs.

   Foreign  bodies  when  introduced into the limbs, are more easily
recognized  than  in the  splanchnic cavities.  They  act, however,
nearly in the  same manner, except that they do not travel there by
the intervention of the natural canals.  It is easy to conceive, how-
ever, that small grains of  lead  or other bodies of small size, might
possibly  after entering a vein be transported to the heart, and give
rise to the  suspicion of a lesion of an entirely different nature.  This
fact, indeed, might involve legal consequences sufficiently serious to
 justify the mention I have made of it.   An inhabitant of Vannes
having been engaged in a duel,  received the discharge of a pistol in
his neck.  Repeated  hemorrhage and various accidents  took place,
and death followed on the  sixteenth day.   The opening of the dead
body demonstrated that the carotid artery had been opened, that the
ball* had  entered into the jugular vein where it still remained, that it
had formed here a varicose  aneurism, and that but for a slight contrac-
tion in the vein, the projectile would evidently have fallen into the
heart.  I have seen  the specimen and  can guarantee that all that
has been said in  relation to this case by M. Jorret is perfectly cor-
rect.   Surgery howaver could have nothing to do with the extrac-
tion of such bodies, unless they had become introduced into the su-
perficial vessels.   As to foreign bodies resulting from mortification
and necrosis  of the bones or  soft parts, I have treated of them at
sufficient length  under the chapter on exsections, to make it unne-
cessary to  recur to them now.   There remain then the foreign bodies
which have come directly  from without, and those which may have
 come from a  distance through the cellular tracks, (trainees.)

                                §1.
   Under these we have needles and pins.  A  pin having a head,
does not generally go deeper than the level of the skin, and may  be
extracted  without difficulty in  almost all cases.   It is no longer the
 same  with pins  without heads and  with needles.  Frequently we
 see these lost in  the tissues,  while they allow the wound by which
 thev entered  to  be cicatrized, and cannot be found again without
 difficulty.   A young man  sat down upon the point of a needle and
 pricked  himself severely; his master being alarmed, sent for me
 two hours after.  Finding neither a  puncture nor the slightest ap- 
744
FOREIGN BODIES.
pearance of a foreign body on the point of the breech indicated by
the patient, I supposed he had been deceived, and  that the needle
had  been  lost in the chamber.   At the expiration of eight days,
something sharp-pointed  was perceived underneath the skin upon
the outer side of the thigh, and which I laid bare with a cut of the
lancet;  it was the point  of the needle, which then became easy of
extraction.  A  boy eight years of age  broke  a needle in his calf.
He himself insisted that there was nothing left in the leg ; his mother,
on  the  contrary, was convinced  that  every thing except  the eye
of the needle had become hidden in the flesh of her child.   By dint
of searching, I was enabled to discover at the distance of two inches
from the puncture a hard point, pressure made upon which caused
pain.  Having laid open the skin at  this  place, I found the needle
there lying naked, and that it was an inch  in length.   It would be
difficult  for me to say how many times the same thing has happened
to me in respect to  the fingers, palms of the hand, fore-arm, arm,
shoulder, foot, body of the leg, thigh and breech.   Even the  face and
cranium are not exempt  from similar occurrences.   When  we are
called therefore to such wounds, two cases may present themselves :
either by means of a well-conducted exploration we establish the
presence of  the foreign body in the tissues, and then it is important
to extract it  forthwith ; or in spite of our most minute researches we
find or recognize nothing, and here prudence suggests that we should
wait and watch the wound,  and  that  we  should be prepared for
any event, without affirming  that there is  nothing  there,  but also
without  having recourse to any expedient or any  inconsiderate ope-
ration.   [See notes on Special Operations, inf. T.]

                             §11.
  After  needles, fragments of glass are those which,  having been
introduced under the skin, most  frequently remain there  without
producing inflammatory symptoms, while at the same time allow-
ing the external wound to close over them.  An adult man retained
for the space of fifteen months, under  the integuments of the fore-
head above the eyebrow, a triangular plate of glass nineteen lines in
length and eight lines in  width at  its base.  For a long time con-
cealed by  a  cicatrix,  this  foreign  body ultimately showed itself ex-
ternally  and projected at two or three lines above the eye, but
without  ever having  produced the least degree of inflammation, or
any other result than a slight degree of inconvenience in the move-
ments of the eyebrow and forehead.  After having  moderately en-
larged the wound, I extracted the body, which proved to be a frag-
ment of a pane of glass.   In  the thigh I have seen fragments infi-
nitely larger. A laborer, aged 25 years, was thrown from the base-
ment story through a window, and  by this means received a wound
in the left thigh, for which he  was taken to the hospital of La  Pitie.
I found the wound an inch and a half long, and upon the outer side
and near the middle of the limb.   I removed  from it three pieces
of glass, respectively of  an  inch,  half an inch, and some  lines in
length.  Every thing went on well until the eighteenth day, when,
in pressing slightly upon the thigh of the patient, I perceived that he
 elt, in the neighborhood of the femoral vessels, a considerable deal 
NEW ELEMENTS OF OPERATIVE  SURGERY.
745
of pain, which  was augmented on the least movement of the mus-
cles.  An incision there  enabled me to extract from it a portion of
glass five inches in length by about fifteen lines in breadth, together
with some other small fragments of the same substance. Some dilata-
tions  afterwards became  necessary,  and the patient  recovered.
Another young man had  retained in this way,  for the space of
seventeen days, an irregular portion of glass of an inch in diameter,
and without experiencing any other inconvenience than some prick-
ing when he was obliged to walk.   The  wound being cicatrized, I
made an incision of two inches externally, and where this fragment had
arrived, and  this slight operation was followed by nothing unpleas-
ant.   The palmar surface  of the fingers  and the plantar surface of
the foot, are frequently the seat of similar wounds. I have removed
a  fragment of glass  more than an inch long, and three  lines in
breadth, which had  existed in the fold of the arm for the space of
seven months.  A young distiller who had broken a liquor phial in
his hand  fifteen  months  before, though  cured of his wounds,  had
never ceased to be entirely without pain.  An incision of an inch in
length upon  the point originally wounded, enabled me, after some
researches, to reach and extract a triangular fragment of glass of
from five to six lines in length.   I  was obliged to  perform the same
operation,  occurring  from a similar  accident, on a young chemist
then employed at the hospital of La Pitie-.
   A man had, for the space of thirteen  months,  at the  root of the
thenar eminence, an imperfect cicatrix resulting from a wound caused
by a piece of broken bottle.  As this  man scarcely suffered any and
did not mistrust that  any thing remained in the hand, he continued
at his  labors, only occasionally asking some surgical advice of the
surgeons of the three or four  towns where he had beon.  Suspect-
ing that there was some foreign body there, I made an incision in
the track of the  ancient wound.   The probe having confirmed me
in my first idea, I enlarged the incision and succeeded in extracting
a fragment of glass  fourteen lines  in length by two in  diameter in
its smallest dimensions.  To explain how fragments of glass, though
angular, irregular and cutting in their edges, should thus be enabled
to remain  in  so  many instances in the midst of the living tissues,
without producing any reaction, is a matter of very great difficulty.
All that we can say is that they are insusceptible of chemical action,
or enlargement or diminution, and that being devoid of  inequalities,
 (rugosites,) the glass is  restricted  in its  action to the mechanical or
 physical disturbance of the parts, without irritating them or altering
them in any  manner whatever.  As for the rest, whether it admits
of explanation  or not, the fact is nevertheless as stated, and as expe-
rience  has a thousand times demonstrated, which makes it proper
that it should be so received in practical  surgery.

                              § III.

   Glass moreover, is not  the only substance which sometimes  acta
 in this way in the midst  of the organs.  I have seen in the midst of
 delicate tissues large  sized and long pieces of wood, which caused
 no more disturbance than bits of glass.  An adult man had been
   vol. n.                      94 
746
FOREIGN BODIES.
wounded in breaking a box of black wood eighteen months before.
The w Dund, which was between the thumb and forefinger of the left
hand, soon healed.  Nevertheless it reopened  from time  to time,
and the patient suffered a little  at  the thenar eminence.   I  re-
moved from it a piece of wood  of eleven lines in length  and two
lines in its other diameters, resembling a nail or peg, and which had
been driven in from before backwards, from  the commissure  of  the
thumb to the root of the first bone of the metacarpus, between the
muscles in that region.  A man employed in the service of Count
Demidoff,  came to the  hospital of La Charite', in consequence,  he
said, of an abrasion which he  had received from the point  of a nail
in breaking open the cover of a box.
  The injury had  occurred fifteen days before, and there  was  no
longer any wound;  but a  phlegmonous erysipelas had appeared
upon  the fingers and  almost  the entire hand.  Having made some
incisions to give greater freedom for the  escape of the pus, the parts
were  speedily disgorged, and the patient believed that he would
soon  recover.   Having returned to his labors the inflammation re-
appeared,  and  he  came back to the hospital  at the  expiration of a
month and a half.  Finding a spot  on  the anterior surface of the
metacarpal bone of the middle finger more sensitive than the others,
I made there a deep  incision.  Surprised to find  the  point of my
bistoury arrested as if it had struck into wood, I examined the bottom
of the wound,  and found there a foreign body, which I immediately
extracted with a strong artery forceps.  What was not our astonish-
ment  in finding that this was a pliant fragment of wood fifteen lines
in length !  This patient, who had still some other particles  of wood
remaining in the hand, was ultimately cured  of his  wounds and  in-
flammation ; but the adhesion which took place among the  different
tissues and the tendons, and especially their  synovial  sheaths, left a
stiffness and numbness in the fingers, which he will probably never
get rid of.  Bagieu (Examen de plus part, de la Chir., etc., p. 103,)
speaks of a splinter of wood 26  lines long and 8 in breadth, which
had remained for two  years underneath the skin below and outside
of the knee, without any body having ever suspected it.  A dragoon
treated by Thomassin, (Extract,  des  corps etrang., &c, p.  10,) had
for  the space of three weeks, without knowing it, a piece  of wood
in the skin 24 lines long. In  the  year  1838, I saw at  the hospital
of La Charite  a man who had under the skin upon  his  legs a great
number of indolent  tubercles, which had been  there twenty-five
years, and which had been produced there in  consequence of the  ex-
plosion of a mine.  Desirous of ascertaining  if they were in reality
foreign substances, I removed  one of them which had caused consid-
erable pain, and which was of the size of a small nut, and was  situa-
ted above the internal malleolus of the  left leg.   This foreign body
I found to be an irregular fragment of iron, which had become  in-
corporated (combine^ as it were with the surrounding cellular tissue.
A few days later, having removed a second  fragment. I found that
this was a portion of brownish earth,  dried very^ hard, and also
combined  with the living tissues; while other portions were  of  the
melted metal (la fonte) or silex.   Quite a long fragment  of bone
driven in bv the powder, was also found in the tissues. 
               NEW ELEMENTS OF OPERATIVE SURGERY.          747


                          § IV.—Balls,
   More perhaps than any other foreign  body, may form for them-
 selves a lodgment, and thus establish themselves in the living organs,
 and remain there for an indefinite period of time, without the patient's
 being aware of it.   There are in fact some cases of this kind, where
 they are found at a great distance from their place of entrance.   In
 the case of the Prince of Rohan they had ascended along the course
 of the tibia, and in that of Saint Mars (Dionis, Operat., p. 818,) along
 the femur ; in a child which recovered, two balls which had entered
 at the thigh ascended  as high up as into the belly, (Blegny, Jour, de
 Med., t. IV., p. 78.)   M. Dujaric Lasserve (Cas de Chir., etc., p. 23,
 1830,) in extirpating a tumor which a patient  had had for a long
 time upon  the sternum,  was greatly astonished to find two balls in
 its centre.   In the bones balls have often  been found which had re-
 mained there from ten to fifteen and twenty years, without giving
 rise  to any particular  symptom.  An ancient soldier who, in conse-
 quence of a gun-shot wound received twenty-five years before, had a
 necrosis at the lower third of the femur, with an ulcer, which from that
 date  had opened and closed a great number of  times, ultimately died
 of pulmonary phthisis at the hospital  of La Charite in 1836.   The
 examination of the limb  in the dead body  of this patient, enabled  us
 to ascertain that he had a ball in his ham,  which had worked itself a
 perfectly smooth and regular cavity upon  the posterior border  of the
 articular interstice.  It has been laid  down, therefore,  as a precept
 from these facts, to make no dilatation (debridement) or any serious
 operation whatever, for the purpose of discovering either balls, shot,
 or any other foreign body whatever, so long as we have not ascer-
 tained to a degree amounting almost to  certainty, the place where  '
 they  have  been arrested.   When, however,  we have ascertained in
 addition, that they are retained in the midst  of the tissues, we may
 proceed in opposition to  this precept, if there is no important  organ
 that  might be wounded, or  if the operations deemed necessary,
 should in themselves  present no difficulty or danger.   A fragment
 from a grenade, as large  as the hand, was  extracted from the breech
 of an officer by Dionis, (Op., D. X., p. 812.)   Ravaton (Chir. cVArmee,
 p. 2M),) and  Bagieu (Examen, <fec, p. 78,) have removed biscayans
 of from nine to twelve ounces in weight, and which had remained a
 long  time in the  tissues, causing there all sorts of disturbance.   A
 ball imbedded  in  the  instep, at the  bottom of an abscess, was left
 there at the desire of the patient, and did not, it is true, prevent the
 wound from consolidating; but a fistula in the thigh did not close up
 until  after Deschamps  (Thomassin, p. 28,)  had effected the extraction
 of a  ball which  rested upon the  femur; a ball which had passed
 through the knee, and which was left in the ham, made it. necessary
 to amputate, and  caused  the  death of the patient, (Journ.  de Med.
 Milit., t.  XIV., p.  535.)  Another  ball  on  the contrary, retained
 between the patella and femur, after having traversed the'knee from
 behind forwards,  was extracted  with entire success by Desport,
 (Plaies d'Armes  a  feu,  p. 242.)   Morand  (Opusc.  de Chir., 2e
partie, p.  252,) and Thomassin (op.  cit., p.  100,)  have obtained
similar successes in making use of the seton. 
748                     FOREIGN  BODIES.
                 Article  III.—Operative Process.

     Operations required for the extraction of foreign bodies must ne-
   cessarily vary from an infinity of circumstances.  In most cases, the
   fingers, the dressing or the artery forceps, or the end of a spatula,
   or extremity of a probe, or the  polypus forceps properly managed,
   will answer the purpose.   But it is  proper to add, that in certain
   cases we require instruments  and  operations that are more compli-
   cated.

              § I.—Foreign Bodies retained in the Skin.

     It is rare to find  any other matters implanted  in the dermis except
   grains of powder, small  shot,  sand, pieces of earth or mortar.   Sup-
   posing that it should be desirable to extract them, we  should proceed
   best in doing so with the point of a pin, an ordinary needle, or a lan-
   cet, or cataract needle.  It would be then necessary  to scrape care-
   fully, and as perfectly  as possible, each little cup or spot on the  skin
   with the instrument, if we  desire to prevent all subsequent abnormal
   discoloration.

                                § II.

     Rugose  or irregular bodies  concealed underneath the skin or in the
   depths  of  the parts, require that we should first lay them bare by
   means of incisions  of  sufficient length.   After that, it is advisable  to
   seize hold of them with an  erigne the same as for a tumor,  and to re-
,   move by excision the cellular tissue, which it seems in most instances
   has become incorporated  with them.   Pieces  of wood,  scales of
   bone, portions of clothing, and inert concretions that have  come from
   without, especially belong to this  category.   Fragments of glass,
   pins, needles, and all metallic bodies somewhat regular in  shape, also
   require for their extraction an enlargement  of the wound by which
   they entered,  or that we should cut down to them in a proper
   manner by new incisions.   As they contract no adhesions with the
   natural  tissues, these  foreign bodies should then be seized and ex-
   tracted  either  by means of the fingers  or the forceps.   Being also
   sometimes very brittle, they moreover exact that the tractions made
   upon them should be managed skilfully and prudently.

                                § III.

     The  enumeration which I have made farther back,  shows that cer-
   tain foreign bodies partially show themselves outside in the form of
   stems or plates.  Thus a needle, pin, splinter of wood, or fragment
   of glass, the blade of  a  knife or sword, or a  foil or ramrod, may be
   plunged to a greater or  less depth into the tissues, while at the  same
   projecting  outside to  the  extent  of some lines  or inches. In  such
   cases, the hand or  fingers are the first instruments to be had recourse
   to, and they almost always suffice when the foreign body has trav-
   ersed only the  soft parts,  and  offers  a sufficient  purchase outside.
   Next to the fingers come the  dressing or the artery forceps, and 
NEW ELEMENTS OF OPERATIVE  SURGERY.         749
lastly the blacksmith's nippers.  [See under Trephining, Vol. II., the
fortunate application of this last power in the case I  have above al-
luded to.  T.]  If the foreign body has been implanted in bone, it is
possible that  the  tractions  made  in this way may not be sufficient.
It is in such cases that the  nippers called tricoises  in veterinary sur-
gery, may become of  great  utility.  Seizing the  projecting  por-
tion of the foreign body, near the tissues, in the manner of a cut-
ting pliers and without incurring the risk of too readily breaking it,
they furnish  the  operator  with an extreme  degree of force.   If a
solid plate of wood or metal were placed on the skin around the pro-
jecting stem, the nippers  would thus be  furnished with a  point
d'appui, by which we would be enabled to succeed with them much
better, and without  causing so much concussion upon the organs of
the patient.   If by chance the surrounding body should  project  into
some natural cavity, as in the pleura, as was seen in the case of Ge-
rard, or the mouth, nose, vagina or rectum, it might be advantageous
while making traction  outside, to apply on its point a finger, armed
with a thimble, so as to push it forward at  the  same time.   This is
what Gerard states that he did,  and what M. Champion has  also
sometimes had recourse to,  with the precaution  of placing upon his
thumb only a few transverse grooves.  It is readily perceived, how-
ever, that for the mouth, vagina and rectum, the cavity of a small scoop,
or small spoon, would answer full as well, and be more convenient than
a thimble.  The instrument of M. Charriere would become important
and should be preferred where the resistance  to  be  overcome  ap-
peared to be very considerable, and where it would  be requisite to
avoid all concussion in withdrawing the blade or metallic rod which
had passed through the bones.

                             § IV.

  Another circumstance still may present  itself;  it is when the for-
eign body implanted in the bones  does not furnish a  purchase either
without or within the part.  Then it becomes necessary to apply the
trephine by embracing the projectile  in  the crown of the instru-
ment, or we  may employ the chisel, gouge, and mallet, in order to
chip out at the same time the portions of bone which  confine it, or at
»east to liberate its periphery, and enable us to seize  hold  of it  with
some kind of  instrument. If the bone were not large  or important, it
might then be allowable to  divide it on the two sides  of the wound,
and exsect it entire by means of any description of osteotome.

                          § V.—Ball.

  No foreign body, in relation to the means  to be employed for
their extraction, has more particularly occupied the attention of sur-
geons, than balls^   Every body knows the  species of forceps called
the ball-extractor (tire-balle) of Alphonse  Ferri,  and from whence
have been derived almost all the litholabes of our days.  The spoon-
bill, the elevator, formerly so much used, and the tribulcon devised
by  Percy, have been introduced into surgery almost exclusively for
thio purpose ; but the noose, (anserine,) concave and toothed forceps,
the crow's-beak of  Maggi,  the cane-beak and stork's-bill, the instru- 
750
FOREIGN BODIES.
ment of Ravaton, a mere improvement of that of Alphonse, the sheath-
forceps of J. L. Petit, erroneously called Hunter's forceps,  (Thomas-
sin, p. 55,) the lizard's-beak, parrot-billed and claw-forceps, and the
auger-forceps  (tarieres) mentioned by Guy de Chauliac,  Pare and
Fabricius ab Aquapendente, the crotchet, and an infinity of other in-
struments, which are figured or described in the authors  I have
named, are generally abandoned at the present time.  We still find
in Thomassin, (Extract, des corps etrang., Strasbourg, 1788, pi. 1,
fig. 3, 4, 5, 6, 7, 8,)  the figures of three descriptions of forceps, of
which  one only, viz. that of the  figure G, deserves to be retained.
This is an instrument  analogous to that of Ravaton, composed of
two pieces, which are intended to glide upon each other in the man-
ner of the pelvimeter.  When opened it represents a lithotomy scoop.
An effort is made to introduce it below the ball, which is then secured
by forcing against it the other half of the instrument, which is straight
and slightly pointed.  It  is  rare, however, that  extraction of balls
cannot be effected by means of ordinary instruments or the polypus
forceps.  To favor the  operation  it is unnecessary to replace the
patient in the position he had at the time of receiving the injury, un-
less the  foreign  body should appear to be less easily accessible, by
any other mode.   Most usually  it is advantageous to enlarge the
opening  by which  the  ball has entered,  and  consequently to make
some incisions.   If there should be but one opening, this is the one to
be  dilated.  If, however, the  ball  should  be  found at  a  great dis-
tance,  and that in order to fall directly upon it, it would only be ne-
cessary  to divide a few layers that were  neither very thick or
important, we should not meddle with the first wound, but proceed
to make a counter-opening.  When once  laid bare, we endeavor to
force it out by enucleation,  or by means of the finger, or  a spatula,
scoop,  or spoon-bill.  Supposing  it should have existed a  long time
in the tissues, and had become enveloped in them, it would be better
to remove its cyst with it than attempt to disengage it from that.  I
have stated, in speaking of balls introduced between the ribs, how we
should, under such circumstances,  proceed in removing them.   It is
scarcely but for  balls that have become actually encrusted or impri-
soned in the body of bones, that there can be a call for the trephine,
or for some of the forms of exsection.  Thus in the cranium, os cal-
cis, olecranon, body  of the tibia,  condyles of the femur, and great
trochanter, the extraction  of the ball might require the division of the
bone itself, and consequently become the occasion for the use of the
trephine or for exsection.  The most simple mode then is  to include
the  ball within the crown of the trephine, so as to remove it with the
osseous disc.   If this process were not applicable, it would  be neces-
sary to apply the instrument to the neighborhood of the ball, in order
that a chisel inserted in the hole might reach underneath the foreign
body, and thus cause its expulsion.   It is readily understood that by
means  of the chisel, gouge and mallet,  we should succeed equally
well in bones of a  certain size, those of the limbs, for example, but
that there would be some danger in making use of those instruments
to the cranium.   If the trephine should not appear to be very suitable,
it would still be practicable to have recourse to the concave rowels of
M.  Martin, or the  osteotome  of M. Heine or  M.  Charriere, after 
              NEW ELEMENTS OF OPERATIVE SURGERY.          751

the rules laid down in  the chapter on Exsections.   It is moreover
well understood,  that during these  operations we ought, by all the
means known, put ourselves on our guard against wounding the ves-
sels, nerves,  tendons, articulations,  and in fact all  the important
organs ;  and that, whether at the moment of the operation or after-
wards, we should prepare ourselves against every kind of danger or
accident that might occur, the same as we would for  any other ope-
ration of a  somewhat serious character.

      Ariicle IV.—Foreign Bodies  in the  Articulations.

  Among the foreign bodies which become established in the centre
itself of the organs. I design to say one word only of those of the
articulations.  It  is not of fragments of fungosities, fractured bones,
diseased cartilages, or particles detached from the neighboring sur-
faces and become free in the joint, in consequence of a  malady still
existing, that I wish to speak upon the present occasion, but of those
bodies known under the name of free cartilages, [loose] in the articu-
lations ; bodies of which  I  have pointed  out  the origin, symptoms
and danger in another work; (Diet, des Sc. Med., 2e edit., t. IV., p.
179.)  It is in the ginglymoid articulations that they have been most
frequently  encountered.  Morgagni, according to Boyer, had seen
many of them in the tibio-tarsal articulation.   Haller states that he
found twenty in the temporo-maxillary articulation.   An elbow ex-
amined by M. Robert, contained eighteen or twenty; and  M. Mal-
gaigne states that  he found  nearly sixty in another  humero-cubital
articulation.   It is  in the knee, nevertheless, that they are almost
exclusively found.   Pare, Pechlin, Henkel, Sim^fen, Hewitt, Ford,
Bromfield, Theden  and Desault are the authors who have more par-
ticularly drawn  public  attention  to this subject.   The size of these
bodies is exceedingly variable.   The one  mentioned in  the case of
Pechlin was  of the  size of  the finger, while that  in  the patient of
Pare had  the volume of  an almond.   I saw one removed from the
knee, in 1822, which might have been taken for a flattened chestnut,
[meaning the marron or large chestnuts of France, which are treble
the size of our American  chestnut.  T.]  A man admitted  into the
hospital  of Saint Antoine in 1829, had one which  was yet larger
than  that  by one half.  Sometimes, however, they scarcely exceed
the size of a barley seed.   When there is but one only, it is gene-
rally of large size ;  when numerous, on the contrary,  they are almost
always diminutive.  Some are hard and, as it were, stony; others
bear so  strong a resemblance to fragments  of cartilage  that it  is
difficult at first to distinguish them from this last.   M. Bourse, a
physician in  the environs of Paris, sent me one in 1834 for the Royal
Academy of Medicine, which, to all appearance, was only a fragment
of the external condyle of the tibia still invested with its cartilage.
They have ordinarily less consistence, and may almost always be
crushed  under a  certain degree of pressure.  They contain neither
vessels nor laminae, and present no appearance of texture.  Whether
loose or  not they have  an unctuous aspect, which has  made some
suppose they had a synovial envelope.   Their centre is usually the
part  that has least consistence, and desiccation considerably dimin- 
752                     FOREIGN BODIES.
ishes their dimensions.  Being truly foreign bodies they are, in my
opinion, simple concretions, whether fibrinous or lymphatic, or mor-
bid sanguineous productions.   These cartilages  when they have
once become smooth and unctuous, do not seem to be of a nature to
disappear spontaneously.  We can conceive  only that they  may
become attached, engrafted  or concealed in  some region  or some
recess of the articulation, where they are sheltered from every kind
of pressure and displacement for the future.  It is  thus that certain
patients, after having been more  or less tormented by them, have
suffered no more and  believed themselves cured.   Other persons,
again, are so  little incommoded by them, that they scarcely think of
them. A young lady of Arras, who consulted me in 1832, had had one
in the knee for ten years, and suffered only when through accident she
hit it against some other body.  I saw in 1830, at the hospital of Saint
Antoine, a man of  from fifty to sixty years of age who had never
been troubled by one that he had  had in the knee for more  than
twenty years.   But the great majority of patients unfortunately
have not  the same good luck.  Besides the pain that the least  un-
steady movement may re-excite, they have, moreover, to fear in the.
sequel that the joint may become  altered, as in the  patient of M.
Knox, or that it may become attacked by either acute or chronic
inflammation; whence comes the necessity of considering  the  ope-
rations that  possess the power of effecting a cure.   Various means
have been proposed for this purpose.  Extirpation is the first which
has presented itself to the minds of practitioners; but experience
having soon demonstrated its dangers, it has been  necessary to de-
vise others.   Compression in fact is the only resource  that can be
advantageously substituted for it in certain  cases.  Whether by
fixing the body at a determinate  point external to the articulating
surfaces,  it  places it  out of the  possibility of being injured, or
whether  it acts by promoting its solution and absorption, certain it
is that many patients have experienced great relief from it.  Middle-
ton obtained  undoubted successes from it.  Gooch also says he has
had much reason  to be  satisfied with  it.   The same is remarked
by Hey, who  gives many examples, and who made use of a laced
knee-cap (genouillere).  Boyer in  two or  three cases was equally
fortunate.  When we have decided  upon making use of it, it is im-
portant above all,  to compel the  cartilage to recede  into a pouch
(cul de sac) of the capsule, on the sides of or above the patella, for
example, if it is in the knee, in order that by fixing  it  there we may
maintain  it there firmly, without having need of any very great de-
gree of constriction.  The bandage or knee-cap, moreover, should
be disposed in such manner, that the patient may not be impeded in
walking.   We would not have recourse to absolute rest, nor an ap-
paratus for preventing any  movement in the joint, unless the first
method had been used for a long time and failed. Its use, moreovei,
is very inconvenient; the more so  inasmuch as" it acts at first only
as a palliative, and that it is  often necessary to  continue it for  a
number  of years  before a  radical cure  is effected.   Also, it  fre-
quently fails entirely.   Raymarus had seen its inefficacy in the hos-
pitals of London.
   M. Averill has given the case of a patient in whom M. Ballingall 
NEW ELEMENTS OF OPERATIVE  SURGERY.         753
 had used it without any advantage, and a great number of practition-
 ers have related similar failures.  Their extraction is an operation so
 simple and easy in appearance, and so prompt, that it seems astonish-
 ing at first that compression should be preferred to it; but the sur-
 prise ceases the moment we reflect that it exposes to the same dan-
 gers as wounds penetrating into the articulations.  A patient operated
 upon by Hewitt, and whose case is given by Raymarus, died in con-
 sequence of it. That  of Simpson created the greatest  degree of
 anxiety  for  several months.   M. S. Cooper cites two other  cases
 that perished from this cause.   An example also is given in the cases
 of M. Kirby, which is  calculated to inspire serious apprehensions.
 A young girl, whom I saw operated upon  in 1822, was seized with
 symptoms so formidable, that her recovery attended with an anchy-
 losis seemed in some degree to be miraculous.  M. Richerand  states
 that out of twelve operated upon by him, four died;  two mentioned
 by M. Decaisne (Encyclogr. des Sc. Med.—Bulletin Beige, 1836, p.
 102) also succumbed.  Bell, on the strength of facts of this kind to
 which he had  been  witness, goes  so  far in such  instances  as to>
 express a preference for amputation of the leg, unless the  cartilage
 should appear  to  be  very superficial.  David,  cited by M.  Ledo,
 confines himself to an  anchylosis which he recommends should  be
 artificially produced.   Bromfield,  Cruikshank  and  Boyer express
 nearly the same apprehensions.  It nevertheless appears to me that
 the danger  of  this operation has been exaggerated.  Ford, Hunter
 and Desault have performed  it sufficiently often without  its  being
 followed by any unpleasant results.
   Numerous cases of a successful  issue have been  collected  in the
 theses of M. Champigny and M. Ledo.   M. Larrey, J. Clarck, M.
 J. Coley, M. Brodie, M. Allan, MM. Muller, Soender and a multi-
 tude  of others have also furnished  similar examples.   Aumont
 (Archiv. Gen. de Med., t. II., pp. 412,  472,) removed four of these
 bodies at two different occasions, with an interval of forty days, with-
 out causing the least accident. Most frequently, in fact, the cure is ex-
 ceedingly prompt; and many patients have had it in their  power to
 walk and resume their usual occupations at the expiration of six or eight
 days.  So great a difference in the results is however  readily ex-
 plained.   If it  is possible to obtain immediate reunion of the wound
 and no inflammation take place under it, the whole matter is reduced
 to one of the most simple solutions of continuity.  On  the contrary,
 as soon as inflammation attacks the  synovial and the interior of the
 joint, there is every thing  to apprehend, and the danger of the dis-
 ease cannot be dissembled.  We should not therefore operate until
 after  having duly  weighed  all these  different  circumstances, and
 forewarned  the patient  or some of his friends of the risks  to which
 he will be exposed.  The following is the  rule  which  prudence, in
 my opinion, prescribes in such cases.  So  long as the cartilage pro-
 duces but slight inconvenience we should endeavor to persuade the
 patient to support  it;  if it really causes disturbance in  the functions
 of the joint, compression is then indicated.  When it does not yield
to the bandaging, or that the dressings used  cause too much incon-
venience, it  is then time to think of its extraction.   We  should not
however decide upon this step when the cartilage is concealed deep
  vol. n.                       95 
754
FOREIGN BODIES.
within the joint or too difficult to be reached from without, unless it
shall  have produced unpleasant accidents, and after having in vain
made trial of the other means.  In such cases then when the carti-
lage,  on  the other hand, is very much diseased, and that it may be
easily fixed without the articular interline and near the skin, the ope-
ration has every prospect of success.  Many surgeons apprehend-
ing the introduction of air into the capsule, have suggested that we
cannot take too much precaution on this point.  Also to prevent the
parallelism of the wound of the synovial and that of the integuments,
they have carefully endeavored to draw the skin sometimes upwards,
after  Bell, at other times downwards, according to  Bromfield, and
in some instances to the side, as recommended by Desault and Aber-
nethy.
  What  I have said of the action of the air, in  speaking of articu-
lar wounds, (Diet, de Med., art. Articulation—see also M. Velpeau's
opinions  and those of other surgeons on this matter in our abridged
account  of the  Discussion on Tenotomy, at Paris,  in our notes of
Vol. I. of this work,) renders  it unnecessary for me to discuss here
the value of these precautions. The only precaution which really de-
serves to be retained, is that which consists in conducting the body
to be  extracted as far as possible  from the centre of the  articula-
tion,  and to a point where there is the least amount  of important
parts  to   be divided.   Being once brought there, it is firmly held
between   two of the fingers, or  better still, as recommended by M.
Averill, by means of a metallic ring, so as to stretch the  skin uni-
formly, as advised by Simson, Theden, Vielle, (fee, and in order that
it may not escape under the action of the  instrument  and re-enter
the capsule we have just opened.  As for the rest, the most rapid
and neat incision is evidently the  best.   For example, it is advisa-
ble to make it fall perpendicularly upon the foreign body, and to
give to it at once an extent  proportioned  to the size of the morbid
concretion.   If the cartilage does not emerge by pressure in  the
manner of a kernel out of its fruit, we immediately seize it with a
forceps, hook or erigne, and with one cut of the scissors divide the
pedicle if it has any.   The wound being brought together with
adhesive plaster, the most perfect  repose is recommended up to the
time of its complete cicatrization.  We might also, for greater secu-
rity, apply to the whole of the joint exact but moderate  compres-
sion, and keep the dressings wet with cold water during four or five
days.   As the accidents, after all,  which may supervene, belong to
arthritis  complicated with wounds, we have no  need of occupying
ourselves with  them any further.  I  will only call to mird that the
disease is very liable to return, and that we must take care not to
pronounce too  sanguinely on this  point. 
NEW ELEMENTS  OF OPERATIVE SURGERY.
755
TITLE  FOURTH.

 SPECIAL OPERATIONS.
                   PART  FIRST.

OPERATIONS WHICH ARE PERFORMED ON THE HEAD.
                         CHAPTER  I.

                      THE CRANIUM.

                 Article I.—Fungous Tumors.

   Degenerescences of the dura mater  almost always exhibit them-
 selves under the form of tumors.   These tumors, united under the
 title of fungous tumors since the time of Louis, are nevertheless suffi-
 ciently varied in their nature ; there have, moreover, been associated
 with them a certain number of bodies which are altogether  in-
 dependent of the dura  mater.  The case mentioned by Hebreard
 (Bull, de la Fac, t. V.) was a species of cyst, filled with pultaceous
 matter, and lodged in the left middle lobe of the  brain, and which had
 only subsequently invaded the  dura mater.   In the same way, also,
 certain cases related by Abernethy (Surg. Obs., vol. II., p. 51, 54,)
 seem to belong to degenerations of the brain, rather than to those of
 the dura mater.   The confusion in this respect is  so great, that we
 find comprised under the  same title, fibrous, scirrhous, and hematic
 tumors, encephaloid masses, and various vegetations and fungosities
 which project  from underneath the integuments  of the cranium,
 whether they have  had their primitive seat in the dura mater, the
 substance of the bones, or in the brain itself.

                     § I.—Fibrous Tumors.

   Though rarely found  there, masses of a purely fibrous  character
 are, nevertheless, sometimes encountered in the cranium.  M. Senn
 (Espinosa, These, No. 129, Paris, 1825) appears to have met with
fin example.  In that which was exhibited to the Academy of Medi-
 cine in 1825, (Archiv. Gen. de Med., t. XIII., p. 121,) the tumor was
 of the size of an egg, occupied the  base of the cranium posteriorly
 and to the right, had depressed the corresponding lobes of the brain,
 and had not been revealed by any symptom during life.  As  these
 tumors do not appear to have been yet seen except on the outer sur
 face of the dura  mater, it would  have been interesting to know if
 the  fibrous productions noticed by M. Del Greco (Arch. Gen., t.
 XXIII., p. 432) in the pterygo-maxillary fissure, or the  nasal fossae. 
756
FUNGOUS TUMORS.
and by M. Rayer in the zygomatic fossa, in  a woman who died  at
La Charite, in December, 1834, might not be classed in this category.

                    § II.—Hematic Tumors.

  The blood which  has been effused into the diploe, or between the
dura mater and the  bones, between the dura mater and brain, or into
the most superficial  layers of the brain itself, may undergo various
kinds of degeneration, and assume the  form of tumors that might
be denominated hematic.  Some facts related by Abernethy come to
the  support of this  supposition.   In the case of a man 40  years of
age, who had been struck violently by  a  stone, and who had in con-
sequence thereof a species of cerebral  hernia, the tumor was found
to be similar to coagulated blood. (Abernethy, Op. cit., vol. II., p. 51.)
The same author speaks of a carpenter who was trephined  for a de-
pression of the parietal bone, and who, on the twelfth day from the
operation, had a sort of cerebral hernia, the tumor in which case also
appeared  to  have  been  formed from blood extravasated  into the
substance of the brain.   From these facts, Abernethy moreover con-
cludes, that what has been described  under the name  of  cerebral
hernia, is sometimes formed  by blood, and that it is  the  same with
certain fungous tumors of the dura mater.  A fungus developed  in
the  head of the  tibia, and which  he  also compares to  coagulated
blood, also what I have said  of contusions, and  what I  have  often
since remarked, (These sur les  Contusions, 1833,)  serve  but to cor-
roborate this  view of the subject.  We could thus explain the ap-
pearance of tumors,  which it seems difficult to range under cancers,
and whose origin in  reality appears to be ascribable to some external
violence.

         § III.—Phlegmasian (phlegmasiques) vegetations.

  Wounds of the head, fractures of the cranium and trephining have
been frequently followed by fungosities  and vegetations upon the
dura mater, in such  a way that Louis especially was led to confound
these productions with true fungus.  When they have been preceded
by a protracted  suppuration, and that the surface which  supports
them has become exposed to  the air, it  is difficult to say in what such
fungosities differ from those which are so frequently found at the bot-
tom of external wounds.  In  other cases, on the contrary, they proba-
bly result from some  extravasation of concretible lymph, or from fibrine,
and sometimes also  from sanguineous morbid layers which have ulti-
mately become organized. I have elsewhere (Plaies de Tete, 1834) pub-
lished some facts of this kind.  Perhaps also, the following case which
I find in Abernethy, (Op. cit.,  p. 106,) belongs to the same description?
A man from  thirty  to  forty  years of age was afflicted with violent
pains in the head, in consequence of a  severe salivation;  he was tre-
phined and pus was found under the bones, and the dura mater,
which  was greatly  tbickened, was covered with a soft and reddish
substance.
                        § IV.—Fungus.

  All, or nearly all the other  tumors of the dura  mater are  cancers. 
NEW ELEMENTS OF OPERATIVE SURGERY.
757
Almost all those that have been described, were evidently composed
of encephaloid  matter.  The one which Pare (liv. XII., chap.  23)
mistook for an aneurism, was formed from the brain.   The patient
mentioned  by Rey (Acad, de Chir., t. V., p. 22) had at the same
time, a cancer in the thigh, or the femur vegetated (carnifie.) In that
of Philippe, (ib., p. 36,) the bones of the cranium were also vegetated
(carnifies.)   In a case cited by M. Chelius, (Arch. Gen. de Med., t.
XXVIII., p. 422,)  the substance of the tumor resembled marrow ;
and how is it possible not to recognize a cerebriform fungus in the
encephaloid (venteuse) tumor, described at  such length by Lecat,
(Soc. de  Sante de Lyon, 1798, p. 31) ?  The  production was also of
an encephaloid  character in the two lunatics, noticed by M. Blandin,
(Espinosa,  These, No. 129, Paris, 1825,) also in  the case mentioned
by M. Deneux, (ib., p. 9,) the child eight years of age, spoken of by M.
Marjolin, (Diet, de Med., le edit., t. IX., p. 305,) and in the case referred
to by M. Bouvier, (Bibl Med., 1825 ; or Espinosa, Op. cit. p. 10.)  The
tumor removed by  M. A. Berard (Gaz. Med., 1833, p. 735) was also an
encephaloid mass;  and in the patient of Siebold, (Journ. Compl., t.
XXXIV., p. 304,) and who died under the operation, it was a cavern-
ous substance.  Schindler also says (ib. p. 325) that cerebroid matter
was found in a tumor of this kind in an aged woman, and M. Eber-
mayer (Arch. Gen. de Med., t. XXII., p. 229) states the same thing of
a young girl aged four years.  I could say the same thing of a lady
seventy-one years  of age, whom  I  saw with M. Durand, and also
of a case communicated to me by A. Lauth.  M. Cruveilhier  also.
who describes and  has given the figures,  (Anat. Path., 8e livr.) six
cases  of fungous tumors of the dura mater, speaks only of encepha-
loid tissue.  Scirrhous tissue, however, may  also form its  base.  A
woman, whose case I published in  1825, had two tumors of this last
description, which  I showed at the time  to the Professors of the
Faculty of medicine, and which I have for a  long time preserved in
alcohol.  Whether encephaloidal or scirrhous, these tumors never-
theless differ in a remarkable manner, in respect  to the parts of the
membrane upon which they are situated.   Out of fifty-one examples
where this location was given, I found thirteen in the parietal regions,
eight in the temporal, seven in the frontal,  seven  in the orbito-nasal,
seven in the occiput, five  in  the vertex, three on the  petrous bone,
and one in the  substance of the falx of the  brain.   I  have,  in  two
cases,  seen them   protrude  from  the ear,  and once  through the
pharynx.   All  ages are liable to it.   The following is the proportion
in this respect, which was found in forty cases: From birth to ten
years, six cases; from twenty to thirty, seven; from thirty to forty,
ten; from  forty to fifty,  nine; from  fifty to sixty,  five ; and  from
sixty to eighty, three cases:  from whence it follows, as had been re-
marked by Boyer, (Malad. Chir., t. V., p. 186,) that  they are, not-
withstanding, more frequent between the ages  of  thirty and  fifty
vears,  than at any other  period  of life.   As  to  the sexes, I notice
that in forty-four cases, twenty-three were men and twenty-one wo-
men.   The legitimate fungi of the cranium are in their nature  inca-
rable.   Those tumors which seemed to be formed by effused blood,
like those  examples given by Camerarius  and Abernethy, (Eber-
mayer, Journ.  Compl, t. XXXIV., p. 301,) those which result  from 
758
TUMORS  OF THE DURA MATER.
syphilitic disease, and whose character is  not  decidedly cancerous,
may alone leave some hope of cure.  The prognosis for all the others,
as has been remarked by Delpech, ought to be the same as for can-
cers of the most serious  description.  Moreover, these tumors some-
times are exceedingly slow in their progress.  The patient  of M.
Graefe (Arch. Gen., t. XVIII., p. 421) suffered for thirty-seven years
and then died.  The child mentioned by Schindler in the same way,
lived over five years, (Journ. Compl, t. XXXIV., p. 320.)   Death
did  not take place until at the expiration of forty-five years, in the wo-
man whom Robin (Louis, p. 18) caused to be exhumated five years sub-
sequently ; not until after thirty years in one of the patients of Voisin ;
(Thibault, These, No. 133, Paris, 1816;) aften ten years in another,
and after fifteen years in a case extracted from the English Journals.
(Journ. Gen., Avril, 1814.)  Also, it is less by hemorrhages, destruction
of the tissues or extension  of the degenerescence, that these  tumors
cause death, than by cerebral accidents which ultimately supervene.
  In at least twenty cases out of  fifty these  accidents have been
brought about by attempts at  operations.   These accidents consist
of convulsions, delirium, symptoms of compression of the brain in
fine, or of inflammation of the meninges.  Sometimes also, as  I have
seen in the case of a woman, they are reduced to symptoms of de-
bility, soon followed  by hebetude, afterwards  partial or general, or
incomplete or complete  paralysis, and a continual desire  for  repose
or even for sleep.  This state may be maintained for many months,
gradually becoming  aggravated.   The patients then ordinarily ex-
pire without spasms,  and so to speak, imperceptibly.   In this last case
death almost always happens by compression.  Upon the opening of
the dead body it is seen that  the tumor has augmented in growth
within, either in breadth  or depth (epaisseur) so as to  react with
more or less degree of force upon the mass of the brain. If on the con-
trary the patients sink rapidly, we find the dura mater, or the surface
of the brain inflamed and covered with pus,  as though it were ulcer-
ated or had undergone ramollissement, or been reduced to a state of
putrilage (putrilage.)  Small apoplectic cells (epanchements apoplec-
tiques) are also sometimes remarked in the substance of the hemispheres
themselves, and it is  not unfrequent to find the purulent infiltration of
the  arachnoid extending  itself as  far  as  the occipital foramen and
around the spinal marrow.
  A. Treatment.—The disappearance of a fungus of the dura mater
by  resolution or suppuration  has  never been noticed ; therefore, the
plasters, pomades, unguents, and other topical applications proposed
or made trial of, with a view of obtaining  one or the other of these
terminations, must be absolutely proscribed.  Nor does the compres-
sion of the tumor  appear  to possess any more curative power ; it is
allowable only in the character of a palliative, and even then cannot
be  made use of but in a very small number  of cases.  The destruc-
tion of the fungus, whether by caustics, the ligature, or the knife, is
in reality the only medication which merits  consideration.  Extirpa-
tion itself, the only remedy which reason  sanctions  the employment
of,  appears  to have been  but very rarely followed  by success.   In
fact the external tumor is often only the smallest portion of the evil.
After having removed it, we soon see it reproduced, if in fact new tu- 
NEW ELEMENTS OF OPERATIVE SURGERY.
759
 mors do not also appear.   In this  respect they have that feature in
 common with cancerous tumors in all other parts of the body.   But
 not being  enabled  to make their way outwards, except  through  an
 osseous opening, it  is not  possible, as in the last, to designate  their
 limits beforehand.  I cannot perceive, however, why we should not
 attempt to extract them, when there is every reason to believe that
 they  are clearly circumscribed, and  that the  disease is altogether
 ocal.   In  a woman who had been cured of cancer of the breast and
 who died of a pleurisy at the  hospital  of the School of Medicine in
 1824, a scirrhus of  the size of a small pullet's egg, commencing at
 the dura mater, had traversed the bottom of the  right inferior  occi-
 pital fossa, made a slight projection under  the  splenius muscle, and
 was found to be so regularly circumscribed, that  it certainly would
 have  been possible  to  have removed it entire, if its existence had
 been suspected during the  life of the patient.  The operation might
 be made trial of, at least for the fungous tumors of new-born infants,
 to which M. Naagele has been  one of the first to  endeavor to draw
 the attention of practitioners, and also upon those which Abernethy
 derives from certain degenerated sanguineous or  lymphatic concre-
 tions.   Five out of the  six cases  in which  caustics were employed
 perished.   The  individual  mentioned by Cattier,  (Obs.  de Med., p.
 48, obs. 15,) and  who was  treated by caustics against the advice  of
 Pimpernelle, who advised the trephine, also  died;  it is also probable
 that that of M.  Eck, (Ebermayer, Jour. Compl, t.  XXXIV., p. 323,)
 the only one which was cured, had only a simple hematic tumor.  It
 is equally doubtful  if M. Ficker, (lb., p.  320,) had to do with  can-
 cer, in  the case of partial  success, which he relates, with the  liga-
 ture.   As to extirpation, it has not, up to the present time, produced
 but very uncertain results.  Franco says, (Tr.  des Hernies, p. 485,
 An 1561,)  "I saw a child who had a fungus tumor which two of us
 wished  to extract, (tirer.)  Nevertheless  I was somewhat deterred,
 [je fus  aucunement refrody—ancient French, T.] perceiving that
 the cure appeared to be difficult and not what it seemed to be (non tant
 qu'elle l'estoit) ;  at the expiration of some days, my companion alone
 undertook it, when he found it within the brain itself, which was follow-
 ed by the death of the patient.   It is therefore very necessary to re-
 flect and to ascertain (taster) if the brain is or is not entire." A patient
 mentioned  by Camerarius (Ephem., c. n. dec. 2, obs. 99, an. 8) also died
 from this cause.  Amatus, (Cent. 5, obs. 8,) Schmucker (Bibl Chir. du
 Nord,p. 10,) and Rossi, (Med. Op., t. II., p. 261,) relate similar instances.
 It is necessary also to concede that it has scarcely ever been successful.
 In one of the cases of M. Walther, (torn. XXXIV, p. 314,) he was
 prevented from finishing the operation by a  hemorrhage which made
 it necessary to apply the ligature to ten arteries ; in a case mentioned
 by Klein, puncture was had  recourse to, and then an incision. M. Eber-
 mayer, (Archiv. Gen. de Med., t, XXII., p. 229,) in the case of a child
of four  years, whose history he gives, mentions only a single cut of
the lancet.   Nor was there any other treatment than incisions made
 use of in the patient of Sivert, who nevertheless died two days after.
  In the case of Rey, (Louis, p. 22,) the tumor was  only laid  bare
without removing it.  The  patient of Courtavoz and Chopart, (Mem.
de VAcad., t.  V., p. 28,) died on the following  day, though here 
760               TUMORS OF THE DURA MATER.
also  incisions only were made use  of.   A  similar attempt was
followed  by the  same results in the  case of Philippe, (Ibid, p. 36.)
Nor  was the excision complete in the case of Saltzmann, (Ibid, p. 30,
or Mem.  de Saint  Petersburg, t. HI., p. 275.)  The same  was the
case  in the patient of M. Graefe, (Arch. Gen. de Med., t. XVIII., p.
421 ;) which however did not prevent the wound from cicatrizing,
nor life from being prolonged to the period of seven months.  The
same should be said of the new-born infant, mentioned by Schneider,
(Ebermayer,  Journ.  Compl  t.  XXXIV., p. 320,)  since it became
necessary to repeat the operation at the expiration of five  years, at
which time it proved  fatal.  Nor could Siebold in his case complete
the extirpation of the tumor,  for the patient  died under his hands.
In remarking that he removed all  that he  could, M. Orioli, (Gaz.
Med., 1834, p. 410,) leaves it quite apparent that the disease had not
been effectually destroyed in his patient, when gangrene came, so to
speak, to complete his operation.   Reasoning moreover, would have
sufficed  to demonstrate  what experience has now placed beyond all
doubt, to wit: that such attempts were calculated but to  augment
the danger of an evil, already so formidable and  insidious in itself.
Such facts, therefore, are not  to be taken into the account, when we
undertake to determine the value of the operation of extirpation for
fungus of the cranium.   The  small number of cases where the ope-
ration has been effectually accomplished,  furnish results somewhat
less alarming.  The Spaniard that M. A. Severin (Journ. Compl, t.
XXXIV., p. 300,) states  that  he cured, could have been so only by
the trephine.  The same must be said  of the patient of Grosmann,
(Stoltz, Theses de Halter, 1708, presid. de Sand.)  M. Eck says he
succeeded without trephining ; but he employed caustics after  extir-
pation.   I have already  remarked that  the success of M. Orioli was
as much  owing  to the gangrene as to extirpation.  M. Klein twice
cured the same  patient with an interval of a year, by means of the
trephine  and extirpation ; but he believes the glands of Pacchioni
were the seat of the fungus.  In another patient the same operation
was  followed by death,  (Arch. Gen. de Med., t. XXII., p. 225.)  In
the case  related by Volprecht, (Louis, p. 31,) the trephine was ap-
plied around the tumor;  but this last was not removed, and the au-
topsy showed that other  fungi existed in the cranium.   A meningitis
caused the death of the  patient that  Dupuytren had operated upon,
(Denonvilliers, These, 1789, p. 76,) by  embracing the whole tumor
in a large crown of a trephine.  The patient operated upon by M.
Berard,  also it is true died, but it had  been rendered necessary to ap-
ply sixteen crowns of the trephine, and to remove a portion of the lon-
gitudinal sinus.  M. Pecchioli, in operating upon a man 46 years of age,
(Gaz. Med., 1838, p. 414,) who had a fungous tumor to the right of the
sinciput,  succeeded perfectly by means of three  crowns of the tre-
phine, and by removing a portion of  the dura mater.  I perceive
that  M.  Syme,  (Edinb. Med. and Surg. Journal, vol. CXXXVIL,
p. 384,)  going as far down as to the  dura mater for a large fungous
tumor of the cranium,  cured his patient also.   If it were proved
that  the  tumor  attacked was  almost  never solitary, these  few suc-
cesses perhaps  would not be sufficient to justify the operation of
which we  are now speaking ; but it is to-day demonstrated by the 
              NEW  ELEMENTS  OF OPERATIVE SURGERY.          761

patient of Pohlius, by that  of M. Berard and  by many others, that
fungus of the  dura mater,  like cancer of the breast, is  at first quite
frequently uncomplicated (unique) ; nor do I hesitate to say that ex-
tirpation is indicated at the cranium as in any other region,  and that
there it  presents the same counter-indications as for other  cancers.
It must, however, be admitted, that in itself the ablation of deep-seated
cancers of the  cranium is infinitely more dangerous than in any other
region of the body, and that these dangers, taken in connection with
the unfortunate prognosis which naturally belongs to the disease, are
calculated to make us exceedingly circumspect in such cases.
   B.  Operative Process.—If however it should be decided upon, it
would be necessary, while taking care to cut the flaps in the sound
parts, to preserve  as much of the  cranial teguments as  possible.
Crowns of the trephine should then be applied all around the tumor,
and  the  intermediate osseous angles forthwith destroyed by  a saw
made expressly for this purpose  (ad hoc), or by means  of the  chisel
and  leaden  mallet.  If the tumor should be  situated  in the  bones
only,  the surgeon  would  remove  it immediately without incising
the dura mater.   In the  contrary case we  should not hesitate  to cut
round the entire morbid growth, including moreover in the circle a
sound margin  of the dura mater.  Having arrived at this stage of the
operation, we ought even to penetrate still deeper if the  tumor should
be found to have its origin between the pia  mater and the brain.
   In  cases of very large  fungus, perhaps  it would  be advisable to
perform  the operation at two periods, at an interval of  from twenty-
four to forty-eight  hours, to apply  but half the crowns of the tre-
phine on the first day, for example,  as M. A. Berard did, and not to
complete the perforation of the bones until  the day after, or the day
after  that, and immediately previous to the  extirpation of the tumor.
A woman recovered in this way after having  sustained the applica-
tion of fifty-two crowns of the trephine, for a large  necrosis of the
cranium, accompanied with caries, (Mehee de la Touche, Plaies de
la Tete.)  As  it is not possible in such cases to unite the wound by
first intention,  a piece of linen spread  with  cerate, and perforated
with holes, should be extended over the entire solution of continuity.
Balls and then gateaux of lint should  be applied over this, and kept
in place  by means of a  suitable  bandage, so as to fill up  the void
which has been made in the cranium, and  make moderate  pressure
upon the brain.  This last precaution is of the highest importance
when we have been forced to  excise the dura mater.  The patient of
M. Berard, who during the operation had  experienced no  inconve-
nience in this respect, swooned away as soon as the tumor with its flap
of membrane  had  been  entirely extirpated, and  did  not  come to
until  after the compression which  they had the presence of mind
immediately to make, at the  place where  the parts had just been
detached.  It  cannot be denied also that the sudden abstraction of an
abnormal pressure which may have been considerable in its amount,
and existed in  many cases for  several years, must necessarily expose
to serious accident in regard to the brain.   Extirpation, therefore, of
cancers of the cranium,  in my opinion, presents but few chances of a
favorable issue  when the  disease proceeds from the pia mater, or
where we have to destroy only a somewhat extensive portion of the
  vol. n.                     96 
762
ENCEPHALOCELE.
dura mater.  Consequently then it is for th|e tumors only with a nar-
row base, and for such as do not render it necessary to remove any-
thing but the bones, that this operation is in reality admissible.  The
rest of the manual and its consequences, moreover, are too analogous
to those of the trephine, to require that I  should sa^y anymore on this
subject in the present article.

                  Article II.—Encephalocele.

  There is no resource for hernias of the cerebrum  and cerebellum
but that of making  the patient wear a bandage  furnished  with an
elastic pelote properly adjusted.   Every kind  of bloody operation
would be dangerous  and  probably cause death, as in  the  case that
Lallement has published, and in that of M. Baffos.   Many surgeons,
however, have ventured upon its excision.  These excrescences from
the brain, so frequent in traumatic phlegmasias, and those that follow
openings into the cranium, and which M. Champion denominates hy-
percephalose, which  Gall considers as the unfoldings of the convo-
lutions, and upon which Langius has written very learnedly, (Epist.
6, liv. I.—Bonet, Corps de Med., t. III., p. 173,) are attributed by Arne-
mann (Gaz. Sal, 1787, No. 50, p. 2,) to the expansion of the anterior
ventricle of the brain.  It succeeded to a fracture in the case of Tul-
pius (Bonet, Corps de Med., t. IV., p. 37, obs. 54,)  and in that of Las-
sus (Med.  Op., t. II., p. 273.)    Diemerbroeck (Anat., t.  II.,  p. 235,
liv. III., ch. 5,) speaks of one  which detached itself several times,
and which resulted in death.   In the case of Tudecius  (Planque, t.
XXVII., p. 87,)  the cause was the presence of a foreign body, viz.,
the blunt  point  of a  halberd.   In a case where the hypercephalose
protruded  through the opening made by the trephine, F. de Hilden
(Bonet, t. II., p.  374,) states that Bourg had exsected it with success.
According to  Henry Psetrus (Bonet, Corps de Med., t. IV., p. 49, obs.
73,) extirpation was also performed by Rhodius.  The excision of a tu-
mor of this kind, put a stop to the serious accidents it had occasioned
in a case related by Trioen and Ravaton, (Prat. Mod. de la Chir., t. I.,
p. 222,225,) who advises that they should  be extirpated as far forward
as possible, (le plus avant possible,) and has often performed this opera-
tion without accidents: the pulse after it rose and the head became more
free, [i. e. less or rather not at all oppressed any longer by the tumor,
T.]  Tetu (Mem. de  Med. Chir.  et  Pharm. Milit., t. XIV., p. 33, et
39,) after having performed excision, had recourse to compression
with success.   Deidier (Encyclop. Meth. Med., p. 252, col. 2,) in a
case excised many excrescences from an encephalocele without caus-
ing pain.  It is nevertheless true, that apart from some rare exceptions,
I should prefer  with Rossi  (Elem. de Med. Oper., t. II., p.  240,) to
restrain these tumors by means of plates, or by any kind of compres-
sion whatever, rather than attack them with the  cutting instrument.

            Article III.—Meliceroma,* (Meliecris.)

  Many persons will carry during their  whole life, under the hairy
  * [The Greek coinage of this word is we deem perfectly justifiable, to harmonize with
steatoma, atheroma, lipoma, &c. T ] 
NEW ELEMENTS OF OPERATIVE SURGERY.          763
scalp, steatomatous, atheromatous, or meliceromatous tumors, without
being sensibly inconvenienced by them or even attempting to do any
thing to get rid of them.  Others suffer more or less from them and
for some reason or another  desire at any hazard to be disembarrassed
of them.
   The nature and formation of these loupes, still imperfectly under-
stood, appear, in my opinion, to require further researches.   There
are some of them which, at their beginning, exhibit themselves under
the aspect of a small,  hard, yellowish,  friable, unorganized mass,
similar to collections of fibrine, or blood deprived of its coloring mat-
ter and serous portion.  Increasing in growth, they begin by becom-
ing soft at the centre, and are thus transformed  into a cyst, which is
so much the thicker in proportion as  the tumor is  less ancient or of
less volume ;  a cyst which is filled with grumulous substances, in a
greater or less state of fluidity, and which resemble neither pus  nor
fat.   Should we not ascribe their origin to some of the elements of
effused blood ?  It is at least certain that they are not distended cu-
taneous follicles, as is asserted by Beclard and M. A. Cooper.  Their
cyst,  which is thicker in proportion to their less degree of develop-
ment, is always independent of the skin.   A tumor twice the size of
the head, and which perhaps was only an atheromatous cyst, though
the author describes it  under the title of lipoma, was removed with
perfect success by M. PI. Portal, from the forehead of a child of four
years of age, (Clin. Chir.,  p. 279.)   Sebaceous, serous  and other
kinds of cysts, lipomas and fibrous tumors, are to be treated at the
cranium as in any other part of the body.   I have seen sub-cutaneous
encephaloid  cancers in many individuals, an erectile conical tumor
of an inch in length, with  a thick pedicle, in  a  young Moldavian of
twenty-four  years of age, and  melanotic plates of sufficient size in
three or four cases.  There might be  cases where the ligature would
suffice to detach  them,  as in a case related by Boyer, but it is rare
they  are strangulated at their  base.  M. Bertrand, (Arch. Gen. de
Med., t. XX., p. 285,) states that he cured one by passing through it
a  long needle, which he kept there in the manner of a seton.   De-
mours, who placed two  needles crosswise instead of one, asserts that
he thereby obtained successful results.  But the cutting instrument
here is infinitely better, and ought always to be preferred.
   Operative Process.—When the tumor is of great size, and the skin
much attenuated, an elliptical flap of integuments should be removed
with  the cyst.  Two  semilunar incisions  are  then first  made.  A
transverse  incision is then made from each lip of the wound, and pro-
longed outwardly, so as to  circumscribe four flaps, which being raised
up with care, enable us to  remove the loupe entire and without  diffi-
culty. In most cases these two last incisions may be dispensed with.
While the surgeon, with an erigne or  good pair of forceps, draws on
the cyst with one hand, he dissects with the other, by means  of the
point of the bistoury, its external surface, and thus readily succeeds
in separating  it  from the surrounding tissues.   In the ordinary pro-
cess  and where it is unnecessary to sacrifice  any part of the skin, it
is  recommended to make a simple crucial or T incision, and to take
every possible precaution  not to open into the  cyst while dissecting
the flaps of the wound, which latter is to be united by first intention, 
764                      MELICEROMA.
after having  extirpated the tumor.  M. A. Cooper adopts another
course.   He  first opens freely into the tumor,  empties  it by com-
pressing  it with  the thumb and forefinger;  then  seizes  the cyst on
one side  by the  hook or forceps, and dissects and  removes it.   The
incision being made  in  such manner as to leave intact the posterior
wall of the meliceromatous pouch, M. J. Cloquet immediately seizes
with a forceps its anterior wall under the right  lip of the wound,
draws  upon it in proportion  as he divides the adhesions, which are
ordinarily very feeble, and thus effects, to some extent,  by a single
stroke, the enucleation of the whole cyst.  I have,  on more than one
occasion, confined myself to dividing the integuments only, and then
seizing the tumor at the bottom of the wound with a strong erigne,
after which it becomes easy to dissect and remove it.  By these three
variations of the process of simple incision, the  operation is much
more prompt  and less intricate than by the ordinary process.  After
the removal of the sac, the borders of the wound, so to speak, replace
themselves in contact, and reunion is generally  accomplished in the
space of a few days.  M. Tealier, (Transact. Med., t. II., p. 430,)
who, after a simple incision, confines himself to making  traction on
the sac in order to extract it; M. Brachet, (lb., p. 371,) who removes
this cyst after having slit it  open and emptied it;  and M. Chailly,
(lb., p. 431,) who lays it open and empties it, and then besmears it
with red oxyde of mercury;  and all which surgeons supposed they
had imagined something new, were doubtless ignorant of what I have
said above.   The process which  I now adopt by  preference, is ex-
ceedingly simple; the youngest pupil may perform it with impunity.
Having opened into the tumor by puncture with  a bistoury or lancet,
the same  as for  an abscess, I seize,  with a  good pair of artery for-
ceps, one of the commissures of the cyst, which latter I remove by
enucleation, separating it by means of the beak of a spatula, as M.
Champion does,  or by the myrtle-leaf, cataract scoop, the handle of
a scalpel, or merely the nail of  the little  finger.  The  operation,
therefore, is so easy and prompt, that  I cannot see what would be
the advantage in substituting for it the employment either of potassa,
as proposed by M. Brachet, (lb., t.  II., p. 371,) Guerin, or M. Canihac,
(Rey, These,  No. 79,  Paris,  1834, p. 91,) or the Vienna  caustic, as
eulogized  by  M. Hennau, (Transact. Med., t. II., p. 385,) and by
M. R. Gerardin,  (Journal des  Conn. Med. Chir., 1837.)   It is never-
theless true that, like every other operation, it sometimes gives rise
to serious accidents.  In a case cited by M. Merat, (Transact. Med.,
t. XL, p. 432,) it was  followed by tetanus.  A  female patient,  who
was operated upon for it in 1825 at the  hospital  of the Faculty, was
seized with an extremely dangerous erysipelas; and in another wo-
man it caused her death.   But these are very rare exceptions, wh;ch
do not take place in  one case out  of fifty.  The wound almost
always  heals  in less  than eight  days.   Left  to itself,  moreover,
the tumor increases  in  size,  and may be  transformed into cancer.
This is what took place in an old  man I operated upon in 1836, and
in a woman  aged seventy years, whom I operated  upon on  the
12th of January, 1839.  I have removed as many  as eleven of these
tumors at one sitting.   Some patients  also  have  their cranium as
it were covered  with them. 
NEW ELEMENTS OF OPERATIVE  SURGERY.          765
                  Article  IV.—Hydrocephalus.

   The principal operation which has been proposed for hydrocephalus
 is puncture  of the cranium.  Holbrock and Vose (Duges, Manuel
 d'Obstetrique,  &c.,) profess to have performed it, or to have seen it
 performed with success.  Rossi (Medecine Operatoire, t. II., p. 46.)
 has drawn in  this  manner, at several times, six pounds of serosity
 from the cranium of a child eleven to twelve years of age, and who
 got well.   M.  Syme, in 1826, had  recourse to it five times on the
 same child, in the space of a few months, and  each time with some
 apparent  advantage, though the little  patient ultimately  perished.
 M. Greatwood (The Lancet, 1829,  vol.  II., p.  238,) succeeded with
 it in one  case, and  M. A. Cooper appears once to have obtained
 partial success from  it.   M. Bedor, (Gaz.  Med., 1830, p.  188,) who
 has also made trial  of it, likewise believes that it may answer.  But
 the injury done  to the  brain  by  hydrocephalus, is ordinarily too
 deep-seated for a simple puncture in such cases to restore the health.
 Nevertheless, should it be decided upon, nothing is easier to do than
 this, either with the lancet, bistoury, or a small trochar.  There would
 be no other precaution to take than to  avoid with care the track of the
 venous sinuses.   Upon the supposition that we did not wish to draw
 off at once the entire amount of  the liquid, I would much  prefer re-
 peating the  operation from time to  time,  rather than to  leave a
 canula resting in the wound, as  has  been  proposed by Lecat.  As
 to the rest, it is an  operation which now counts a great number of
 trials.  Theodoric (Portal, Hist, de VAnat., etc., 1.1., p. 185,) had already
 made the  remark, that hydrocephalous children treated by the appli-
 cstion of the red hot iron to  the forehead  or the occiput, had ulti-
 mately recovered.  It appears also that S. Chabbi (Hevin, Path.
 Chir., t. L, p. 232,) had performed it with success.   Also  in cases
 of this disease where it would seem  to be required, other  surgical
 means have been resorted to.  Warner (Obs. de Chir., obs. 11., p. 69,)
 says that in a case in which extirpation for  a hydrencephalocele  was
 performed against his advice, it caused death ;  and Thiebaut (Journ.
 de Desault, t. III., p. 327,) gives the history of two similar attempts,
 which were followed by the same result.  A case also operated upon
 in Scotland, and in  which a hydrencephalocele that projected above
 the nose  was  excised,  terminated  fatally.   Leveille (Nouv. Doct.
 Chir., t. III., pp.  47, 48,) who relates  this fact, says the  same thing
 took place at Gottinguen.  In the case  of an infant aged seven months,
 in which the tumor, projecting through the parietal bone, was cut
 into by Rambaud, (Journ. de Dehorne, t. IV.,  p. 212.) death in fact
 followed on  the  day after the  operation.   The case of  an infant
 mentioned by  Sulpius, (Bonet, Corps de Med., t. IV., p. 6, obs. 7,)
 was no less unfortunate.  I have seen, says M. Champion, two infants
 die, who were operated upon for this disease in spite of my advice
 to the contrary, one at the forehead, and the other near the occipital
 hole.   The. first  died the day after the application of the ligature,
 which had been placed around the  tumor;  the other survived only
some hours after the ligature had  been applied, followed by excision
of a hydrencephalous sac of considerable size. 
7G6
HYDROCEPHALUS.
   Puncture of the cranium also for hydrocephalus wTas performed in
France before the  English  surgeons had received  it.   Pelletan
(Heurtault, Consider, sur Diff. Points de Chir., p. Ill, 1811,) had re-
course to it at the Hotel-Dieu of Paris, the  7th Thermidor, and year
VII, on an infant  aged twenty-two months.  A canula was left re-
maining in the parts, and the patient died  at the expiration of five
days.   Besides the above examples, we might mention at the present
time many other instances of puncture of  the cranium in  cases of
hydrocephalus.  Thus M. Graefe (Arch.  Gen. de Med., t. XXVIIL,
p. 409,) and  M. Russel (Gaz. Med., 1832,  p. 641,) have each  had a
successful case.  M. Iloefeling (Encyclogz. des Sc.  Med.,  1838, p.
251,) gives a case of hydrocephalus  in a  child aged five years, who
having  received a kick from a cow,  had  the cranium fractured and
was thus cured of his disease.  I will add that M. Allaire, (Jour, des
Conn.  Med. Chir., t. II., p. 305,)  who drew by this operation, re-
peated three times in one month, six  ounces of liquid at each of the
two first punctures, and four at the last, had not the same success, as
his patient died soon  after.  It is nevertheless  true that the cases of
M. Conquest (Gaz. Med., de Paris, 1838, p.  251,)  are  now sufficient-
ly numerous to merit all the attention of practitioners.  In his last
table tihis practitioner  relates  nineteen cases of this operation per-
formed  by him during the last  ten  years.    In the first  of his cases,
M. Conquest, who  made but one puncture, drew off 32  ounces of
liquid, and obtained complete success.  The second underwent  three
punctures, which yielded thirty-four  and  a  half ounces of serosity,
but ultimately  ended  in  death.   The third recovered after two
punctures and the evacuation of twenty-four ounces of  liquid.
  In the fourth, death  occurred after the fifth puncture and the re-
moval of 48i ounces of fluid (de matiere.)   The fifth died also after
four punctures, which furnished 45 ounces of serum; the sixth was
cured by the extraction of 26  ounces of liquid in three punctures;
whilst in the 7th, 8th,  9th, and 10th,  who died, as well as  the  12th
and 15th, it was not practicable to make [respectively] but two, one,
two, two, one, and four punctures, which obtained  20, 8, 22, 17, 7,
and 33  ounces  of serosity.  The 11th, 13th, 14th, 16th, 17th,  18th,
and 19th, which recovered, furnished [respectively] 55, 13,  9, 6, 31,
14, and  9 ounces of liquid, by means of 5, 1, 2, 4, 3, 2 and one punc-
ture for each ; from whence we have 9 deaths and 10 cures, on the
total amount above  mentioned.  If it were allowable  to count on
so large a proportion of successful  cases as this, there  could be no
doubt that paracentesis of the cranium ought to be practised in  cases
of hydrocephalus.  But, on one hand, the observations of Pelletan,
many similar attempts, collected in  the practice of  Dupuytren, to-
gether with  the facts of M. Bedor and M.  Allaire, show that  up to
the present moment,  it has scarcely ever succeeded in France.  On
the other hand, when  we reflect upon the possible chances that certain
patients might have of living a long  time with a hydrocephalus of
considerable size, while by puncture  they generally succumb at the
end of a few days, we have good ground  fo not deciding upon this
operation without some apprehension.  In  the halls of the Clinique
of the Faculty, I have seen a hydrocephalus child of from 5 to 6
years of age, who in other respects  appeared to be in sufficiently 
              NEW  ELEMENTS OF  OPERATIVE SURGERY.          767

good health.   I have also  had an opportunity of seeing a child of
from four to five years of age, who had the cranium quadrupled in vol-
ume, and which a man hawked about the country to exhibit as a
curiosity.  A hydrocephalus of considerable size, did not prevent a
patient who was for a long time seen at the hospital of Perfectionne-
ment, from living  to the age  of  25 or 30 years, and  Marechal gives
an instance of a patient with hydrocephalus, who attained to his 70th
year.   These, however, are  but  rare exceptions, and no one  will
dispute  that hydrocephalus  is almost a certain cause of death.  A
consideration,  moreover, which  would perhaps influence me in such
cases is this, that  the existence  of hydrocephalic subjects, being ac-
companied with more or less complete paralysis, and an absolute an-
nihilation almost of  the intellectual faculties, is reduced in  fact to a
vegetative life, and  can be of no great moment either to society, the
family, or to the individual  himself; from whence it follows, that with-
out deceiving ourselves as to its importance, we ought, nevertheless,
to have recourse to  this operation in patients who seem  in other re-
spects to be placed under the most favorable conditions possible.

                   Article V.—Spina  Bifida.

  We ought, perhaps, to have treated of spina bifida, under the chap-
ter on Serous  Cysts.   But the relations  of this description of tumor
with the encephalon, have in some sort forced me to examine it im-
mediately  following  hydrocephalus.  Modern  surgeons  believing
that they had  established the fact that spina bifida always communi-
cates with the arachnoid or subarachnoid cavity of the  spinal mar-
row, have thence concluded that it was a disease placed beyond the
domain of operative surgery. Under that view the same opinions have
been expressed of this disease as of hydrocephalus, of which spina
bifida was  considered as nothing more than a dependence or variety
which might be called hydrorachis.  On the one hand, however, it
may be supposed that many serous  cysts, noticed on the posterior
plane of the spine, do  not communicate with the envelopes  of the
spinal marrow, and  that they originate outside the dura mater.  This
is nearly demonstrable, especially  in one  of the patients operated
upon by M. Trowbridge,  (Journ. des Progres, t. XVII.,  p. 274,) and
who had a serous cyst, with numerous cells, in  the lumbar region.
On the  other  hand, we possess, at the present  day, sufficiently nu-
merous examples of cures of tumors of this description obtained by
various  operations.   An infant a year old, and who had one of these
tumors  along  the vertebral  column, was relieved of it by means of
five punctures (mouchetures, see Vol. I.) by M. Labonne  (Revue
Med., 1826, t. II. p. 281,) who professes to have in this  manner cured
a spina bifida.
  An infant aged three months, and who had had a  similar tumor
from its birth, was  submitted to puncture by M. Probart, (Biblioth.
Medic,  1828, t.  II.,  p. 120.)  Erysipelas and  convulsive move-
ments  supervened ; leeches, purgatives  and plasters  were had  re-
course to, and  the cure was accomplished.   M. A. Hawarden (Ibid.)
is referred  to for  a fact in every respect similar,  and which possibly
might be the  same.  Two examples of successful results obtained 
768
spina bifida,
by small punctures on tumors which were situated on the posterior
face of the sacrum, have been related by M. Bozetti, (Journ. des
Progres, t. V., p. 253.)   An interesting case  of this  kind has been
given by M.  Wardrop, (The Lancet, 1828, vol. I., p. 308.)  The
tumor, which was also situated upon the sacrum, was fourteen inches
in circumference.  After several punctures, it was found at the expi-
ration of six weeks to have been reduced two thirds of its dimensions.
But convulsions and death, which then took place almost suddenly,
afforded  an opportunity of proving that  the serous pouch  commu-
nicated directly with the vertebral  canal, and that the spinal mar-
row was sound.  M.  Trowbridge, of whom I  have just  spoken,
states that he  has  in two instances succeeded by excising these
tumors after having submitted them to a gradual constriction (con-
striction).  From whence it follows, as it  appears to me,  either that
many of the cysts described under the name of spina bifida, do not
communicate with  the  interior of  the spinal membranes,  or that
hydrorachis with hernia of the  cyst, is  not absolutely  incurable.
According  to this induction we should naturally be led to conclude
that it is  proper to  treat spina bifida by  surgical means.  In these
cases I think we  have it in our power  to lay down the following
rules: 1. If the tumor is not accompanied  with paraplegia and the
cyst is not too much attenuated, we ought to wait and confine our-
selves to the use of topical astringents  or  compression ; 2. Although
there may not  be paraplegia, if the cyst is very prominent and with
a large base, we should perform the puncture with a lancet rather
than with a trochar, and repeat the same operation weekly, at the
same time that  astringents and compression should also be used; 3.
Whether the  cyst  be attenuated or  not,  or  accompanied or not
accompanied by paraplegia, it should be strangulated at its root pro-
vided it is pediculated; and we should wait until it is shrunk before
incising  it outside of the constricting ligature; 4. When paraplegia
is  present, whatever be  the  form, volume or thickness of the cyst,
the treatment to be employed  by preference is repeated  punctures.
Though the surgeon ought to hesitate with a child who is  in other
respects in the enjoyment of perfect health, the case, in my  opinion,
is very different when  complicated with a profound alteration in the
functions of the spinal marrow.   In this  state  the little  patient is
devoted to a certain death if nothing is done, and we have seen by
what precedes, that by means  of an operation there is some chance
of saving him.   In 1824 I saw at the  hospital of Perfectionnement,
an infant two months old, who had at  the point of the  sacrum  a
serous cyst, which was flattened in shape, of a reddish color, and of
the size  nearly of the  fist; and which  was  ultimately cured by
means of four  punctures practised during the space of a  month, to-
gether  with compression, aided  by topical astringents,  continued
about five months.  A young boy  whom I saw at the Hotel Dieu,
in 1835, had on the base of the sacrum a transparent tumor, existing
there for several years, and having the size of a large pullet's egg,
and which certainly would have  received the name of spina bifida,
if it had  been  met with in a new-born infant.   I  have  since learned
that this tumor, treated by puncture and afterwards by incision, had
ultimately entirely disappeared.  As for the rest, it is at the base of 
                 NEW ELEMENTS OF OPERATIVE SURGERY.          769

    the lumbar region, and on all the posterior surface of the sacrum, that
    the operation in my opinion  presents the best chances of success.
    There in fact there is no longer any spinal marrow, and the inflamma-
    tion must necessarily be less dangerous than in the other regions of
    the spine.  Certain it is that, restrained by this idea, I did not venture
    to meddle with a spina bifida which was  situated  in the  cervical
    region,  another which was  found  near the middle  of the dorsal
    region, nor a third which was sent to me in November, 1838, by M.
    Larrey, and  which had its seat  in the upper part of the lumbar re-
    gion.  I have, however, at  the maison  de sante of M. Dufrenois,
    made trial of repeated  punctures with the  lancet on  a spina bifida
    in this last-named region, in a new-born infant.  The tumor had the
    dimensions of two  five-franc pieces; its walls were  thin  and of a
    bright rose color, and threatened to  become ruptured; a first punc-
    ture sensibly diminished the  paraplegia ; it was the same with a
    second and third, and  finally with the fourth.  But on the twentieth
    day, convulsions and other signs of arachnitis announced to us that
    the scene was changed; death took place at the end  of the month,
    and the  opening of the dead  body performed by M. Behier, in pres-
,    ence  of M. Guersent, showed  that a purulent inflammation which
    had  commenced  at  the cyst, had extended  itself throughout the
    whole length of the spinal marrow, reaching into the cranium.  I
    will add to these details, that in the last century, Orth, (Theses de
    Holler, t. V., p. 218, Juillet, 1719, French translation,) following Salz-
    mann, had already  endeavored to make it appear that certain cysts
    which are developed  along  the track of the spine ought not to be
    confounded with spina bifida, and that in our time, M. Busche (Revue
    Med., 1829, t. IV.,  p. 118,) has exerted  himself to prove that many
    of those cysts were partitioned (cloissonn6s)  like the ovaries, and
    without communicating with the cephalo-spinal cavities.  The four
    examples related by this last  author, are calculated in  this respect to
    inspire practitioners with a certain degree of boldness.  Finally, the
    case of an infant seven months old, who had  in the lumbar region a
    legitimate spina bifida, which Skimer (Arch. Gen. de Med., 3e serie,
    t. II., p. 494) attempted to treat by repeated punctures, was not more
    fortunate than the one I have mentioned above.

      Article VI.—Cephalematoma  (Sanguineous  Tumors of  the
                               Cranium).

      Sano-uineous cysts  of the  cranium are sufficiently often encoun-
    tered in new-born infants to induce many practitioners to  consider
    them a  specific disease, generally known at the present day under
    the name  of cephalematoma (cephalematome).  Having elsewhere
    (Art des Accouchements, t. II.,  p. 590, 2e edition)  treated  of these
    tumors  I  will now speak of them only in their  connection with
    operative  surgery.   These cysts, moreover, have  been sometimes
    confounded  with encephalocele, as is proved  by the observations of
    Le Dran Trew, M. Michel, and  some others.   M. Champion informs
    me that he has seen a surgeon,  in other respects a man of great ex-
    perience, make also a mistake of this kind a short time since.  We
    should, moreover, be deceived if we calculated on  finding cephale-
      vol. n.                      97 
770
CEPHALEMATOMA.
 matoma only among new-born infants.   Since the publication of the
 work above cited, I have met in an infant twenty months old, with
 a sanguineous cyst of more than three inches in diameter, and which
 covered almost the whole of the frontal bone.  Another infant, aged
 six months, whom I saw with Dr. Demey, had one of similar dimen-
 sions  on the  left  parietal  bone and a portion  of the occipital.   A
 woman, aged 49 years, and a man 26 years of age, presented to me
 similar  examples, one  on  the  right region of  the  forehead  and
 temple,  the other on almost  the entire  right half of the cranium.
 Other analogous  facts,  but less striking than those last mentioned,
 have  also assisted in confirming me in my first opinions on  the
 mechanism and nature of sanguineous tumors of the cranium, to wit:
 that these cysts are formed by an effusion of blood, which takes place
 in consequence of vascular rupture or spontaneous exhalation, some-
 times between the skin and aponeurosis, more frequently between
 the aponeurosis and pericranium, quite  frequently also between  the
 pericranium and bones, and sometimes between the bones and dura
 mater.  A case noticed by M. Neve (communicated  by the author
 to M. Champion,) would go, in fact, to show that the blood primarily
•extravasated between the dura mater and cranium, may transude and
 pass through the bones, and arriving externally, constitute a throm-
 bus or  cephalematoma.   The  mode of  curing these  tumors is  not
 considered in the  same point of view by all practitioners.   Puncture,
 followed by compression and topical resolvents,  have obtained  de-
 cidedly  successful results with M. Champion.  Others have had  the
 boldness to recur to large incisions, and even to the seton; but I
 have  satisfied  myself that with a  little  patience  and some topical
•astringents, we may almost always succeed in dispersing the tumor
 without the necessity of an operation.  The cephalematoma which I
treated  in this  manner, in consultation with M. Cisset, disappeared at
the expiration of a few weeks.  The  child that M.  Demey sent to me,
got welkin fifteen days.  I have seen others which recovered still more
 rapidly.  In the man and woman whom I have  mentioned above,
 the tumors, notwithstanding their extreme dimensions, receded more
and more, and ultimately disappeared in the space of a month.   It is
 however true,  that in the patient first mentioned,  after having made
 a puncture on  the forehead and extracted from it  four to five ounces
■of a sanguinolent liquid, I found that the walls of  the tumor aggluti-
 nated, and that a  complete cure followed.
  In conclusion, then, I would, in these cases, advise  temporization,
 afterwards compresses wet with a solution of muriate of  ammonia,
tannin or alum, or  some other astringent  liquid.  Puncture  would
not be admissible until after unavailing attempts by compression, or
unless at the end  of  a month's treatment, the tumor remaining sta-
tionary, seemed rather  to  have a tendency to increase.   Pure and
 simple puncture will then, in most  cases,  succeed, especially if we
associate with  it for some days a slight degree of compression properly
 applied.  To  cover the whole extent of the  cyst with a temporary
 blister, would also be an exoellent remedy as an adjuvant to puncture
 or the simple  incision ; but the most certain remedy in all these old
 cases, and especially where the cyst contained scarcely any thing but
 liquid matter,  would be the iodine injection, the same  as in cases of 
               NEW ELEMENTS OF OPERATIVE  SURGERY.           771

 hydrocele.  I would not, in fine, decide upon laying open the tumor
 largely or on many of its points until  after having made use  of all
 other means, or unless there should exist some serious accident, or
 that a suppuration kept  up by the cephalematoma had actually be-
 come established.

 Article  VII.—Operations  required  by the  Diseases  of  the
                          Frontal Sinus.

   There are two regions in the cranium  where the diseases may re-
 quire operations so diversified, that we  are almost  tempted  to  make
 them the subject of two special articles.   These regions are the fron-
 tal sinuses, and the mastoid process; but  as it is next to impossible
 to separate what relates to this last from  the operations  required for
 the  diseases of the ear, I  shall not treat of it upon the  present occa-
 sion, but  speak only of what relates to the frontal sinus, properly so
 called.  Operations have been performed upon the frontal  sinus, in
 cases of  fractures, caries, necrosis, abscesses, hydatids,  polypi,  the
 presence  of foreign bodies, collections of  fluid, and various kinds of
 degeneration.   The relations of the frontal sinus with the interior of
 the nasal  fossae, and with the cranium and orbit, will always render
 its diseases difficult to diagnosticate and cure,  at the same time that
 they generally  increase their danger.  The operations  which they
 render necessary must, moreover, in their nature  be sufficiently deli-
 cate, and sometimes in  themselves formidable.

                               § I.

   When from & fracture  in the forehead,  some fragments remain dis-
 placed posteriorly, in such a manner as to give rise to accidents, it
 may become advisable to  remove the anterior wall of this sinus, either
 wholly or in part.  Facts of this kind have been related by Fallopius,
 Trew, Marechal, Colignon, Jackson and many others.   In a  patient
 whose case is given by  Home, (Acad, de Chir., t. VI., p. 203, in 12°,)
 there was a fracture at  the superciliary ridge.  The ablation of the
 osseous projection was  effected; accidents supervened, and bleeding
 had  to be resorted to eight times ; but the  patient recovered.   Lassus
 (Med. Op., t. II., p. 259) and M. Larrey, as well as Fichet de Flechy,
 (Observat. de Med. et de Chir., p. 213,) have related examples of cures
 obtained in the same way, and without the patients having been ex-
 posed to the slightest dangers.  Muys, (Nouv. Obs. de  Chir., p. 438,
 obs.  5, decad. 8,) who was already aware that the opening into the
 frontal sinuses has a tendency to  become  fistulous, and who, on that
 account directed his attention to the passage of the  air,  and  then to
 the rolling  up  (recoquillement) of the skin,  recommends that we
 should be careful to contract (raccourcir)  the borders of the wound
 in a  proper  manner immediately  after  the operation.  It is readily
 conceived also, that in  cases of fracture  it may sometimes become
necessary to enlarge the pre-existing wounds, at other times to es-
tablish new ones, also that if the fragments  are somewhat loose, we
may be enabled to detach them by means  of a good pair of forceps,
while, on the other hand,  if they  remain adherent at some point, it 
772
FRONTAL  sinus.
may become  necessary to employ the osteotome, gouge, mallet and
trephine.  In these cases, the surgeon should not forget that purulent
collections are especially to be apprehended in  the  direction of the
orbit, and that in order to prevent them, there  is no  better method
than to leave or to establish  a free issue for the fluids in this quarter.
The incisions required, therefore, should be placed as much as it is pos-
sible to do so, rather below than above the eyebrow.   I will add, that
it is better to make them large than small, and that the cutting pliers,
modern osteotomes and trephine should be employed in preference to
the chisel or hammer, whenever their application  would not seem to be
attended with too much difficulty, or except the  slightest danger was
to be apprehended from any concussion upon the cranium.   It would
appear that Langguth (Theses de Halter, translation, 1.1., p. 125) had
foreseen this danger when he advised the employment of the scissors
rather than recur to the trephine.  O. Acrell, (Sprengel, Hist, de la
Med., t. VII., p. 31,) on the  contrary, confined  himself to trephining
upon the superciliary ridge, in a patient where the frontal  bone had
been fractured and driven in.  In spite of the unsparing censures of
Bertrandi, in  1763, on the use of the trephine to the  frontal sinuses,
and the accusation he makes against it, of leaving an incurable fis-
tula, and of being inconvenient in its application, M.  Larrey (Cam-
pagnes Chirurg. d'Egypte, p. 136) employed it with advantage, even
in perforating through the cranium;  Collignon  (Biblioth.  Chir.  du
Nord, p. 179) speaks of a fragment of ball which,  having become ar-
rested in the upper eyelid,  produced an  exfoliation  of the  anterior
wall of the  frontal sinus, without being followed  by any fistula;
and we find in the Memoir of M. Gaultier de  Claubry (Bull de la
Fac. de Med. t. III.)  a great number of  instances where trephining
of the frontal sinuses was evidently attended with utility.

                  §  II.—Caries and Necrosis.

  Caries and necrosis of the frontal sinuses are a double disease, which
there, as elsewhere, are  sufficiently often found blended  together.
Beranger de Carpi and Dulaurens (Portal, Hist, de  VAnat. et de la
Chir., t. VI., p. 491) had already noticed that the vault of the frontal
sinus was sometimes perforated with  holes and,  as it were, worm-
eaten, and to such extent as to allow of the  fluids  penetrating into
the cranium.   Similar facts have since been  pointed  out by Fabre,
(lb., t. XL, p. 164.)  Sellien (Biblioth. Chir. du Nord., p. 100) gives
a case of venereal caries, with fungosities of the frontal  sinus, and
which he cured by means of red  precipitate.   A man had a caries
with  softening  of the internal  orbitar process; Janin (Memoire et
Observations  sur les Maladies des Yeux,  p. 290) having made an in-
cision, then excised a portion of the lips of the  wound, and removed
all the bone he  could  by means of the bistoury.   Camphorated  oil
was then applied to the remainder of the caries,  which ultimately ex-
foliated and allowed the whole wound to  cicatrize.  Delpech (Revue
Medicate, Mai, 1838) speaks of a necrosis, the extraction of which left a
large opening into the nose and frontal sinus, which opening he treated
by rhinoplasty.  The frontal bone was altered to the extent of an
inch; a crown of the trephine and some  strokes upon the gouge 
NEW ELEMENTS OF OPERATIVE  SURGERY.
773
removed the caries entirely.  Obstinate hemorrhages took place at
first, but the patient nevertheless, says Cavalier, (Societe de Medecine
de Marseilles, 1817, p. 38,)  got well in the space of a month.  M.
Riberi, (Gaz. Med., 1838, pp. 795, 796,) in two cases with caries, ac-
companied by necrosis of the frontal sinus, was not enabled to succeed,
except by means of the gouge and mallet.   So that examples at the
present day are not wanting  to  show the  resources of surgery in
cases of necrosis or caries of the  frontal sinuses.   In these cases, the
operation to be preferred is the  same as for caries or necrosis in
general.   It ought moreover to vary according as the disease is more
or less extensive, or according as it exists in  a simple state, or with
different complications.  Should the soft parts  be  sound, it would
be advisable to cut from them a semilunar  flap, with its free or con-
vex border turned upwards  and inwards, so that its lower extremity
might terminate on the ascending process of the maxillary bone.
  In cases where ulcers and  fistulas existed, all  that  would be re-
quired perhaps  would be, to enlarge  them without  making any dis-
tinct incisions.  In whatever way we have proceeded in laying bare
the diseased region, we should, in order to  complete the operation,
employ the forceps  to extract the  movable fragments, the bistoury,
or a strong  scalpel to destroy the softened  bones, the chisel or the
gouge and  mallet, if there were  only some splinters to remove, the
cutting pliers, or Liston's scissors, in cases where the diseased por-
tion might be very projecting and well circumscribed, and the osteo-
tome of M. Heine or M. Charriere, or even the trephine rather than
strokes with the chisel, should it  be necessary to go down  deep and
take away  a large portion of bone.  Caustics and  the red hot iron
employed by some surgeons, and  again recently by M. Riberi, would
not be advantageous  in such  cases, unless  we had to destroy simple
fungosities, as in the case related  by Sellien,  or thin lamellae.

                        § III.—Abscesses.

  Caries and necrosis of the frontal sinus  frequently result from an
abscess which  has formed  in the interior of this cul-de-sac.  The
pus confined in an unyielding cavern, ulcerates the mucous mem-
brane which lines it, denudes it, soon mortifies its walls, and finishes
by making a passage  to itself, either in the  direction of the orbit, or
the nasal passages, or even into the interior of the cranium ; but be-
sides that such purulent collections in themselves  involve sufficiently
severe dangers, there may also result from  them fistulas or an altera-
tion of the bone which could scarcely be cured but by one of the opera-
tions which have been described above.  It would  be advisable, there-
fore, to remedy the  difficulty in  the beginning,  if it  can  be done.
Although Borelli, Bartholin, Boetius, Tulpius,  Marchettis, Chevassieu,
D'Audibert and Celier, have seen cases where abscess in the frontal
sinus  has got well by making its way through  the nasal passages,
Richter (Bibl Chir.  du Nord., p. 242 to 249,) nevertheless advises
that we should  endeavor to re-establish the natural passages, or to
create a new one, rather than to destroy the mucous membrane of
the sinus.   Sauvages, (Nosologic, t. VIII., p. 345,) who first makes
trial of detergent injections, also orescribes the trephine.  An abscess 
774
FRONTAL SINUS.
of the frontal sinus having invaded the ethmoid bone, led to the sup-
position that it had extended to the maxillary sinus, which was unne-
cessarily perforated.   Other remedies, says Jourdain, (Maladies de la
Bouche, t. II., p» 101,) directed to the frontal sinus,  effected the cure
of the patient.   In another, Jourdain (Op. cit., t. L,  p. 78,) destroyed
the anterior nasal wall of  the maxillary sinus, in order to reach into
the frontal sinus, which was filled with pus, and to introduce  injections
into it;  Frank (Medec Prat., t. V., p. 38, French translation,) says a
physician of Vienna has  frequently trephined the frontal sinuses in
order to extract from them inspissated mucosities.  I should certainly
however not recommend that we should go to the extreme  of trephi-
ning the forehead, for the sole purpose of extracting mucosities or some
few drops of pus  accumulated  behind the internal  orbitar process.
So long as the collections in this  cavity have not disorganized its
walls, there is reason to hope  that they will make their way through
the nares ;  and this is the  termination which we ought to encourage
by means of fumigations, injections, or even sternutation, before think-
ing of the trephine. But should the disease have been of long standing,
and have resisted every thing, and caused violent pains and severe
accidents, and that its diagnosis can be clearly made out, trephining
in my opinion would be the best remedy.  Two processes may then
be employed:  either after the manner of M. Riberi, we may  incise
the soft parts in the upper portion of the  great angle of the eye, and
perforate  with a punch  or the perforating  trephine, or  with  the
scalpel only ; or what is better, with a small crown of the trephine,
the upper part of the os unguis, or the ascending process of the maxil-
lary bone, and  the extremity of the  internal orbitar process, in such
manner as to penetrate into the nares and create there a passage for
the liquids, and to be enabled to shut up the solution of  continuity
in  good season,  without  having  any apprehension  of the  forma-
tion of a  fistula.  It is  important under  such circumstances  to
avoid wounding the lachrymal sac, and the tendon of the orbicularis
muscle ;  also, it would be advisable to cut out a semilunar flap whose
free border should look inwards and forwards.  No doubt this me-
thod would be successful, if the collection  in the  frontal  sinus was
prolonged very far  downwards, and if it were not  yet complicated
either with caries or  necrosis.   Otherwise it is better directly to at-
tack the frontal sinus itself;  taking  care if it  is not yet ulcerated to
open it  at its most depending part, that is to say, between  the upper
eyelid and the  top [or the inner extremity (la tete)] of the superci-
liary ridge. The operation moreover would, in almost every parti-
cular, be the same as  that which I have pointed out in the preceding
case.   It would differ from it  only in  having to prolong the incision
in the form of an arc a little higher  up and somewhat  more out-
wardly, and that  the  trephine and perforators would act exclusively
on the frontal  bone, instead of including at the same time both the
maxillary bone and the os unguis.

                     § IV.—Foreign Bodies.

   Besides  pus, there  have been found in the frontal sinuses, undei
the character  of foreign bodies,  clots of  blood, polypi,  stones 
NEW ELEMENTS OF OPERATIVE  SURGERY.
775
worms, &c.   Chaptal, the father, (Sauvages, Nosohgie, t. VI., p.
177,) having  noticed that pains of the head which had persisted
with violence  for a long time, disappeared in consequence of a nasal
hemorrhage, concluded on that account, without, as  it seems to me,
being perfectly authorized to do  so, that blood retained in the frontal
sinus had been the  cause  of this suffering.  Instances of calculi in
the frontal sinus, related by Bartholin, F. de  Hilden, and Schenckius,
are somewhat more  positive, since an opportunity presented of iden-
tifying the objects by direct observation.  The same  may be said of
the cases of a tent there mentioned by Holegost, and also those of
a ball which, according to Zacutus Lusitanus, would constitute con-
ditions calling for the application  of  the trephine.   Cesar Magatus
(Journ. Gen. de Med., t. XLV., p. 331,) says a patient was cured by
trephining his frontal sinus for a worm, and  Rossi (Medec Op6r., t.
II., p. 116, note 5,) had recourse  to this operation in order to place a
ligature around the root of a polypus,  which  he afterwards extracted
through the nares.   A fistula which was thereby caused in this case,
lasted for  the  space  of three years, and was not cured until after
the rupture of the osseous lamina which separates the sinus from  the
nasal cavities.   In the case of M. Hoffman  (Rev. Med., 1826, t.  II.,
p.  152,) it became necessary after the extraction of  the polypus, to
pass a seton from the sinus into the nose. M. Langenbeck (Biblioth.
Chir., or  S. Cooper's Dictionnaire de Chir., t. L, p.  439,) finding a
large tumor external to and above the root of the nose, had recourse
to  the trephine in  order to open into it, when he recognized that it
was made up of an  enormous hydatid mass.  A cavity two and a
half inches deep remained at the place which  the tumor had occupied.
Other  foreign  bodies also have been noticed in the frontal sinus:
Salzmann (Convulsions des enfans, p. 248,)  states that he has found
and killed worms there.    M.  Maunoir {Questions  sur les corps
etrangers, p. 204,) and also M. Breschet (Diet, des Sc. Med., t. VIL,
p.  4,) speak of balls  retained in this  cavity for  the  space of three
months.   M. Larrey (Campag.  Chir., t. IV., p.  89,)  relates that  the
Chevalier Erasme retained the point of a javelin for fourteen years
in  the frontal  sinus.   M. Dezeimeris (L'Experience, t. I., p.  572,)
has extracted  from the cartons of  the ancient Academy of Surgery,
the case of a fungous tumor of the form of the patella, and which was
situated in the frontal sinus.  M. Brunn, (De Hydrope Cystico, &c,
Berlin, 1829 ;  Journ. des Progres, t. II., ser. 2, p.  255 ; L'Expe-
rience, t. I., p. 568,)  a Prussian surg.eon, speaks of a young girl who,
being tormented by a supra-orbitar tumor,  died after having been
submitted to a crucial incision upon the same and the  employment of
the seton.   Now this tumor, which was attended with a sero-san-
guineous liquid  and  a fetid suppuration, and which  was five and a
half inches long and four  and three-quarters in  breadth, situated in
the frontal sinus and  composed of cells or small bladders, which had
become developed in the  space  of five years, might  have evidently
been extirpated if it  had  been attacked at an earlier  period and in a
proper manner; an instance of a hydatid tumor of the forehead had
already been mentioned by M. Corby, (Biblioth.  Medic, 1829, t. III.,
p.  20,) but in this case the disease was altogether independent of  the
sinus.'  The presence of foreign bodies in the frontal sinus would still 
776
FRONTAL SINUS.
more positively call for the application of the trephine than any other
of the diseases of which I have hitherto spoken.   Their  diagnosis,
therefore, is a point of great delicacy.  As  to the operative manual
here, also, two modifications would be offered, according as the sinus
was intact or already laid open.  In the first case it would be neces-
sary to cut down in  such  manner  as to lay bare  the  tumor exten-
sively, and in preference by the semilunar flap which I have indi-
cated in the beginning.   The crown of the trephine would be better
adapted here  than any where  else, and even than the other osteo-
tomes: only that it would be advisable to apply two small ones, one on
the.side towards the orbit below, the other at the top [inner extremity]
of the superciliary ridge above, which  should be  done  in order to
obviate the inconveniences which result from the irregularities of the
frontal bone in this region.  The points, bridle or bridge left between
the two crowns, could afterwards be easily destroyed by  means of
the scalpel, cutting pliers  or  chisel.  Should  there  have already
existed any fistulas or ulcerous  passages, they could be made use of
as a guide  by which to reach the foreign body, and the enlargement
of these might be all  that was  required to give to the incisions the
form and extent that were necessary.  I have no need of remarking
that the foreign body itself when once laid bare, may require the aid
of the forceps, even the cutting pliers, and  elevators and  ligatures,
and  the use of the bistoury and dissections, more  or less cautiously
conducted, according  as it is movable in the sinus or implanted in the
bones, or is in  a fluid state or concrete.  This remark applies also to
necrosis as well as to foreign bodies.

                              §V.

  Though the  immediate consequences of this operation might be se-
rious, they  are nevertheless ordinarily very simple.  One of the most
disagreeable is that of often leaving a fistula, which is exceedingly
difficult to close up.  I have, however, seen this fistula heal up in two
instances in patients who had  the anterior wall  of the frontal sinus
destroyed  by necrosis, and in  a third in whom this wall was  lost in
consequence of a comminuted  fracture.  That of P.  Gerardi, after
receiving no benefit from the dilatation of the frontal  sinus through
the nares, yielded to the action  of a machine similar to  that which F.
ab Aquapendente and Petit made use of to compress the lachrymal sac,
a contrivance which Rossi, (Medec Oper., t.  II., p. 244,) who does not
pretend to  have  invented it, calls a presser  (pressoir), and which M.
Riberi, who again revived it in  1838,  appears to have  employed like
his countryman, but without obtaining, however, any real advantages
from it.   "Perhaps it has not been sufficiently examined  in these cases
if the interior of the sinus was  perfectly free of disease.  I suspect,
in fact, that the fistula here depends chiefly upon certain  particles of
altered bone, or ulcerations, or points of caries, much more than on the
physical and natural disposition of the sinus.  I would, therefore, ad-
vise before all other steps, that  we should carefully explore the parts
and remove from the region every thing which has the least appearance
of disorganization.   If after this, lotions and detersive and  astrin-
gent injections, and even slight cauterizations  should  not suffice,  I 
NEW ELEMENTS OF OPERATIVE  SURGERY.
777
would then willingly give the preference to perforation of the inner
wall of the sinus in its lower portion, and in such manner as to make
[t communicate freely with the nose. Rossi (Med. Oper., p. 116, note,)
by dilating the internal orifice and breaking the nasal wall of the sinus,
succeeded  completely.   Perhaps even an  opportunity  would here
otter of  inserting  a large  and  somewhat  short canula constructed
after the model of lachrymal canulas.   In conclusion, the facts which
relate to the operations required for the frontal sinus, are  so dispersed
through  works of science, and  given  mostly with details so  vague,
and these operations have been so rarely performed with us,  that it
would  be difficult at the present time to subject them to general rules
that are either very precise or very useful. [See a note farther on. T.]
CHAPTER  II.

     FACE.
   The operations which are performed on the face are numerous and
varied, but many of them have been described elsewhere, (see Vol.
I. and Vol. II. of this work, on the respective subjects of Anaplasty,
Exsections, and Tumors.)

   Article  I.—Operations which are performed  on the Nose.

   I have not to consider here the different  forms of rhinoplasty, the
details of which will be found under the chapter on  Anaplasty, (Vol.
I. See also our notes there.)

                          § I.—Tumors.

   Tumors of various kinds may be developed in the nose, the same as
in any other region.  As I shall have to treat of polypi of the nasal
fossae after having spoken of the operations which are performed on
the velum palati, I do  not  design at the present moment, to touch
upon  any other than tumors which are situated  in the substance of
the nose, properly so called.  As respects the operation they  require,
these  tumors form two classes, some of them having their seat on the
body  of the organ, others in the septum.
   A.  The nose, properly so called.—I. We find on the body of the
nose three principal varieties of tumors  which occasionally require1*
the aid of operative surgery.  These are worms (tannes or maggots),
cancers or elephantine masses.  In no region, perhaps, are the sebace-
ous follicles more frequently altered than upon the nose.  So long as the
substance with which they are filled does not exceed the dimensions
of a pin's head, and are unattended with any degenerescence of the
cutaneous tissue, the disease would not justify any kind of operation.
On the contrary, should the crypt itself become thickened and trans-
formed into a tumor which had acquired the size of  a bean or the
   vol. 11.                       98 
778                           nose.                             '

head of a nail, it might be  advisable to attack it by other means than
by simple pressure.   In such  cases the subject of extirpation might
be taken  into consideration; but  cauterization  with a  crayon of
nitrate of silver  cut into the shape of a cone, with its point carefully
introduced into the aperture and down to the bottom of the sebaceous
follicle, will almost always answer.   If the tumor were still more de-
veloped ; if, for example, it exceeded the volume of a small nut, and
presented itself under the aspect of a cyst with  thin walls, filled with
matter of a purely fatty character, then  extirpation would evidently
be preferable.   [See  our  note  above, pp. 60-63, giving the case
(with plates) of  those  enormous tumors  of this kind, which I suc-
cessfully removed at Nassau, capital of the Bahamas, in 1824.   T.]
   II. Tumors and cancerous degenerescences of the nose usually exhi-
bit characters that are altogether peculiar.   They are usually rather
plates, bumps, (bosselures,) or incrustations, than tumors that are ex-
actly circumscribed, or that can be arranged under scirrhus, or those
that  are encephaloidal, or melanotic, or of the colloid tissue.   Their
origin  most frequently seems  to be connected with a vitiated secre-
tion  or degenerescence of the sebaceous follicles themselves.   In all
cases these tumors, which are usually badly defined, and scarcely
found  except  in persons advanced in age,  exact certain precautions
in a surgical  point of view.  The treatment by caustics generally
succeeds with them perfectly well.   A lady who had one  of the dia-
meter  of an  inch for many years, was cured by means of four cau-
terizations with  the nitrate acid of mercury.  An ancient officer of
marine, whom M. P. Pelletan  sent to me, had, on the left  side of his
nose, a cancerous, bosselated, sanious plate of a reddish color, which
had been there over two  years.  Every kind of topical and internal
treatment had been resorted  to in this case.  Slight cauterizations
with the liquid above mentioned, effected a cure in the space of six
weeks.  The father of a young physician, in the environs  of Nantes,
had,  on the lobule of his nose, one of  those plates, (plaques,) which
completely disappeared under  the influence of four similar cauteriza-
tions ;  and I could at the  present time relate a great number of simi-
lar facts.  To succeed in such cases, it becomes necessary to clean
the tumor carefully of all the  crusts with which it may be covered.
I  then besmear it with butter in the evening  and morning, with the
view of softening this incrustation the night before each cauterization.
All the crusts thus  besmeared easily allow afterwards  of being de-
tached, and we thus have the altered plate immediately naked before
us.  I  then take  a small pinch of lint which has been saturated with
the liquid above mentioned, to touch in every part,  and even a little
beyond it, the surface to be destroyed.   The pain which it produces
at first is  sometimes quite severe.   The  parts touched by the acid
become white, and  excite occasionally a slight exudation of blood;
there is then formed upon the surface a yellowish crust,  which  may
be detached at the expiration of four or five days, in order to renew
the same operation,  and so on to the end of the  cure.  From four to
six or eight cauterizations applied in this manner are  generally suffi-
cient.  If the plate should be composed of an agglomeration of seba-
ceous follicles, the cone of nitrate of silver introduced to the bottom
of each one of them would succeed equally well, and would even be 
NEW ELEMENTS OF OPERATIVE  SURGERY.
779
more suitable.   When it is thicker, hard, and of a certain breadtn,
the zinc paste appears  tome to be preferable.   Having vivified
(avive) the altered surface, by means of ammonia 01 a blister, and
taken  care to  do so effectually,  which  the nature of the tissue in
these cases sometimes renders difficult, we apply over it a plate of zinc
paste, (pate de zinc) from one to three lines thick, in such  a manner
that this plate goes half a line beyond the entire circumference of the
tumor; we then  fix it here by means of a suitable containing ban-
dage, taking care that nothing is disturbed, at least during twenty-
four hours.  All the degenerated tissue is transformed, by means of
this caustic, into an eschar, which falling off at the end of six to twelve
days, leaves in its place  a wound whose  aspect soon announces that
cicatrization is about to commence, and whose bottom dries up and
quickly becomes  a  sufficiently regular  portion of the  surface of the
nose.   Moreover it  is important, when we employ zinc paste, potash,
or butter of antimony on the nose,  not to penetrate too deeply, and
to remember that in this  region the teguments are very thin, and that
it  would be easy to come down upon the bones or to the cartilages,
so as to produce a necrosis there, as M. Champion has seen in two
instances.    Upon the  supposition that the tumor had much  more
thickness than breadth, we might perhaps attack  it with the bistoury
rather than by caustics.   We should succeed by  this method if, after
the tumor was removed, the lips  of the wound  could be readily
brought together, either by simple tractions, or after having detached
them  on their  deep-seated surface to  the extent  of some lines all
round.  Should the  loss  of substance be too considerable to do this
with facility, we should have nothing more to do  than to recur to the
resources  of rhinoplasty, or be contented with  a cicatrization by
second  intention.  This  last practice would have to be adopted for
the operations  performed on the sides of the nose, and between the
forehead and the wings  of this organ;  and in this case there could
be no  other than advantages  follow from cauterizing at the first the
whole  bottom of the wound.   At the root of the  nose anaplastic pro-
cesses present sufficient chances of success to authorize their employ-
ment.   At  the point  or the  alae,  they  would  become  still  more
important, since  cicatrization there by  second  intention  is almost
always followed by considerable deformity.
   III. Elephantine Tumors.—The nose, in certain individuals, is some-
times transformed into a reddish mass of a violet color, at other times
simply greyish  and covered with bumps, and which has given rise to
the expression  of mushroom or potato nose.   This alteration, which
seems to be no other than an extraordinary development of the natural
integuments of the part, may acquire so great a degree of extension that
there results from it upon the nose an actual tumor, very analogous as
to its nature to elephantine tumors of the scrotum.  These tumors have
sometimes been seen to acquire a weight of several pounds.   As they
do not cause any pain, rarely ulcerate, or undergo any transformation
of a bad character ;  and  as it is also almost impossible to get rid of
them by other than by surgical means, patients do  not usually pay any
attention  to them until they have arrived at a very advanced stage
of their development.  Imbert de  Lonnes (Oper. Faite, le 16 Bru-
maire, an VII, in 8°, 8 pages,) has published a very remarkable exam- 
780
NOSE.
 pie  of one.  A former mayor of Angouleme had on his nose a bos-
 selated tumor  of the weight of about two pounds, and which hung
 down as far as the chin, hermetically closing up the nostrils  and the
 mouth.  This man, in order to breathe and speak, was obliged to bend
 down with his head forwards.  He could neither eat or sleep except
 by raising up his tumor, which he suspended by means of a sling fixed
 to his night-cap,—a ligature, which had been made trial of, caused
 such pain  that it  had  to be laid aside.  Imbert then decided upon
 extirpating  it,  and was obliged to lay bare the whole surface of the
 nose, which operation required  twenty-two minutes.   No  accident
 took place, and the patient  got perfectly  well, preserving a nose
 which was not very greatly deformed.
   Analogous facts have been related  by the Academy of Surgery,
 (Mt  moires, t.lll., p.  511,) and the work of Hey contains some which
 are not less interesting.  The subject, however, had no longer been
 spoken of by practitioners, when M. Dalrimple  (The Med. Quarterly
 Review; Gaz.  Med., 1834, p. 136,) communicated  new facts in re-
 lation to it.   In his first patient, who was fifty-four years of age, the
 tumor hung down upon the mouth and reached nearly as  far as  the
 chin ; the surgeon removed  it on the 4th of August, 1826, and  the
 wound healed  up in a month without leaving  any disagreeable  de-
 formity.  Another patient operated  upon in the same manner, got
 well in as short a space of time.  In pei-forming this operation in 1831,
 in a  man who was more than eighty years of age, M. Dalrimple was
 obliged to remove a  tumor  almost as voluminous as that which has
 been described and  figured  by Imbert de Lonnes.  No indications
 of a return  have shown themselves since.  In  these different cases,
 it is  important during the  dissection  of  the parts, that the surgeon
 should place one of his fingers in the nostril, in order to direct the
 action of the bistoury, and to guard himself better against every per-
 foration.  As for the rest, the removal of maggots, cancers, and ele-
 phantine tumors of the nose does not differ from that of diseases of
 the same kind which are seen in any other region.   It would be  the
 same also with erectile tumors: Marechal (Archiv. Gen. de Med.,
 t. XXIIL, p. 149) successfully extirpated one which was of the size of
 a nutmeg, and which was situated at the tip of the nose.
   IV. I will nevertheless remark, that on this  last point it is impor-
 tant  to recollect the cul-de-sac which lies under it, and that the lobule
 of the nose is hollow behind,  and generally  furnished with walls that
 have but little  thickness.  So that in fact this  organization renders
 their perforation almost inevitable when the cutting instrument is ap-
 plied to it, or the slightest  caustic of any  activity.  From whence
 there results a  species of hole which is  readily transformed into a
fistula, and which being once cicatrized in its periphery, cannot after-
 wards be closed but  with an extreme degree of difficulty.   I  have
 met  with two patients in whom the end of the nose had been excised
 in order to destroy a cancer, and in whom this fistula resisted every
 kind of attempt directed against it.   A  young girl, who in falling
 from her bed cut her lip and the lobule  of the nose, in striking her
 face against a chamber-pot, which she broke, rapidly got well of all
 her wounds, with the exception of a point of the lobule of the  nose,
 which remained fistulous.   I was not  however enabled to cure this 
              NEW ELEMENTS OF OPERATIVE SURGERY.           781

fistula, until after having abraded it by means of the  bistoury, and
reunited its borders by a point  of the twisted suture.  The attempt
at reunion by every different kind of bandage  or  plaster, cauteriza-
tions with the nitrate of silver, nitrate acid of mercury, and the  head
of a probe heated to a white heat, which had been  made trial of du-
ring the space of two  months, had  completely failed.   We should
have, therefore, in such cases, to  resort to  abrasion and the suture,
provided the suspension or the elevation of the end of the nose by
means of adhesive plasters or any kind of bandage  and  cauterizations
well applied, did not answer at first.
   B.  Tumors of the Septum, (cloison.)—The septum of the nose in
front of the cartilage which divides the nares into two  passages, is
quite frequently the seat of tumors, to which the moderns only  have
paid any serious  attention.   These tumors  sometimes  concrete, but
most  usually  liquid,  establish  themselves  between  the two tegu-
mentary layers which are continuous from the exterior  to the interior
to line the nasal  fossae.   An  English surgeon,  M.  Fleming, (Dublin
Journal, 1833 ;  Gaz. Med., 1833, p. 798,)  has  frequently met  with
tumors purely sanguineous in this part, a disease which is sufficiently
common in that country, says the author, in consequence of the mode
of attack which the  English  so often make use of in their pugilistic
combats.  M. Cloquet (Journ.  Hebd., No. 91, p. 544, 1830) appears
to have observed abscesses here  very frequently, and M. A. Berard
(Arch. Gen. de Med., 3e serie, t. I., p. 408) has published two cases
similar to  those of M. Cloquet.  I have also  on my part seen in the
substance of the sub-septum of the nose, collections  of blood or of
pus and masses that were semi-contrete, and, as it were, tuberculous.
Whether liquid or concrete, the tumor, nevertheless, in such instan-
ces, protrudes on each side into the openings of the nose.  If it is a
deposit of blood from external violence, time and  topical resolvents
will generally remove it in the  space of fifteen days or a month.  la
case of failure, we should have at a subsequent period  to treat them
by incision, or in the manner I have  said of cephalematomata.   Ab-
scesses should be laid  open as soon as possible upon  one side, and
freely, if the same sac projected to the right and left; upon two sides,
on the  contrary, if there were two abscesses there in  place of one.
We should proceed also in the same manner if the  abscesses were
simply tuberculous, except that we should  then have to apply after-
wards the nitrate of silver throughout the whole extent  of the morbid
cavity.   For tumors that were purely concrete, or where there was
an alteration of the anterior border  of the cartilage of the septum
narium, we should have to proceed in another way.  In  describing the
sub-septum  of the nose, Bichat indicates the possibility of an opera-
tion which up to the present time had existed only as  a  project, but
which M. Rigal has performed.  In backing on the median  line, the
cartilages of the lobule leave  between them a small groove, percepti-
ble even through the skin, which  enables us to  separate  them apart
by means of the instrument, and  to penetrate as far as  to the septum
narium without opening into  those cavities.  A cancerous tumor de-
veloped under the anterior nasal spine, and which  had gradually ex-
tended in  front, downwards, and  on the side, as far as to the  alee of
the nose, had  nevertheless scarcely altered  the tegumentary layer. 
782
NOSE.
  Two incisions, united in front and passing around benind  and out-
  ward in such manner as to represent a \ reversed, having surround-
  ed the cancer laterally, it became easy/by means of a transverse in-
  cision, to  detach it below from the upper lip, then by doubling back
  the two lips of the  first wound, to arrive at  the cartilage of the sep-
  tum,  to excise its anterior  border and remove the entire morbid
  mass.  The sides of the division  were afterwards brought  together,
  and  the  cure was  uninterrupted  by any accident, unless it  was
  that  the progress of the cicatrization, by drawing the  tissues back-
  wards, had ultimately  flattened a little the  alas and  the top of the
 nose.

           $ II.—Occlusion and Contraction  of the Nares.

   In consequence of confluent small-pox, syphilitic or other inflamma-
 tions, rhinoplasty itself, and  all lesions in  fact which may alter the
 form of the nose, the anterior opening of this organ is liable to be-
 come^ closed up, or at least to be narrowed to so great a degree as to
 interfere very  materially with respiration.
   A.  Ordinary processes.—We  remedy such inconveniences by
 three different modes : 1. Dilatation ;  2. Incision ; 3. Excision.  It is
 rare that dilatation alone suffices ; it is besides applicable only in cases
 of narrowing, and not of entire closure of the passages.  Incision in its
 turn almost always requires dilatation to be associated with  it.  Ex-
 cision becomes useful  only where tubercles  or morbid  projections
 are to be removed.   Should the opening be merely narrowed we in-
 cise it by numerous excentric cuts, and to greater or less depth, ac-
 cording to the extent of the  disease.   When it is entirely closed up
 a narrow bistoury should then be plunged in at the place which it
 usually occupies.  We make in this manner an antero-posterior in-
 cision, the  borders of which  it would  be afterwards advisable, as  I
 think, to divide on two or three points of their length.  To prevent
 the wound or small wounds from reuniting  and destroying the effect
 of the operation, it is recommended to keep them open and separated
 apart by means  of a  tent of lint  or linen.  As we must by every
 means m our  power force  them  to cicatrize separately,  ana in the
 position we have  first given them, it appears to me that we micmt at-
 tain our object  better by means of a piece of  sheet lead rolled°up in
 the shape of a ring, and to which we could moreover give such form
 as we desired, than by means of the dilating bodies  generally em-
 T^aa   i/S'  hTever' an  °Perati°n  too  simple to require that I
 should dwell any longer upon it.  Nor have I found that it has been
 as difficult as has  generally been said, to give  to the opening of the
 nares again in  this manner, their  necessary dimensions.   A youm?
 girl  whom I received  into the hospital of  La Pitie in 1833, and in
 whom the openings of the nose had been reduced to a small aper-
 ture, m consequence of an eczematous affection, which had  been for a
 long time cured, was submitted by me  to the excentric incision of the
 cicatrix, afterwards to dilatation bv means of  a large canula  of ffUm
 elastic, and recovered perfectly well.   I saw her again more than a
year after,  and  there was not the slightest tendency to any contrac-
tion of the anterior opening of the  nares. 
NEW ELEMENTS OF OPERATIVE  SURGERY.
783
  B.  New method.—If the incision or the simple excision  should not
appear to present all the chances of success desirable, there might per-
haps be a mode of arriving at  something more certain, by adopting
the following course.  The surgeon, provided with a straight bistoury,
would circumscribe the whole of the deformed cicatrix, by surround-
ing its base on  the border of the  former opening, and very near the
skin of the nose.   Afterwards  dissecting this  circle as if to  isolate
it, as it were, from the internal surface of the organ, and in such man-
ner, that  after having removed the entire arcade of morbid tissue we
should have in  its place a prismoidal groove, there would be nothing
more  to do than to bring together the two borders of this new wound
by a sufficient number of points of suture.   We should thus procure
immediate reunion by  means  of an  operation,  which  leaving no
wound, nor any traumatic surface in the interior, would not expose to
a new contraction.  It would be, moreover, applying to the openings
of the nose, what I  have proposed as  one  of the best methods for
contractions of the  mouth.  I will add,  that by following this method,
it would  be rendered almost unnecessary, to  keep a canula or any
foreign body in the nose  during the   cicatrization of the  wound.
Having treated of the manner of reconstructing the sub-septum and
the alae of the  nose  under the  chapter on Anaplasty, I do not pro-
pose to recur to it again at this time.   I will only remark, that hav-
ing seen  in 1838  the person formerly operated upon by  M. Gensoul
and previously by  Dupuytren,  I was enabled to  ascertain that the
flap borrowed from the upper lip  and fixed to the lobule of the nose,
in order to construct the fibro-cartilaginous septum, which a lupus had
destroyed in this patient, had maintained itself in a  sufficiently satis-
factory condition.   The only inconvenience which results from it is
a slight depression of the lobule of the  nose and too great a projec-
tion of the sub-septum (or  .columna) below.   This fact proves then
incontestably, as do those also which have been published by M. Lis-
ton, that the sub-septum of the  nose may be perfectly well re-estab-
lished by means of an  elongated flap  taken from  the middle of the
upper lip.  (See notes on Anaplasty, Vol. I.)
  C.  Rhinoraphy, or the simple  suture of a slit, either in the alas or
in any other part  of the nose, as practised with success by M. Roux,
and also  by myself, being no other than a modification of rhinoplasty,
or subject to the same rules as cheiloraphy, does not require to be de-
scribed separately.
                               •
           Article II.—Lachrymal  Passages  (voies).

  The nasal canal, formed on the inside by the posterior border of
the ascending process of the superior  maxillary bone, and the  an-
terior third of the  os  unguis, and altogether  below by a  small
lamella  of the  inferior turbinated bone;  outwards, forwards, and
backwards, by  the maxillary bone, and its turbinated bone, and then
in a slight degree by the ensifbrm process (crochet) of the os unguis;
having a length of three to  five lines ;  circular, at the middle part;
a little wider from  before backward than  transversely, on its upper
portion;  and terminating below  by an orifice which flares  open in
the manner of a funnel,—possesses  in  reality  no  solidity except in 
784
LACHRYMAL PASSAGES.
the antero-internal third of its circumference: from whence it follows
that in attempting to pass an  instrument (traverser) through it, it is
very easy to break its other walls, and penetrate either into the nasal
fossae or" the  maxillary sinus.  The lachrymal groove (la gouttiere
lacrymale.—i. e. gutter.) which seems to prolong its internal wall as
far as to the corresponding orbitar process of the frontal bone, and
which is more and more superficial in proportion as we ascend into
the orbit, presents  on the other hand  inferiorly two  lips, which  are
easily recognized ;  one anterior belonging  to  the  ascending process,
the other posterior and formed by the outer  crest of the os unguis.
The fibro-mucous membrane, which  lines the nasal canal, and  to
which it is but slightly adherent, becomes much stronger and more
complicated in the gutter, where it takes the name of the lachrymal
sac.  Here the direct tendon of the orbicularis muscle crosses its an-
terior face at a right angle, as if to divide it into two halves, the one
superior upon which  this tendon sends off a fibrous expansion, known
under the name of reflected tendon, the other inferior and lined out-
wardly by cellular tissue, and which has boundaries which it is exceed-
ingly important should be understood.   This  last  mentioned portion
[of the lachrymal sac] is always confined within that triangular space,
which is  bounded  above by the direct tendon, below by the  border
(rebord)  of the orbit, and outwardly  by  a vertical line  which
would fall upon the outer side of the caruncula  lachrymalis.  It is,
moreover, covered only by some fleshy fibres, and by lamellar tissue,
and the teguments of the  nasal angle of the  eye.  Being but feebly
supported by the  surrounding  tissues, it readily yields to the influ-
ence of causes which have a tendency to dilate it, and thus frequently
becomes the seat of tumor and of fistula lachrymalis.
  The apertures  for  absorbing  the tears,  (puncta lachrymalia,)
and which are surrounded by a  small elastic and dense,  but  not
cartilaginous circle, have  a direction  perfectly vertical, but form a
very distinct angle (coude) where they become continuous with the
lachrymal duct, properly so called.   This  last, which traverses only
the inner fifth of the free borders of the  eyelids, is  situated more
especially upon their  posterior  portion.   Being  formed  by  the
mucous membrane only, it  is  exceedingly  thin,  and superficial
in its postero-superior  half; while the  remainder of  its circumfer-
ence, making part of the body of the eyelids, presents in front and
below a far  greater  degree  of solidity  of texture.  Now, it  is this
anatomical arrangement which obliges  us to enter perpendiculariy
at first, in order to rest afterwards much more in  a direction towards
the eyelid than the eye, when we catheterize the lachrymal ducts
themselves.   At their entrance into the sac these ducts are sometimes
separated  by a small  projection or sort of spur ; frequently also, they
unite together by one opening.  Taken together, the  lachrymal  sac
and nasal  canal present a double curve, which has some  resemblance
to that of  an Italic S, that is to say, that the first  [the sac] is slightly
convex posteriorly and inwards, while  the second [the nasal canal] is
so in the contrary direction; so that in order to perform catheterism
on the upper eyelid, we must take care while the probe is traversing the
sac, to incline its lower extremity rather forwards and outwards, than in
an opposite direction, and that in order to traverse the nasal canal, it is 
NEW ELEMENTS OF OPERATIVE SURGERY.
785
better, on  the  contrary, to push the instrument from  before  back-
wards,  and from without  inwards.  As every  one must  have re-
marked, the axis of the nasal  canal in its relations with the supra-
orbitar  projection, presents  very numerous modifications;  as does
also the depth  to which we  have to go to find it  in the orbit.   In
persons in whom the root  of the nose is flattened and  broad (large)
it appears to be  thrown  outwards,  and perceptibly  contracted.
When on the contrary, the ossa nasi (les os carres) are very nearly
approximated to  each other  at their inner surface, we  cannot  reach
it except by coming  much  nearer to  the  median line.  When the
frontal  bone is very  projecting, and the  maxillary  bone very pro-
minent,  the nasal  canal (conduit  des  larmes)*  is found at a very
considerable distance from the posterior surface of the direct tendon,
while  in  persons  who have the  canine  fossa very deep, and the
forehead depressed, it appears to come  out  a  slight distance beyond
this tendon.  The species of valve or diaphragm which contracts its
lower extremity, is usually perforated  only in its posterior  half.   Its
orifice [i.  e., the outlet of the nasal canal into the nostrrt, T.] is
situated at the depth  of six  or eight lines in the  nose, at  the apex
of a cavity which  is bounded in front by the base of the ascending
process of the os maxillare, and  inward by  the concave surface of
the inferior  turbinated bone.  As  this cavity is  prolonged a little
more in front of than posteriorly to the lachrymal valve, it happens
sometimes that catheterism at this lower part (catheterisme inferieur)
is very difficult  if the surgeon is  not aware of  this  arrangement.
The length of  the nasal canal itself rarely exceeds from  six to eight
lines.   Demours  has met  with  bridles in  the  nasal  canal.   M.
Taillefer (These, Paris,) describes a membranous duplicature [repli]
which was situated in its upper third, and the free border of which,
directed downwards, sent off several filaments, which  attached it to
another point in the same canal; so that if a probe had been passed
from below upwards it would evidently have been arrested by this
anomaly.    Different  authors  whose  observations  are given by
Sandifort, relate examples of small calculi found in the lachrymal pas-
sages ; similar  instances also have been since  related  by Schmucker,
Eller,  Walther,  Krimer,  M.  Levanier, M.  Graefe, and  formerly
by Kern.   More than this, the nasal canal  has been found entirely
closed ; Morgagni gives  an instance where  both were  closed, [en
relate un exemple double,] and Jurine  as  well as Dupuytren, have
both met with one.   The lachrymal passages may be  the seat of
lesions in each of their three principal divisions, viz., in the sac, the
ducts and the puncta  lachrymalia, and  also in the nasal canal.

                § I.—The Puncta and their  Ducts.

   A. The  puncta  and lachrymal ducts may be  obliterated.  Small
pox, purulent ophthalmia, a long protracted blepharitis, wounds and
ulcers on the internal portion of the  eyelids, are the principal sources
of this alteration.   The tears being  then no longer able to penetrate

  * As our author a few lines above  applies conduit lacrymal to the lachrymal or tear
ducts properly so called, this inadvertence might  lead to  ambiguity, but for the subse-
quent rectification it receives by his admirable anatomical precision. T.
  vol. ii.                       99 
786
.   LACHRYMAL PASSAGES.
into the sac, run over upon the cheek, so that the eye is moistened as
if weeping, (lave.) while there is present at the same time a peculiar
drvness in the corresponding nostril.  We may then have present
epiphora, an  alteration, or  even the disappearance of the punctum
lachrymale, and ulcerous, purulent, atrophied or hypertrophied con-
dition of the border of the evelids, and afterwards of the nose, with
the absence of all kind of tumor or fistula  lachrymalis.
  Gunz states that he has seen a case of this kind in which however
the tears found their way into the nasal canal by means of porosities
which were recognizable to the  naked eye.  This kind of alteration,
which has not been taken  notice of but by a few persons, is worthy
 f additional researches and appears to be altogether incurable.  J.
L. Petit and Pellier,  who  pretend to have reconstructed an oblite-
rated lachrvmal duct, by passing a sharp  pointed probe through the
place it had  occupied, were  certainly deceived by some of the cir-
cumstances  of the case.  Whatever in fact may be the instrument
made use of to fray out a  passage so delicate as the lachrymal duct,
and  whatever may be the kind of seton afterwards employed in this
passage to keep it open  permanently, we  may rest assured that the
tears will not take that course, and that it will shut up  as soon as the
•dilating body is removed.  Such operations therefore are perfectly
useless; it is better  in such cases  to imitate  Bosche  (Malgaigne,
 These de Concours,  1835,) and  cauterize  the puncta  in order to
close them permanently, should there be any trace .of  them  left.  If
they were merely contracted or only obstructed by some thick mat-
ter, all  that could be done would  be to  clean  out  the  passage by
means  of Anel's  syringe  and injections.   In such cases  A. Petit
{Peiffer, Theses de Paris,  No. 222,  1830)  and Leveille (Traduct. de
Scarpa, t. L, p. 84,) are of opinion that we ought to establish an open-
ing to the lachrymal sac by means of loss of substance between the
■caruncula and eyelid, at the place which Pouteau had  selected.  But
it is  not probable  that such an opening would keep open for any con-
siderable  time, nor that it would  afford  any particular relief.  An
artificial opening by excision to the duct itself, upon the inner side of
the punctum obliterated, would  do much better.   It continued open
in two  patients upon whom I had operated with another object  in
view.
   B. Fistulas of the  Duct.—Should any  ulcer  or  lesion happen  to
perforate the lachrymal  duct on  the side  towards the eye, there
might result from it a particular form of fistula which is one of the
most difficult to heal.   A thread of gold or silk, or small cord of cat-
gut, passed  in the manner of a seton through the  injured duct,, from
the punctum as far as the lachrymal sac, is the only remedy that art
possesses against  an  infirmity  of this  kind, unless we should have
 recourse to opening the nasal canal  on the inside of  the eyelids.   I
 have moreover, in two cases, seen the tears pass  through  the  new
 route, that is, by the  accidental aperture  into the  duct, in the same
 way as through  the  natural punctum, without any inconveniences
 resulting therefrom, and I doubt if fistula of the puncta lachrymalia
 in reality constitutes  a disease.
   C. Cysts.—Sometimes also one of the puncta of the lachrymal duct
 becomes dilated  in the manner of a  cyst.  So at least J.  L. Petit, 
NEW ELEMENTS OF OPERATIVE  SURGERY.
787
Boyer and Pellier state that they have seen it.  As the tumor causes
no pain, it should be treated by resolvents, so long as it shall not have
acquired  such size as to render it too troublesome.  It would more-
over be unnecessary to extirpate it in order to obtain a radical cure;
as it would be equally certain to disappear by laying it open and
cauterizing its interior.  Formerly  they used  to  expect that there
would result from this an obliteration of the duct  and probably also
an incurable epiphora.  But I shall have occasion farther on to refer
to some facts which will  have a tendency to allay the fears of sur-
geons on this subject.
  D.  Polypi.—The lachrymal puncta are also liable to a species of
small vegetations or kind of polypi.  Demours  (Precis des Maladies
des Yeux, 1821)  speaks of a small fungus which protruded from the
lower lachrymal punctum, and which he cured by excision followed
by cauterization.

       §  II.—Lachrymal Tumors and  Fistulce Lachrymales.

  The lachrymal tumor is rarely if  ever a dangerous disease: it in-
commodes by the crustaceous condition  which  it keeps up on the
border of the eyelids, causing thus a  predisposition to ophthalmia,
the sensation of dryness which it produces in the nostrils, the purulent
matters which it forces to flow back upon the eye, and by the deformity
it causes  in the great  angle;  but it  compromises neither life nor the
general health, nor even the physiological  condition of the globe of
the eye, properly so called.  It may however ultimately, and it is
thus in fact that it most frequently terminates,  give rise  to acute
inflammation in  the sac, then in the neighboring tissues, or it may
become  transformed  into an  internal  anchylops, and finally pro-
duce a fistula lachrymalis.  This inflammation of the lachrymal sac
sometimes reaches the periosteum  of the neighboring bones, as of
the os unguis (lachrymal bone),  for example, or the maxillary or
ethmoid, or even the  frontal and  nasal bone, so  as to denude them
and cause necrosis or caries of the  inner wall of the lachrymal sac
or nasal canal.   I have seen this inflammation extend itself to almost
the entire side of the  face, and terminate in the manner of phlegmo-
nous erysipelas in the eyelids  and at the root of the nose.   Happily
these are but exceptions, and the lachrymal tumor rarely gives rise to
any other than a very circumscribed abscess before it becomes trans-
formed into  fistula.
   Fistula lachrymalis therefore  is- but one of the consequences of
the tumor of the same name.   It appears to me however that this  fis-
tula may in some instances be formed without having been preceded
by tumor of the sac.
   We may conceive for example, and I have now instances in point,
that a loss of substance, either in  consequence of  certain operations,
or we will suppose, from wounds, contusions,  burns, or ulcerations,
might destroy a  part of the free portion of the lachrymal sac in such
manner as to establish there an actual  fistula.  I  believe, moreover,
to have in two instances seen a fistula establish itself from the exterior
to the interior, after  the anchylops had  already  made its  way out
through the skin. However this may be, fistula lachrymalis is an ulcer 
788
LACHRYMAL PASSAGES.
which communicates by an accidental opening with some point in the
track of the tears.   We should, therefore, by that definition, have to
examine fistulas of the lachrymal ducts, those  of the nasal canal, and
fistulas of the lachrymal sac.   But these last only have hitherto been
the subject of special attention, and  as  to the others I have made a
few allusions  to  them farther back.   Fistulas of the lachrymal  sac
are sometimes internal, that is, that  they may open into the middle
meatus of the nasal fossae, into the sinus maxillare or in the  direction
of the eye posteriorly to the palpebral commissure;  but that they are
almost always external.  Under the last circumstances also, the cu-
taneous orifice, which, in ninety-eight times out of one hundred, is
found in front of the lachrymal sac,"may nevertheless occupy another
position.  I have in one case seen it  on the prominence of the cheek,
and in another case near the  ala of the nose;  a sinuous  track of
more  than an inch thus separated   the external from the internal
orifice of the fistula.   Ordinarily there is  but one of these orifices;
but sometimes the skin at the  great angle of the eye is, as it were,
cribbled with them.  Frequently this orifice makes no projection, but
even appears to be a little depressed ;   at other times it is found situated
on the top of a kind of sac which is  flabby or flattened, or occasion-
ally more or less distended.  It is not an  uncommon thing  to see it
afterwards surrounded  with fungosities, and presenting the aspect of
an ichorous ulcer of bad character.   In fact, nothing is so simple as
the mechanism of a lachrymal fistula. The sac,  for a long  time dis-
tended in the state of tumor, is worn through (s'eraille) or ulcerates ;
the inflammation extends sometimes suddenly, at other times by im-
perceptible degrees, to  the neighboring layers, and an  abscess is
formed.  Whether this abscess opens of itself or is opened  by art, it
nevertheless puts the cavity of the  sac in communication  with  the
atmosphere through the skin.   If the ulceration makes its way di-
rectly to the skin, the fistula is direct  or complete ; if it spreads (fuse)
or the contrary, either between the periosteum and bones, or among
the other organic layers in the direction of the nostril, it  is indirect
and incomplete, and becomes an exception.   We can readily under-
stand how the os unguis, which is so  thin and fragile, and the osseous
plates with which this  bone  articulates, may  ultimately become
necrosed and  carious,  when  we  reflect  upon their relations with
such seats of inflammation and suppuration.   As the  treatment of
fistulas in practice has generally been confounded with that of lachry-
mal tumors, I propose, in this place,  to examine under one  head  the
therapeutic of these two forms of the same disease.  The treatment
of lachrymal tumor and fistula has, at every epoch,  occupied  the
attention of practitioners; after having been for  a great number of
ages almost entirely pharmaceutical, it  became almost exclusively
mechanical from the moment when the functions of the lachrymal
apparatus became well  understood.  At  the present day opinion
seems to have taken another direction. Recognizing that the lachry-
mal tumor and fistula were  the result  of an  inflamed  condition of
the nasal  canal  or lachrymal  sac, practitioners  finally asked them-
selves the question, whether the treatment of inflammation, modified
according  to the individual,  and the peculiarities  of  the  diseased
region, ought not, in a great number of cases,  to have the preference 
NEW ELEMENTS OF OPERATIVE  SURGERY.
789
 over mechanical means.   At the present time, therefore, before pro-
 ceeding to surgical remedies, these affections are to  be treated by
 resources of another character.
   A. Topical Applications and General Treatment.—The first object
 of the surgeon ought to be to ascertain the causes, whether individual
 or constitutional, of the tumor or fistula.  If the patient under treat-
 ment were  affected  with syphilis, scrofula, or scurvy,  it would be
 necessary, before doing  any thing else, to  bring about  the cure of
 these general derangements of the economy.   It is to be understood,
 also, that tumors of the nasal passages, orbit or maxillary sinus, as
 well as any other disease in  those regions, ought to  be previously
 destroyed, should they have been the point of departure of the dis-
 ease in question.  If the affection should  have developed itself  in
 consequence of any disease of the skin, of the lips, or the Schneiderian
 membrane,  it would  also be  necessary to commence by removing
 them.   In those instances, quite common, of lachrymal tumor and
 fistula, which originate, as it has appeared to me, from an eczema of
 the upper lip and the encrusted condition of the opening of the nostrils,
 I have made use, with advantage, of a  pomade composed of a gros
 of white precipitate  to  an ounce of  lard, and sometimes  also of
 another pomade containing eight grains  of nitrate of  silver to an
 ounce of lard.   The  parts affected are to be rubbed morning and
 evening with one of these pomades, taking care to remove the crusts
 previously, by means of emollient cataplasms.  If, on the other hand,
 the case in question is  one that comes under those tumors and fistulas
 originating  from disease  of the eyelids, I  employ, before all  other
 things, the means proper to cure this last.   Influenced by the idea of
 an inflammation of the mucous membrane of the lachrymal passages,
 all the school of Beer maintain that we should treat it by debilitating
 remedies.   It is for this reason that M. Mackenzie eulogizes general
 bleeding, leeches, and water, as a topical  application  and for the
 regimen, in the acute, and even also in the chronic state of the disease.
 M. Lawrence, still  more specific, prescribes leeches to the internal
 angle of the eye and upon the tumor, and compresses wet with cold
 water as a resolvent.
  The credit of this practice might equally well be ascribed to De-
 mours,  for this  surgeon was in the habit of treating the diseased
 condition of the lachrymal passages by leeches and regimen; every
 where he speaks of having cured lachrymal tumors and fistulas of
 long duration without an operation.  Emollients, procrastination, and
 cold lotions  (les  lotions froides—means of course, cold water,) were
 his   favorite remedies, and we see by the consultations  described in
 his great work, that it  was the method also of his father.  It is from'
 not  having  been au courant  on this subject with the history of the
 science, that some surgeons among us between 1820 and 1830,  sup-
 posed  that they were  the authors of  it.  In fact, it goes still much
 farther  back; for Manget,  in  1693, wrote that fumigations by the
nose and general treatment did exceedingly well with lachrymal fis-
tula.  Heister, who like  Platner was  aware that inflammation  was
the immediate source  of this  disease, and  who compared the affec-
tions of the lachrymal passages to those of the urethra, treated them
also  by injections, bleeding, blisters, and regimen, which are almost 
790
LACHRYMAL PASSAGES.
always sufficient he says, if there 'be not yet either ulceration or ca-
ries  in the great angle.   It is  to  be added,  however,  that  before
M. Gama, M. Guillaume, M. Paris,  and some other military surgeons,
(Mem. de Medec.  et de Chir. Milit., etc.,  t.  XIV— XVI.) but few
persons in France, except Demours, thought of combating lachrymal
tumor by means of antiphlogistic remedies.
   Practice of the author.—One  consideration naturally suggests it-
self here  ; that  is, to know to what extent debilitating measures are
allowable under such  circumstances.   A  regimen which is  quite
rigid, with some general bleedings,  repeated application of eight, ten,
fifteen, twenty or thirty leeches  to  the temple, mastoid  processes or
nasal angle, emollient cataplasms, cold topical applications, injections,
or aqueous fumigations,  continued  for two, three, four, and six
months, do not at first succeed but  in a very small number of cases;
afterwards this practice manifestly becomes  more painful and dan-
gerous than most of  the  surgical  remedies  now  employed ;  from
whence it follows that we should  be wrong in according  too much
confidence to this kind of medication, and that we ought to consider
well before adopting it. There  are  some lachrymal fistulas, more-
over, which we have  it in our  power to cure without an operation,
by means of a treatment better regulated, and less calculated to dis-
turb  the constitution.   Thus, unless there are particular indications
to the contrary, I would advise neither general bleeding, nor leeches
to the temples, or behind the ears, nor a seton to the nape, which Fa-
bricius de Hilden  (Bibl de Bonet, p. 394, 397,) recommends, nor a
plaster of tartar emetic as eulogized by M. Weller, nor internal re-
medies ; but I willingly employ, and have often done so with success,
some of these remedies applied  as near as possible to the  parts dis-
eased.  From six to ten leeches on the track of the nasal canal and
lachrymal sac, renewed three to four times in  the space of a month,
may  be useful, if there be remaining  a certain degree of inflamma-
tion and heat in these parts ;  the same remark applies to the fumiga-
tion of Manget  or Louis,  and to topical emollients.  After this first
period it would be necessary to recur, as was already the practice in
the time of Rhazes, (Guy de Chauliac, Traite IV., doct. II., chap. 2,)
to the  application  of friction  to  the tumor or collyria between the
eyelids.  Upon the tumor  we may apply either mercurial  ointment,
that of hydriodate  of potash or ioduret of lead, and also temporary
blisters.  As collyria, we no longer employ the melange, lauded by
Rhazes, but may make use with advantage of a lotion of sulphate of
zinc, lime-water, a solution  of nitrate of silver, and in fact any resolv-
ent or styptic collyrium. • Introduced into  the lacus lachrymalis, (le lac
lacrymal,) these liquids are absorbed there by the puncta lachrymalia,
and thus tend to destroy the inflammation which constitutes the ob-
stacle to  the  course of the tears.   Le Dran, who had already em-
ployed liquid collyria under this form, and Mackenzie, who has sub-
stituted them for the injections of Anel, have obtained with them de-
cided success ; I have  myself often  used them and with very excellent
effects. Nevertheless we must not deceive ourselves in respect to their
efficacy.   Though in the space of one year I have seen four women
cured of lachrymal tumor and fistula under the treatment I  have just
described, I ought to add also that most of the other cases of the same 
NEW ELEMENTS OF OPERATIVE SURGERY. '
791
 kind to which I had before been witness, have since returned to me,
 and convinced  me that the  cure was not permanent.   We succeed
 by this treatment then only as an exception, and not eight times out
 of ten, as some persons at the present day have ventured to affirm ;
 but what justifies trials of this kind is, that the surgical means at
 present known, in  spite of their number, nevertheless  still leave the
 treatment of lachrymal  tumor and fistula very imperfect  and mea-
 gre.  In truth, the  methods which  have  been from time to time eu-
 logized for the cure of fistula and  lachrymal tumor, having almost
 exclusively for their object the  removal of a presumed obstruction,
 which is  sometimes wanting, and  which is only in fact the result
 of another disease, could not have otherwise than failed frequently.
   These means, moreover, are so diversified, that in order to appre-
 ciate them properly, it  is important  to  separate them into several
 classes.  Thus, among those who  have proposed  them, some  like
 Mejean and  Anel,  by means of catheterism and injections had no
 other object than the cleansing out of the nasal canal by penetrating
 through the lachrymal ducts ; others, namely, Lecat, J. L. Petit, Ca-
 banis,  Palucci, Foubert, Jurine,  Desault, Pamard and Scarpa,  had
 especially in view the dilatation of this canal.  Many persons recur-
 ring to the idea of Heister, have supposed it more rational to employ
 in those parts injections  of various  kinds, or to apply caustics, in the
 same way as  is done for contractions of the urethra.  A fourth group
 in fine, embrace the methods which, like those of Woolhouse, Hunter,
 Warner, and many others, were designed to establish a new route for
 the course of the tears.   Among these methods there is a considera-
 ble number which would deserve to be consigned to entire oblivion;
 but as they are still employed by some practitioners, I think it advi-
 sable to make a brief review of the  greater portion  of them.   In
 conclusion, I  would divide the  surgical treatment of  lachrymal tu-
 mor and  fistula, into  four general methods, namely: the  method
 of catheterism and injections, that of dilatation, thirdly, cauterization,
 and lastly, the method for establishing an artificial lachrymal passage.
   B. Catheterism and  Injections.—To  believe Bianchi and Signo-
 retti, Stenon, Valsalva, and Stahl, a veterinary surgeon mentioned by
 Morgagni, must have already made an attempt to penetrate the  tear
 ducts,  by means of very fine styles (tiges)  more or  less adapted to
 their object, until Anel  attracted attention  to this  subject  in 1716.
 Portal, (Hist, de VAnat. et de la Chir., etc., t.  IV., p. 486,) in fact,
 asserts that we find  the  germ of this principle in Cajus Julius, Plato,
 Septalius and Duret; but it is easy to perceive that Bianchi was de-
 ceived, and that Manget, in reality, is the only one who effected the
 passage of these ducts  before the  time  of  Anel.  According to its
 partisans, catheterism of the lachrymal  passages is called for, in
 tumors, fistula, simple obstruction, more or less complete obliteration,
 partial or general contraction, ulcerations and chronic inflammation
 of the lachrymal ducts, sac and  puncta, as well as of the nasal canal.
 We may have  occasion  for it in order  to  introduce threads, tents,
 different kinds of meches, injections, and medicated  liquids, and we
 may perform it either through the eyelids or the nares.   This method
presents two  principal varieties: with it in fact we propose some-
times to clear out, sometimes to  modify the interior of the diseased 
792          ,         LACHRYMAL PASSAGES.
 ducts:  in one, the object  of the surgeon is evidently mechanical; in
 the other, it is more physiological.
   I.  The mechanical variety.—a. Process of Anel.—Anel had two
 modes of treating affections of the lachrymal passages : sometimes
 he endeavored to clear them out (les desobstruer) by means of a very
 fine  probe, at other times by the aid  of injections that  were  either
 detersive or impregnated  with some other medicated property.
   1. Injections.—To  introduce injections,  Anel  devised  a  small
 syringe  of the capacity of two to three gros, terminating in a very
 fine  syphon, to the point of which was adjusted a copper pipe  much
 finer still.  The patient was made to sit down fronting a well-lighted
 window.  With the left hand  for the left eye, and the right hand on
 the contrary for the right, the surgeon  gently depresses the lower
 eyelid and inclines its free border forward.   With his  other hand he
 takes the syringe, introduces its point perpendicularly  into the orifice
 of the tear duct, causes it to penetrate in this direction to the depth
 of about a line ; then placing it horizontally, he inserts the little cop-
 per syphon to the extent of two or three lines, then presses his thumb
 upon the ring which is at the  posterior  extremity of the piston, and
 cautiously forces forward the medicated liquid into the lachrymal sac.
 The inferior lachrymal punctum is preferred for this purpose, because
 the operation by that of the upper eyelid, would in fact be less con-
 venient and  less certain. Should the operator prefer placing himself
 behind the patient, he would depress the lid of the right eye with his
 right hand, and the lid of the left eye with his left hand.
   He might  also, were he not  ambidexter, employ the  same  hand
 for both sides, by taking care to place himself in front for one of the
 eyes and behind for  the other.  At first the patient bears these ma-
 nipulations rather badly:  they produce in fact, in some  instances, a
 good deal of irritation.   It  is only after having gone through with
 them for several days successively that he gets accustomed to them,
 and  that they become as  simple as they do  trifling in  pain.  Saint-
 Yves and Heister also had recourse to injections, but they made  them
 through the fistula.   W. Blizard (Transact.  Phil, t. LXX. ;  Journ.
 de Med., 1781, t.  LXXIII.) influenced like his predecessors, by the
 principle of clearing out the passage, proposed  that mercury should
 be used in the injections.
   2.  Catheterism.—When the injection does not arrive at  all, or
 but in very small quantities into the nasal fossee, Anel recommends
 that we should immediately have recourse to the  use of the probe
 The  operator, if to  act upon the superior  lachrymal duct, places
 himself  behind the patient, gently reverses the eyelid  outwards and
 upwards, with the left hand  for the right  eye and  with the  right
 hand lor the  left eye, seizes the probe with the other hand in the
 manner of a writing pen, perpendicularly  applies the  blunt  point
of the instrument on the lachrymal punctum, afterwards  inclines its
other extremity  outwards and upwards, as  if to  carry it towards
the external  orbitar process, 'cautiously advances  it in, draws  with
his other hand the nasal  portion of the lid inwards and towards the
internal orbitar process,  as if to give him a vertical direction, imme-
diately pushes in the probe  in this  last mentioned direction, taking
care  when meeting with  the  slightest  obstacle, to raise it  up, or 
NEW ELEMENTS OF OPERATIVE  SURGERY.           793
 incline it a little either in front or outwards or backwards or inwards,
 in order to force it in  fine to penetrate into the corresponding nostril;
 after which he withdraws it to have recourse again to the injections.
 The introduction of this probe is a delicate operation, which cannot
 be otherwise than fatiguing to the patient.   It demands on the part
 of the surgeon an exact knowledge of the arrangement of the parts.
 The slightest fold, whether natural or morbid, is sufficient to arrest
 the instrument, which, in consequence of its small size and flexibility,
 is in reality incapable of overcoming the  least degree of resistance.
 I will add that in every point of view it is a useless operation, for the
 lachrymal  tumor and fistula are scarcely  ever owing to a complete
 obliteration of the nasal canal.  Moreover,  if matters  that would
 yield to the action of the probe could  be the  cause, they might  be
 displaced full as well by simple pressure made upon the tumor.  This
 pressure, which Richter recommends to be made from above down-
 wards, and acting in the manner of injections  forced into the urethi-a,
 would evidently have more efficacy than Anel's probe.   Neverthe-
 less the operation of catheterism continues to be performed  and de-
 scribed, because, as will be seen farther on, some practitioners have
 applied it to the radical  cure of fistula lachrymalis itself.
  b. Process  of Laforest.—Perceiving that  injections  and catheter-
 ism by the  method of Anel were sometimes very difficult, and  believ-
 ing them  moreover  to  be of unquestionable  utility, Laforest and
 Allouel, nearly about the same time, proposed to penetrate into the
 lachrymal passages through the nares.  To attain his object, Lafor-
 est had constructed small plain sounds curved into an arc, and cathe-
 ters  (algalies) of the same form,  which  were conical  and  open at
 their apex and terminated at their base by an  ear (pavilion) furnished
 with a small lateral ring, designed  to fix the instrument upon the side
 of the nose in the interval between the dressings.  The plain sound,
 inserted from  below upwards into  the nasal  canal,  was  intended to
 clear it out.  After having removed this,  Laforest replaced it by the
 hollow  sound, which enabled him to inject by means  of a  small
 syringe, the liquids adapted to the  nature  of the disease.   Laforest's
 sounds  in our times  have been modified  by  a number of surgeons.
 M. Gensoul has given them much  more  length and a curvature ex-
 actly shaped to that of the nasal  canal.   Those  of M. S. Pirondi
 are of metal at their extremities, and gum elastic in the  middle.
 Those of M. Serre differ only in their curvature from the catheters
 of M. Gensoul.  With this last form of the instruments, catheterism
 of the nasal canal is in reality very simple, however little we may be
 practised in it, and modern practitioners are in my opinion wrong in
 so entirely  neglecting to employ it.
  II.  Physiological  variety.—The method of Laforest,  like that  of
 Anel, has been but  seldom used  for the purpose designed by the
 author ; but other surgeons have endeavored  to combine it with cer-
 tain  stages  of the operation for fistula lachrymalis.  Heister and
 Le  Dran had already become satisfied that  in a large  number of
 cases, injections in the character of topical resolvents might render
every  kind  of operation unnecessary.  Briot,  for example,  as M.
Champion  also does, was  still  employing the process  of Laforest
with the most decidedly advantageous results.   These injections,
  vol. n.                      100 
794
LACHRYMAL PASSAGES.
 either from above or from below, are in reality remedies that deserve
 to be retained.   It is in  fact obvious, that  by directing medicated
 liquids upon the seat of the evil, we must sometimes succeed in dis-
 persing it; only that the question arises  whether by processes still
 more simple, we should not be enabled to attain the same object, and
 whether substances introduced  through the nose by means of fumi-
 gations, as Manget proposed, or by inhalation, would not in the same
 manner pass into the  syphon of the tears, as Monlac and Louis affirm
 they have caused them to do with success.
   C. Dilatation.—When the lachrymal tumor has become ulcerated,
 or does not yield to the processes of Anel, Laforest, Louis and Le
 Dran, nor to general and local antiphlogistic measures,  nor to anti-
 scorbutic and anti-syphilitic treatment, &c, it is  admitted that it can-
 not be cured except by the operation, properly so called.  It is not to
 be  forgotten, however, that Maitrejean has  seen two fistulas  of the
 most  serious character at the great angle of the eye get well spon-
 taneously ; that Demours rarely treated it by the cutting instrument;
 that the ancients, with their extensive battery (tout leur echafau-
 dage) of escharotics, styptics and caustics, occasionally made some
 cures;  in fine, that  in our own times we have seen cases recover
 which had been treated  only by local bleedings and the soothing
 regimen.  This remark is so much the more important, as we may
 perceive thereby that  all the different methods have  occasionally
 succeeded in effecting a cure of fistula lachrymalis.  As  this disease
 is of a character to get well sometimes spontaneously, it is not there-
 fore surprising that compression, already extolled by Avicenna, and
 for which J. Fabricius, de La Vauguyon, and Schmidt, constructed
 bandages of considerable ingenuity, and that tents of lint besmeared
 with an  ointment of greater or less activity, and that leeches and
 emollient cataplasms, should, in a number of instances, have pro-
 moted the cure.  In November,  1831, an adult  man was sent to me
 at La Pitie by Dr. Grenier, in order to be operated upon for a lachry-
 mal fistula, the existence of which, now of several months'  duration,
 could  be satisfactorily established.  After procuring a canula, the fis-
 tula was found closed up, and when I saw the patient again, at  the ex-
 piration of three months, the cure continued perfect.  If leeches, or
 any other kind  of medication had  been employed,  the cure would
 undoubtedly have been attributed  to them.  In  1836,  I  saw two
 similar results at the hospital of La Charite, and  analogous facts have
 been related  by MM. Moztehan, Caucanas,  (Journ. Compl des Sc.
Med., t. XXXII.,) Demours, and  Moulinie",  (Bull. Med.  de Bour-
 deaux, 1833, p.  138,)  as well as by F. de Hilden, (Bonet, Corps,  de
Med., 394 — 397,) and Fichet de  Flechy,  (Observ. Med.  Chir.,
 p. 258.)  Dilatation comprises two modifications : in one we act on
the natural passages ; the other, on the contrary, exacts an artificial
opening for the introduction of the  dilating  body.   Each of these
methods, moreover, includes quite a considerable number of processes.
  I.  Dilatation by the Natural Passages. — a. Process of  Me-
jean.—Megean, perceiving that  the  employment of injections, and
the clearing out of the lachrymal passages  by Anel's probe, afforded
only temporary relief, proposed to apply to the nasal canal the treat
 ment by dilatation, which had been so long in use for contractions of 
              NEW ELEMENTS OF  OPERATIVE SURGERY.          795

the urethra.   By means  of a fine probe, having an eye at its upper
extremity to receive a thread, this author traverses the parts  in the
manner of Anel, and endeavors to insert the blunt end of the probe
upon its arrival near the wall of the nares, into the groove or open-
ing of  the  canula,  (sonde  cannelee,) which has been introduced
at the bottom of the lower passage,  (i.  e. by the nose,) in order
to meet the  probe,  and to draw it through  together  with the
thread attached to it; forming  afterwards a noose with this species
of seton he unites its two extremities around a pin, which is fixed
into the cap or hair of the patient.  At the expiration of one or two
days,  two  strands (brins) of lint,  folded double, are attached to the
nasal  extremity of this  thread, in order to form a meche,  which
is besmeared with cerate or some other medicated pomade, and has
another thread fastened  to its  free extremity.  The meche is then
drawn from below upwards through  the nose, and as far as to the
upper part of the lachrymal sac.  Each day it is to be removed, and
its size increased by adding  one strand more  of lint.   To remove it
we have  recourse to the thread which retains it in the nose, and
which between  the  dressings is to be kept fixed upon the cheek by
means of a bit of court-plaster, (mouche de taffetas.)
  By this process the treatment requires from two to three, four or
six months, and the cure obtained is rarely permanent. Out of twenty
patients thus treated there are rarely more than three or four in whom
the disease does not reappear at the expiration of a few months. The
method of Mejean, moreover, presents two difficulties which are not
always easy to be overcome.  The  probe often  gets stopped in the
lachrymal sac, and does  not reach the  nasal canal until after long and*
fatiguing trials.   Except we are much practised in the operation, we
have generally considerable difficulty in bringing it under the inferior
turbinated bone, into relation with the groove or eye of the  canula,
or in getting hold of it in any manner so as to bring it out.
  b. Process of Palluci.—Palluci suggested that by introducing a
small  gold flexible canula (sonde  creuse)  instead of Mejean's probe,
we might be enabled to pass through  this canula a portion of  catgut
so fine, that the patient would drive it out in sneezing, when it could
afterwards be made use of to conduct in  the same direction a thread
for the purposes designed in  the process of Mejean. But it is obvious
that this modification complicates the operation of the  physician of
Montpellier in place of simplifying it,  and  that it  must be  more
easy to make our way through  the lachrymal passages  by means of
a probe than with a canula.
  c. Process of Cabanis.—Cabanis, a physician of Geneva, has sug-
gested an instrument designed  for seizing with greater facility Me-
jean's  probe in the  lower meatus, and which is composed  of two
palettes made so as  to  slide upon each other.  Being perforated
with holes which traverse the entire thickness of the upper palette,
but go only to a certain depth in the body  of the lower one, this
instrument is  first introduced below  the inferior turbinated  bone,
(cornet maxillare.)   By means of skillfully combined movements the
probe is arrested in one of the holes of  the two palettes united, by
which it is soon securely embraced,  (exactement pince.)   Cabanis
also recommends, after having brought Mejean's thread through the 
796
LACHRYMAL PASSAGES.
 nose, that its extremity should be attached  to  the end of a flexible
 sound covered  with gold-beater's skin, in order to conduct this sound
 with certainty  through  the lower meatus  into the nasal canal, after
 the manner of Laforest.
   d.  M. Bermond of Bordeaux, who  revived this  suggestion  in
 1825 and in 1827, has very justly remarked, that in order to apply it,
 all that is  required is to bring the conducting thread of Mejean  to
 the outside by any mode whatever.   Inasmuch as the  instrument of
 Cabanis is not indispensable, and removes only a part of the incon-
 venience of the process  of Mejean, and as  the introduction of the
 probe and thread through the  superior lachrymal punctum, counter-
 balances the advantages which  might result from  it for the subse-
 quent introduction of a sound, in the  manner of Laforest, surgeons
 have not adopted these modifications.
   e. Process of Guerin.—Guerin of Lyons, having  remarked that
 a simple thread left to remain  in the superior lachrymal duct, exco-
 riates and sometimes lacerates  its palpebral orifice,  recommended to
 bring  Mejean's tent as high up as this punctum.   Desgranges, who,
 like Guerin, finds it more convenient to  reach the extremity of the
 probe through the nose by means of a  small blunt erigne,  than
 with the canula, or the  palettes of Cabanis, adopted this suggestion,
 which Care on his part has  more  recently endeavored to render
 popular.
   /. The process of this last  physician, according to what he has
 stated to me and from what I have seen in the practice of M. Bougon,
 consists in  passing from  below upwards or from above downwards,
^y means of the instruments of Mejean, a meche of raw silk, com-
 posed of three, four or six brands, in order that the same may, while
 traversing through the superior lachrymal ducts and puncture, dilate
 them as it proceeds.   When it has been passed from below upwards,
 one of its extremities  is  afterwards fastened to the forehead of the
 patient, or in the contrary case, upon the side of the nose.   With the
 remainder of the meche we form a sort of peloton which  is to be
 attached in  the hair.  A. Dubois appears to have several times fol-
 lowed this method, which I have also made trial of in two instances,
 and which differs in nothing from that of Guerin.  Care's meche, by
 dilating the sound part only, without acting directly upon the diseased
 point of the  organs it traverses, deforms and paralyzes the lachrymal
 puncta and their ducts.   As I  have  not  understood that experience
 has  pronounced in its favor, I do not see any inducement  to make
 any more trials with it.
   II. Dilatation by an artificial opening.—When in order to dilate
 the nasal canal we penetrate by an artificial  opening, we sometimes
 make use of temporary dilating bodies, and at other times of dilating
 bodies that are  left to remain in the lachrymal passages.
   Temporary dilatation.—For this kind of dilatation, surgeons make
 use of meches of lint, bougies, or metallic bodies.
   a. Meches and Setons.—1. Process  of J. L. Petit.—Petit was the
 first who endeavored to inculcate, that in fistula lachrymalis we
 ought to exert ourselves to re-establish the natural passage of the
 tears, much rather than to create a new one  for them.  His method
 may be considered as the source of all those that are employed at the 
NEW ELEMENTS OF OPERATIVE SURGERY.
797
 present day.  An assistant placed behind the patient draws the tem-
 poral angle of the eyelids outwards, in order to stretch the parts;
 the operator then directs the point of a bistoury into the sac below
 the direct tendon of the orbicularis muscle, and makes at the great
 angle of the eye an incision of about six lines; glides in the place of
 this instrument a canulated sound, which he pushes with more or less
 force into the nose, through the nasal canal, and makes use  of it to
 introduce a tent  or conical bougie  oL wax, the  upper  extremity of
 which should  be more or less dilated and supported by a thread.
 The operation is then terminated.   The bougie is to be renewed or
 at least cleaned every day before putting it in its place, until the canal
 no longer furnishes any evidence of suppuration, that is  to say during
 two, three, four, five, or six months.   At a subsequent period, J. L.
 Petit  thought  that he could  make  a substitute  for the canulated
 sound, by making a groove near the back and on  the  anterior sur-
 face of the bistoury, which would answer to direct the  extremity of
 a blunt probe; but as a special bistoury would be required for each
 side, practitioners have generally paid no attention to this pretended
improvement.
  2. Process  of Monro.—The  approbation  which  the method of
 Petit first received did not prevent some surgeons from recognizing
its defects.  According to Monro it would be imprudent to open the
 sac without supporting its  external or anterior wall.  It is for this
reason he proposes to introduce through the inferior lachrymal duct,
 a small sound, in order to distend it and to enable him to open it with-
out wounding  its posterior wall.  Monro also recommends we should
 force  through  the nasal canal, by means of a shoemaker's awl, an in-
 strument already mentioned by Guy de Chauliac, rather than with a
 sound; that by means of the scissors we should prolong the opening
upwardly at the risk of dividing the direct tendon, and that in place of
the bougie of  Petit, we should make use of a small tent of lint or
catgut.  His precepts  have been neglected.  The wounding of the
lachrymal sac  posteriorly, besides being easy to avoid  by the ordinary
process, cannot involve any danger, whatever M. Rougier may
say of it, while  that of the tendon of the orbicularis  is in itself a
serious accident.  The employment of an awl would expose us too
much  to be misled, and to the making  of false routes, to render  it
possible that it can ever be preferred to the blunt-pointed probe and
the canulated  sound.
  3. Process of Pouteau.—Introduced from  above downwards, the
bougie ultimately produces in the great angle an ulcer whose borders
 are reversed inwardly, and which sometimes leaves as a consequence
a cicatrix which is greatly depressed.  Pouteau having in vain tried
the method of Mejean in a young lady, and not daring to propose
the incision of the sac in the manner of Petit, decided  upon  passing
his bistoury between the lower palpebral border  and the caruncula
lachrymalis, in such manner as to penetrate into the nasal canal
without interfering with the skin.  There resulted  from it, says the
author, only a slight ecchymosis, which itself was owing to his having
made the incision too  narrow.   With the exception of one of the
Pelliers, but few persons, however, have thought  it advisable to imi-
tate his example, though it has since  been lauded by Leveille, and 
798
LACHRYMAL PASSAGES.
that M. Bouchet has employed it in one instance with success.  The
apprehension has been, that the conjunctiva would be too much irri-
tated.  Moreover, the  inconvenience which Pouteau has  proposed
to remedy is reduced to so trifling an affair in the modern processes,
that at the present day it is scarcely regarded.
  4.  Process of Lecai.—Lecat  after having incised the sac in the
manner of Pet'it, made  use of meches of lint, which  he introduced
through the nasal canal from ^bove downwards, by means of a cat-
gut, a fine bougie, or Mejean's probe.  In this respect he is the first
who has endeavored to combine the method of Mejean  with that of
Petit; but as his meche also had a tendency to produce the reversion
of the borders of  the wound, so much dreaded, very little attention
has been paid to the precepts that he has endeavored to lay down.
  5.  Process of Canolle, (Memoire sur Vetat actuel de la Chir., par
Montfalcon. p. 118, 1816.)—M.  Canolle, when he thinks a seton in-
dispensable, inserts a treble cord of a violin (chanterelle) which has
been  oiled, through the opening  of the fistula, as far  as  into  the
nasal  fossae.   When the patient feels an itching at the back part of
his mouth, the surgeon  explores this cavity, seizes the foreign body
with the forceps and brings it outside ; he then introduces a  small
bougie into the nostril corresponding to the side upon which the fis-
tula is, until he has arrived  behind the wall  of the palate; he then
withdraws this also with the forceps and proceeds to tie it  to the ex-
tremity of the cord.  He immediately withdraws the bougie through
the nostril, then follows the cord ; it is separated from the bougie, and
a thread attached to its extremity.  The cord drawn through the open-
ing of the fistula, brings with  it into  the  lachrymal passages  the
thread to which the seton is attached.
  6.  Process of Desault.—To  obviate as  much  as possible the in-
conveniences of the preceding processes, Desault gives to  the inci-
sion of the sac only two or three lines of extent.  A canulated sound
is immediately made use of to clear out the narrowed canal; a probe
or a whitlow  sound is then put in its place.   A small silver canula,
from twelve to fifteen lines long, conical in shape, and having a ring
on the side of its pavilion, is brought from above downwards,  as far
as into the nose, by means of the probe which forms its axis or guide,
and which is  immediately afterwards  withdrawn.   The  thread is
then made to descend into it, and the patient forces out its extremity
by making efforts  to blow his nose ; after which the operation differs
in no respect from that of Mejean.
  7.  Modification of Boyer.—In order to be certain of making as
much thread as we desire descend through  the canula of Desault,
we may, after the manner of Boyer, make use of a  small probe of
three  to four inches long, bifurcated below, and terminated above by
a ring ; then  afterwards, in order to extract this thread, have re-
course to  the little erigne of Deschamps, the dressing forceps, or
merely make the patient blow his nose.  If neither of these suffice we
abandon it in the nose, when in almost every instance the mucosities
ultimately draw its extremity through at the end of from twelve to
twenty-four  hours.  In the contrary case, injections driven with  a
certain degree of force through the opening of the lachrymal sac,
would not fail to expel it downwards. 
NEW ELEMENTS OF OPERATIVE  SURGERY.
799
  8. Process of Pamard.—Pamard and Giraud, embarrassed by the
difficulties  of  extracting  the  thread according  to the method of
Desault, devised,  almost  about  the  same  time,  an improvement
which many surgeons of  our day still  make use of.  It is  a  small
elastic stem or watch-spring, terminated by a blunt point (bouton)
and presenting an eye at its other extremity.   The head of this spring
is inserted into  the canula of Desault.   Having  arrived under the
inferior turbinated bone, its elasticity naturally carries it sometimes
towards the opening of the nares, and sometimes under the lobule of
the nose, where it is easy to secure it either with the finger or the dress-
ing forceps.   Nevertheless, when  the spring is not well tempered,
and even sometimes when it  is perfectly constructed, its extremity
cannot be disengaged from the inferior meatus of the nasal fossae but
with a considerable degree of difficulty.
  9. Process of Jurine.—In order to leave as little deformity as pos-
sible in the angle of the eye, Jurine performed the operation with a
small  trochar of gold, and whose canula  is pierced near its point.  It
is plunged in as  far as the nose.  After having withdrawn the stilett
we introduce Pamard's spring; in other respects we conform to the
rules established farther back.  If, in spite of its apparent simplicity,
this process has not been adopted, it is because, in reality, it is  more
painful  and less easy than many others.  It will always be  more
rational to  open the  lachrymal sac with a bistoury than  with a
trochar. And then the process of Pamard is preferable to  that of
Jurine.
  10. Process of Fournier.—An ingenious modification of the opera-
tion of Petit, and which I am astonished to see omitted in our modern
treatises, is the  one which has been proposed by M. Fournier of
Lempde.   This  physician proposes we should attach a small  shot or
grain of lead to the conducting thread  of Mejean; drawn down by
its weight this shot traverses the canula of Desault, and falls  of its
own accord into the  interior  of  the nose, from whence the patient
readily expels it by merely taking the precaution to incline his head
forward.  G. Pellier had already, with  the  same  purpose, made use
of the end of a leaden sound.
  11. Process of Janson.—M. Janson (Compte Rendu  de la Prat,
Chir. de VHotel Dieu de Lyon, 1822, p. 51) anoints  the lachrymal
sac and clears out the nasal canal with a whitlow sound, whose notch
enables him to direct a catgut into the  nasal cavities; he then pro-
ceeds to seek for this last with a blunt-pointed erigne; on the second
or third day he substitutes for it a silk thread, which  serves to con-
luct from below upwards  a small meche of cotton, the size of which
,s gradually augmented until the cure  is  completed.  This  process
Aas the advantage of leaving nothing to appear outside but the portion
of thread of flesh color, which, from the great angle  of the eye, is con-
cealed under the head-dress of the patient.  " It would be difficult for
me," says the author,  " to relate the number of fistulas operated upon
in  this  manner; but  what we may assert as  indisputable is the
superiority that  may  be accorded to it over every other  method
whatever."
  12. The editors of Sabatier have also remarked  that the combina-
tion of the methods of Mejean and Petit may be effected without the 
800
LACHRYMAL PASSAGES.
array of instruments brought into use by Desault, Pamard, Boyer, and
M. Roux.  What need is  there, in fact, of introducing successively
into  the nasal canal, a sound, a probe, a canula, and then a watch-
spring ?  Why not be content to place the thread in the conducting
instrument, and to glide this last into the nose as soon as the lachry-
mal  sac is incised ?   The species of spring acting in the canula in
such manner as to transform itself into a hook, which was proposed
in 1806 by M. Benezech, in order to  extract Mejean's probe more
readily, would have  no advantage over most of the other means
which  have been hitherto  pointed out,  and consequently does not
require any farther notice.
  13. Process of J our dan.—Apprehensive that the  whole extent of
the evil might not be laid bare, and desirous of avoiding the cicatrix of
the  integuments, M.  Jourdan, imitating Pouteau, has  proposed to
open the lachrymal sac throughout its whole length, behind the in-
ternal commissure of the eyelids within the caruncula.  M.  Vesigne
is doubtless wrong in asserting that it would  be generally impossible
to conform to this advice ;  but it is nevertheless true that the process
of M. Jourdan offers no advantage o,rer the  others, that it would
incur the risk of wounding the  internal  extremity of the lachrymal
ducts and of dividing the muscle of Horner, and that  it would present
more difficulties than any of those that are in daily use.
  14. Process of Manec.—Should the  introduction of the conducting
thread  of Mejean still present some difficulties, we might readily  sur-
mount  them by means of the instrument devised by M. Manec.  It
is a  sort of spear-pointed  sound, introduced  through the nose from
below, upwards  into the nasal canal, and  as far as to the palpebral
angle.   The spear point is then made to pierce through the anterior
wall of the lachrymal sac, and its eye  is made use of to draw the
thread  through the nostrils.  What will hinder this ingenious modi-
fication from being generally adopted,  is the difficulty that many
practitioners experience in penetrating  with any instrument what-
ever, into the nasal canal through the inferior meatus.
  b.  Bougies  and Cylinders.—1. Process  of Scarpa.—While in
France they endeavored to give popularity to the seton of Mejean,
the  physicians of Germany, Italy, and England, limited themselves
to a  modification of the method of J. L. Petit.  Scarpa, having no
more apprehension of dividing  the direct  tendon than his pupil, M.
Luzardi (Journal de Med. de Nancy, 1825,  p. 234) has  since  had,
advises that we should insert into the lachrymal sac  and nasal canal,
which  he first cleanses by means of meches besmeared with red
precipitate or nitrate of silver, a leaden pin or a species of conical
nail, terminated above by a flattened head, and more or less inclined
downwards, in order that it may accommodate itself to the form of
the  inner angle of the eye.  This pin  (clou), which B. Bell  kept
m for eight to nine weeks only,  ought  to be withdrawn from time to
time to  be cleansed,  and  reintroduced  immediately  afterwards.
During the first weeks the surgeon himself attends to this duty, and
injects  with warm water into the lachrymal passages  before replacing
there the metallic stem, which Scarpa calls the tear conductor.   At
a later period the patient has no need of any person to attend to the
dressing.   As soon as the tears flow freely into the nose without 
NEW ELEMENTS OF OPERATIVE SURGERY.
801
any obstacle, and  that the pin ceases to be covered with purulent
matter, we  may, in fact, dispense with its  employment.   Neverthe-
less, it is advisable to continue it for some weeks longer, in order to
be more certain of preventing a return.  " There are some patients,"
says  Scarpa, " who  are  so little annoyed by it that they cheerfully
carry it all  their lives."
  2.  I have seen at Paris Dubois and  M. Bougon, successfully use
a leaden pin, which only differs from that of Scarpa in having its up-
per extremity merely curved in the form of a hook, in place of being
flattened like the head of a nail.   After having  employed both I give
the preference to Scarpa's pin, to which I allow a length only of ten
to twelve lines, and to whose point  I give  a strong curve, while
others prefer to have this end in an enlarged base.
  3.  Process  of Ware.—There are those who prefer a silver pin to
the tent that I have  just spoken of.  Ware, for example, has given
rise  to  the  adoption by many surgeons in England of a silver pin„
which in other respects is  in almost every point similar to  that of
Scarpa.   After having lauded the canula of Wathen, Ware has sub-
stituted for  it  the  pin in question, and  maintains that it conducts the
tears into the nose by a sort of attraction.  We thus perceive that the
process of Scarpa was entirely modelled upon that of Ware.   De-
mours, before having adopted the gold canula,  employed a silver pin
sixteen lines in length and curved into a hook above.
  4.  Process of Larrey.—M. Larrey in his turn substitutes for these
instruments a  portion of catgut, three to six lines in length, fixed on
a plate or sort of button made of taffeta of flesh color, in such a man-
ner that the whole has considerable resemblance to the little  candle,
known under  the name  of veilleuse.   This instrument is removed,
cleansed, and  reapplied every morning.   Adherent by its head upon
the skin, and requiring only a small aperture, it is  scarcely percepti-
ble at the great angle of the eye and  causes no  annoyance to the
patient.
  5.  Beer, Scarpa, and Welter, eulogise also small bougies or catgut,
•but under another form.
  D. Permanent Dilatation.—a. Permanent Canula.—According to
Louis, Foubert had  proposed to place  permanently into the nasal
canal a  silver  canula about  an inch in  length, conical in shape, and
terminating inferiorly in  the form of a spoon.   Bell  and Richter have
also mentioned this canula on the authority of La Faye, who himself
mentions canulas  of gold, silver, or lead, left in the canal as a com-
mon practice, and without citing Foubert.  But Louis having formally
censured it, it was scarcely any longer spoken of by the surgeons
of that time in spite of the  efforts of G. Pellier, who in  1783, gave
himself out as the inventor  of  it, relating in his  work facts which
plead strongly in its favor.  Pellier moreover had  modified  it  very
ingeniously.  His, which is of less length than that of Foubert, was
made to terminate above in  a  border, and presented  in  the middle
ar.cther border; so that being once introduced  it became impossible
tor it to ascend or descend.   It does not appear moreover, that it has
ever fallen  into complete oblivion.  Distel says that one of his pa-
tients carried one for more than fifteen years, and that he took one of
tin from another which had been  in place for forty years.   I perceive
  VOL. II.                      101 
802
LACHRYMAL PASSAGES.
 also by a thesis sustained in 1802, that at  the Hospital of Strasbourg
 no other method than this  had been pursued for a long  period.  M-
 Marchal, the author of this thesis, furnishes nine cases which are al-
 together  of a  conclusive  character.  In  Germany it was employed
 also by Himly and Reisinger; but  it had been almost  forgotten in
 the schools of Paris when Dupuytren recalled the attention of prac-
 titioners to it, by giving it only one border instead of two.  This border,
 concave inwards, where it  presents  a circular groove, is arranged in
 such manner, that in order to withdraw the canula if any accident
 requires it. it is sufficient to introduce into its interior the beak of an
 elastic forceps  terminated  by two little hooks,-whose points  turned
 outwards readily draw it from below upwards.  I will however add,
 that if Ansiaux is to be believed, these modifications of the canula
 of Pellier had  been proposed by Giraud even at the Hotel  Dieu,
 ten years before Dupuytren used them, and that they were adopted
 at Liege  in  the year 1806.   In place of  presenting a border in the
 middle, that of M. Brachet has the second one at the lower  ex-
 tremity.   M. Taddei has approached much nearer  than  any other
 person to the views of Pellier, by recommending that we should place
 •a  slight  border below its upper third.  M.  Grenier, who considers
 that the  canula only escapes in consequence of its  ceasing to be
 pressed upon in a sufficient degree  by the nasal canal, has proposed
 to construct one  which may be contracted when it is compressed,
 and which on the contrary  acquires  a larger calibre, like a spring, as
 soon as it is left to itself.  In the year 1756, Tillolig  considered that
 it would be  advisable to withdraw it through the nose at the expira-
 tion of a  few  months ;  while in 1781, Wathen  proposed to fix a
 thread to its upper extremity in order to hinder it from descending,
and  M. Nicault recommends that  we should make  use of a cone
composed of several  plates of sheet lead rolled around each other.
Other modifications still have been made to the canula of Pellier.
 Some persons have proposed to perforate it with holes, the better to
 prevent its slipping.  M. Bourjot finds that  of Dupuytren too long,
 and makes the objection to it, that it  ultimately rests upon the floor of
 the nasal fossae.  M. Blondlot is in favor of a bellied canula, in order
 to dilate the canal gradually and imperceptibly.   The one that I em-
 ploy terminates in a blunt point, and  not like the beak  of a pen, which
 would expose it too much to the risk of chafing  the wall of the nasal
 canal or perforating the bones ; but practice teaches us that the form
 of the instrument is not a matter of importance in these cases.
   b. To introduce the canula we may, after the manner of Dupuy-
 tren, make use  of a steel, silver or gold stilett, a sort of lever bent
 almost into a right angle, the lower  portion of which, adapted to the
 canula, is bounded by a shoulder more or less prominent, and the handle
•of which, while it is more or less flattened, has a length of from two to
 three inches.  As soon as the canula has penetrated the little wound
 we fix it in this point by means of the nail of the  forefinger or thumb'
 during which the stilett is withdrawn.  The  patient is then recom-
 mended to breathe out with force, and if the air  is driven through
 the angle  of the eye, the operation is well performed.
   A bit of plaster or taffeta keeps the wound united over the canula
 in such manner that its cicatrization frequently is completed as soor 
NEW ELEMENTS OF OPERATIVE SURGERY.          803
as the following day.  Ansiaux asserts that  before introducing th6
canula, it is advisable to clear out the nasal canal with a sound or a
probe.  An incision having been made into the sac, he introduces  a
blunt probe through it as far  down as into the nose, and  afterwards
makes use  of this probe as  a  stilett to conduct the canula into the
nasal canal, the cleansing of which  by means of  the proper topical
applications he  also  recommends, as  Delpech (Clin. Chir., t. II.,
p. 433) had recommended it to be by cauterization, a practice which
is likewise followed by MM. Bouchet and Lusardi, (Journ. Med. de
Nancy, 1825, p. 235.)  M. Blandino has revived at Paris the modifica-
tion of the Belgian surgeon, which M. Taddei had also believed  him-
self the author of.  M. Cloquet, who does not  leave the canula perma-
nently in, until after having  made use of tents during the space of some
days, and M. Chaumet and M. Berard, who previously dilate the canal
by means of bougies or catguts, gradually increased in size, have also
in these respects, gone farther than Ansiaux.  To penetrate upon the
inner side of the eyelids, as  M. Vesigne wishes, with a view of avoid-
ing a cicatrix, would be truly superfluous, and this assuredly is not a
case for conforming to  the precept of Pouteau.   With  a view of
rendering the operation still more simple and prompt,  M. Daniel has
contrived a sort of trochar  or stilett, terminated in a lancet point, to
carry the canula into  the nasal sac in such manner that the operation
is thereby reduced to one stage.  This instrument, which the author
has shown to me, and which  is applicable to the most simple cases,
would, like that of Jurine, possess the inconvenience  of not making
a sufficiently extensive incision of the  skin, of fraying out with too
much facility a  false  route into the substance of the walls  of the
canal, and  of not permitting the employment of means rendered ne-
cessary by a variety of circumstances difficult to be determined be-
forehand.
   c  The  canula may be of  silver, gold or platina;  the  important
point is, that it  should possess  some degree  of solidity, and that  it
cannot be easily injured.  Its size and length ought to vary according
to the subject.   It is necessary that it should  adapt itself as nicely as
possible to the nasal canal,  and that it should  pass a little beyond the
lower extremity of that passage.  Consequently we ought to recall to
mind, that  in an adult this passage is from five to eight lines in length,
and from one to two  lines  in breadth.   It is also advisable  that  it
should be slightly  concave  posteriorly, and on its  inner side, and that
its point, if it is cut in the  shap  of a pen, should pass beyond the
antero-external rather than th  nasal wall of the  canal which it oc-
cupies.
   d. To adapt its proportions  to the stature of the patient at the dif-
ferent epochs  of life, M. Grenier has proposed a method which, as it
appears to me, attains this  object with sufficient precision, viz., that
the length of the nasal canal  is to be estimated by a line drawn  from
the point where the incision is  made in the great angle to the  supe-
rior depression of the ala of the nose, at the union of the lower bor-
der of the  nasal  bone with  the ascending process of the superior
maxillary bone.
   e.  Appreciation.—The use of the canula having been adopted to
great extent in France, requires in this place that I should examine 
804
LACHRYMAL PASSAGES.
with some care its importance and its inconveniences.  Many ob-
jections have  been made against it.  It is,  they assert, a  foreign
body which, by its presence, causes irritation to the system, produces
cephalalgia and pains in the face and in the  nose, erysipelatous in-
flammations, phlegmons  abscesses and ulceration  in the great angle
of the eye.  Frequently it makes  its way upwards under the integu-
ments, and M.  Darcet  relates twenty-seven cases where its ex-
traction became indispensable.  In other cases it falls into the nasal
fossae, and the  operation is, so to speak, abortive.   All  these incon-
veniences were pointed out by M. Bouchet in 1816, and presented
in a correct point of view, in Italy, by M. PI. Portal.  Like Delpech,
(Clin.  Chir., t. II., p. 433,)  M. Ouvrard, (Med. Chir.,  p. 265,)  Be-
clard, (Clin, des Hop., t. IV., p. 106,) and MM. Cloquet, Bourjot and
Laugier, (Diday, These  de  Concours, Janvier, 1839,)  I have seen
it pass through into the vault of the  palate.   It is even said  that, in
one instance, it fell into the trachea,  and that it became  necessary to
have recourse to tracheotomy;  but this is a statement  that  requires
confirmation.   The canula may also get involved  in the sinus max-
illare, (Ouvrard, Med. Chir. 265,) or into the substance of the alveo-
lar border.
   Mucosities and powders  that many persons put in their nose, ulti-
mately obstruct it and close  up its orifices.  Finally, when we are
obliged to extract it, we find ourselves under the necessity of per-
forming an operation more difficult than that of  the fistula lachry-
malis itself.  If the instrument glides between  the maxillary bone and
the soft parts of the face, instead  of passing  into the nasal canal, as
I have seen it do in two instances, it will cause symptoms more  or
less serious, without having the slightest beneficial effect upon the
fistula properly so called.   The same result takes  place if we force
it into the neighboring sinus, or get its point entangled in the walls
of the canal, or if it descends between the  bones  and the membrane
of this passage, or in a word,  if it does not exactly follow the natural
channel of the tears; it is  also clear that a large canula cannot  be
conducted without danger through a canal which is too narrow,
and  that if we insert  a  small  one  into a very large canal the
operation will equally fail of success.  In answer to these objections
I may reply:  it is  for the surgeon to  be  prepared to avoid  these
different mistakes, or at  least when he commits  them not to throw
the blame upon the operative process.  In the other  methods  it is
necessary to renew the  dressing  every day for several months, and
there are none of them that have not equally caused cephalalgia,
erysipelas, &c.   By the  process  of Dupuytren  some  seconds  only
are required to terminate the operation.  The patients are cured al-
most as soon as they are operated upon ; no dressing, and no particu-
lar care is necessary ; most of the patients  immediately after resume
their customary occupations without thinking that they carry a canula
in the great angle of the eye.  We obtain in this manner from twelve
to fifteen cures out of twenty cases.  A young woman who had the
canal so narrow that in order to introduce  a canula  of very small
 diameter, I was  obliged to employ a very considerable degree  of
 force, got well, however, after a slight degree of cephalalgia, during
 the space of three days; I was, so to speak, obliged to pierce (tarauder) 
NEW ELEMENTS OF OPERATIVE SURGERY.
805
the canal in order to force in a canula in a young man aged twenty-
one years, who, nevertheless, was re-established in  his health on the
following day ; I kept him at La Pitie, and no accident supervened.
The worst that can happen after all is, that we may be obliged to
withdraw the canula; for that  purpose we have to find the upper
opening of the nasal canal, and to seize hold of the foreign  body
with a small pair of forceps.  When any difficulties are encountered,
the stilett of Dupuytren with a  double  hook, the  little hook of M.
Cloquet or M. A. Stevens, or better yet, the stilett  of Caignou, with
a double spur, will  readily overcome  them.   We may  also make
use of a dissection forceps, one  of whose extremities has been made
to terminate on its inner side by a small curved point.   With one of
these instruments, the beak  of which is placed in the groove of the
border, or  equally well below  the  point  of the  canula, we readily
bring it out by making it follow the route which it had already passed.
Up to the present moment I have removed this instrument a great
number of times, and the dissection forceps ordinarily have, in most
instances, sufficiently  answered  my purpose.  We will remark,
moreover, that after the extraction  of their canulas, patients are ab-
solutely in the same  condition as those who would have been treated
during the same lapse of time  by the dilating method of Petit, and
that many then find themselves radically cured.  In two patients the
canula, which had descended more than half its length into the nose,
could not be seized hold of through the lachrymal sac.   An ordinary
probe bent into  a  hook, and directed underneath  the inferior turbi-
nated bone, enabled me to  extract the canula through the nostril.
I have also seen that the canula no longer existed in many persons
who believed they still had  it, and in whom the fistula or the tumor
had become re-established;  for it does in fact often disappear without
the patient being aware of it.  I have seen surgeons give up the
idea of extracting it from the  impression, as I myself have been in
two instances, that  it had become incrusted  in the bones.  If we
perceive nothing  in the nose,  if the canal is free and we strike
against nothing above, the canula no longer exists there ; it is useless
to look for it.  In conclusion, therefore, the canula is not applicable
to all cases.   When the nasal  canal has deviated from its normal
direction, has become narrowed in one part or in another in  con-
sequence of an exostosis, and its walls are greatly approximated (res-
serre) and indurated ; when it contains ulcers or is  the seat of lesions
of a still more serious character, it is better  to recur to the seton oi
Mejean, or to some other  process better adapted to the case.
  Enlightened by a longer experience, I am in fact  at the present day
obliged to admit that cures by the canula  are infinitely less numerous
in reality, than I had at first supposed.   The error into which  many
practitioners in this respect have fallen, is owing to the greater num-
ber of patients, under the  belief that they were cured on the day af-
ter the operation, or the day after that, have not afterwards been seen
bv the surgeon.  Desirous to know what had become of them, 1 have
followed them up or caused them to be followed up as much as could
be done. I have by this means ascertained that the  canula very often
ascended into the lachrymal sac during the first four months; that, in
a great  number of cases, it  escaped through the nasal fossae before 
806
LACHRYMAL PASSAGES.
the terrrination of the second year; that those that remained in their
place, became changed, dissolved and destroyed, to such extent as to
be of no value;  that they sometimes break, (Champion, private cor-
respondence, 1839,) become sometimes filled up by a sort of blackish
colored putty similar to sulphuret of silver, sometimes by stony  or
sandy concretions ;  at other times  by lymph, concrete mucus,  mem-
branous folds, &c, in such manner tha't at the end of two or three
years, for example, there are  few patients who remaining cured pre-
serve it unaltered in the nasal canal; that it merits in fact almost all
the objections that Ware makes against it.  It is, moreover, in fine,
one of the most uncertain remedies that surgery possesses.
  /. Operative Process.—Whatever may be the method that is pre-
ferred in operating for fistula lachrymalis, there is one stage which at
the present  day everybody performs nearly in the same manner ;  I
mean the  opening of the sac and the catheterism of the nasal canal.
an order to arrive with the greatest certainty possible into  the canal,
the operator causes the eyelids to be stretched  by recommending to
the assistant to draw them towards the temple.  With the  forefinger
corresponding with the diseased  side, he seeks in the great angle the
anterior lip of the lachrymal  groove.   After having forced out by
slight pressure the mucosities  (Vempdtement) of this  part, should any
exist, he provides himself in his other hand with a straight, solid and
narrow  bistoury, the point of which he directs behind the angle of
the forefinger in  order to plunge it obliquely inwards, backwards and
downwards.   Having thus arrived in the sac, he immediately raises
up the handle of the instrument towards  the  top of the eyebrow,
(la tete du sourcil,) in order to descend perpendicularly into the nasal
canal.   He then takes a stilett armed with the canula, if he wishes
to follow the method of Foubert; a canulated  sound or a probe, if
he proposes to imitate  Petit or Desault, and directs the extremity of
one of these instruments upon  the back or anterior surface of the bis-
toury in such manner that this last, in coming  out, serves as a con-
ductor to the other.  When the opening of the fistula is sufficiently
large to permit the passage of the canula or sound, the bistoury is not
indispensable.  In other cases  we sometimes comprise the ulcer in the
incision, sometimes leave it above, below or  to the side ;  in  other
cases we pay no attention  to it: if it is surrounded with fungosities
and that they are troublesome, we in the first place remove them, and
afterwards proceed according to the usual  rules.   When we wish to
penetrate into the nasal canal from below upwards, that is through
the nose, the operator holding the  sound like a writing pen, with its
concavity  turned  downwards and  outwards, introduces it into the
nostril to the depth of about an inch: now raising a little the pavilion
of the sound, in  order that the apex of this instrument may arrive
under the inferior turbinated  bone  and glide upon the nasal wall, he
gently draws it forward to the distance of six or eight lines from the
opening of the nostril.  He then turns its concavity little by little out-
wards and upwards ; then by an oscillatory movement skilfully man-
aged, he endeavors by feeling about to make its beak penetrate into the
orifice of the nasal canal.  We thus arrive without  any very great
degree of difficulty as  high up as to the angle of the eye  or even
into the  lachrymal sac.  Force is never required in these cases.  Re- 
NEW ELEMENTS  OF OPERATIVE  SURGERY.          807
sistance can happen only from the bad  direction given to the instru-
ment  or some anatomical peculiarities.   In inclining  the sound  too
much downwards, upwards, inwards, or outwards, we force its apex
against the opposite wall or the periphery of the lower orifice of the
canal.   The efforts which would then be made, would lead to no re-
sult except that of penetrating into the sinus maxillare or  orbit, or
that of fracturing the inferior turbinated  bone, which might be so
low down and so strongly incurvated that its free border almost im-
mediately touched the floor or the  outer wall of the  nose, and thus
transformed the lower orifice into an actual canal.
  D.  Cauterization.—Before the channel  of the tears was perfectly
understood fistula lachrymalis was treated by injections, or by tents
or meches of lint introduced into the lachrymal sac, and especially
by the  application to this  part of escharotics and actual  caustics.
These different methods are already described with  a sufficient de-
gree of clearness in the works of the Greek physicians, those of the
Arabs, and the authors  of  the middle ages; only that it was under
the same character as the treatment of every other fistulous ulcera-
tion.   The ignorance which then existed in relation  to the anatomi-
cal arrangement of the  lachrymal passages did not allow them to
consider it in  other point of view.  What Guy de Chauhac says
of  it  proves  that Sprengel  was deceived in attributing to the
ancients the idea of injections of the nasal canal.   For more than a
 century mention had scarcely been made of cauterization, when, in
 1822, M. Harveng proposed to create  by it a new method of treat-
 ment.  It was immediately  recollected  that the nasal  canal  was
 somewhat analogous  to the urethra, and that its contractions might
 possibly be  submitted  to  the same kind of medication.  At the
 present day we have two  modes of performing cauterization of the
 lachrymal passages :  in one we cause the cauterizing material to be
 inserted from above downwards, while in the other  it is  introduced
 through the nasal fossae.
   Through the Lachrymal Sac.—l. Process of Harveng.—-M. Har-
 veng  proposes that after having opened the lachrymal sac, we should
 introduce through a  canula a cautery heated to  a white heat, or a
 meche besmeared with nitrate of silver upon the contracted points ot
 the nasal canal; that we should repeat this one or more times accord-
 ing as may be required ;  that we should  proceed in fact as in the
 treatment of affections of the urethra by Ducamp.  According to M.
 Vial  whose thesis did  not appear until 1824, Mortier, of  Lyon, had
 a long time since promulgated the same idea, which is also attributed
 to M Janson, and which M. Taillefer, who also believed himself the
 author of it, revived in 1827.  But it is in reality a mode of treat-
 ment which  is very ancient, since  Heister had  already  advised to
 touch the nasal canal with nitrate of silver.  Formerly it was adopted
 bv many practitioners.  G. de Salicet made  use of the  green oint-
 ment (onguent vert).  G. de Chauliac, who prefers  the red-hot iron,
 proposes that  we should protect the eye  during the operation either
 bv means of a canula, as Alcoatin does, or  with  paste, as Jesus
 recommends, or by means of a silver or brass spoon, as practised by

    2.°Process  of Deslandes.—ln the month of May, 1825, M. Des- 
808                   LACHRYMAL PASSAGES.
landes published another process to effect the same object.  An ordi-
nary probe is first introduced into the nasal canal in order to remove
any obstructions and  to clear out a passage for the caustic-holder;
we" then glide in its place a second instrument of the same form, hav-
ing two  parallel grooves  upon its vertical  branch, and which are
filled with melted nitrate of silver;  this is then turned on its axis in
order that the whole circumference of the canal  may be cauterized,
which finishes the operation.
   Through the Nasal Fossce.—I heard in the year 1824, that M.
Gensoul,  whose labors were published  at a  subsequent  period, dis-
pensed with the opening of the great angle  of the eye, and that he
applied the nitrate of  silyer through the lower orifice in the  nasal
fossae.  M. Bermond,  of Bordeaux, in 1825 inserted in the Journals
a memoir on  the same  subject.  M.  Valat  made some mention of it
in his thesis, in 1826, and  M. Ratier, who, without doubt, was una-
ware of these different attempts, announced, in  1828, that he hoped
to apply  the method of Ducamp to the treatment of fistula lachry-
malis  by penetrating  through the lower orifice  of the nasal canal.
   These  different surgeons first proposed to ascertain the place, form
and extent  of the disease; then to direct the  caustic upon  it with
certainty and ease.   In penetrating by the great angle of the eye,
as is recommended by Mortier and MM. Harveng and Taillefer, the
operation ought not  to be  attended with any difficulty; by the other
method, on the contrary, we must begin by making ourselves familiar
with the  proces.s of  Laforest.
   3.  Process of Bermond.—After  having brought the  conducting
thread of Mejean outside through the natural passages  and without
any previous incision, M. Bermond without paying any attention to
the ulceration of the great angle fixes  the thread to the noose of a
meche besmeared with wax,  which  he then draws into the nasal
canal  in  order  to receive the  impression of the diseased surface
(Pempreinte du mal).   By means of the thread which is  attached to
the free extremity of this species of bougie, he draws it out through
the nose, and puts in  its place a tent made of some  strands of lint
covered with a solid paste, and rendered caustic in the part which is
to correspond to the contraction.   This process has but one incon-
venience, that  of requiring the previous introduction  of a thread
through the  lachrymal punctum, duct and sac.   We perceive that
it is the seton of Mejean  rendered caustic ;  but it might evidently
be simplified  if, in place of following exactly the natural passages,
as the surgeon of Montpellier  does, we adopted the precepts of Petit
and all the moderns for managing the conducting thread.
   4. Process of Gensoul.—A small catheter having a curvature ex-
actly similar to that of the passages into which it is to be introduced,
is  first directed  under  the inferior turbinated  bone and as high up as
into the nasal canal, in order to verify the seat of the disease, which
is  immediately  after  attacked with  a  caustic-holder charged with
nitrate of silver.  More than three hundred patients have been treated
in this manner by M.  Gensoul, some with the most perfect  success,
others with  only partial  results, and many without any advantage
at all.  In order to give to his stilett and canulas the form that is
most convenient, he has taken the exact  impression of them by means 
NEW ELEMENTS OF OPERATIVE SURGERY.
809
 of the fusible alliage of Darcet.  Instruments improved after these
 principles were shown to me in 1825, by Dr. Blanc, and  I was really
 surprised to see with what facility they could be introduced into the
 tear duct.
   Appreciation.—In proposing to cauterize the nasal canal, the sur-
 geons whom I have just named have had no other object  in view than
 to apply the method of Ducamp to the lachrymal passages.  It is
 true, that  if cauterization is applicable to the contraction  of the
 urethra, it may also be  so for the  diseases of the nasal canal;  but
 it appears to me that in the two cases, that neither the action of the
 medicament that we employ nor the nature of the affection that we
 propose to destroy, have in all cases been clearly understood.  Like
 those of the urethra, the contractions of the nasal canal are usually
 kept up by a chronic phlegmasia more or less extended, or more or
 less accurately circumscribed.   In  no case could fistula lachrymalis
 have ever originated from the spasmodic contraction, mentioned by
 Janin, and to which Richter  has given so much importance.   Nor
 does the affection of the eyelids, mentioned  by  Scarpa,  become  the
 source of it except by propagating itself to the lachrymal sac  and as
 far as into the nose, where it causes an engorgement and obstruction
 of the mucous membrane which may produce an obstacle to the pas-
 sage of the tears.   In other words, lachrymal fistula and tumor de-
 pend upon an induration and thickening or a simple chronic  phleg-
 masia of  some  portion  of the lachrymal syphon : but  in applying
 nitrate  of silver on  organs that have been thus changed, it  is not
 by producing eschars there and in burning them that we cure them:
 but it is by dissipating the inflammation, and  by neutralizing  and
 destroying the stimulus and the germ (epine) which keeps  it up, and by
 bringing about the resolution of  the morbid engorgement.   It hence
 follows that nitrate of silver is the only caustic which can be reason-
 ably  employed, and that those impressions which have  so much
 occupied the attention of practitioners are in a measure useless ; that
 the principal object is to make  the caustic arrive in the upper part
 of the nasal canal  when we introduce it from below; and  near its
 lower extremity, on the contrary, when we follow the opposite route,
 in order that we may make it act upon almost the entire extent of
 the passage.   All  the  precautions, moreover, that we  might take
 in order to prevent this general action would not attain our purpose.
 As soon as the  nitrate  of silver is in  contact with the living and
 moist tissues, it melts and soon diffuses itself in such manner that it
 is only necessary in the nasal canal to touch a single point to ensure
 that all the others shall immediately feel its influence.  What I here
 say of cauterization I might apply equally well to dilatation.   When
 a meche or a solid stem is kept either temporarily or permanently
in the  nasal canal it cannot in my opinion be of any service, except
in two ways :  1. By transmitting to the affected surfaces medicated
substances that are calculated to destroy the disease ; or,  2. By com-
pressing from  within  outwards the  whole  circumference  of the
altered passage.   In these cases  we cure not by dilating, but in fact
by an  actual resolvent compression, in the same  way as  we cure
oedema, certain eruptive diseases, erysipelas, &c.
  E.  Establishment of a New Canal.—We find in Aetius and Paul
  vol. ii.                       102 
810
LACHRYMAL PASSAGES.
of Egina, that Archigenes had  already pierced through the os un-
guis with a drill, in order to compel  the  tears or matters to pass
into the  nose.   Sabor Ebn-Sael, quoted by Rhazes and Avicenna,
also eulogizes this resource, which is censured by Mesue.  We have
every reason to believe  that Abulkasem, Roger, and  the  Alcoatin
mentioned by Guy de Chauliac,  who all applied the red hot iron on
the os unguis, effected the same purpose.  Certain it is that their pre-
decessor Celsus speaks of the extirpation of the  sac and  cauterization
of the os unguis  as a  usual practice, and that  G. de Salicet advises
when the bone is diseased to cauterize it in such manner as  to allow
the tears to run into the nose, and that  this also was the method of
J. de Vigo.   Almost entirely forgotten for  many centuries, this me-
thod was again  brought  into repute by Woolhouse.   It is the only,
or almost the only method of treating fistula  which was employed
up to the time of Petit and Mejean.
  1. Process of Woolhouse.—The operator makes at the great angle
of the eye  a semilunar incision  which includes the  tendon  of
the orbicularis muscle, opens freely into the lachrymal sac, or even
according to Platner or M. Malgaigne extirpates it, and lays bare
the os unguis ; he immediately fills the wound with lint and does not
finish the operation until  at the  expiration of twenty-four hours, or
even two or  three days,  in order that he may  be no longer embar-
rassed by the  blood.  A sharp  probe  is then plunged from above
downwards, from without inwards, and slightly  from  before back-
wards, as far as into  the  nasal fossae, through the lachrymal groove
or lower part of the  os  unguis.  A meche of lint or small conical
canula is afterwards introduced into this opening in order to prevent
its closing; then after its  borders are cicatrized and become callous,
we introduce a gold canula, which is a  little contracted  in its middle
part, in order that it may not escape either inwards or outwards, and
that we may leave it there permanently.
  2. Process of St.  Yves.—Saint-Yves,  who  had  remarked that
the process  of Woolhouse was  almost  constantly followed  by ero-
sion or reversion of the  eyelids, perceived  that this inconvenience
might be avoided  by respecting the tendon of the orbicularis mus-
cle in making the incision at the  great angle of the eye.  He more-
over prefers like Guy  de  Chauliac to perforate the  os unguis  with
the actual cautery, in order to obtain an actual  loss of substance.
  3. Process of Dionis.—Lacharriere, Dionis, and Wiseman, also
recommend  the  employment of the hot  iron,  which they apply to
the internal wall of the lachrymal sac  through a protecting canula
made in form of a funnel, the first idea  of which funnel appears to
go back as far as Alcoatin.
  4. Process of Monro.—Scobinger, Monro  and Boudou made use of
a trochar for the perforation of the bone,  and had less apprehension
than Woolhouse of wounding the ethmoid.  Ravaton believed that
he could arrive  at the same result by means of a curved forceps
with which he  fractured the os unguis  to a considerable extent, fol-
lowed by a leaden canula.  But  none of these  methods can be fol-
lowed by a perfect  cure, " for very soon after the  aperture of the
bone fills up," says Guy  de Chauliac, " and nothing can any longer
run into or pass off by the nostrils."   Whether the artificial  opening 
NEW ELEMENTS OF OPERATIVE SURGERY.
811
is kept free by means of a meche, or tent, or by a canula analogous to
that mentioned by Platner, or  a little dilated at its two extremities,
like that of Lecat or Pellier, or  still shorter or more contracted, like
that which Dupuytren used, for example, in the  treatment of Ranun-
cula, or by the hooked forceps of Lamorier, &c, it nevertheless almost
immediately afterwards closes up;  and it is rare that the contracted
canula  of Woolhouse keeps  a  sufficiently long time in  its place to
render the new passage permanent.
  5. Process of Hunter.—Hunter believed  that he could succeed
better by carrying away at once a disk of the os unguis, and the two
membranes between which it is placed, in  such manner as to form
there a circular opening from one to two lines in diameter.  To at-
tain this object, he devised two  particular instruments: 1. A species
of cutting canula  similar  to the punch of harness  makers.   2. A
plate of horn or ebony curved in such manner that it could be intro-
duced  into the middle passage of the  nasal fossae,  and  destined to
serve as a point d'appui to the punch, while we were acting with the
latter from without inwards through the opening of the great angle
of the eye.  We thus obtain a neat perforation, which only requires
to be dressed with a meche of  lint to  cause its borders to cicatrize
and become rounded and callous.   As it is almost impossible to ap-
ply the nasal plate, and as the perforation with the actual cautery is
also accompanied with a loss  of  substance, without thereby  ren-
dering it  always successful, no person, with the exception perhaps
of MM. Talabere, Rougier, and Janson, who made  use of it twelve
to fifteen times, and who censures  it, have undertaken the operation
of Hunter on  living man.   If however it should be  desired to make
trial of it, we could easily accomplish it by means  of the compass-
punch of M. Talrich, or  the trephine of M. Montain.   The  perfo-
rated branch of the first of these instruments having  been introduced
into the meatus, would serve as a  point d'appui to the  perforating
branch, which is applied at the great angle of the eye exactly through
the wound of the canal.   All that is necessary after, is to press one
branch against the other, in order to remove the portion of bone de-
sired without incurring the risk of  making a mistake.
  6. Process  of Scarpa.—In our  day, Scarpa and others have re-
turned to  the employment of the actual cautery, in conformity to the
views of St. Yves; that is to say, that after having opened the great
angle,  as  in  the  simple operation of fistula, without touching, and
even at the risk of wounding the direct tendon, they fill the wound
with lint,  leave it there in this  manner during twenty-four hours, or
even more, and afterwards direct  upon the lower and inner part of
the lachrymal sac, a metallic stem heated to a white  heat, with which
they penetrate into the nose.  In order to protect the eye and sur-
rounding soft parts, Scarpa no longer used the simple funnel of Ver-
duc or Dionis, but a conical canula with very thick walls, and which
supports a handle  several  inches long, which is united with its base
at a right angle ; which canula, figured by Scultetus, and rescued from
oblivion by Manowry, is one which Desault also  used in practice, and
the first idea of which is  found in Roger de Palmer or in Alcoatin.
Rivard and A. Petit recommend that we should open the sac behind 
812
LACHRYMAL PASSAGES.
like Pouteau, and not in front of the eyelid, whether we propose to
penetrate into the nasal fossas, or intend to stop at the canal.
  7. Process of Nicod.—At a more  recent  period Nicod has pro-
posed to combine together in this method perforation by means of
the trochar, and cauterization by means of the hot iron.  In a patient
whose nasal canal was entirely wanting, Dupuytren by means of a
drill, as recommended by Wathen, made another in the direction of
the natural channel, then kept it open by placing a canula there per-
manently.
  8. Process of M. Laugier.—Briot having  noticed that  M. Pe"cot
had, in spite oi" himself, penetrated in one instance into the  antrum
highmorianum,  and having himself, on another occasion, penetrated
through the os unguis into the nasal passage, has furnished the proof
that fistula may be cured in this manner, since  the affection  did not
reappear in  the two patients whom he mentions.  This certainly is
better  than nothing, but I doubt if, notwithstanding the reasons, and
some facts mooted in its  favor by M. Laugier, who, transforming
this accident into a rule, has  proposed  to penetrate, at the very first,
into the maxillary sinus, and to leave a  canula there permanently,—I
doubt, I  say, if such a method can ever have  numerous partisans.
Nothing, in  fact, proves that the tears, having  arrived in  the sinus,
could make  their egress from thence  with facility, that they would
not produce accidents, or that it would be easy to make  an exit
for them by piercing the vault of the palate.  The perforation of the
os unguis would have still fewer inconveniences.
  9. Process of Warner.—Warner, desirous at all hazards of obtain-
ing a permanent opening for the passage of the tears into the nose,
destroyed the os unguis extensively, whether  carious or not.   In
union with the extirpation of the sac,  eulogized by Woolhouse,  and
which M. Jameson has again proposed in our times, the process of
Warner has been reproduced by M. Gerdy, since the principal object
of this surgeon is to destroy  the entire inner wall of the nasal canal.
   10. Appreciation.—If, as  1 with so many others have  had it in
my power to testify, the treatment of lachrymal tumor and fistula by
setons, the canula and caustics, will succeed in nine cases out of ten,
the process of Woolhouse, already rejected as useless by Marchettis,
Solingen,  Maitre Jan, and  especially by the Nannoni, would in our
time no longer  be worthy of consideration.   So long  as it is possi-
ble to act on the natural passages, we  should, by this hypothesis, be
censurable in  attempting to create a new  one; in the contrary
case, it would be more rational to imitate the conduct of Wathen, or
pierce through the track of the nasal canal, like Dupuytren, than confine
ourselves to the perforation of the os unguis or sinus, as after the man-
ner of Saint-Yves or M. Laugier.  Should there be necrosis, we ought
then to treat the fistula by one of the other methods, for the disease
of the bone requires no other care than it does when situated in any
other part of the body.  The employment of the actual cautery or
chemical escfyarotics  is not  without its danger,  when they are car-
ried so near the eye:  they have, more  than in one instance,  pro-
duced obliteration  of the lachrymal  ducts, and  by this  means an
incurable  epiphora.  What  would seem to deter still more from the
method of Woolhouse is this, that the tears rarely acquire the habit 
               NEW ELEMENTS OF OPERATIVE SURGERY.         813

of falling  into the nose, even though the passage which  has  been
opened  for them should remain free, (beante.)  " As to the mode
of cure,"  says Guy de Chauliac, " by  piercing through the nasal
channels by means of an awl, it is not approved of by Heben Mesue,
and I have not found  it effectual, for immediately afterwards the
aperture through the bone fills up, and there is nothing which can
run through it or flow into the nose;" so that, besides the deformity
which it makes at the great angle of the eye, the patient is left with
an epiphora,  (iarmoiement, weeping eye or delachrymation,) which
is, in most instances, beyond  the resources of art;  but in my view
it is demonstrated, at the present day, that we have very often de-
ceived ourselves on this point,  and that we are more than ever justi-
fied in still attempting new trials.
  F.  Closure of the Canal.—In  the midst of this labyrinth of me-
thods or processes, there is one, perhaps, which has not been exam-
ined in a correct point of view;  I mean cauterization.   Everything
authorizes us  to believe that practitioners, like Severin, (Med. Effic
Exopyrie, p.  656,) and Scultetus, (Arsenal de Chir., tab. 34, p. 190,
1712,) among others, who had so much confidence in  the red hot
iron and escharotics, rarely cured fistula lachrymalis but by obliter-
ating the  nasal canal.  This  obliteration, which was proposed by
L. Nannoni,  was systematized into a method  by Delpech, and M.
Caffort  of Narbonne  has written to me that nine patienis who were
treated  in this manner were all cured.  A piece of nitrate  of silver,
as large as a  bean, is deposited in the upper part of the canal, while
the sac  is  also cauterized at the embouchure of the lachrymal ducts.
The operation is repeated three or four times in the space of twelve
days, after which we make use of simple dressing.  A hard cord is
formed  in place of the lachrymal passages, and no epiphora follows!
It appears also that Bosche, who cauterized the lachrymal puncta
with the the view of shutting them up, had no apprehension from this
obliteration;  and  that M. Malgaigne, like Anel, Gunz, Petit, and
Demours, has seen instances where the lachrymal ducts  were want-
ing, and where there was no  epiphora produced.   If such were the
fact,  a  very  simple method might be substituted for all those which
have been in vogue up to  the present time.   The excision of the
puncta  lachrymalia would be  all that would be necessary.  I  have
performed it  in two instances,  but I can as yet give no statement of
the result,  except that the tears, notwithstanding, penetrate into the
nasal canal,  and that I have  not been enabled to obliterate in this
manner the lachrymal ducts.   Cauterization,  in the manner of Del-
pech or M. Caffort, was not successful in the three cases in which I
used it.   In conclusion, I am of opinion that there remains at the bot-
tom of this subject, a question  of  physiology and therapeutics which
has to be examined.
  G. Anomalies.—However distended  the sac may  be,  it rarely
happens that we are obliged  to  follow the precept of  Boyer, and
excise a portion of it, or to have recourse to compression, as Guerin
recommends.   Cauterization with the nitrate of silver,  as advised by
Scarpa, would evidently be preferable in the majority of cases.
  Excision, however, is a practice which we should be wrong in reject-
ing absolutely.  If it is true that we may in reality dispense with it, it 
814                  LACHRYMAL PASSAGES.
 is also true that it may, in some cases, abridge  the  period of cure.
 I  have, in four cases, deemed it  advisable to recur  to  it, and have
 been very well satisfied with it.   The tumor, which was half the  size
 of a nut, was of long standing, and with walls very much attenuated.
 After having  laid it open freely from above downwards, and seized
 one of its sides with the forceps, I removed from it, by one cut of the
 scissors, an ellipse of four lines in  breadth.  The  cyst, which in these
 cases is reflected as it were  upon the anterior surface of the direct
 tendon, is only in part formed  by the  lachrymal sac;  so also may
 we remove a large portion of it without wounding the tendon of the
 orbicularis muscle.  In  place of opening into the great angle of the
 eye, the lachrymal tumor has sometimes made its way into the nostril
 through the os unguis, an example of which is given  by Heister.   In
 internal fistulas,  it is not the re-establishment of the  course of tears
 which is the important point, but the ulcerous affection which is to be
 arrested or cured.  If there should exist a tumor, though the lachrymal
 ducts and puncta  were closed, we should have no other treatment to
 oppose  to  them than that of abscesses or chronic  inflammations.
 Compression at first, or resolvents and astringents, and then a cut of
 the bistoury into the cyst, and the employment of meches or deter-
 gent injections, would be all  that there was to  be done, unless  we
 should incline to  leave a canula remaining in the nasal canal.  In
 certain  persons the osseous canal is so small that we are obliged to
 employ force,  and even a very considerable degree of force, in order
 to effect the entrance into it either of a canula or any foreign body
 whatever.   The contraction which I have here reference to, is most
 usually met with  in adult individuals who have  been affected with
 lachrymal  tumor  or fistula from their infancy, and is  not to be con-
 founded with  that which depends upon an exostosis, or a deviation
 of the bones,  &c.; it  is owing  as I  think to this,  that the canal
 ceasing to furnish a passage to the tears, no  longer grows, and un-
 dergoes a suspension  in its development, which prevents it, at a
 later period, from being in relation with the rest  of  the  organ-
 ization ; it  is in fact the canal of a child in the orbit of an  adult.
 If the explanation which I give of this fact  be  correct, we should
 be prepared to meet with still more difficulties for the  insertion of
 the canula in  persons affected with fistula lachrymalis  from  child-
 hood, than  in  others.    I have  operated in five instances  under
 this condition of things.   A young man twenty-three years of age,
 who had been affected with a double  lachrymal tumor from the age
 of eight  years, and who died at the  Hospital of La  Pitie in 1834,
 enabled me to ascertain, by dissection, the existence  of this species
 of contraction.  Monro and M. Lenoir appear to have noticed similar
 facts.  It is moreover quite natural, that not only  fistulas from  child-
hood, but also very old  fistulas should, in general, be accompanied
with a contraction of the osseous canal, if it is true  that the tears
 then cease  to flow into  the  nose.   Since  the  alveoli, like  other
osseous  cavities, shrink (s'affaissent) when they have  been deprived
of the bodies  by which  they were accustomed to  be occupied, we
may without difficulty conceive that  the  nasal canal would have a
tendency to contract, should it remain a long time without giving
egress to the tears.                                             5 
NEW ELEMENTS OF OPERATIVE  SURGERY.
815
   In other persons I have found the nasal canal greatly dilated, and
 in  the  form of a funnel  at its upper part.   This result, which is
 owing  to the  protracted distension of the sac properly so  called,
 prevents the canula from remaining in its place but with great diffi-
 culty, causes it to  mount up towards the forehead, or to fall almost
 inevitably into the nasal passage, at the expiration of a few weeks.
   [The extirpation of the  lachrymal gland for the cure of fistula
 lachrymalis, was performed with partial  success  in  1843, (Revue
 Med. de Paris, December,  1843,)  by  M. P.  Bernard; the weeping
 moisture, however, continued.   This operation had been  suggested
 for the  disease in question  by MM. Nannoni and Biangini, and has
 also been performed  in extirpating the globe of the eye for cancer,
 (see Arch. Gen., Avril, 1844, pp. 501-503.)  M. Bernard found the
 gland hypertrophied.   T.]

                     Article  III.—Eyelids.

                        §  I.—Ectropion.

   Two causes may lead to the reversion of the eyelids outwards,
 the protrusion  (boursouflement) of the conjunctiva and the narrow-
 ing (raccourcissement) of the skin.  This last condition, or ectropion,
 properly so called, is  the most serious.
   A. Ectropion from exuberance of the conjunctiva.  This first case,
 which is  generally the  easiest  of  cure and the most  rare that we
 meet with, presents itself under the acute stage or in the chronic
 form.
   I. If  the malady is recent, cauterization, which had already been
 recommended  by G.  de Salicet, by means of a particular kind of
 cautery, will ordinarily suffice.  M. J. Cloquet has in this manner
 effected the  cure of an ectropion of the conjunctiva, which had
 existed  more than a year.   Saint-Yves and  Scarpa  particularly eulo-
 gize nitrate of  silver in such cases.  A good many of the dry col-
 lyria would  produce the same effect.  Calomel and sugar, tutty, the
 white oxyde of  bismuth finely pulverized, with an equal part of
 sugar candy, especially, have enabled  me  to effect cures that were
 truly surprising and exceedingly prompt, by  applying them in small
 quantities (par  pincees) morning and  evening,  on all the  engorged
 parts.   Cauterization  with nitrate  of silver, I have found to answer
 in many patients, while the nitrate  of mercury became  indispensable
 in two others in 1837, at the hospital of La Charite.
  II. Excision.—When these resources have been tried in vain, we
 may, in a case of necessity, imitate  Anel, by  passing a noose of
 thread  through the skin near the  lids, and act  upon it by drawing
 upon it  above, in order to  readjust the  diseased lid to  its  normal
 position, and apply at the place where the thread is, as recommended
 by J. Fabrice and  Solingen, adhesive plasters, by which we  attach
its other extremity upon the forehead for the lower lid,  and upon the
face, on the contrary, for the upper; but  besides  that such means
would scarcely ever  succeed, it is infinitely  more  simple, sure and
prompt  to excise the conjunctiva.  This also  is the method adopted
by all the moderns, and th«  one which Antylus had already recom- 
816
EYELIDS.
 mended, and which  Hippocrates himself advised though obscurely,
 when the scarifications  performed .by his ophthalmoxis did not suc-
 ceed.  While an assistant keeps the eyelid turned back, the surgeon
 with a good pair of dissecting forceps in  his left hand, embraces a
 fold of the diseased  membrane sufficiently large to  restore the eye-
 lashes to their normal  direction, but not so much of it as to turn
 them inwards; excises  this fold from the great angle towards the
 smaller angle of the eye when  he operates on the right eye, and in
 an  inverse direction for the left eye;  endeavors  to  include in his
 incision the conjunctiva only, and to cut rather  in proximity to the
 globe of the  eye than to the palpebral  border;  and,  moreover, for
 the performance of this  excision makes use of a straight pair of scis-
 sors, or a  pair curved  flatwise.   A very sharp bistoury or even  a
 good lancet would also attain our object, but the  scissors  are the
 most convenient.  The blood,  which at first flows out abundantly,
 soon stops  of its own accord.  The operation is now terminated, and
 for  the subsequent treatment we proceed  in the same  manner as
 if the  patient was affected with an  ordinary  or traumatic  oph-
 thalmia.
  In cicatrizing, the wound  pushes back the convex  border  of the
 tarsal  cartilage towards the skin, and  thus  by shortening the inter-
 nal  surface of the eyelid, replaces it in its natural relations.   To
 perform this excision, Paul of Egina in lieu of forceps passed a thread
 transversely from one ocular angle to the other, in order to raise up the
 conjunctiva.   This excision  in ectropion, which is disconnected with
 external cicatrices, is an operation so natural, that we have reason to
 be  surprised not  to  find  it adopted  by  all the  ancient  authors.
 Though it be true that it was performed and  described formerly, by
 a number of  authors, it  is nevertheless a fact that M. A. Severin is
 the  first, who after having obtained a great many cures by it, estab-
 lished it as a  fixed principle in surgery.  The remarks of Severin
 (Medec efficace, part 2, chap.  33,) on  excision  of the conjunctiva,
 were forgotten like  those  of his predecessors, when  Bordenave
 (Mem. de VAcad.  de  Chir., t. XIIL, p.  150,) proposed it as a new
 operation, and  endeavored  to demonstrate  all its  advantages.   It
 must be evident to whoever reflects a moment on this subject, that
 the  best mode of bringing into their proper line the internal and ex-
 ternal  coverings  of an everted (renversee) eyelid,  must  consist in
 shortening  that which is too  long, when we cannot or ought not to
 elongate that  which is too short.   Such was the reasoning of Borde-
nave, and since that time the excision of the conjunctival  protrusion
 (bourrelet)  in ectropion, has been  adopted as a  general process in
 practice.  Some surgeons (see Carron du Villards,  Guide Pratique,
 etc., t.  I., p. 342,) under the  impression  that  they could render this
process more efficacious, have suggested that it would be advisable
after the  excision is  terminated, immediately to  raise  up the border
of the eyelid  towards the eye, and to keep it adjusted in this manner
 by means of strips of adhesive plaster or bandages, in order to favor
 the  approximation of the two lips of the wound which has been es-
tablished upon the conjunctiva.  Others, as  Dzondi (Guthrie. Mala-
dies de VQZil,  1830; Carron du Villards, t. I., p.  343,) especially,
have gone so  far as to propose  the excision of cutaneous cicatrices, 
NEW ELEMENTS OF OPERATIVE  SURGERY.          817
 when any exist, or to make a semilunar incision upon the  root (la
 racme)  of tlie eyelid, in order to enable the plasters or bandages to
 straighten with more  facility the  ciliary border.  But it is evident
 that such accessories would only tend  to complicate the  operation,
 and that they will not be retained.
   III. The only treatment in fact, therefore, that can be advanta-
 geous, when there exists no loss of substance, or organic alteration
 in the tissue of the skin itself, consists in astringents and caustics, or
 excision of the conjunctiva by the method of Bordenave.  The only
 modification, perhaps, under such circumstances which might be pro-
 posed with advantage, would consist in cutting the flap (or fold) of
 the  conjunctiva, in such  manner that its  anterior border might be
 made  to approximate as  near as possible to  the free border of  the
 lid, and then to unite the two lips of the wound by a few points of
 the simple suture.   It is probable that we  would  by this  means
 abridge the time of the cure, by avoiding the inequalities of an  in-
 ternal cicatrix.
   B.  Ectropion from shortening (raccourcissement) of the  skin.—
 Bridles and cicatrices, which are sometimes left as the consequence
 of burns, wounds and ulcers of  the face, frequently produce  an  ec-
 tropion much more  difficult to destroy than  the  preceding.  Desi-
 cants and caustics applied upon the palpebral conjunctiva are then no
 longer of any use; and it would be fruitless to attempt to re-adjust
 the lids by means of threads or plasters.  Cauterization  with the red-
 hot iron, and excision of  the relaxed surface itself, are usually insuf-
 ficient.  Many  practitioners, even  among the moderns, admit, that
 the disease may then be considered as incurable.   It is in such cases:
 especially, that blepharoplasty may be called into  requisition.  [See
 Vol. I., also our notes on this subject in that volume. T.]
   I. Method of Celsus.—Up to the  time  of Boerhaave and  Louis,
 an infinity of processes were practiced in order to elongate  the ex-
 ternal  surface of the eyelid thus reversed.   Some with Demosthenes
 of Marseilles, Celsus (Lib. VII.,  cap. 7,) and A. Pare, proposed to
 make upon the  skin a semilunar incision, with its horns turned  to-
 wards the opening of the  eye ; others confined themselves to a trans-
 verse  incision, the lips of which they endeavored to keep apart, by
 filling  the  wound with lint or any  other foreign body; others, like
 Paul of Egina, and Acrel, endeavored  to destroy effectually all the
 bridles and cicatrices, either by making simple incisions upon them,
 excising them with the bistoury or scissors, or by strangulating them
 by means of a ligature.   At present it is admitted, that these differ-
 ent operations, far from being advantageous, are almost always hurt-
 ful, and that in spite of every precaution, the wounds which result
 from them, shorten the integuments of the eyelid in place of favor-
 ing their elongation.
  Though it  be true that  the ancient method of Celsus  is frequently
 the most inefficient in cases of ectropion from alteration of the skin,
it is, moreover, also  true, that it may  sometimes succeed.   M. A.
Petit (Obs.  Chir.,  p. 175,  obs. 94,)  gives a curious  instance  of  it;
there  existed a  breadth of scarcely three  lines between the tarsal
cartilage and the eyebrow; the conjunctiva  was incised without any
benefit; when the external semilunar incision, and in  such manner as
  vol.  n.                       103 
818
EYELIDS.
to comprise only the skin, was then resorted  to, and the  lips of this
incision kept apart by lint.   The bottom of the wound by healing
up (par dessication,) was transformed into a  cicatrix of three lines
in breadth, and the eyelid was thus enabled to cover the eye as in
health.  M. Malvani, (Journ. Gen. de Med., t. 108, p. 28,—or Arch.
Gen. de Med., t. XXL, p.  273,) and  Pellier  de Quingsy, (Obs. sur
Vceil, p. 502, obs. 201,) moreover,  who  relate facts  borrowed  from
Daviel and Marchand, equally prove  that this method does not de-
serve all the  blame, which following the  example  of Herlse, who
wrote  in  1668,  the moderns  have generally reproached  it with.
It is, however, to be considered that it is exceedingly uncertain, and
that it is scarcely worthy of being revived at the present day.
  II. Process  of Antylus and M. Adams.—In 1813, M. Adams, an
English oculist,  proposed  for difficult cases a  process which he
supposed  he  had invented,  but  which  M. Martin (These, Paris,)
attributes  to Physick  and M. Bouchet, and which is found in part
described  in Aetius, (Serm.  3, cap.  61, 62.)   A  triangular flap or
V, whose  base corresponds  to the eyelashes,  is cut out  at  the ex-
pense of the  affected  eyelid.  The two sides of the division  are
then reunited  by means of suture.   The advice of M. Adams has
been adopted  in France by Beclard, and especially by M. Roux.
I have seen it employed, and often employed it myself successfully.
Antylus (Peirylhe) who  made his incisions from the adherent to the
free border of the lids, was careful in dividing only the conjunctiva,
tarsal cartilage and orbicularis muscle ; of leaving, in a word, the
skin  intact, which  manifestly distinguishes his process from that of
the English surgeon.  M. Adams and M. Roux first seize  the eye-
lid with a ligature forceps, then cut on each side  through its whole
thickness, and in this  manner circumscribe  the  triangle mentioned
above, by commencing at  its base.   The blood which immediately
runs out copiously, and  which comes from the ciliary or palpebral
artery, soon ceases of itself.  To reunite, M. Adams restricts him-
self to a single point of suture placed very near the eyelashes.  M.
Roux proceeds precisely as in hare-lip, that is to say, that with one
or two short, strong  pins, or those little pins called minnikin pins,
(camions) he constructs the twisted suture.  In place of the bistoury,
it would be as I  think,  more convenient to employ a  good pair of
scissors, as I  have frequently  done.   The operation is  then more
prompt and certain, and the  section of the tissues neater and incom-
parably more easy.  Also,  I  cannot see that there would be any
use in giving more than two or three lines breadth to the  base of
the flap to be cut out, or  to  prolong its extent beyond the tarsal
cartilage.
   III.  Process of M.  Walther.—In a patient in whom the ectropion
occupied only the temporal half of the eye, M. Walther, (Bulletin de
Ferussac, t. XIII., p. 77,) after having extracted the eyelashes, seized
with a forceps the outer  extremity of the lower lid, which he divided
through its entire thickness as far as the temple, then did the same
for the  upper  lid, and removed the flap of soft parts thus circum-
scribed.  The  two lips of  the  wound approximated  from  above
downwards, were kept  in contact by two points of suture, and  the
patient  recovered perfectly.  This process,  it is seen, is  no  other 
NEW ELEMENTS OF OPERATIVE  SURGERY.
819
 than that of M. Adams, applied to the smaller  angle of the eyelids,
 and cannot be applicable except in cases similar to that mentioned
 by M. Walther.
   IV. Process of M.  Key.—In  1826,  M.  Key  had to  treat an
 ectropion, which MM. Travers, Tyrrell and Green had vainly endea-
 vored to cure by the ordinary methods.  M. Key, supposing that the
 cause of the reversion  of the  lid in this  man might have depended
 upon the spasmodic contraction  of the orbicularis muscle,  made a
 transverse incision in the skin, and penetrated little by little as far
 as to the convex side of  the tarsal cartilage; directed an assistant
 to keep the two lips of the wound apart, and was then enabled to
 seize with the forceps a bridle  of fleshy fibres, which he divided by
 means of a very sharp pair of scissors.  The operation was attended
 with entire success.  I do not know if practitioners will  adopt the
 views of M. Key;  I am not aware that they have  been precisely
 stated ; what is certain is, that we cannot well conceive of the ex-
 istence  of these supposed  spasmodic contractions, nor how the ex-
 cision of  a portion of  the  orbicularis muscle  of the eyelids can
 remedy ectropion ;  nevertheless, as in surgery especially, as soon
 as a fact is averred, whether it  is comprehended or not, prudence
 recommends that it should be admitted, I have not thought it proper
 to pass by in silence the operation of the English surgeon.
   V. M. Brach, (Kleinert's Repert, Fevrier, 1837, p. 22,)  who pro-
 poses to circumscribe and then excise  a quadrilateral flap  of the in-
 teguments, and to have  recourse afterwards to the suture, appears
 to me to have intended  to speak  of, or to propose an  improvement
 for the treatment of entropion, rather  than that of ectropion.  The
 same remark I think may be made of M. Jacob, (Dublin  Hospital
 Reports, vol. V., p. 390,) who imagines the  operation  may be ren-
 dered more sure,  by confining ourselves to the  division of the tem-
 poral angle of the eyelids.
   VI. The process of M. Dieffenbach, (Bulletin de Ferussac, torn.
 XXVL, p. 97,) consists  in an incision on the base of the eyelid, with
 a view of penetrating in this manner to the internal  surface of this
 organ, and to draw its  conjunctiva with  the convex border of the
 tarsal cartilage outside,  in order to fix them by means of a suture in
 a fold of the skin.   This, however, is an  operation which it ap-
 pears to me ought not to  have the preference  but in a very small
 number of cases, and which would expose to a deformity  nearly as
 great as that of the ectropion itself.
  VII.  Should any of  the  processes of which  I  have hitherto
 spoken, not appear to be suitable, ahd should the shortening of the
 skin be considerable, we should have at our  command the  resources
 of blepharoplasty, such as I have described it in another part of this
 work.  In such cases I think satisfactory results might be hoped  foi
 from the method of Jones, even  more than from the modification pro-
posed for blepharoplasty in general by M. Hysern of Madrid, (De la
Blepharoplastic temporo-faciale, Madrid, 1834,) though this  modifica-
tion, which I had  not an opportunity  of speaking of at the proper
time, and in favor of which the author relates two  successful exam-
ples, is in other respects very ingenious.  The method of Jones has
the immense  advantage of not  substituting a deformity in place of 
820
EYELIDS.
that which we wish to destroy, and of being easy of execution and
devoid of serious dangers.   I  had suggested it  in 1834, and I still
believed myself the inventor of it in 1837, when I learnt that M. A.
Berard made a trial of it without success, and that M. Jones had em-
ployed it in two instances with advantage.  M. Sanson, who, accord-
ing to M. Carron du Villards, (Maladies des Yeux, t.  L, p. 347,) had
also employed it, had  no reason  to be satisfied with it, since his pa-
tient, who was soon seized with an erysipelas, ultimately died.  Hav-
ing finally put it in practice in 1838,1 ascertained that it was in reality
easy and more prompt than any other, and that we should be wrong
in not giving it the preference  in cases where all that would be re-
quired to adjust the eyelid would be to  elongate  the skin to the ex-
tent of some lines.  The young man whom I operated upon in this
manner, had had almost the entire left cheek destroyed by a carbuncu-
lous affection.  The lower eyelid was thus depressed as far down as
to a line with the suborbitar  foramen, and the inferior half of the eye
thus remained  entirely  uncovered.   Having cut and dissected the
flap, I first united the apex of the wound, to the  extent of six  lines,
by means of three points of suture.  Three other points of suture
outside, and as many on the inner side, afterwards approximated the
sides of the flap and the borders of the  solution of continuity  that
were still  free.   An erysipelas which made its  appearance on the
sixth day, did not prevent the  agglutination of the parts from being
accomplished, and the patient left the hospital at the end of a month
with his eyelid raised  up to the extent  of four lines,  though still a
little reversed, and in  such  manner as not to touch the upper lid ex-
cept under the influence of a very strong contraction of the orbicu-
laris muscle.  It would  be necessary, morever, in order to derive all
the advantage possible from  this operation, to prolong to a very con-
siderable distance the incisions on the  side of the base of the orbit,
and to dissect the flap nearly as far as the root of the eyelashes, in
order to separate its apex as much as possible from its point of de-
parture.  It would be moreover necessary to  reunite the whole by
numerous points of suture, and to endeavor to place in  contact the
borders of  the wound to an extent of from  four  to ten  lines below
the point of the V, which  moreover would be included by one of
the threads or one of the pins.  (See Blepharoplasty.)  Should ectro-
pion have been  caused by any tumor whatever developed in the in-
terior of the orbit, or in the substance of the eyelid itself, it is unne-
cessary to say that the surgeon should direct his  attention to this tu-
mor, and not to the reversed eyelid.

                     § II.—Blepharoptosis.

  When the upper eyelid is kept depressed to such degree as to com-
pletely conceal the eye,  and  without the eyelashes being turned in-
wards, whether  such  disease  should depend upon  the  inaction of
the levator muscle, or  that it is owing to any other cause, if it is an-
cient, and has not yielded to antiphlogistic  or  exciting remedies, or
to local  or general pharmaceutical means, we are necessarily obliged
to have  recourse to the resources of surgery for this malady.   The
process  ascribed  to M. Hunt, (Carron du Villards, Oper. cit., t. L, 
NEW ELEMENTS OF OPERATIVE SURGERY.
821
p. 254,) and which I have described above under the  name  of M.
Brach, might in this case be useful.   Having excised his elliptical or
quadrilateral flap, the surgeon would attach the palpebral border to the
superciliary border of the wound, and would thus place the movement
of the eyelid  under the influence of the  occipito-frontalis muscle;
we should be wrong, however, to put too  much confidence in this
remedy.  The operation which the fall of the upper eyelid may re-
quire, and which is the  same nearly as for entropion and trichiasis,
has moreover  considerably varied.

                       § III.—Trichiasis.

  Hippocrates passed two nooses of thread through the skin, one
near the free border, the other towards  the base of the eyelid, and
knotted them together in order to turn the eyelashes outwards.
  A.  Excision of the integuments.—But it is to  the excision of a
transverse  cutaneous flap, that  attention  has been more especially
directed.  Already carefully described by Celsus and G.  de Salicet,
this excision is performed in various ways. Acrel, who also proposes
it, recommends that we  should give  a rhomboidal form to the flap.
As it appeared to him that it would not always be attended with suc-
cess, he suggested the idea  of incising the  integuments  above the
eyebrow, and  to remove therefrom a segment of very considerable
size.  Celsus and Galen  traced out with ink the limits of the flap to
be removed, and afterwards reunited the wound by means of a sin-
gle point of suture.  Aetius advises  that one of the incisions, the su-
perior, should  be semilunar, and that  the inferior  should be straight.
In place of one point of suture he employed five.   Paul of Egina com-
menced by making upon the internal  surface of the eyelid, behind the
eyelashes, a transverse incision, extending from one angle of the eye
to the other.  This was associated  with  excision and three  points
of suture.   L'Habitant,  (Annuaire d'Evreux.—Jour, de Med., 1806,
t. XII.,  p. 368,) cured a  patient in five days.
   B.  Cauterization of the Skin.—Rhazes  had  already endeavored
to replace  excision by  means of caustics.   Abul-Kasem made use
of the hot iron or quick-lime.  Costasus especially, and D. Scachi
have eulogized the actual cautery.  Ware incised before cauterizing.
M. Heling (Bulletin de  Ferussac, t. II., art. 20) and M.  Quadri have
bestowed warm encomiums upon sulphuric acid.   The professor of
Naples  commences  by causing the  eyelids to be gently separated
apart and then washes,  wipes and carefully dries them  by means of
a fine piece of linen or  a sponge.  He then, by means of a small bit
of polished wood, applies  the acid upon the skin which corresponds
to the border of the tarsal cartilage, and this to the extent of four to
six  lines transversely;  waits some  seconds, in  order that the first
application of  the  acid  may combine with  the tissues ; repeats it  a
second, third and even a fourth time,  until the eyelid is slightly crisp-
ed outwardly,  and he adopts moreover every precaution possible to
prevent the caustic from penetrating to the eye.
  The excision and cauterization of the skin, whether with sulphuric
acid,  or with  potash, as M.  Solera  (Bulletin de Ferussac, t. II., p.
417) prescribes, evidently  produce the same final  result.  By both 
822
EYELIDS.
methods there is a loss  of substance.  In order that cicatrization
may be effected, the lips of the wound  are obliged to approximate to-
wards each other.  The  result is always a shortening of the eyelid
and especially of its outer surface.   After excision, to which more-
over we should  give a variable extent,  according  to  the degree of
retraction that we desire  to produce, should we, after the manner of
the first authors  who have employed it, as De Beer and  M. Langen-
beck, have recourse to the simple or quilled (emplumee) suture, 01
should we, as Scarpa recommends,  confine ourselves  to a simple
dressing and  union by the second intention ?  This is a matter of
choice, and not of necessity.
  C.  Tearing out (arrachement) of the Eyelashes.—One of the most
ancient methods of treating trichiasis, and especially districhiasis, is
the extraction of the deviated hairs, the first idea of which, accord-
ing to Galen, is to be attributed to Popius.   Nothing, in fact, seems
more natural, in order to destroy the  pain and inflammation which
then exist in the front part of the eye, than  to remove their cause.
Unfortunately it is soon perceived that this remedy is only a pallia-
tive, and only relieves but for the moment;  and that, in growing out
again, the  extirpated eyelashes almost constantly retake their  morbid
direction.   Nevertheless it is almost the only operation approved by
La Vauguyon, Maitrejan, De La Motte, and  even Richter, when the
tarsus itself is not diseased.  In order to protect ourselves from such
an inconvenience, practitioners proposed to apply a caustic upon the
root of the hairs which have been extracted.  Sulphuric  acid, buttei
of antimony and nitrate of silver have in turn been lauded for this
purpose.  If there are only two or three  hairs that have  deviated,
then  mere extraction by means of a tweezers (epilatoire)  very fre-
quently will be found quite sufficient.  In repeating it as  soon as the
eyelashes  reappear, we ultimately either destroy their root or change
their direction.   It is, moreover, an operation too simple, and which
too constantly affords relief, not to be  made  trial of at the very be-
ginning.   I have employed it three times with complete  and  perfect
success.   Excision with the extraction of the eyelashes, as Forlenze
advises, (Annuaire d'Evreux, 1810, p. 68,) could have no  object.
  D.  Cauterization of the  Eyelashes.—Perceiving  that  all these
remedies might fail, some surgeons made trial of the actual cautery,
after  the  advice of Rhazes.  In our  times,  also, some practitioners
have  found no better method of remedying trichiasis than an im-
provement on the  mode  of cauterization employed by  so many
ancient authors,  and especially by Celsus, who made use of a needle
heated to  a white heat.   The form of cauteries  formerly employed
did not allow of carrying the caloric to a sufficient depth.  That of
M. Champesme (Revue Med., 1826) is terminated by a point which
supports a large, smooth dilated ball which approximates it a  little to
the cautery called sparrow-head (tete de moineau). Heated to a white
heat this point, though very small, maintains the  heat sufficiently to
form rapidly eschars on every part to which it is applied.  M. Cham-
pesme asserts that he has  seen trichiasis several times radically cured
by his instrument; and we could  not  deny its advantages if, as A.
Pare sustains, cauterization of the  lashes ought to have  the decided
preference.  M. Carron du Villards, (Op. cit., t. L, p. 307,) plunging 
             NEW ELEMENTS OF OPERATIVE SURGERY.         823

in an insect pin to the depth of a  line and a half, in following the
direction of the lash in each bulb, afterwards unites together all the
pins thus  implanted, by means  of a silver thread, and  then  seizes
hold of them with a curling tongs (fer a papillottes) strongly heated.
The process of Celsus, Pare, or of M. Champesme, is by this means
rendered as simple as it is easy.
  E.  Reversion of the Eyelashes  outwards (eversion).—A  mode
less  severe, and which  appears to  have been  attended with some
success, consists in reversing the deviated eyelashes  upon the skin
of the eyelids.   Heraclides, who passes for the inventor of it, kept
them there, as did also Acton,  by means of plasters.  I have suc-
ceeded by this mode in a case which had resisted  excision of the
integuments.  Celsus and Galen say that in their time some persons
introduced through the skin  by means of a needle, a woman's hair
doubled in such manner as to enable it  to entangle the deviated eye-
lashes in its noose.  According to Rhazes, we  succeed  full as well
by crisping (frisant) them with  a hot iron.

                       § IV.—Entropion.

  A. Excision of the skin, so strongly recommended by Bordenave,
Louis and Scarpa, and almost all the moderns,  as a  remedy for en-
tropion, is an operation too simple and one that too  frequently suc-
ceeds not to be made trial of at  first.  The surgeon being placed
in front of the  patient,  seizes with  an  ordinary forceps  or with his
fingers, or with the crutch forceps (pince en bequille) of  Beer, a fold
of the integuments sufficiently large to make the lashes turn upwards
and forwards.  If this fold should be too large,  we should incur the
risk of producing an ectropion ; if not sufficiently so,  we should only
obtain an imperfect cure.   It is to  be excised moreover, in the same
manner and with the same precautions as  the protrusion of the con-
junctiva in lagophthalmia or simple ectropion.   After the operation,
Scarpa recommends that the skin of the face for the lower eyelid,»
and that of the eyebrows and forehead  on the contrary for the upper
eyelid, should be pushed back towards  the orbit, and  maintained and
gathered  at this point by means of graduated compresses or adhesive
plasters extended from the  cheek bone to  the  forehead.  " On the
following day," he remarks, " the  patient may open  his  eye, and if
proud flesh or fungosities grow up at a subsequent period at the bot-
tom of the wound, they are  repressed by nitrate of silver.  It is in
such cases especially that Beer and  M.  Langenbeck consider that the
suture ought to be employed, in order that the eye  may cease as soon
as possible from being fatigued  by the  presence of the  lashes.  As
the skin divided is very thin and very pliant, and  as nothing is more
easy  than to perforate it with a thread, and as there would more-
over evidently be an advantage in  immediate reunion without gath-
ering the  teguments together like Scarpa, on the  side of the eye, I
cannot see why we should  refuse to make use of the simple suture,
were it only for the space of twenty-four hours, as is recommended
by M. Langenbeck.
  B.  Avenzoar  speaks  of practitioners who preferred compressing
the flap of the integuments between two splints, and thus cause its morti- 
824
EYELIDS.
 fication, rather than to excise it with a cutting instrument.   Bartisch
 has reproduced this idea under another form, by proposing to com-
 press the skin between two plates of iron united by a  hinge.   Adri-
 anson. according to Heister, invented another method.  By means
 of an instrument almost  similar to  that  of Bartisch, and garnished
 with holes, he pinched up a large flap of skin, the  base of which he
 traversed by passing threads through the apertures of the instrument,
 (pince,) then excised the upper border and left it to itself as well as
 the threads, which required to be knotted immediately, like  so many
 ligatures.  .
  C.  Excision of the Palpebral border.—In  obstinate cases, Dr.
 Schreger removes, by means of curved scissors, a triangular flap from
 the  border of the  eyelid, including  in it  the deviated eyelashes,
 and even goes, according to M. S.  Cooper,  to  the extent of recom-
 mending the excision of the entire reversed portion  of the tarsus ; but
 we cannot see for what reason this process, already lauded by Heister
 and De Hayes-Gendron, ought to have the  preference over simple
 excision of the palpebral  integuments.
  D.  Process of M. Crampton.—M. Crampton, after having perpen-
 dicularly divided the free border  of the eyelid to the right  and left
 of the point which supports the  deviated hairs, reunites the  two ver-
 tical wounds which he has  made,  by a transverse incision of the
 conjunctiva, then brings the portion of the cartilage thus divided into
 its natural position, and maintains it there by means of adhesive plas-
 ter, or a suspensory to the eyelid.   M. Travers, who partially adopts
 the views of M. Crampton, thinks that in certain cases it would  be
 still better to excise the little flap  of the tarsus.   The physicians  of
 Bimarestan, mentioned by Rhazes, and who, after having incised the
 cartilage, traversed it with a thread, in order to turn  it outwards;
 Richter, who in obstinate entropion advises  that we should  make a
 transverse incision upon the tarsus, and  Paul  of Egina himself, who
 recommends that we should  incise the eyelid transversely upon  its
 deep-seated surface, are the sources,  as we  perceive,  from  whence
 M. Crampton obtained the idea of his process, which has again been
 recently attended with success in  a case of ancient entropion, as em-
 ployed by M.  Mackenzie, (Gaz. Med., 1838, p. 775.)   At all events,
 however, it is a remedy only to be made trial of as an  exception in
 cases where all other means fail.
  E. Process of Guthrie.—M. Guthrie also  incises the tarsus  near
 the ocular angles; but in such manner as to go  a little beyond  their
 convex border, afterwards he reverses it with the finger, either to-
 wards the forehead or face, according to the  eyelid  affected.   If in
 falling  upon the  eye, the cartilage continues to turn inwards, M.
Guthrie recommends that we should moreover divide it transversely,
 and that we should  excise a portion of it at the same time with the
 skin which covers its external surface.   Without being important or
meriting any great degree of confidence, this process, nevertheless,
appears to be less objectionable than the preceding.
  F. Process of Saunders.—The  most sure mode, says Saunders, is
to remove almost the  entire diseased  organ.   A thin  plate  of" lead
or silver curved like the eyelid,  being previously introduced between
this curtain and the eye, the operator causes the parts to be stretched; 
              NEW ELEMENTS OF OPERATIVE SURGERY.          825

divides the skin and the orbicularis muscle, behind the eyelashes, a lit-
tle beyond and in the direction of the tarsus, dissects the flap and ter-
minates by the extirpation of the cartilage.   The inconveniences of
such a method are too evident to make it necessary for me to expose
them.   There would  be more advantage in  following the advice
given by M. Jaeger, then by M. Flarer, to excise the cutaneous  por-
tion of the free  border of the  eyelid, respecting its ocular portion,
while at the same time removing the deviated eyelashes  and their
roots.
  G.  Process of Vacca, (Journ. de Progres, t.  III., p. 273; Bull de
Ferussac, t. VlL, p. 361.)—The conduct  of Vacca appears to me to
be much more reasonable.  In one of the  most obstinate cases of
trichiasis, this surgeon proposed to lay the  roots  of the eyelashes bare,
and to destroy them, either by means of a cutting instrument or nitric
acid.   A concave thin plate, having a transverse groove on its  con-
vex surface, is first placed in front of the globe of the eye.  An as-
sistant stretches  the  eyelid and keeps the border confined  in the
groove of the plate.   By  means of two vertical incisions  of a  line
long united by a  transverse incision, and comprising only the  skin,
the operator cuts out a little parallelogram, which  he  reverses to
wards the side of the  palpebral opening, thus lays bare the cartilage,
seeks the bulbs of the diseased  eyelashes with a forceps, excises them
with scis,sors and burns them, replaces the  flap, and makes use of
plasters, not the suture, to keep the wound united.  The  numerous
branches, furnished by the palpebral artery to  the eyelashes, are cut
and  bleed  freely.  Nevertheless, the hemorrhage is never trouble-
some, and  always stops of its own accord.
  Delpech, who  also  eulogizes cauterization of the eyelashes, not of
their  root, (tete,) but  of  their  neck,  counts chiefly on the establish-
ment of an elastic cicatrix, or an modular tissue, and consequently
prefers union  by the second intention.  Besides the processes already
described under  the head of trichiasis, viz. excision of a fold of the
skin, eulogized also by Dionis, Saint-Yves, Janin and Gleize, or the
the red hot iron, also recently lauded by M. Jobert, entropion has been
attacked by the  process  of Guerin, that of M. Gensoul and that of
M. Segond.
  H. Guerin, (Journ. de  Montp., t. II., p.  281 ; Carrondu Villards,
t. I., p. 314,)  attributing  the disease, without doubt, to a spasmodic
contraction of the fibres of the orbicularis muscle of the eyelids, pro-
posed to slit perpendicularly to the extent of several lines, the free, from
the adherent  border of the  eyelid.   It is  said that Physick, Beclard,
and M. Bouchet also had recourse to this method for entropion.  We
thus produce a coloboma, or a sort  of hare-lip of the eyelid, which
gives momentary relief, but which cannot effect a definitive cure but
at the expense of a very  disagreeable deformitv.  It is consequently
a method which should be rejected.
  I. The  process attributed to M. Gensul (Carron du Villards,  t. I.,
p. 315, 326, Gaz. Med., 1832, p.  568,) would  be  less objectionable. In
place of a transverse fold, this  surgeon excises a vertical fold of the
teguments of the eyelid.   In the process of M. Segond, (Revue Medi-
cate, 1836,) there is excised successively  a vertical and a transverse
fold of the skin,  so as to unite the ancient method to the process of
  vol. ii.                       104 
826
EYELIDS.
 the surgeon of Lyons.   I do not doubt that we may succeed in this
 manner in  curing  entropion in a number of cases;  but I scarcely
 understand the necessity of this species of crucial incision devised by
 M. Segond  and extolled by M. Carron du  Villards.  An examination
 of a great number of cases of reversion of the eyelids also has never
 enabled me to comprehend the utility of  the processes of Saunders,
 Crampton,  Flarer,  &c,  the excision in the  manner  of Bordenave
 always having succeeded and appeared to answer with me.
   J.  Process of the author.—To render excision as simple and effec-
 tual as possible,  whether by the ancient  method or  the method of
 M. Gensoul, I adopt the  following process : If the palpebral border
 is reversed inwards, rather  towards its extremities than middle por-
 tion, I  prefer the excision of a vertical fold;  in the contrary case I
 adopt excision of the transverse fold.  In the first case I take care
 that the wound  is  larger at its lower  part  than above, and that it
 represents a sort of oval.  In the second case I incise as near as pos-
 sible to the  ciliary border, and I am guarded in giving to the flap a
 breadth so  much the greater at its  middle,  in  proportion as  the
 middle  third of the eyelid is  found more completely deviated in-
 wards.   By means of these precautions,  the approximation of the
 borders of the wound is effected entirely at the expense of the rever-
 sion of the eyelashes, and the least loss of  substance of the skin pro
 duces a decided effect upon the entropion.  When, after excision oi
 the integuments, we leave  the  wound to  cicatrize by second inten-
 tion, the cure may be long and incomplete.  To confine ourselves to
 the employment of adhesive plaster, to approximate the sides of the
 wound, is very uncertain, and the blood or the tears,  which flow in
 abundance,  render the application of the suture quite difficult.   These
 difficulties all disappear by my method, which may be adopted by any
 body.   Having raised up, with the fingers or a good pair of forceps,
 the vertical or transverse fold to be excised, I immediately traverse
 its base with a needle, first at the middle and then at each extremity,
 in order to leave there three threads, each a foot long.   I then excise
 this fold at a line in advance of the threads,  and there remains nothing
 more for me to do than to tie them into a knot,  in order to complete
 the suture and accurately unite the wound.  In this manner we avoid
 all  embarrassment  caused by the blood ;  besides that it is infinitely
 less difficult to traverse  the tissues, and that we cause less pain to
 the patients  than if it were necessary to pass successively afterwards
 the threads through the two lips  of the wound.   This process, made
 trial of already  in  ten to twelve patients, either at  the hospital of
 La Charite  or in private practice, has appeared to me  to be of
 such great simplicity, that I have no longer felt it necessary to make
 use of any other.
  K. Appreciation.—-In  simple  blepharoptosis excision of the inte-
guments is  almost always followed  by success.  It is also the most
effectual remedy  for ordinary entropion.  If it were a  paralysis of
the levator muscle,  we should have recourse to  the process of M.
Brach.  In trichiasis and entropion, extirpation, extraction and rever-
sion of the eyelashes, in the manner of Heraclides, when their length
permits  it, or even the  process of Hippocrates, might be first made
trial of.   Then  come,  1st. Excision  of  the integuments,  which, 
NEW ELEMENTS OF OPERATIVE SURGERY.
827
as Physick recommends, ought to be made very near the palpebral
border.  2d.  Cauterization of the skin by the method of Helling, M.
Quadri, M. Solera, or M. Carron,  which  I have tried in three in-
stances with success.  3d. Process of Vacca for the most severe cases.
And, finally, 4th. The excision of the cartilage, according to the views
of M. Guthrie,  Schreger,  M. Travers, Saunders, and M. Crampton,
or even by the  process of M. Adams, if no other could succeed.

                  § V.—Tumors of the Eyelids.

  If the tumor which occupies either one of the eyelids has not dis-
organized this curtain but only deformed it, we must  destroy it with-
out encroaching on the natural organ.
  A.  Encysted tumors come under this class;  being  a sort of hyda-
tid  productions  or sebaceous cysts  or degenerate mucipares, they
scarcely ever disappear by resolution.
  I. Extirpation.—When  the vinous solution of muriate of ammo-
nia, recommended by Morgagni as well as  by Boyer do not succeed,
we ought, if  the patient is  disposed to be relieved propose the oper-
ation  properly so called.   In these cases  the ligature, incision, cau-
terization, and extirpation  have  been recommended.   The ligature
has been long since, and  very properly, abandoned.   Cauterization
is  equally rejected, unless it should be combined with incision.   A
needle fixed like a seton in the  substance of  the tumor, as  recom-
mended after a case or two by Demours, (Arch. Gen. de Med., t. XVI.
p. 107,) and by M. Jacquemin, would not in my opinion succeed ex-
cept by chance.  So that it is to extirpation that attention has been
more especially directed.  In order to perform  it, it  is altogether
useless previously to pass  a  thread  through the tumor whether laid
bare or not,  as Bartisch proposes, in order to  act upon it with more
certainty.  When it is small and appears to have its seat nearer to
the conjunctiva than to the skin, we  must  seek for it upon the inter-
nal surface of the  eyelid, because the operation then does not oblige
us to go through the tarsal cartilage.   The greater projection that it
makes externally even ought not always to deter us, for this  promi-
nence depends much more  upon the pressure of the globe of the eye
than upon the precise seat  of the  tumor.   When the  skin is changed
and very much attenuated, when it is attended with too much diffi-
culty to reverse the  eyelid,  or  when the tumor exists  outside the
tarsal cartilage, we are then under the necessity of  dividing the in-
teguments.
  a. First Process.—With the thumb placed on the inner side of the
tarsus  and the  forefinger  applied upon the skin, the surgeon seizes
the diseased  lid;  reverses it outwardly ;  presses upon the  tumor
with his finger in order to make it project in front of his thumb ; lays
it bare by means of a transverse incision ; seizes it  with an erigne,
which is taken charge of by an assistant;  then immediately resumes
the bistoury,  dissects  the  tumor, and isolates it in such a manner as
to leave nothing of the cyst behind. .  The little wound which  results
from this operation requires no particular  care, and the cicatrization
is effected in the course of a few days.  We  might  also, as soon as
the tumor is secured with  a  hook, and when it has but little volume 
828
EYELIDS.
and may be readily raised up, excise it with one cut of the scissors
curved flatwise.   Nevertheless it is important to respect the conjunc-
tiva  and subjacent  tissues, and to incise rather than excise them,
seeing that their destruction would expose to the danger of entropion.
  b.  Second Process.—When from  necessity or choice we wish to
attack  the cyst  through the skin, the  forefinger takes the place of
the thumb, and vice versa.   In pushing the tumor the finger stretches
the whole eyelid, protects the eye and answers  a better purpose than
the little cup of lead or silver formerly used, or the plate of gold or
leather still recommended by Chopart and Desault.   We afterwards
divide the integuments cautiously, in order not  to open into the mor-
bid body.   As for the rest  there is nothing particular, and the cure is
rarely  protracted beyond  from three  to four days, and without the
necessity of dressing.
  c.  In  both cases we ought to be on  our guard against perforating
the eyelid, and as much as  possible of wounding the tarsal cartilage,
because the cure would in  most  cases  be thereby retarded,  and
that  there might perhaps result from  it a sort of  fistula or some
other deformity.   A good pair of forceps may advantageously  be
substituted for the fingers in  most cases.  Two forceps, one on each
side confided to  an assistant, gives still greater facility in stretching
the eyelid while the surgeon  dissects and removes the tumor.   If the
operator is sure of his hand,  he may moreover  himself fix the eyelid
upon the globe of the eye by means of his thumb and left forefinger,
while with the bistoury in his right hand he makes the division of the
skin.  Having secured the cyst with an erigne he isolates it, and af-
terwards  separates it without  danger.  A plate of horn or shell
glided  between  the eye and the eyelid, and  which allows of the
ciliary  border being fixed on  the transverse groove  which  exists
on its anterior surface, by means of the nail of the left thumb, gives
still greater security and freedom.  A man from the country who had
in each upper  eyelid a fibrous tumor  as  large as a duck's egg, was
cured by  M. Fleury, (Bull, de la  Fac.  de Med., 1807, No. 2, p.  16,)
who, removing an ellipse of the integuments together with the tumor,
effected a cure without interfering with the movements of the eyelid.
  II. Modified Cauterization.—Maitrejan, Heuerman, Nuck,  and
Loyseau,  (Observat.  Chir.  &c,  p. 112, 1617,) before  them  com-
menced by largely opening the tumor in order to empty it, and after-
wards  to  cauterize its interior.   Chopart and Desault,  who profess
the same  doctrine, use  for the second stage of their operation the
crayon  of nitrate  of  silver.   In  adopting this method, Dupuytren
gives as the reason  that it  is  more easy, and in every respect as cer-
tain as any other, that it ensures us against the danger of perforating
the eyelid, and that it is the only one that can be undertaken, when
in spite of every precaution, we have  penetrated into the cyst while
endeavoring to lay it bare.   Nothing is more  easy than the manual.
The organ is seized in  the  same manner as in the preceding case.
With one stroke of the bistoury we  divide the skin and small sac,
which we empty, or is emptied immediately.   With a crayon of ni-
trate of silver, directed with a certain degree of force upon the bot-
tom of the wound, we cauterize its entire  surface.  The heteroge-
neous (coque) mass soon exfoliates, and the wound afterwards heate 
NEW ELEMENTS OF OPERATIVE  SURGERY.
829
 up very rapidly.   All other things being equal, excision is preferable;
 but the process of Dupuytren is almost equally as good, and will be
 found applicable  in intractable subjects.  Only it  is important that
 the whole cavity of the cyst should be accurately and very strongly
 touched by the caustic ;  it is probably from the want of this precau-
 tion that a return of the disease took place in the three patients men-
 tioned  to me by M. Champion.  I  have, moreover, employed  both
 modes with like success.
   B. The Chalazion, the  Grelon and Grando, which are so often
 confounded with palpebral cysts, are on the contrary small concrete
 tumors, occasionally fibrous,  sometimes as it were caseous or tuber-
 culous, and at other times  of a  fungous  or mucous  aspect.  Under
 this last form they often show themselves near the conjunctiva, where
 I am in the habit of excising them, and afterwards cauterizing their
 root.  It is  evident that  incision and  cauterization would not be ap-
 plicable to the others, and that extirpation is the only resource which
 can succeed with  them.   Like  M. Champion, I  have observed that
 many of these tumors have  no cysts, and  that in order to remove
 them, we  are obliged to dissect them, as for example, we dissect  tu-
 mor's of the breast.  I will remark that this small operation is quite
 painful, and that in certain patients it causes a manifest tendency to
 syncope.
   C.  Erectile Tumors.—The eyelids are subject also to other tumors.
 I have elsewhere given examples of the erectile tumors which are found
 here.  I will add  here that a tumor of this species which occupied
 the great  angle of the eye, disappeared unber the action of a com-
 pressing bandage  and topical astringents, as proposed  by M. Carron
 du Villards, (Malad. des  Yeux, t. I., p. 353.)  Caustic potash appears
 also to  have obtained a remarkable cure of this kind (Ibid., p. 355)
 with  the same practitioner, who also asserts that the hot iron proved
 very efficacious in the hands of  M. Jules Cloquet.   It would appear
 that it is to his father to whom we are indebted for the treatment of
 erectile tumors by vaccination, and that  a tumor of this  kind which
 was situated upon the right eyebrow, was  cured in this manner by
 himself in 1822«
   D. Cancerous Tumors.—Experience has sufficiently proved that
 cauterization  is an objectionable mode for destroying  cancerous
 tubercles  of the  eyelids.  Though even it should  be a tumor  of a
 less alarming nature, it  is still with  the cutting instrument that we
 ought to attack it,  so often  as the degenerescence has extended to the
 natural tissues.  In this part, as  in other regions, it is much better to
 do nothing than to leave a portion of the disease behind and not to
 trench into the sound parts.
   I.  When there  exists only a simple  tubercle  accurately  circum-
 scribed, should it  actually  occupy only the  border of the tarsus, we
 must  isolate it by two incisions  united in a V, remove it at the same
 time with  the triangular  flap which includes it, and  have recourse to
 the twisted suture  to unite the wound by first intention.  If the alte-
 ration extends more in breadth than in depth; if after its extirpation
 we are of opinion that  we  cannot approximate the borders of the
wound, we  excise  the tumor by a semilunar incision more or less
elongated, or to a greater or  less depth, either with a very sharp  bis- 
830                        EYELIDS.
toury, or as M. Richerand prefers, with curved scissors, doing every-
thing in our power not to wound  the puncta or the lachrymal ducts.
The solution of continuity cicatrizes by second intention.. Gradually
the integuments approximate to the  eye,  and ultimately form a bor-
der which replaces in part the eyelid which has been destroyed.
  II. Cancerous degenerations show  themselves, moreover, in the
eyelids, as upon all other regions  of the  body under various forms.
It does not follow, as has been supposed, because the  cancerous tu-
mor has extended as far as the  conjunctiva, that its extirpation be-
comes impossible, or that we are prevented from  having recourse to
this remedy.   M. Champion, who ventured to remove a large can-
cerous plate, and to perforate through and through the diseased eye-
lid, nevertheless succeeded  perfectly in the. case which  he has com-
municated to me.
  III. Again, the free border of the eyelid affected with tylosis is
often transformed into a thick bourrelet, which in  ulcerating soon as-
sumes the aspect of cancer.  But this kind of granulous and ulcerated
border, which many practitioners  who denominate it noli me tangere,
prefer attacking by general medications rather than by active topical
means, is in general  very readily removed under the  action of cau-
terization, by means of nitrate acid of mercury.  Having reversed
the diseased eyelid outwards and protected the globe of the eye by
the usual means, I carefully  touch all the ulcerated surface, and even
the edges  of the degenerated  border with a piece of lint, slightly
imbued with the caustic.  These applications, renewed every  four or
five days, for three weeks or a month, transform the  cancerous into
a simple ulcer, and effect such a reduction in the surrounding tissues,
that the wound soon  cicatrizes  and  permits  the eyelid to  recover
almost all its pliancy.  I have, in this manner, cured  a number of
persons whom other practitioners  had refused to treat otherwise than
by extirpation  of the eyelid, and  it is a method  which I cannot too
much recommend.
   IV.  If the case should be one of  a cancerous plate, of less thick-
ness than breadth, and which did not extend to the free border of
the eyelid, cauterization with the same acid or with tine Vienna pow-
der, or  better still with  the zinc paste, would be preferable to the
knife ;  upon the condition, however,  that upon the eyelids themselves,
there were no other than the teguments yet altered, and that these
different caustics should be applied in such manner as to not compro-
mise the globe of the eye. I have often applied with entire success to
cancerous ulcers at the inner extremity of the upper or lower eyelid,
or solely and  simply at the grand angle  of the eye, a plate  or thick
piece of zinc  paste, according as it appeared  desirable to cauterize
superficially or deeply, and I am of  opinion that this caustic ought to
be substituted for the bistoury whenever the cancerous ulcer, plate or
tumor do not present well defined limits.

             § VI.—Ankyloblepharon, Symblepharon.

   A. The adhesions which the eyelids contract  with  the eye  have
been observed at every  epoch.   In order to destroy them, Heracli-
des, who employed  the  bistoury, lays down  as  a precept, that we 
NEW ELEMENTS OF OPERATIVE SURGERY.
831
should incline the edge  of the instrument rather towards the skin
than towards the eye, and in order to prevent the reproduction of
the adhesion should charge the patient frequently to move the organ
of vision in every direction.   When they are slight or but little ex-
tended, it is  sometimes practicable, as Alix says, to tear them out
by means of a sound  or probe.  If they show themselves under the
aspect of bridles or lamellae, and we can succeed in  gliding under
them, upon the globe  of the eye, the blade of a canulated sound, we
may, according to the direction of Maitrejan and Boyer, divide them
upon this instrument without any danger.  It is never allowable at
the present day, to raise up the eyelid by means of a thread while
we are dissecting it, as was the practice in the time  of Bartisch.
Moreover, the important point is not the division of these adhesions,
but  to prevent  their reproduction.  The movements  of  the  eye,
recommended by Heraclides, the  plates of  lead, gold, or leather,
which Solingen and others recommend to keep between the eye and
its connections, rarely attain the object in view.   The porcelain  or
glass eye recommended by Demours, and the  plate of softened ivory
preferred  by M.  Carron, (Oper. cit., t.  I., p.  264,) are scarcely any
better; inflammation  soon renders the presence  of  such foreign
bodies insupportable.   The most prudent course  is to restrict our-
selves to passing, from time to time, a ring or the  head of  a  large
pin between the contiguous surfaces, in order that they may cicatrize
separately.   It is an operation after all, which, whatever M. A. Seve-
rin (Med. Efiic,  part II., chap. 55, p. 215,) may say of it, ought not to
be attempted, except  in patients whose transparent cornea has con-
tinued  unaffected and unchanged, at least opposite to the pupil.   The
case mentioned  by this physician, who was operated upon twice by
A. Petit and Dussausoy, (Obs. Clin., art. 13, p. 181,) and afterwards
by a charlatan,  shows all  the danger  to be apprehended  from an
opposite  course.   Perhaps, however, we should then succeed if, after
having slit up the eyelid vertically, as Guerin advises, (Soc. Med. de
Montpellier, t. II., p.  285,)  we should keep its  flaps reversed  up to
the period of the cicatrization of the bridles, and afterwards reunite
them by  suture.
  B. Congenital or accidental union of the palpebral borders, always
a less  serious affection, may be complete or  incomplete, and  may
exist alone or at the same time with the preceding infirmity.  In the
first case* in place of acting with the bistoury from before backwards,
as the ancients  did,  upon the whole extent of the line which the
natural division ought to occupy, we first make a small opening near
the temple, in order to introduce afterwards, through this incision, a
canulated silver  sound, which is a little  concave on its  back, in order
that it may accommodate  itself to the convexity of the eye.   The
bistoury, guided by this  director, would pass  without danger  from
one palpebral commissure  to the other in following the interline of
the eyelashes.   In the second  case the  preparatory incision is not
necessary.   We insert the sound through the remains of the ancient
opening,  as was successfully done by Hevin,  (Pathol, et  Therap.,
t. II., p. 135.)  In a patient operated on successfully by Quesnault,
(Lelong,  These,  No. 179, Paris, 1819,)  there existed at the angle of
the eyelids a small opening, which partially allowed of vision through 
832
EYELIDS.
 it.   An opening existed also in the cases cited by Botin and Seiler,
 (Carron, Oper. cit., t. I., p. 257.)   Of the three brothers operated on
 in this manner by G. Lagree, (Anc Journal de Med.,  1760, t. XII.,
 p4 157,) one died on the eighth day from marasmus.  After having
 separated the eyelids, if ankyloblepharon should have coexisted with
 the disease, we must proceed to its destruction according to the rules
 indicated above.  In  the place of the bistoury  conducted upon a
 sound, it would be practicable to employ scissors bearing a ball of wax,
 as J. Fabricius recommends, or a small button at the extremity of one
 of its blades, according to the recommendation of Scultetus.   But it
 would be trifling to pass a noose of brass wire furnished with knots be-
 hind the abnormal agglutination (soudure), as  Duddell did, and to ap-
 proximate its two halves with the view of gradually dividing the bridle.
   Finally, no one at  the present day would be so absurd  as to imitate
 F. de Hilden, by knotting the two  ends of this noose and attaching
 weights to it in order to drag it by degrees to  the outside.  Inasmuch
 as after every process the disunited borders  retain, after the opera-
 tion, a great tendency to become re-agglutinated, the surgeon should
 not  neglect  to place  between them, near the commissures, some
 strands of lint imbued with cerate, nor frequently to separate them
 apart by means of a metallic stem  or ring.  To dissect  the conjunc-
 tiva in order to  unite it afterwards with the skin by  means  of a
 suture, as M. Ammon recommends, would often fail and  presents too
 many difficulties.  Three points of simple suture on  each  \jjp of the
 wound near the  commissure, would  better  attain  our object and
 would cause infinitely less embarrassment.
  C. Simple phymosis, or contraction (retredssement) of the eyelids,
 should be treated like ankyloblepharon, and requires no other details.

     § VII.—Tumors.—Folds at the Great Angle of the Eye.

  Two kinds of  tumors, disconnected with the lachrymal passages,
 have been  noticed in  the great angle of the eye ;   one having the
 caruncula lachrymalis for their seat, the other  placed between the in-
 teguments and the direct tendon.  I know but one fact of this last kind,
 and which belongs to M. Besson.   The tumor, which existed on both
 sides, had the size and form of an almond : it was extirpated, and the
 patient got  well.
  A. The other kind is known  under the name of encanthis.   It
 has been noticed by a great number of practitioners, and I myself
 recently met with an example of it  in the  month of December, 1837,
 in a young girl of six years of age.   The  disease may in these cases
 assume the  character of different kinds of tumors, whether fibrous oi
 cancerous;  in general, however, it presents  itself under the aspect
of a small reddish granulated mass, slightly painful, and which seems
to prolong itself to a  greater or less distance in the orbit, and which
also  protrudes more  or less between the eyelids near the inner com-
 missure.  Encanthis, unless  it should  be  attacked at the beginning,
yields neither to debilitating  or resolvent means.   The ligature, em-
ployed  in one instance by Purmann, would be suitable only to pedi-
culated encanthis.  It  will  be by means  of caustics or the bistoury
that we shall succeed.  Among the first there  are scarcely any othei 
NEW ELEMENTS OF OPERATIVE  SURGERY.
833
than the  nitrate of silver or the nitrate  of mercury, which can be
applied with  safety.  Potash, the butter  of antimony, and the zinc
paste, would  in fact expose to too much danger of injuring the lachry-
mal  sac  or the nasal extremity of the eyelids.  Extirpation of the
tumor is in itself an  operation sufficiently delicate, inasmuch  as it
would be easy to wound either the puncta, the lachrymal ducts, the
muscle of Horner, the tendon of the orbicularis muscle, or in fine the
outer wall of the lachrymal sac.  The patient ought to be laid on a
bed  of sufficient height, or seated  on a chair;  an assistant placed
behind steadies the  head and attends to keeping the eyelids separate.
The surgeon, securing  the tumor with an erigne,  which he immedi-
ately consigns to a  second assistant, isolates, by means of  a straight
bistoury, the  morbid mass, first below, then above, then inwardly, in
order finally  to dissect it from behind forwards, and from within out-
wards, avoiding with care the globe of the eye.  M. Fleury (Bull.
de la Fac. de Med., 1806, p. 157,  or  1807, No. 2, 3 annee, p. 16,)
has  extirpated  two of them which were of the size of a large egg,
but they were  situated  upon the  upper  eyelid and not at the angle
of the  eye.   M. Carron du Villards,  (Malad. des Yeux,  etc., t. I.,
p. 462,) who says that he has twice performed the operation of remov-
ing encanthis, perceiving that in one case it was a fungus and in the
other a melanotic  tumor, considered  it necessary to touch the bot-
tom of the wound with the button cautery in his first patient, and
with caustic  potash in  the second.  The palpebral artery, which is
ordinarily divided  by this operation, sometimes gives rise to a kind
of hemorrhage  which is quite abundant, but which simple tamponing
generally arrests without any difficulty.   The wound is then  filled
with small balls of lint, after which a fine piece of linen perforated
with holes and imbued with cerate, and then a plumasseau of lint,
are placed above to cover the great angle.  After this nothing more
is required to keep  on the dressing than to envelope the whole with a
compress and  a few turns  of bandage  in the form of the monocle.
After the first dressing  we reduce every day the size or the number
of the  small  balls  of lint, and the wound generally cicatrizes in the
space of from  fifteen to  twenty days.   It was in this manner that
M. Marchettis succeeded in detaching a meliceromatous tumor which
extended over even  a  part of the transparent cornea, but he had
recourse to the scissors  to terminate his operation.
   B. Epicanthis.—Should the fold of integuments, which  from the
root of the nose sometimes advances forward in the form of a crescent
upon each side, as if for the purpose of covering the caruncula la-
chrymalis, have too  great an extension, patients might readily be
relieved  by means of an operation which MM.  Ammon  and  Car-
ron, who designate this deformity under the name epicanthis,  have
frequently employed with success.  Raising up the skin at the root
of the nose,  a vertical  elliptical flap  is excised, of such dimensions
that the approximation of the lips of the wound by suture will imme-
diately cause the disappearance of the two angular crescents.  If
before excising it we should pass pins  or threads through the base
of the cutaneous fold, the operation would be still  more simple.
   [Mr. Dalrymple, a surgeon of London, (Cormack's Journ., October,
1843, p. 952,) has  had occasion to remove from the upper eyelid an 
834
ORBITAR CAVITY.
encysted tumor about the size of a pea, composed  of closely agglu-
tinated epithelial scales, containing granular earthy molecules, in-
stead of being composed as is usual of thin transparent lamina?, with
a central nucleus.  T.]

                 Article IV.—Orbitar Cavity.

  Loupes, encephaloid masses, aneurisms, exostoses, &c, may be de-
veloped in the interior of the  orbit.   The lachrymal  gland itself
sometimes  acquires a considerable volume in passing into the con-
dition of schirrhus.  These different lesions, whose especial peculiar-
ity is to push the eye forwards, and at  the same time  to incline it
towards the point opposite to that at which they are situated, have
often given occasion  for its extirpation.  Nevertheless, so long as
the globe is not itself implicated in the degeneration it may be saved.
This is indisputably demonstrated by an elegant operation of Acrel,
the case related by M. Cantoni, (Journal des  Progres, t. XIIL, p.
256,) that of M. Gerdy, (Archiv.  Gen.  de Med., t. VIIL, p.  339, 2e
serie.)  and the practice  of Dupuytren, (Clin, des  Hopit., t. III., p.
196.) An ancient memoir of Daviel and Guerin  of Bordeaux  proves,
on the other hand, that  the lachrymal  gland has often been extir-
pated with success by those  two surgeons.   M. D. Lasserve (Cas
de Chirurg., &c, p. 52, fig. 15,) has extirpated  from  the  orbit of a
woman a cyst which strongly protruded the eye outward, and the
interior of which  was cribbled with hairs.  Even osseous  tumors
may be removed without injuring the eye, either by the chisel and
mallet, or by tractions or well-directed movements, as is  proved by
the case related by M. Sultzer.   The  rules to be followed for extir-
pation, either of  the lachrymal gland or of any  other  tumor situated
in the orbit, will have necessarily to vary according  to the volume,
form, nature and seat of the disease.   If, for example, it was only a
cyst filled  with matters more or less liquid, nothing more might be
required than to  plunge a bistoury into  it, and to  keep  its  •avity open
by means of a meche of lint.  MM. Schmidt  and Rutdhorffer, in
fact, who have often met with cases of this kind, consider that punc-
ture with a trochar would be sufficient.  Ware (Mai des Yeux, p. 188,
1805,)  cured his patient of a serous cyst, which he had in the orbit,
by means of sixty-three punctures.  Guerin of  Bordeaux, supposing
that he was to extirpate the lachrymal gland or  a cancer, perceived,
after he  had passed through the eyelid,  that  he  had fallen  upon
a tumor filled with  semi-liquid matters ;  he  opened and emptied it,
and  introduced  a tent  into it,  after which the cyst exfoliated  on
the twenty-first  day.  Spry, who fell  into  the same error in 1755,
would have probably preserved the sight of his  patient if, instead of
going on to extirpate the eye, he had had the  prudence  of  Guerin.
The liquid humors mentioned by St. Yves,  (Mai.  des Yeux, p. 188,
1805,) Pellier, (Obs. sur VCEil, &c, p. 40,) and  M. Graefe, (Archiv.
Gen. de Med., t. VIIL, 2 serie,) the collection of hydatids described by
M.  Lawrence, (S.  Cooper, Diet,  de Chir.,  &c.,) and  M. Travers,
(Synopsis, &c, p. 229, 235, 1821,) the  meliceroma, steatoma, glairy
cysts, and  purulent collections, indicated by St. Yves (Oper.  cit.)
and MM. Lawrence, Richerand, Guthrie, (Mai des Yeux, p. 147,148,) 
NEW ELEMENTS OF OPERATIVE SURGERY.
835
and  Travers, (Oper. cit.,  p.  229,) are to be treated in the  same
manner.
                              § II.

  In respect to solid tumors, there are two modes of removing them
Whether they are osseous or osteo-fibrous tumors, as in the cases of
Baillie,  MM. A. Cooper, Crampton, (Mackenzie, p. 56,) and Travers
(Loc cit.) fibrous, adipose,  or cartilaginous tumors,  like those men-
tioned by M. Mackenzie, (Ibid.;)  or even exostoses, properly so called,
examples of which are given by Sue, J. L. Petit, (Mai des Os, t. II.,
p. 303,) and Brossaut,  (Mackenzie,  Op. cit., p. 48,  1830,) they are
notwithstanding to be extirpated.
  A.  Process of Acrel—The whole thickness of the eyelids is to be
divided in the natural direction of their curvature, near their root, and
upon the point corresponding to  the most  prominent  part of the tu-
mor.  An assistant then separates apart the lips of the wound.   The
surgeon, by means of a narrow bistoury, guided  by the forefinger of
one of his hands, isolates the tumor from the orbit, secures it with an
erigne, dissects its inner surface, in order to separate it from the eye,
either by the finger or the cutting instrument, and makes an effort to
remove it from its apex to its base.  It was in this manner that Daviel
and Guerin  proceeded, and none of their patients died.   Although in
one of their cases the tumor had, on its inner side, a groove adapted
to the  optic nerve, and that in  another there supervened an enor-
mous tumefaction of the eyelids with severe fever, all preserved their
faculty of vision.   It might at first have been doubted if the lachrymal
gland itself  had  actually been  extracted; but  Guerin  dissected it
after  the operation, and made  even  a model of it in plaster; the
original of which,  preserved by  him  in  alcohol,  he exhibited to the
Academy of Surgery.   It is moreover an operation which, at the
present day, is perfectly well understood.  MM. Todd, Lawrence and
O'Beirne have performed it in England with  no less success  than
Daviel,  Guerin and M. Duval in  France.  The treatise of M. Mack-
enzie gives two  other  instances of it,  and Warner, as  well as M.
Travers, had already had  recourse to it.  I have seen a woman  in
whom M. J. Cloquet performed this operation, so effectually that there
was  no longer any flow of tears on this side.
  B. Process of the Author.—In my view, we could attain our object
better than by the process  of Acrel, if we  were to  commence by
prolonging the external commissure towards the temple in such man-
ner as to be able to reverse the eyelids.   Different trials  have  satis-
fied me that by acting in this manner we may  readily lay bare the
two outer thirds of the orbital circumference.  This being done, the
surgeon separates  the tumor he is about to remove from  the osseous
cavity which contains it, by dividing the cellular tissue from its ex-
ternal surface; dissects it down  to its greatest depth, isolates it  with
every possible precaution,  either from  the muscles, optic nerve, or
globe of the eye itself, and draws it to  the outside by means of the
finger or an erigne.  For more facility, it would  be well  perhaps  tc
circumscribe it also by a semilunar incision on the side towards the
transparent  cornea.
  It must  undoubtedly have been through inadvertence  that an ob- 
836
ORBITAR CAVITY.
jection  has  been made to this process of incurring too  great a risk
of wounding the ducts of the lachrymal gland, (Archiv. Gen. de Med.,
t. VIIL, p.  354, 2e  serie ;) for if  they required the attention, this
process  would enable us to respect them still  better than that which
consists in penetrating into the orbit through the upper eyelid.
  C. Sequelce.—After the operation there sometimes succeeds such
an extensive swelling that it is not unusual to see the eye at  the end
of three or four  days make as striking  a projection as it did before.
But  this condition of things soon subsides.   In  the space  of from
ten to thirty days everything returns to its normal condition, and the
cure usually takes place.   Immediate reunion ought not be attempted
in either process, since  the cavity which is left in  the orbit, cannot
immediately be filled up, and  that the  tissues, lacerated rather than
divided, are  obliged to suppurate.  In a patient whose wound closed
up too  rapidly, Guerin saw supervene  symptoms so formidable that
he found himself obliged to break the  cicatrix with a sound.  All
that  is necessary then, is to dress with a meche or tent imbued with
cerate, to approximate  the wound at the palpebral angle, if it has
been found  necessary  to  divide it, and to cover the whole with
plumasseaux, and then by some compresses, which are kept in place by
the bandage called the monocle. When the suppuration is established
the dressing should be renewed every day.  Injections often become
necessary, and we do all in our power to enable the solution  of con-
tinuity to close up from the bottom to the exterior.  If by traversing
the eyelids we should  render  the  operation more easy, even though
the deformity which it involves would necessarily have to be greater,
we ought to  give the preference to this manner of proceeding; but
unless the tumor should have acquired  an enormous volume this  is
not the case.  The incision of  the outer  palpebral angle  will always
enable us to  procure a sufficient degree of separation, even though
there should have been alteration of the  bones, to enable us to re-
move the tumor  as well as the necrosed splinters, as was the case  in
one  of the patients of Guerin.  In  a case of M. Hope, the tumor,
which had existed for seven years, had so elongated the optic nerve,
that  it became necessary to push back the eye with the hand, and  to
keep it fixed  there by means of a bandage ; the cure, nevertheless, was
complete.  In  a young woman whose indocility was uncontrollable,
M. Wardrop bled her to the amount  of fifty ounces of blood,  in
order to produce syncope, which enabled him to perform the opera-
tion with so  much ease and success,  that the  patient coming to her-
self,  could scarcely believe it.'  In  a  case of pancreatoid sarcoma
mentioned by Bouttate of Moscow, (Abernethy, Mel de Chir. etrang.,
t. II., p. 453,) the tumor, which was seven inches in length, and three
and  a half in  circumference, weighed  two pounds and  a half.   It
was  intimately united with the conjunctiva, which it pressed upon ;
but it was not difficult to isolate its base from the cornea, which had
preserved its transparency.  After the ablation, the patient recovered
his sight. 
NEW ELEMENTS OF OPERATIVE SURGERY.          837
                Article V.—Globe of  the Eye.

                     § I.—Foreign Bodies.

  Numerous and various kinds of foreign bodies may become fixed
on the eyelids or on the front part  of the eye, in the same way as
between the eyelids and the eye.  Besides the ordinary signs which
reveal their existence, I have ascertained, like Andrieu, (Avis, au
Citoyens, &c, p. 19, 1780,) that pungent and fixed pain correspond-
ing to the  middle of the upper  eyelid, indicates the presence of a
foreign body upon the cornea ; in the same manner  as  those which
are concealed in the oculo-palpebral fold  of  the conjunctiva,  are
announced by a  dull pain, which  corresponds to the upper border
of the tarsal cartilage.
  A.  The ciliary border of the eyelids is sometimes invaded by in-
sects. A young peasant girl who had this part of the coverings of the
eye transformed into  a  brownish colored border, and who  suffered
from it to a considerable degree, carried there so great a number of
pediculi pubis that M. Champion, who was then consulted, could have
never believed it possible that so many of them could have attached
themselves upon so narrow a space.   In such cases, all that is neces-
sary is, to cause  the parts to be rubbed with mercurial ointment, that
of white precipitate, or the pomade  of Desault, and no operation is
to be attempted. There have been seen, moreover, different sorts
of worms either in the ulcerated border of an  eyelid,  or at  the
bottom of the oculo-palpebral groove.  We have already an example
of this kind in the Ephemerides of the Curiosa Naturae,  and we owe
to M. J. Cloquet the  history  of a man, who had the eye  and  the
orbit deeply excavated by a species of worm known  under the name
of asticot.  I have  also met  with a patient, who being  habitually
uncleanly, and for  a long time  tormented by a ciliary blepharitis,
had six enormous asticots at the great angle of the eye,  between the
inner extremity  of the upper  eyelid and the caruncula  lachrymalis.
The mode  of destroying them,  moreover, is the same  as for  the
pediculus pubis,  and other insects.  It is also probable that camphor,
so much praised by M. Raspail, (Gaz.  des Hdpits, Novembre et
Decembre, 1838,) if it were  associated with mercurial topics, would
give them still greater efficacy.
  B.  Foreign  bodies  of a certain size may also sometimes remain
implanted for a  considerable  length of time in  the eyelids or front
part of the eye without  being perceived  there.  A  young man
entered the hospital of La Charite, in 1837, with a sub-acute  ophthal-
mia.  The cornea preserved its transparency; a grayish colored che-
mosis with an erysipelatous tumefaction of  the upper eyelid, which
phenomenon was more  marked  in the  direction of the temple than
towards  the  nose,  immediately  struck my attention.  The young
man, who suffered but  little,  did not know to what  to  attribute his
malady, which  had existed for the  space of fifteen  days.   By dint
of researches, I finally discovered  in the superior  oculo-palpebral
groove, the yellow extremity  of a body which I immediately seized
with a forceps, and which was nearly an inch in length and a line and 
838
GLOBE OF THE EYE.
 a half in diameter.  It was a piece of hay-stalk, which had penetrated
 into the orbit while the patient was asleep upon a cart loaded with
 hay.  Borichius (Collect. Acad., partie etrangere, t. VII., p.  321)
 speaks of a thorn which in this manner remained for a period of
 thirty years in the inner angle of the  eye  before it occasioned  any
 pain, and which  ultimately produced  a violent inflammation.   A
 stem which was more than an inch long, and which entered the orbit
 through the eyelid, remained there also, says Willius, (Collect. Acad.,
 t. VI., p. 248,) a very long time without being recognized,  though it
 produced  very serious accidents, with delirium and convulsions.
  C. Fragments of whalebone of a  line or two in length have, in the
 same manner, become lost  under the conjunctiva in a patient men-
 tioned by  St. Yves, (Mai des Yeux, p. 210, art. 12.)  Bidloo, Schar-
 schmidt and Percy (Chirurg. d'Armee, p. 112, 113,) give similar in-
 stances of pieces of wood, glass  and pipe-stem.  M. Maunoir (Corps
 etrang., 1812, p. 212) speaks even of portions of chesnut shells which
 have thus become fixed on the front part of the globe of the  eye; and
 M.  Champion has noticed the same thing.  There  have also been
 seen hairs that had  grown from the caruncula lachrymalis, as in the
 case cited by Albinus, and become incurvated  outwardly so as to give
 momentary irritation to the eye.  Demours (Stance de 1'Academie de
 Med., 22d May, 1828)  speaks of a barb of a barley ear which had
 introduced itself into the lachrymal punctum in such manner as to
 project outside, but  to a very small extent.   A case also  has been
 mentioned which was noticed by Dupuytren (Archiv. Gen.  de Med.,
 t. XVIL, p. 126),  and in which  an eyelash  had, by curving back-
 wards, become entangled in  one of the lachrymal puncta.  I will
 add that a woman who thought she had a small tumor on the  sclero-
 tica, at the outer angle of the  eye, and who had carried  this pre-
 tended tumor for the space of nineteen months, had there nothing
 more than a particle  of millet seed, which had come out of a bird-
 cage, and  which appeared  to  have been kept in its place merely
 by atmospheric pressure.  I have seen the same thing  on various
 other points of the globe of the eye, and even on the  cornea.  In
 all cases,  the little cup reposed  by its concavity on the  eye, and
 seemed to have embedded itself into the conjunctiva.   I have also
 found on the cornea small scales, either of  cinder or copper or iron,
 which had retained their position in the same manner  for the space
 of several weeks without occasioning  serious accidents.   A patient
 whom I exhibited at the clinique of La Charite, in 1837, had one of
 these scales in the  front part of the cornea for the space of fifteen
 months, and had paid so little  attention to it that it was for another
disease that he was  induced to come  to the hospital.
  D. A gold or silver ring, the head of a  long pin,  a small roll of
 paper, an earpicker, or any other smooth and round substance, will
 answer for removing the different solid foreign bodies which continue
movable between the eyelids;  but it is not always the same with
particles  of metal, stone, wood,  &c, which  having been projected
upon the organ of vision, become fixed and retained there.   In such
 cases, when we are not afraid of breaking  them, the point of a pen,
cut  in  the manner of a toothpick, or  any other similar  instrument
glided upon the front* part of the cornea often succeeds in detaching 
NEW ELEMENTS OF OPERATIVE  SURGERY.
839
them.  At other times we cannot do this except with the point of a
lancet, and in some cases even only by making use of a small pair of
forceps skillfully managed.   It is only under very rare circumstances,
and when the ferruginous corpuscle is scarcely adherent, that the load-
stone, as recommended by F. de Hilden, (Bonet, Corps de Med., p. 393,)
(who boasts much of  the successes thus obtained by his wife,) could
be usefully employed.  The same remark would apply to the roll of
Spanish wax employed by Deshayes Gendron, or to a piece of amber
to attract to the outside particles of straw.   When we decide upon
the operation an assistant is charged with holding the eyelids apart.
The operator directs the point of a lancet or of a very sharp-pointed
bistoury  to the circumference of the foreign body, which he isolates
down to  a certain depth  in the substance of the cornea, then seizes
hold of it with a very fine and well adjusted  forceps, draws  it while
moving it gently for fear of breaking it, and afterwards  pursues the
same treatment as in a patient  having an  ordinary ulceration or
simple ophthalmia.  This operation  moreover does not in itself pre-
sent any difficulty; it merely exacts address and great precision in
the movements.   Moreover, when the body to be extracted  projects
beyond the level of the eye, if it is solid and does not penetrate into the
chambers, we almost  always succeed in detaching it by scraping it
with the  border or the side of the point of a  lancet or cataract needle.
   E. If, as I have seen in different patients,  grains of powder, or lead,
or fragments of percussion-caps, glass, metal, or of a watch-spring for
example, should  happen to penetrate into  the eye, we should, sup-
posing that they could be perceived, not hesitate to cut into either the
cornea or sclerotica in order to search for and extract them  with an
ocular forceps, or cause their expulsion in any manner whatever.

              §  II.—Various  kinds  of Vegetations.

   A. Pterygion.—When,  by means  of resolvents judiciously em-
ployed, we have not  been  able to disperse  the pterygion, and that it
advances upon  the cornea to such extent as to make us apprehend
the loss of the sight, it must be removed by means of the bistoury or
the scissors.   The section  of the vessels which  go  to it, and which
Beer still recommends, its strangulation by  means of a thread passed
between  the conjunctiva and sclerotica, as  preferred by La Vau-
guyon, and  also cauterization, have  succeeded in more than one
instance  ; but as all these means are uncertain and  more difficult of
execution than  excision, they have generally been abandoned.  In
order to  remove the pterygion we seize hold of it with a good pair
of forceps in one hand, at one or two lines  from its  point; we draw
upon it a little towards ourselves as if to detach it; and soon perceive
a  slight  crackling sound  similar to  that  of unrolling  parchment.
Then it becomes easy to isolate it either from its apex to its  base, or
vice versa,  as M. Flarer  recommends, (These de Lefebvre, Paris,
1829,) by means of the bistoury or a good  pair of scissors.  As  the
cornea rarely resumes i,ts primitive transparency opposite the wound,
Boyer recommends with reason, as I  think, when the point of  the
pterygion has approximated very near the  pupil, not to prolong the
dissection as far as  that, but to excise only the posterior four-fifths 
840
GLOBE  OF THE EYE.
of it.   Emollient lotions during some days, and afterwards resolvent
applications, as in all chronic phlegmasias of the conjunctiva, consti-
tute its consecutive treatment.   I have operated for pterygion by this
process, in  patients who had two, three, four, and even five of them
on the same eve ;  I have never found any serious difficulty in it, and 1
cannot comprehend either  the dangers which M. F. Cunier (Bulletin
Med. Beige, t. I., p. 296) charges  it with,  or the importance of the
methods which have been  proposed to be substituted for it.   When
the pterygion is not very thick,  Scarpa is  of opinion  that  in  the
greater "number of cases it  is sufficient to excise a semilunar flap
from it opposite the point of  union of the sclerotica with the cornea,
and that in other cases we may destroy it entirely ; that in order to
prevent a cicatrix raised up  in the form of a border,  we should first
detach the  apex, then the base, and finally terminate with its  middle
portion.  I do not, however, conceive that this last  precaution can
be of any great moment, and partial excision, which  I have tried in
three instances, has not succeeded with me.  In all cases  it  is  pru-
dent to follow the advice of  Boyer, and to apprize the patient that,
notwithstanding the operation,  he  may  not   be  perfectly  cured,
because of the species of spot which is too  frequently  the result of it.
   B. Pannus.—The periphery of the cornea is sometimes covered
by a grey  or reddish flattened vegetation, granulated like the back
of the  tongue, indolent,  from a quarter to  a half a line in  thickness,
and advancing more or less,  in the manner of a ring,  on the transpa-
rent portion of the eye.  In certain  cases, however, this variety of
pannus  forms only the  segment  of a circle, while in others there
appear to be detached from  it semilunar or triangular plates, which
prolong themselves a little  farther than the rest upon the cornea.
M. Graefe (Revue  Med., Mars, 1818, p. 464)  gives  an instance of
one which  entirely covered both eyes.  Nothing but complete excis-
ion or cauterization can  remove this disease.  If the pannus has  but
little thickness and  is entirely circular, the nitrate of silver answers,
and should have the preference.  When it is more solid and forms
somewhat  large plates, excision  by means of  a lancet or cataract
needle held flatwise, (portee  en dedolant,) followed immediately after
by cauterization,  is more appropriate.  A vegetation of the same
kind may  be developed upon the  cornea and remain completely
independent of the conjunctiva.  I saw a remarkable example of this
kind in a forgeman, forty-five  years of age.  The plate, which was
half a line  thick, more than three  lines long, and a line and a half in
breadth, placed transversely  and slightly concave above, was situated
below the pupil, and left a very perceptible and perfectly sound strip
of cornea between  its lower border and the sclerotica.  I destroyed
it three times with  the nitrate of  silver, and three times the  patient,
who was very anxious  to resume his  occupations, left the hospital
before being absolutely cured, and at the moment when there was the
best reason to hope for a perfect cure.
  C. Horny Plates.—M. Mirault speaks of a production which is much
more singular still.  The cornea of a man affected with trichiasis from his
infancy, was covered with a kind of dirty white dry, and as it were, scaly
skin.  It was probably a xerophthalmia. Similar productions, or such as 
NEW ELEMENTS OF OPERATIVE  SURGERY.
841
were horny, have also been encountered on the front part of the eye
in certain individuals affected with ichthyosis.
  D. The cornea is also liable to other excrescences.  Guerin makes
mention  of a young person of Macon, who had a fleshy tubercle as
large as a pea on the front part of  the pupil, and which he cured by
one  cut of the scissors.   Some of them may be compared to ncevus.
M. Wardrop gives examples of them.   In one case, the tumor was
granulated,  of a brownish color,  and but little  vascular.  It was
softer, of a reddish color, and placed half on the cornea and half on
the sclerotica, in another patient.   In  a third  case, three  long hairs
proceeded from it, and  protruded like a pencil from between the
eyelids.   The same  author quotes a  case similar to this last, in the
Baron of Gloucester, and remarks  that Gazelli had also seen hairs
growing from the cornea.
  E. Among these  tumors, there are some of them that are analo-
gous to  vegetations from the mucous membranes.  These are a sort
of fungus.   M.  Wardrop  has seen two  examples ;  one irregular,
granulated,  and partially on  the  sclerotica;  the other darker and
more solid.   In  a case cited by Voigtel,  a cartilaginous point was
found in the centre.   Sometimes  also the tumor  derives its origin
from an ancient  ulcer.   Maitrejan  gives  an example of this; but it
appears that in his patient, the fungus came rather  from the interior
of the eye, than from the cornea properly so  called.   These differ-
ent projections can only be cured by excising them completely ; also,
we must take care to cauterize  the  bottom of the wound immedi-
ately, if we expect to prevent all return; it is in this manner that
Pellier succeeded in  a patient who had a tumor  of this kind caused
by a burn from  gunpowder.

                        § III.—Cataract.

   Although Galen and the Arabs had already  pointed out the nature
of cataract, centuries passed away  before it was generally understood.
The pellicle which constitutes the disease is  situated, according to
Culsus,  between the uvea and the crystalline  ; on the contrary, ac-
cording to Guy  de Chauliac and G. de Salicet, between the iris and
the transparent  cornea.  What contributed most to give prevalence
to such  errors,  was  the idea that the crystalline was the seat of
vision.   Therefore, as soon as Kepler had demonstrated in 1604, that
the lens of the  eye was  no other  than a refracting body, an actual
surgical revolution was promptly brought about on this subject.  Gas-
sendi, who wrote in  1660, as well  as Palfin and  Marriotte, attribute
to R. Lasnier or F. Quare, the  honor of having first sustained the
idea that cataract does not depend upon an  accidental pellicle, but
on  an opacity of the crystalline.   Schelhamer,  who  imparted it to
Rolfink, had taken the idea from a surgeon of the Hotel Dieu.  Bris-
seau, Mery, P. du Petit, Borel, Tozzi, Geoffroy, Albinus, Bonnet, and
Freytag, had also without doubt derived it from the  same source.
But it is to Maitrejan to whom we  are indebted for having placed the
fact beyond all dispute.  In going from one  error they were upon
the point of falling into another; in  place of  never seeing cataract
in the crystalline, it was now  maintained  that it was  always there.
   vol. n.                      106 
842
GLOBE OF  THE EYE.
Ph. de la Hire,  Freytag,  and Morgagni,  did  not  succeed without
difficulty in establishing the fact, that this malady  may also be pro-
duced by the opacity of the capsular membrane.  It was S. Muralt,
Didier, Heister, and  Chapuzeau, for whom it  was reserved to de-
monstrate, without rejoinder, that cataract is produced by opacity of
the crystalline, that of its capsule, or of the matter in which it floats,
and not always that of one part only.
  A. Cure without an operation.—Though since the time of Celsus,
who was the first that has spoken lucidly on this subject, it has been
acknowledged that confirmed  cataract is rarely cured except by the
operation, properly so called, we should nevertheless be wrong in de-
nying absolutely, the  efficacy of any other treatment.
  The cataract which is seen in scrofulous, scorbutic and syphylitic
subjects,  or in consequence of an inflammation or any other disease
in the neighborhood of the eye, has disappeared in more than one in-
stance, either spontaneously with the constitutional  disease, or under
the influence of  general  or  local treatment  judiciously  directed.
Maitrejan, Callisen, Alberti, Gendron, Murray, Richter, Ware,  and
many others, have given examples of this kind. Hyoscyamus  ap-
plied to the eye according to M. Nostier, or a simple seton to the nape
in the opinion of M.  Champesme, (Arch. Gen. de Med., 1.1., p. 290,)
have succeeded in curing cataracts of very long standing.   M. Die-
trich recommends that we should arrest its development by repeated
punctures to the eye, and  M. Schwartz (Revue Med., 1828, t. III.,
p. 126) has cured  three cases by means of revulsives,  &c.  With
MM.  Rennes, (Archiv.  Gen.  de Med., t. XXIL, p.  206), P. Delmas
and Manoury (Biblioth Med., 1827, t. IV., p.  185), I  have seen it
disappear spontaneously. M.  Janson (Hotel Dieu de Lyons, Compte
Rendu, 1824, p. 83)  also gives two  examples of this  kind.   MM.
Larrey and Gondret  affirm, moreover, that they have obtained simi-
lar results by means  ofmoxas, the actual cautery, or the ammoniacal
pomade applied upon different points of the head, especially to the
sinciput.   Without admitting as certain with M. de  Blainville (Nouv.
Bull  de  Sc  Med., Fevrier, 1835, p.  31,) that the crystalline may be
formed by its capsule; without conceding also with M. Campaignac,
that cataract is only a symptom  of disease  of the envelope of the
crystalline, it must at least be admitted that  the cataract which  re-
sults quite frequently from wounds  of the eye, is to be ascribed as
M. Watson  (Arch. Gen. de Med., t. XII., p. 610)  asserts to inflam-
mation of the neighboring lamellae.   The repeated experiments of M.
Neuner (Journ. de Prog.,t. VIIL, p. 117 ; Bull de Ferussac, t. XIV.,
p. 194) have  since shown with what facility opacity of the crystal-
line may be produced, by means  of certain  liquids introduced  into
the eye.   The experiments and observations still more varied of M.
Dietrich, (Bull, de Fer., t. VI., p. 84 ; Arch. Gen. de Med., t. XII., p.
295,)  Tartra, Beer, and Szen, though contradicted by those of M.
Watson,  exhibit the decided influence of wounds and certain acids in
the formation  of some cataracts.   A cataract from infancy was
cured by the evacuation of a brown matter, by means of a  small
puncture into the capsule.  The crystalline, which was sound,  re-
mained, it is  said, (Gaz. Salut., No.  5, 1783, p. IV) in its place in
both  eyes, and the sight was reestablished !!  From hence, without 
NEW ELEMENTS OF OPERATIVE SURGERY.
843
doubt, came  the  new method of M. Jungken, (Arch. Gen. de Med.
2e serie, t. X., p. 93.)   It is  doubtless difficult to believe that tho
crystalline, which is an inert body and the actual product of an exu-
dation, and which receives neither vessels  nor nerves, can  recover
its iransparency after having actually lost it;  but pus and other pro-
ducts which may be deposited in front of it, as in the three examples
related by M. Boudant, (Arch. Gen. de Med., t. XXIIL, p. 429,) being
in more direct relation with the iris or ciliary circle, would be more or
less  influenced by the particular state of the eye  and  the  general
constitution of the individual.  It is also well established at the pres-
ent time, that traumatic cataract very frequently gets well  without
an operation.  The  case of cataract caused by a blow on  the eye
from the branch of a tree, as mentioned by M. Mondiere, (Arch. Gen.,
third  series,  t. II., p. 352,) ultimately disappeared spontaneously.   I
saw  a similar case at the Hospital of La  Charite in 1836.
  A young peasant, of fifteen years of age, was struck upon the eye
by the free extremity of a small green twig of a tree.   A cataract
was  thereby  immediately  produced, which was perfect when first
brought under my notice, at the  expiration of fifteen days.  In order
to reduce the inflammation which existed in the eye, and also to faci-
litate the cure of the cataract, I had recourse to bleeding at the arm,
a few leeches to the temple, frictions around the orbit with the mer-
curial pomade combined with belladonna, and  afterwards to a large
temporary blister over the cutaneous surface of the eyelids.  After hav-
ing become broken up into many fragments, which successively passed
into  the anterior chamber, the  crystalline ultimately became com-
pletely dissolved,  so much so, that the boy, after having been in the
hospital two  months, left there almost perfectly cured,  and with a
pupil which  presented only one single small opaque point.  I saw a
similar result in  1837, in a young lady who wounded her eye with a
pair of scissors.   Another example  occurred at La Charite  in 1838.
Some of the observations also  related by M. Convers, (Gaz. Med.,
1838, p. 513,) fully corroborate this fact.   In  a child of five years of
age, mentioned by M. Gerson, (Arch. Gen. de Med., 2d series, t. VIIL,
p. 224,) the cornea having been wounded by  the  point of a  knife,
a cataract was  thereby produced,  which got well  spontaneously.
Nevertheless, if on changing its color, the crystalline evidently un-
dergoes a  molecular action subject to the laws of  chemistry, and if
spontaneous  cataract is not  the product of either an electric action,
or of that  species of oxydation  suggested by MM. Richerand and
Leroy,  it "would be still more difficult to refer it constantly,  with M.
Campaignac, to alterations in the secretion of its capsule.   Such being
supposed to be the case, we cannot see why, by a contrary combina-
tion, it might  not sometimes be possible for it to return to its primitive
condition.  M. Luzzato (Encyclogr. des Sc Med., 1836, p. 405,) speaks
of a patient who,  after having been a long time afflicted with cata-
ract, was cured of it by a violent ophthalmia.   On the other hand, the
crystalline  capsule may be torn and place the lens which it contains
in contact  with  the  humors of the eye, which  in their turn effect its
solution or favor  its absorption, facts of which description we have
on record.   The  crystalline having passed into the anterior cham-
ber, in a patient of Ansiaux, (Clin. Chir., 2d edit., p.  161,) ultimately 
844
GLOBE  OF THE EYE.
became dissolved  there.  This body disappeared in the same man-
ner in the case cited by M. Bobillier, (Rec. de Mem. de Med. Chir. et
Pharm. Milit,  t. XVI., p. 240,  1825,)  and I have seen the same
thing occur in three instances.
  B.  Surgical  Treatment.—Surgeons, moreover,  have attempted,
from the remotest antiquity, to destroy cataract by means of particu-
lar  instruments.   Celsus in  fact leaves it to be inferred, that among
the physicians of Alexandria there were many, especially a certain
Phvloxenes, who had  acquired  in this respect a very great degree
of skill.
  Conditions.—I.  If the cataract be simple, if it has its seat in the
crystalline or has  not  contracted any unnatural  adhesion with the
surrounding parts,  if the iris retains its power of contracting and
dilating alternately, if the patient still  distinguishes light from dark-
ness ; if no inflammation exists either in the eye or in the periphery
of the orbit; if  there be present neither  cephalalgia, nor a catarrhal
affection,  nor  any general disturbance;  if the  eyes are neither too
projecting or too much sunken in their socket; if the patient is not
too much  advanced in  age, and if he is sufficiently tractable to sub-
mit to all  the necessary treatment, the  chances  of success are ag nu-
merous  as could be desired.  When, on the contrary, the patient  is
enfeebled  by age, that spots exist upon the cornea, that the pupil re-
mains immovable, that a greenish tint is observed at the bottom of
the eye, that  deep-seated pains  are felt or continue to exist in the
orbit, that a chronic ophthalmia or any other malady tedious and dif-
ficult to cure,  and more or less serious in its character, exists in the
neighborhood  of the  eye, we cannot  count on success.  In  other
words, so  often as the crystalline and its capsule alone are diseased,
that apart from the cataract the organ is in a natural state, and that
there is nothing in the orbit that prevents  the reestablishment of
vision,  then, whether the cataract be true or false, formed by  plastic
exudation, (Simmeon,  Bull, de  Fer.,  t.  X.)  or by a  return  of the
crystalline to its embryo condition, (Grandclaude, Journ. Comp. des
Sc. Med.,  t. XXXI.) whether the cataract be lenticular, capsular, or
capsulo-lenticular, anterior  membranous or  posterior membranous,
hard or  soft, milky or gypseous, barred, oscillating, stellated, pearly,
with three branches or central, purulent, putrid, spotted or trellis-like,
marbled,  dry  or husky, sanguineous, dendritical,  yellow, grey or
black, the operation  should  be recommended.   In other cases, and
especially if it  is complicated  with infiltration  of  pus {Dujardin,
These, Paris,  1830) or  blood into the little receptacles of the vitre-
ous humor, it  should not be undertaken but as a dernier resource,
when every thing had  failed, and not until  after having forewarned
the patient of the slight chances that exist of a cure.   Nevertheless
we must not allow ourselves to be deterred by appearances.
  The immobility  of  the pupil  is  not a certain  sign of amauro-
sis.  Wenzel,  Richter, MM. Larrey, Watson,  S. Cooper, &c, have
shown, as I have often myself seen, that adhesions of the iris or con-
tractions of its opening after an iritis  may also produce it, and also
that it will dilate and contract itself though the retina be paralyzed.
I have many  times seen  dilatation with immobility of the pupil,  in
patients affected with  cataract  without complication of amaurosis. 
NEW ELEMENTS OF OPERATIVE SURGERY.
845
 Others  nave remained with  a movable,  narrow and very regularly
 formed pupil, without  recovering their vision.   Some patients who
 could not in any manner distinguish day  from night have, after hav-
 ing been operated on, been more  fortunate.
   II. Black cataract, (cataracte noire,) which had already been noticed
 by Guy de Chauliac, Morgagni, Rolfinck  and Freytag, and of which
 Maitrejan, Janin, Pellier, Arrachard, Wenzel, A.  Petit,  Edwards,
 Coze, (Dujardin, These, Paris, 1830,) and MM. J. Cloquet, Riobe,
 Luzardi and Sanson, (Journ.  Univ. des Sciences Med., Juillet, 1819,)
 have related examples, is too  rare to arrest the attention of an intelli-
 gent operator, even in supposing, which  is not demonstrated, that it
 may exist without, changing of the color of the  pupil.   A young girl
 twenty-six years of age, blind in the usual way  that patients  affected
 with cataracts are, had nevertheless the pupils almost perfect.   The
 crystalline was first extracted from  one  of the eyes and then from
 the other, and the operation, which was performed by M. Roux, (Diet.
 de Med. et de Chir. Prat., t.  II., p. 108,)  was  perfectly  successful.
 M. Carron du Villards, (Pasquet, Lancette Franc,t. XIL, p. 524,) and
 M. Robert (Carron  du Villards, t. II., p. 271,) have observed similar
 examples:  I also have noticed  two cases.  Moreover,  when no
 organic lesion nor any serious symptoms  render the operation formi-
 dable, I do not see  why, when the patient is completely blind, we
 should  refuse to  undertake it.  In such  cases the  patient can lose
 nothing, while on the other hand,  should there be only one chance in
 a thousand, it would be uncharitable not  to let him have the benefit
■ of it.   We  must nevertheless absolutely desist from it as  soon  as
 there is a certainty  of a deep-seated  alteration in the eye.
   III.  Tremulus Iridis.—Should  the crystalline or the humors be
 movable, or  offer the slightest  appearance of tremulus iridis, we
 should at least be careful not to operate by extraction.  The  case of
 a crystalline thickened, and spontaneously depressed, as  mentioned
 by Turquet  de May erne, was  it not  in fact complicated with tremu-
 lus iridis 1 (Prat, de Med., p.  90.)   In a  man who was in this con-
 dition,  and  to whose solicitation  I  finally yielded,  the crystalline
 gently issued out of itself enveloped with its capsule a few moments
 after opening into the cornea, and  the  vitreous humor was  in so
 limpid  a condition  that it  would have escaped like water, if  I had
 not immediately made pressure on the fore part  of the eyes by means
 of lint.   Cerebral accidents supervened and were sufficiently serious
 during  some days,  to  give me  the  greatest degree of uneasiness.
 The left eye suppurated, and  the right, although perfectly clear, re-
 mained altogether insensible to light.   This is a  state of things which
 I have often since met with, and which is imputable to a liquefaction
 of the vitreous humor.   Depression alone may be attempted  in such
 cases, if it is thought  prudent to attack the cataract; the opera-
 tion then produces scarcely any reaction  in the eye.   It has  at least
 the advantage of causing the disappearance of a deformity by again
 giving to the pupil all its  regularity, and  this result is not to'be dis-
 dained when there  is only one of the eyes in  a state of cataract.
 The  mobility of  the  crystalline  is  sometimes  hereditary.  Portal
 (Malad. Heredit., p. 87, 3rd edit.) gives an instance of two brothers
 who were thus  affected, and whose father had the same peculiarity. 
846
GLOBE OF  THE EYE.
 The crystalline rested in part in the anterior chamber, as in the two
 patients noted by me.
   IV. Anomalies.—False  cataracts,  which are almost always com-
 plicated with affections of the iris, or some other membrane of the eye,
 are  not generally so easy to destroy as the true cataracts.  All other
 things being equal, the crystalline cataract is of a less serious charac-
 ter  than the capsular, or that of the humor of Morgagni.  I have
 seen patients completely blind, though  their crystalline  was only
 slightly  opaque.  In others, the cataract appeared so advanced that
 nothing more was  required  for its maturity, and nevertheless they
 could still see very  well.  A dealer in grain in the environs of Paris
 furnished me a very fine  example of this species in 1838,  at La
 Charite.  Arrived at  the Hospital from his own residence without a
 guide, he could count his fingers and distinguish  faces, though to ap-
 pearance his two cataracts were  as  complete as possible.  I have
 had  occasion to remark, that, persons  who could see in spite of their
 cataract, had an opacity of the  crystalline only, or of the posterior
 capsule,  and that in them there existed a certain free space between
 the iris and the lenticular apparatus.
   V. A  light which is made to pass in front of the eye of a patient
 who does not see, will, provided there be no opacity in front of the
 vitreous  humor, produce three images, one anterior, regular, (nette,)
 and  straight, one deep-seated, large, diffused, and also straight, and a
 third in  the middle small, pale, and reversed.  The anterior image
 alone will  remain in  the case of complete cataract.  But it is the
 deep-seated image only which is effaced when the opacity is concen-
 trated upon the posterior layers of the crystalline  or its  membrane.
 This method, which I have often tried, and the use of which has been
 sanctioned  by M. Janson, (Pasquet, These, Paris, 1837,) has how-
 ever appeared  to me  to afford  very  little reliance.  It is useless in
 ordinary cases, and  I  do not think  it  would be sufficient  in doubtful
 cases.
  VI. Ages.—In children, the operation, though difficult to be per-
 formed, succeeds better than in adult age, and so much the better
 after that, as the patient approaches nearer to the middle period of
 life.  The table arranged by M. Drache (These, No. 180, Paris, 1837,)
 shows what are the influences of age and other personal conditions
 on the formation of cataract.  Almost all authors agree with Sabatier,
 that  we ought not to recur to the operation  except in persons who
 are old enough to know the benefit of it;  that it ought not for exam-
ple to be employed before the tenth or fifteenth year.
  a.  The intractability of children, the little anxiety they  have  about
obtaining their sight, and the dangers we  should have to incur in en-
deavoring to operate upon them in spite of their wishes, and the diffi-
 culty of subjecting them to the necessary precautions, are the principal
motives upon which this precept is established.  But if in the tender
age the operation is  more delicate and more hazardous, and the mem-
 branes of the eye from being more tender, thinner, and less dense, are
 more easily penetrated; the  eye is  less movable, the  pupil  more
 large, and such patients, dreading only the pain, are in nowise con-
 cerned about the consequences of the operation.   As this operation
 is  rarely accompanied  with severe pain, I cannot see how in such 
             NEW ELEMENTS OF OPERATIVE  SURGERY.          847

cases it can have any thing in it of a very formidable character.  It is;
moreover, always practicable to confine even the youngest subjects,
and to  keep their eyelids separated apart.  The eye is an organ es-
sential  to the development of intelligence, and the source of the great-
est number of our ideas.  If its functions should be found abolished
at birth, its  development ordinarily remains  incomplete ;  it acquires
gradually an excessive degree of mobility, which renders the opera-
tion much more delicate, and diminishes the chances of success.
   In conclusion, when we reflect upon the importance of  the educa-
tion of children, it would be really difficult not to admit with Ware,
Lucas, Saunders, Travers, Beer,  &c,  the  advantage of relieving
them as speedily as possible of cataract.  Nevertheless, I  am not of
opinion that we ought, in such cases, to select the age of two years,
as Farre recommends, or the  period of six weeks, with M.  Lawrence,
rather  than the the first or third year.
   b.  In old men, the disease  being almost a natural  consequence of
old age, the operation is inadmissible, except they earnestly desire it,
and are moreover found in the best conditions possible. I have  per-
formed it, however, in a man of eighty years of age, and in a woman
of eighty-five, with a successful result, which is far from being always
obtained  in young subjects.
   VII. The five hundred  cases of cataract which I have noted up to
the present time have not enabled me  to assert that males are more
frequently affected with it than females.  We see by the  researches
made  by M. Maunoir, (These, No. 345, Paris, 1833, p. 13,)  that out
of one  hundred  and twenty-one  cases of cataract  observed at La
Charite there were sixty-one men and sixty women; while at the
Hotel  Dieu, out of two hundred and seven patients, there  were  only
seventy-two women, while there were  one hundred and thirty-five
men.   Before the age of thirty years, acquired as well as congenital
cataract  is almost always soft or capsular.   After sixty, it is almost
constantly solid and lenticular.   The period  from forty to  sixty years
is that  which is most liable to it.   Between  fifteen and forty years,
we must be on our guard, for it often indicates a more profound dis-
ease of the eye.   Although out of seventy-two cataracts examined un-
der this point of view by M. Maunoir, (Lancette Franc, t. I., p. 392,)
thirty-five only had commenced in the right eye ; this eye, according
to my  observation, is  more frequently  affected the first than the left.
I have met with five  patients who, from different  causes, had   been
suddenly seized with  it, like  the  peasant mentioned by M. Wendel-
strum,  (These citee, p. 29.)  In twenty cases out of two  hundred it
has appeared to me to be  hereditary.   A man whose two elder bro-
thers, a sister, his grandfather, and great grandfather had had the
same misfortume, was seized with cataract at the  age of forty-two
years.   M. Maunoir (These citee, p. 21) states that  out of thirty-nine
cases of cataract he found ten that were hereditary.  In the  same
family  at Argentan, (Duval,  These, Paris, 1830,) four of  the daugh-
ters and the father and mother were attacked with this disease.   But
all this should not prevent us from recurring to the operation.
   VIIL Single or double.—When the cataract occupies one eye only,
there are physicians who proscribe the operation.  With one eye, say
they, we can see sufficiently well to get along, distinguish  objects, 
848
GLOBE OF  THE EYE.
read, and, in fine, fulfil all the duties  required of us by our social
wants.  The operation may produce an acute inflammation, render
the sound eye itself diseased, as M. J. Cloquet has seen, and produce
a complete blindness.   Even upon the  supposition that it does suc-
ceed, the focus of luminous rays being  no longer the same in both
eves, there necessarily results  from it  a  discordance, followed with
confusion  of vision, &c.  To this reasoning it may be objected that
if the sound eye is sometimes destroyed after the operation, this acci-
dent rarely happens; that we see undisputably better with two eyes
than with one only, and that the presence of one cataract appears to
be good grounds for supposing that another may supervene upon the
opposite side.  As to the difference which it is supposed will take place
in the field of vision after the displacement or extraction of the crys-
talline, experience has now demonstrated that it is not the  fact.
Maitrejan, St. Yves, Wenzel,&c, relate cases  in which  no mention
is made of it, although  the patients had been operated on in one eye
only.  I have published some facts of this kind, collected at the Hos-
pital of Perfectionnement.   M. Luzardi writes me that he possesses
a great number of similar instances, and I could myself, at the pres-
ent day, add  near fifty cases  to those  which I announced in  1826.
Nor, finally, has M. Roux, who has very often extracted the cataract,
found,  though it existed on one side only, that it was necessary for
the patients afterwards to  wear glasses of different forms for the two
eyes.  Therefore, if the patient is young and of good constitution, if
he desires or earnestly  requests to be cured, we ought to subject him
to the operation, even though one of his eyes may be wholly sound.
  IX.  Maturity of the Cataract.—Formerly it was supposed that
cataract passed  through different degrees of consistence; that soft
and diffluent  in the beginning,  it becomes gradually firm and solid;
in a word, that it may be ripe  or not ripe.   At the present day sci-
ence is under the empire of more correct opinions.  It is now known
that cataract  may  be very solid at the commencement, and become
almost  liquid after a long lapse  of years.  It is nevertheless true, that
the contrary is very frequently observed, and that the idea of ma-
turity and immaturity is not altogether  destitute of foundation.  Cat-
aract being almost constantly the result of a morbid action from
some internal cause, is not in reality perfected  until  at the moment
when this  cause ceases  to act on the eye, and when the opaque body
is no other than a necrosed portion of  the organism, and  an actual
foreign body.  It is not, therefore, because it is too soft or too hard,
that we ought to wait for its complete development;  but because its
progress not  being limited, there are then evidently less chances of
success than at a  more advanced epoch, and when its separation
(coction)  has  been perfectly effected.
  X. The two Eyes.—Scarpa,  Dupuytren, and  many other  skillful
surgeons have maintained  that it is better when the cataract exists in
both eyes, to  perform the operation first on one side, and not to have
recourse to the other until after the cure of the first.  If it succeeds,
the patient may rest satisfied  with it, so  long as the  eye is  not too
much enfeebled.   If it fails in its results, there still remains at  least
one more resource.  The patient  bears  the second  operation  with
more courage and less  alarm than the  first.   When  we operate on 
NEW ELEMENTS OF OPERATIVE  SURGERY.
849
both eyes at the same time, the inflammation may be communicated
from one to the other, the reaction must be more acute and the danger
of accidents supervening greater than when we operate on one eye
only.  Boyer and Dupuytren have remarked on this subject, that double
ophthalmia when once developed, rarely fails of arresting itself defini-
tively on one eye only, which takes upon itself, so to speak, the onus
of the  disease  of both,  and in most  cases  ultimately  becomes de-
stroyed.   The  whole of this is questionable ; and as the simple ope-
ration, even in the most fortunate cases, only imperfectly reestablishes
the sight;  as patients much rather prefer  to sustain the two opera-
tions consecutively, than after  a certain interval of time ; as the ope-
ration on one  side sometimes causes inflammation  of the sound as
well as diseased eye ; and as the double operation presents numerous
favorable chances for one of the two eyes  at  least, if not for  both,
I conclude, with Wenzel,  Demours, Forlenzi, Boyer, &c, that all
other things besides being equal, it is better to  adopt this last course.
  XL The preparations that  the ancients  caused  their patients to
submit to, are almost wholly laid aside by the moderns. At the pres-
ent day, we limit ourselves  to the employment  of a regimen more or
less rigid during the space of several days ; bleeding, some laxatives:
or a gentle purgative ; diluent drinks  or antispasmodic and anodyne
preparations, according  as the  patient exhibits  certain indications of
plethora, obstruction in the alimentary passages, or too great a degree
of nervous irritability.  As a preventive means  of inflammation, there
are some who apply a blister.   Scarpa places it upon the nape fifteen
days beforehand, and M. Roux only the evening before.   ForlenzL
prefers placing it  upon the  arm.   I am not certain that this applica-
tion is not more dangereus than useful.  Many practitioners dispense
with its use, and do not appear to have had cause to regret it.  If
adopted  as a general precept, it must frequently do harm.   During
the first days, it sometimes  produces a heat  in the skin, and an irrita-
tion which may react in an unfavorable  manner upon the eyes.  If
we confine ourselves to placing  it upon the neck, it would then be
better to follow the rule of Scarpa, or of Dupuytren, who, when he
thought proper to make use of it, left it  on fifteen days before pro-
ceeding to the  operation.   On the arm it is evident that the patients
can receive no disadvantage  from it; nor  can we perceive that it
can have the least degree of efjicacy.  For myself, I use it only after
the operation, upon the  supposition that special accidents require its
employment, and  I have not found that there were  any objections to
be  made against this mode of proceeding.
  XIL Seasons.—Spring and autumn, which are more favorable than
winter or summer for the success of all operations, have been selected
also for those of cataract.  We  cannot undoubtedly refuse  to  those
two seasons some advantage to  the  patients, in  consequence of the
temperature, which is usually  more mild and  uniform then than at
other periods of the year ;  nevertheless,  as these conditions may be
obtained or found at any time,  cataract may in fact be operated upon
at any season.  We ought  not, however, to decide  upon it without
caution, if an epidemic of a somewhat  grave character should be pre-
valent, especially  those which  more  particularly affect  the mucous
membranes.  When there are  prevailing catarrhal affections, dothin-
  vol. ii.                     107 
850
GLOBE OF  THE EYE.
enteric  fevers, ophthalmias, measles, or even erysipelas, prudence
requires that we should refrain from it.
  C.  Operation for Cataract by  Depression.—In some cases we
confine  ourselves to displacing the  crystalline, or placing it  under
such circumstances, that it may disappear under the influence of the
action of the organism; in  other  cases, on the contrary, we expel
the cataract from the eye, in endeavoring to remove the opaque body
in its totality, which  constitutes two general methods,  that of de-
pression and'that of extraction.  The first, still known under the title
of the method  by depression, comprises, moreover, the  method by
reclination (reclinaison), or reversioner that by discision  (discision),
or breaking up (broiement),  and is performed in different ways; it
takes the name of scleroticonyxis for  example, when in  order to
reach the crystalline the needle is directed upon the  sclerotica, be-
tween the uvea and  the vitreous humor, or when  we purposely
penetrate through the hyaloid substance; and it is called keratonyxis
when we  reach the eye in its anterior  chamber, through the trans-
parent cornea.
  I. Preceding steps.—The evening  before the operation,  the patient,
who should  have taken  only light soups, ought to have administered
to him an injection, if his bowels are not already free. An aqueous
solution of the extract of belladonna applied  between the eyelids an
hour  or two beforehand, forces  the pupil to  dilate  itself  largely,
•enables us to follow  with the greatest  degree  of certainty all the
movements  of the needle, to avoid the iris with greater facility, and
more readily to compel certain portions of the cataract to pass into
the anterior chamber, should that be judged necessary.  The irrita-
tion which such an application produces, is too trivial to be worthy of
consideration.  The  momentary  mydriasis which results  from it
soon disappears, and alters in no respect the  functions of the organ.
The advantages which it gives are in reality of the highest degree
of importance, and should not be sacrificed to idle fears.  In irritable
and timid persons, in whom the eye is very movable, it is well in
order to  accustom this organ  to  the contact of foreign bodies, to
touch it several times during the space of some days, with the blunt
extremity of any instrument whatever, or even with the finger.
  a. The articles  comprise two needles at  least, in order that if
one should fail, we may continue the  operation with the other ; a cap
or serre-tete, which should accurately embrace the cranium ; a long
compress to cover the sound  eye while we are operating on the
other; small oval pieces of fine linen,  perforated with holes,  and
which are to be  placed in  front of the   orbit after the operation, in
order to prevent  the  lint from coming  directly in contact with the
lids;  a bandage of linen folded double, sufficiently long to go round
the head,  four to five fingers' breadth in width, and presenting at its
middle portion, near its free border,  the division of a  jq reversed, to
lodge the nose ; finally, a band of black  taffeta designed for covering
the preceding;  lastly, a fine sponge,  hot water and pins.
  b. Needles.—As it is more especially  for extraction that the specu-
lum, elevators  and opthalmostats  have been proposed,  I shall  say
nothing of them in this place.
  As to the needle, we have an infinite  variety of them. The  one 
NEW ELEMENTS OF OPERATIVE SURGERY.
851
that Celsus recommends was spear-shaped, straight, and two inchea
long; at a subsequent period, it was found more convenient to make
use of those that are round ; since then the triangular needle has been
revived.  At the present time, every oculist, so to speak, has his own.
That  which Scarpa succeeded in rendering popular,  slender,  and
only eighteen lines  long, is terminated  by a point  slightly widened,
curved  into the shape of an arc, flat on its  convexity, and cut into a
ridge on its concavity, and like all the others, mounted  upon a han-
dle of flat sides and bearing a mark of a different  color on  its back.
Dupuytren rejects the kind of crest which  is found on  the  concave
surface  of the  needle of Scarpa ;  his, on the contrary, is somewhat
more  flat on this side than on the  back, in order more accurately to
embrace the crystalline, and to expose it less to be  divided when we
endeavor to depress this into  the  bottom of the eye.  He also re-
commends that it should have  less breadth, and that its body, slight-
ly conical, should completely fill up the track traced by the point, in
order that the humors cannot in any degree flow out during the ope-
ration.   The point  of that which is adopted  by M. Bretonneau, is
shorter  and also as broad as in the needle of Scarpa.  Its  body,
which is of melted steel,  finer  and almost cylindrical, passes  freely
and without the least effort through the opening into the  sclerotica.
It is an  advantage which the instrument of Dupuytren does not pos-
sess, but one which exposes  the  eye to  be partially emptied of its
aqueous humor.  The needle of Beer, which many German oculists
make use of, is  straight and spear-shaped, and differs from that of M.
Bretonneau only in having its body conical and thicker.   Hey pro-
posed one which has only ten to twelve lines in  length, and which
in its form approaches much nearer to a chisel than that of a needle ;
being a simple  modification of that  of Hilmer, which  is  conical, its
free extremity,  which is flattened and terminated in a half  moon, is
its only cutting portion;  the edges, which are straight and rounded,
and its  want of a point, make it difficult  to wound the iris when
we are  directing it towards the pupil, while its form of that of a small
palette  renders the  depression of  the crystalline  less embarrassing.
With an instrument of this kind, it  would  be almost impossible to de-
stroy  a  membranous cataract,  or even to  open conveniently the an-
terior capsule in lenticular cataract, and  inasmuch as  the breaking
up of the lens to which the author specially designed  it, can be per-
fectly well accomplished with any other  needle, there  is no reason
why it should have  the preference.  MM. Graefe, Langenbeck, Him-
by, Schmidt, Spitzac, (Fascicul d'Obs., &c, p. 22, Paris, 1829,)  Mid-
dlemore, &c, have  also each  in their  particular way  modified  the
cataract needle.  But the difficulty does not lie here.   In the hands
of a skilful operator, all these instruments  are good.  In this respect
those  of Scarpa, Dupuytren, and M. Bretonneau are quite  as good as
any of the others.   The needle designed  by Guerbois, (Journ.  des
Conn. Med., t.  I., p. 250,) with a double  rest on its concavity, does
not present sufficient advantages to  be retained.   M.  Bergeon  has
proposed one which two lines in breadth,  and hollowed  out in  the
form of a small spoon, would  in my opinion be of dangerous em-
ployment ; although it renders the displacement  of the  crystalline
sufficiently easy.  If the needle which M. Charriere has shown me, 
852
GLOBE OF  THE EYE.
  and which when once in the eye opens itself in the manner of a lith-
  otome of F. Come, did not expose us to the danger of wounding the
  iris, and of entangling itself in the neighboring tissues, it  might pos-
  sess some advantages.   The one which I  prefer is  somewhat more
  incurvated and more flattened, without being less in length or much
  broader than that of Dupuytren.
   II.  Scleroticonyxis.—Up to the eighteenth  century, they caused
  the patient to be seated astride a bench.   Barth and Arnemann pre-
  fer  that he  should be  standing.  Poyet, A. Petit, and Dupuytren, ad-
  vise that he should be operated on in bed.   In France, the patient is
  generally placed upon a. solid chair of moderate height.  Beer recom-
  mends a stool, and Kichter a chair with a perpendicular back, while in
  England they give the preference to a music stool.  In this respect
  there  can be nothing  fixed. Though the seated position is evidently
  the  best,  the others  may also be adopted without  serious  incon-
  venience.
   a. Ordinary process.—The surgeon places himself in front, either
 on the same bench with the patient, whose knees he holds between
 his thighs, as in the time of Celsus, with a small cushion to support his
 elbow, as recommended by J. Fabricius; or he stands up, as Dupuytren
 and a great number of others advise ;  or he seats himself on a chair
 somewhat elevated, in such a manner as to be able to place his  foot
 upon a stool, and to support his elbow upon a cushion on his knee, as
 directed by Scarpa.  When seated, there is more fixity in his move-
 ments, since the elbow is  supported ; when standing up  he is more
 free and  more at  his ease.   Some  surgeons  separate  the eyelids
 themselves, and  dispense with assistants.   Barth never  operated
 otherwise.   In this respect there has been  much praise bestowed
 upon the skill  of M. Alexandre, who again, it is said, is surpassed by
 Dr.  Joeger in Germany.   The thing doubtless is possible, but exhibi-
 tions of force  cannot be taken  as a rule, and there is no operation in
 surgery which more requires an intelligent assistant, than  cataract.
 It is necessary that he should have a light hand, that he should per-
 fectly comprehend every stage of the operation, and all the movements
 of the operator, and that he should be as practically conversant with
 it as possible.   Being placed  behind  the patient, he embraces the
 head, and holds it against his  chest with one hand,  while with  the
 other he elevates  the upper eyelid.   Should  we  desire to have re-
 course to any instrument to open the eye, the double erigne of Be-
 renger, or  the blunt hook of  some others, could  evidently be re-
 placed by Pellier's elevator of  silver wire.  In general the  finger is
 preferable, whether with Scarpa, we make use of it to raise and  to
 keep up the free border of the  upper eyelid against the supra-orbitar
 arch, without  touching  the eye ; or whether after the manner  of
 Boyer, we push it (l'enfonce) against the posterior surface of the su-
 perciliary border, while incurvating its last phalanx in the manner of
 a hook. By this  last mode, the eyelid  is found  to be more firmly
fixed ;  but the angle formed by the phalangeal  articulations, causes
more inconvenience to the operator, and the eye runs more risk of
being compressed.  Forlenze was in the habit of causing the entire
tegumentary covering of the eyelid to be drawn towards the eye-
brow, as if for the purpose of folding it or forming a  border with it 
NEW ELEMENTS OF OPERATIVE  SURGERY.
853
there.   In  this manner  the  ciliary border,  or  tarsal  cartilage, is
raised as high as possible, and the pulp of the finger leaves  less fa-
cility for the skin to escape.  The most certain means of preventing
our loosing our hold  before it is time, consists in placing a piece of
dry linen between the finger and the  integuments, in order to pre-
vent them  slipping over  each other.  If the patient is in bed, the
surgeon places himself on the right for the left eye, and on the left
for the right eye ; adjusts the cap and fixes it  with the bandage ;
covers one of the eyes, whether it is  diseased or not, with  a  small
piece of coarse lint, and  a long compress passed  obliquely round the
head.  The assistant, free or raised on a chair at  the head of the bed,
prepares for elevating the eyelid.
  First stage.—With the forefinger corresponding to the diseased
side, the operator depresses the lower lid and fixes the eye.  With
the other hand he seizes the needle in the manner  of a writing-pen,
directs its point perpendicularly upon the sclerotica, at one or two
lines from the transparent cornea, a little below  its transverse  diam-
eter ; turns its  concavity downwards, one of the cutting edges to-
wards the cornea, and the other towards the  orbit,  in order that he
may penetrate, rather by separating apart, than by dividing through,
the fibres of the coats of the eye ; first inclines  the handle of the instru-
ment with  a considerable  deal of force downwards, then raises it
gradually in an opposite direction in proportion as he enters  into the
posterior chamber, and makes use of his  two  last fingers in order to
procure a point d'appui, between the parotid  and the cheek bone.
  Second stage.—Before  plunging it in farther,  he  turns the instru-
ment upon its axis, in order that its concavity may  face backwards,
and that he may be enabled to pass without  danger below, then in
front of the crystalline, while penetrating from without inwards and
slightly from behind forwards, without touching  the iris or lenticular
capsule,  if he  possibly can,  as far as into  the pupil and  anterior
chamber.   He then passes its point circularly several  times around
the anterior circumference of the  lenticular  body,  the  envelope of
which is in this manner lacerated as completely as possible.
   Third stage.—This  being  accomplished, the  surgeon applies the
arc of the needle direcLy upon the front  part of the cataract, which
he then  draws by an  oscillating movement  downwards, outwards,
and backwards, into the  bottom of the eye, below the  pupil and the
vitreous humor, where he holds it fixed for the space of a minute, in
order that it may not become disengaged.
   Fourth stage.—The instrument  is then drawn back without sha-
king it, by small movements  of rotation; it  is brought back to the
horizontal  position;  we  again turn its convexity upwards, and re-
move it from the eye, by making it pass through the  same track it
had taken in entering.
  Remarks on the preceding different stages.—Many points in this
operation require particular attention.
   1. To make use of the right hand,  for the  right as well as the left
eye  could be of use only to those surgeons who are not ambidexter,
and  it is not often that these  latter venture to perform  operations on
the eyes.
  2. If the needle were directed above the transverse diameter  of the 
854                    GLOBE OF  THE EYE.

sclerotica, as some practitioners, and among them M. Pilson, have
recommended,  it would  become almost  impossible  to  depress  the
crystalline  completely, or to avoid leaving it more or less near the
centre of the  eye.   In applying it exactly upon the external extre-
mity of this diameter, we should  be certain to wound the long ciliary
artery, and to produce an internal hemorrhage.   It is below it there-
fore that we must apply it.  When its convexity is turned forward, as
Scarpa recommends, the fibres of  the sclerotica, as well as some of
the ciliary nerves and vessels, are necessarily divided, whereas no-
thing like this takes place if we conform to the precept which I have
laid down.
  3.  J. Fabricius laid  it down  as a rule that the needle ought to be
plunged in at the union of the sclerotica  and cornea.  Others, with
Purmann, say at half a line from  this last;  some at a line and a half;
several at two lines, two lines and a half, and even three lines ; there
are those who say the breadth of the nail or of the stalk of a straw,
the middle of the white of the eye, &c, and those who are in favor
of going  as distant as possible from it, are influenced by the fear of
wounding the ciliary circle  or processes.   Among others, there are
those who, like Platner,  apprehend the lesion of the tendinous  por-
tion  of the rectus externus  muscle or the nerve of the sixth pair.
Fabricius, in  approximating the  cornea, specially designed thereby
to reach more directly in front of the cataract, while the majority
look only to avoiding with greater certainty the retina.  As to the fact
itself, two things appear to  me indisputable: it is that the puncture
of the fibrous expansion of the rectus muscle involves not the slightest
inconvenience,  and that  that of the retina is unavoidable when we
penetrate through the sclerotica, at whatever distance it may be from
the cornea ;  from whence it follows,  as a  general rule, that there is
no danger in receding from, while there would be in approximating
too near to the ciliary body.
  4.  In turning  the back of the needle forward, when we wish  to
pass it below and then in front of  the cataract, and to conduct  it in
this manner in the. anterior chamber through the pupil, our object is
to protect, with as much certainty as possible, the retina and the iris
from the  action of its point or cutting edges.  If we work with it in
the anterior chamber, it is in order to be more certain that it may not
work between the lens and its envelope.  The laceration of this last is
a more delicate and important operation than is generally supposed ; it
is upon its circumference that we must commence.   If we pierced it
first at the centre, it would be very difficult afterwards to detach the
flaps  from  it, and to prevent the formation of a  secondary cataract.
The best  mode undoubtedly would  be to depress  at once both the
crystalline and its capsule, without breaking them,  as some authors
have recommended ; but by what mode could we force a membrane
so delicate to the bottom  of the eye without dividing it, provided that
its adhesions have retained some degree of firmness ?
  5. It is not sufficient, in order  to depress the opaque body, to seize
it with the point of the  needle.   The concavity of the instrument
ought moreover to embrace exactly and flatwise its anterior surface
at its  middle portion, from the inner side of the pupil as far as to its
outer portion; otherwise it would  be reversed upon the slightest de- 
NEW ELEMENTS OF OPERATIVE  SURGERY.
855
gree of pressure,  either from above downwards or from below up-
wards.   The depression having once commenced, the needle repre-
sents a lever of the  first kind,  which finds its point d'appui in the
opening of the sclerotica, and which, in order to make resistance out-
wards, backwards and downwards, should have the concavity of its
point slightly inclined upwards,  while we give to it the oscillatory
movement mentioned.
  6. When the cataract is depressed, it is recommended to the patient
to look upwards and inwards without moving the head, supposing by
that, but erroneously,  that the crystalline would  be made to descend
lower down.  In  not withdrawing the needle until at  the  end of
some seconds, time is given to  the  depressed  cells of the vitreous
humor to resume their natural position, and to imprison, so to speak,
the cataract, which wrould almost mount upwards if we left it imme-
diately.  The small movements  of rotation which the instrument is
made to perform before disengaging it from the eye, have evidently
for  their object to disturb the  crystalline  as  little as possible, and to
be more certain of leaving it in its new locality.
  7. If, notwithstanding all these precautions, the cataract  mounts
upwards again as soon as we cease to keep it depressed, we must
seize it a second time and depress it farther  down, and  continue  in
this manner until it rises up  no longer.
  8. When it  is soft the  instrument ruptures it, and we  rarely
succeed in entirely depressing it  below the pupil; in such cases, if it
is not practicable to displace its  fragments backwards, we endeavor
to break it down into  small particles, which are to be pushed forward
into the anterior chamber, in order that their solution by the aqueous
humor may prepare them for absorption.  It is also to  this place that
we  must direct every opaque particle which may be found to remain
in the  centre of the  eye after the displacement of the crystalline.
The foreign corpuscles are in this manner easily pushed forward  in
front of the pupil, provided  they  are completely liberated.  Unfortu-
nately the case is not  the same, when our design is to place there the
flaps from the crystalline envelope.  In this case we must have skill
and address to  transfix, so  to speak, each flap in succession, from
before backwards or behind forwards, with  the point of the needle
near the centre of their base, and to detach them while rolling them
up upon themselves, or by drawing them  on the side near their apex.
If the capsule adheres to the uvea we ought, before all other things,
to effect  its separation, and in doing this avoid the iris  as much  as
possible.  Upon the supposition that some circumstance may occur
to prevent this  disunion, we  should necessarily be obliged to displace
the crystalline at first, and act afterwards upon the anterior layer of
the capsule, as has been described above.
  9. Crystalline in the Anterior Chamber.—The cataract,  at the
moment  of the operation,  may, in  comsequence of some  sudden
movement of the  patient or the operator, escape through the pupil
and fall into the anterior chamber.  This may also happen  sponta-
neously from various causes, as blows, falls, sudden strokes, and any-
thing which may concuss the head of the individual, or in any man-
ner bring about  the  rupture of the lenticular cyst.   This circum-
stance does not necessarily oblige us, as has been supposed, to resort 
856
GLOBE OF  THE EVE.
  to the  extraction of the  displaced disc.  Inasmuch as it  has gone
  through the pupil, in order to place itself in front, it could traverse
  it again to get behind, and  it will always be found  more agreea-
  ble, both for the patient and the surgeon,  to  terminate the opera-
  tion while the needle is in the eye. than to withdraw it again in ordei
  to incise the cornea.  In the  cases even where  nothing yet has been
  attempted,  it is  no obstacle to depression, provided  the  pupil re-
  mans dilatable and that there is but very little degree of inflamma-
  tion.  Dupuytren and M. Luzardi, who, under such circumstances,
  have made use of the ordinary needle, have  plunged it through the
  sclerotica and pupil into the anterior chamber, in  such  manner as to
  seize hold  of the lens, whether opaque or not, and which they have
  afterwards succeeded in conducting into the bottom of the  posterior
  chamber.   I have frequently noticed this  accident, but it never has
  appeared to me of serious character at the moment of the operation.
  There are, moreover, some singular facts in  relation  to this  subject.
  In a patient of M. Monod the crystalline remained in the anterior
  chamber.   This woman, having left the Hospital of Cochin, came to
  the clinique two months afterwards.  I then noticed that the crys-
  talline occupied its usual place in the posterior chamber.
   Having left my service at the expiration of six weeks,, the patient
 came back again three months subsequently, when  the  crystalline
 was  again found in the anterior  chamber, having vessels which ap-
 peared to have penetrated into it, and where, being now reduced to
 a. third of its volume, it appears  to constitute a part of the cornea!
 In another case the crystalline having passed into the anterior cham-
 ber several  months  after depression, repassed into the  posterior
 chamber while  Pellier (Gaz. Salut., No. 50, p. 4,  col. 2, 1760,) was
 dividing  the cornea in order to extract it.
   10  In milky cataract, if as almost always happens,  the capsule
 itselt is affected, it is almost indispensible to carry the instrument as
 Jar as to  the centre of the pupil without dividing  anything, otherwise
  he opaque  liquid diffuses  itself into the eye,  renders  the  humors
 turbid, and  prevents us from any longer seeing  what we are doing.
 lXevertheless  should this accident happen, and whether the needle
 was or was not m the anterior chamber, we ought  before withdraw-
 ing it, to simulate as accurately and with as much  caution as possi-
 ole, the manipulations  necessary to break down whatever it mieht
 De necessary to destroy.                                       °
   11. Purulent cataract, of which I have seen two very marked ex-
 amples, would require no  additional attentions, as its absorption is
 also speedily accomplished.
   12. If  as I have often seen, the cataract  should, on the contrary,
 be very hard, stony, cretaceous, or  like tupha, (tophacee,) which is
 recognized by its unequal, ridgy, and white or yellow calcareous
 color, we should treat it in the same manner precisely as  an ordinary
 crystalline, except that its capsule being folded and  retracted, and, as
 it were, parched up, cannot be isolated from the rest, and must be
 depressed with the same stroke.  Should the cornea, (Darcet, These
 citee,) the crystalline,  (Kulm, Chir. des Hopit., t. III.,  p. 397) or
 vitreous humor  (Middlemore, Revue Med., 1838, t. III.,  p. 269) be
ossified, any operation doubtless would be useless. 
NEW ELEMENTS OF OPERATIVE SURGERY.
857
   b. Other Processes.—1. Process of Petit.—At the commencement
 of the last century, some authors sustained, contrary to Hecquet, de
 la Hire, &c, that the seat of the cataract was always in the crystal-
 line.  Petit, adopting  this hypothesis, proposed  to accomplish the
 depression of the opaque  body without touching  the  anterior layer
 of the capsule.   After having plunged the needle into the  posterior
 chamber, he inclines one  of its  cutting edges  outwards and  back-
 wards ;  opens into the vitreous  humor in this direction ; brings the
 needle back to the outer, lower, and posterior part of the capsule, which
 he ruptures, secures  the crystalline by hooking into it, and passes it
 into the substance itself of the hyaloid body, while conforming in other
 respects to the  general rules for depression.   This modification, re-
 vived some years subsequently by Ferrein, who declared himself the
 inventor  of  it, was afterwards supported by Henkel, Gunz, Gentil,
 Walsborr, &c.   In allowing the anterior capsule to remain intact, it
 was to leestablish  the  vision  more completely than by the ordinary
 process.  It was maintained that in falling upon a convex membrane
 the luminous rays would scarcely feel the loss of the crystalline: that
 the concordance of the focus of vision would be preserved; and that we
 should not in fact be  under the necessity of using spectacles after the
 operation.  To  these reasons, practitioners  objected that the capsule
 is frequently itself the seat of cataract, either alone or conjointly with
 the crystalline;  that  more often  still  it becomes opaque afterwards,
 and produces a secondary membranous  cataract, should we fail  to
 destroy it at the time of the operation ; that consequently, so far from
 preserving it, we ought to endeavor to break it up as thoroughly as
 possible;  finally, that in depositing the crystalline exclusively in the
 vitreous  humor, in place of simply depressing  it  into the  posterior
 chamber, we should run the risk of producing serious accidents.
   2.  Process of the  author.—The last objection  raised by the ad-
 versaries of Petit is the only one  destitute of foundation.  If the lace-
 ration of the vitreous body were dangerous,  the operation for cata-
 ract  by  depression would scarcely ever succeed,  for  it is almost
 impossible to be avoided.  Should not the crystalline  enter, to some
 extent, in spite  of the  operator, into the vitreous humor, can  it be
 supposed  that it would ever remain  depressed, pushed back as it
 continually would  be by the  natural elasticity of the  hyaloid mem-
 brane ?   Moreover, in  causing it to  glide between the coats and
 humors of the eye, how could we avoid lacerating the  retina ?  Pro-
 ceeding upon this  idea, M. Bretonneau has deemed it advisable  to
 adopt the process  of Petit by modifying it;  that  is to  say, that  in
 place of opening the capsule  posteriorly, this surgeon, after having
 traced out a  passage  for the crystalline into the vitreous humor, pro-
 ceeds to the rupture of  the capsule in front as by the ordinary pro-
 cess.  Being a witness  of the successes obtained by this process at
 the Hospital of Tours, in  1818 and 1819, I have adopted it without
 having had  any reason to regret it.  I perform  it in the following
 manner: the needle is  directed as  if  to pass behind  the cataract;
 when it has arrived at about four lines of depth, before changing its
 position,  we  incline  it  downwards, backwards, and  outwards, in
order to open into the anterior  cells of the vitreous humor;  immedi-
ately  afterwards, we turn its back towards the iris; then while ele«
   vol. n.                       108 
858
GLOBE OF  THE EYE.
vating its handle, we cause its point to pass under the  lower border
of the crystalline, that it may  afterwards  be conducted  into the
pupil; then  lacerate the anterior  layer  of  the  capsule ;  seize' the
opaque body, and push it by a well regulated  vibratory movement,
in the direction of a line which would extend  from the great angle
of the eye to the mastoid process on the same side.  We thus avoid
wounding the iris ; the elasticity of the vitreous humor, though some-
times quite  considerable, cannot however offer the least degree of
resistance, and enables  the cells of  its membrane, while immediately
closing the passage, to become an obstacle to the reascension of the
crystalline.
  3. Another process.—I have  often also employed  another pro-
cess which has appeared to me to be very convenient.  In  place of
inclining the needle downwards, I  direct it upwards, and  from be-
hind forwards, in order to bring it above and in front of the crystal-
line, and into the pupil.   By this means we more completely detach
the cataract, and nothing is  more  easy afterwards than to force  it
backwards and downwards.
  4. An itinerant oculist, M. Bowen, has published a method which
he calls hyalonyxis, and which appears to him preferable to every
other.   His  object is to traverse the vitreous humor from behind
forwards, then to lay open the  posterior layer of the capsule, and to
detach the crystalline after the method of Petit or Ferrein, without
interfering with its anterior envelope.   For that purpose M. Bowen
pierces the sclerotica at four lines from the cornea.  The results of
his practice  are all in favor of hyalonyxis, for he scarcely counts two
failures  out  of twenty  operations.  From this therefore we may at
least conclude, that the  wounding of the retina and the vitreous hu-
mor is a matter of very little consequence.   I do not see, moreover,
any advantage in going so far  from the cornea, and' there  is no ne-
cessity of recalling the  inconveniences to which we are exposed in
not destroying the anterior layer of the capsule.  Nothing moreover
would prevent our avoiding it,  if we desired to do so, by the process
which I have adopted.
  5. M. Ruete, (Gaz. Med., 1838, p. 677,) in causing  his needle to
penetrate at the side of the capsule  on a line with the pupil, then
turning the point of his instrument  forwards, in order to rupture the
envelope of the crystalline, and proceeding afterwards to the depres-
sion of the cataract, has in this  process done nothing more than what
often happens to other surgeons without their being aware  of it.
  6. M. Goyrand plunges his needle into the  vitreous humor from
behind forwards like M. Bowen, and immediately causes it to per-
form a circular movement upon the whole circumference of the crys-
talline, which latter he  transfixes in order to  drag it into the vitreous
humor, without paying any attention to the anterior capsule.  I have
seen him operate in this manner with great rapidity.
  7. M. Gensoul formerly made  use  of a  process, which he soon
after abandoned, but which M. Roux has since  thought  proper to
make trial of at Paris, and the  idea of which seems to belong to B.
Bell or to M. Giorgi.  A small  incision is first made behind the iris,
at the union of the sclerotica with the cornea.  The surgeon intro-
duces through this opening, a sort of scoop to the fore part of the 
              NEW ELEMENTS OF OPERATIVE SURGERY.          859

crystalline, which he pushes down or depresses, and the operation is
thus terminated.   The only advantage from so  large an opening of
the  sclerotica, would  be in giving relief  more easily  than by a
simple puncture to the too great degree of fullness  of the eye, (trop
plein de l'ceil.)   But the division of the ciliary body, the possible
escape of the humors, and the impossibility of carrying the cataract
sufficiently far backwards, would  of themselves suffice on the face
of them to cause this process to be forever  proscribed, though even
the trials of its inventors and of M. Roux, did not come to our assist-
to demonstrate its inconveniences and dangers.
  8. Reversion or  Reclination.—Since the time of Pott, some
authors, among others Willbourg and Schifferli, have maintained that
in place of depressing the crystalline, it would be better to effect its
reversion.   We cannot  deny that this modification would render the
operative process both more  simple and  more easy.  When  the
needle has lacerated the anterior capsule, all that is necessary is to
apply it a little nearer to its superior than to its inferior border, in
order that by pressing upon it, the reversion of the lens  may be
effected at the moment by an oscillatory  movement, which  places its
anterior surface above, and  its superior  border behind.   If we de-
sired, moreover, to drag the cataract into the  substance, or  below
the vitreous humor,  as Beer, Weller, and others  recommend, rever-
sion evidently becomes  the usual mode of depression, whereas, if
we should abandon it in  the posterior chamber,  below the centre of
the pupil, it  is clear that it will in  most cases  reascend, or that its
presence would irritate  the iris and the rest  of the eye  to such a
degree  as to  give  rise  to  accidents.  Reversion then, is  only a
dernier resource, and never a process of election.
  9. Discision or breaking up.—Pott, after having endeavored to
demonstrate that the crystalline, when it  is once  placed in immediate
contact with  the  aqueous humor, is dissolved,  and ultimately  dis-
appears, wished also to  prove that it is not indispensable to depress
it below the  axis of vision; that it  is sufficient, as  Warner had  ad-
vanced, to reduce it  into fragments;  that  in fact, as Ware pretends, a
cure  may be  effected  by rupturing  its capsule.   Experience  has
occasionally confirmed this opinion, for the examples of solution  and
absorbtion of the crystalline, whether it was left entire or broken up
into fragments, are not uncommon.   As on the other hand, the break-
ing up of the  crystalline relieves us of the most  difficult point of the
operation, it  is very natural that  M. Cappuri, (Paccini,  Bull de
Ferussac, t. XIV., p. 192,)  as well as  many other oculists, should
have  adopted the opinion of M.  Adams, who recommends that it
should be made use  of in all cases.  Nevertheless,  I will say of  this
the same thing that I would of reversion.   It is a process which is to
be adopted when the cataract is soft or too difficult to be displaced,
but it is one which, notwithstanding  the  eulogiums bestowed upon it
by M. Parmi, is less certain than depression properly so called.   If
it is true that the fragments of the crystalline are  sometimes dissolved
with sufficient rapidity, it is also  true that very frequently they re-
main there for months, and even to an indefinite period, and  in such
way as  to prevent the re-establishment of vision.   If the wounding of
the vitreous  humor is thereby less difficult to be avoided, that  of the 
g(JO                   GLOBE  OF THE EYE,
iris is ordinarily more so.  Upon the supposition that there might be
some advantages in leaving  the cataract to be gradually absorbed,
they will be found  more than counterbalanced by the anxiety of the
patient, and the loss of time  which must elapse between the moment
of the operation and  the period when the pupil is again restored.
1 am still less  capable of comprehending  M.  Lowenhardt,  (Gaz.
Med., 1838, p. 812,) who has had the temerity to pass a seton through
the crystalline in order to cure the cataract, and who declares that
he succeeded !   All  the  needles  are  good for effecting discision.
That of Beer, or M.  Lusardi's small needle, in  the  form of  a sickle,
seem more convenient, however, than those  of Hey and  Dupuy-
tren, and even than those of Scarpa  and M. Bretonneaji.  Although
we may break  up the crystalline by  attacking it on its posterior
surface, it is, nevertheless, preferable to act upon its opposite  surface,
in order that we may be better  enabled to see what we are doing,
and  to  be  more cei-tain of avoiding the iris.  In this mode, when
the instrument  has once arrived in the pupil, and that the  capsule
has been properly ruptured, we  direct  its point  and  one  of its
cutting  edges upon the middle of the cataract, which latter is di-
vided at first into two parts,  in order to return upon each fragment
separately, in order that they  may be  reduced into as small parti-
cles  as  possible, after which we  endeavor to  push the  largest of
them into  the  anterior  chamber,  by means  of the  back  of the
needle.   When we operate  from behind forwards, and employ the
straight needle, the  breaking up of the  lens is in  reality more
easy, so long as the anterior  layer of the capsule  remains entire,
because the crystalline being then shut up as  it were in a sac, and
unable to escape,  is  compelled constantly to  present itself to the
action of the  instrument;  but the vitreous humor suffers much more
than by the other process, and it is very rare, moreover, that  the lens
and  its envelope are not pierced  through  and  through at the very
first movements.
  III. Keratonyxis.—Depression,  reversion, and broiement, which
are generally performed, as we have just seen, by scleroticonyxis or
by sclerotico-hyalonyxis, are  also accomplished by keratonyxis, that
is to say, by penetrating through the transparent cornea.   This pro-
cess, whose invention has been disputed by many moderns, is  far from
being new.   Avicenna speaks of practitioners who first opened the
cornea and penetrated by that means to the crystalline,  which they
afterwards  depressed  by means of  a needle that they denominated
al-mokadachet.  Abu'l-Kasem asserts positively that he adopted this
method, and that when the  needle  is plunged  into the  crystalline,
some gentle movements are  required to be made upon it in  order to
depress  the  cataract.  M. Herbeer (Carron du Villard,  Oper. de la
Cat. &c, p. 11,239,) affirms that this has been the practice in Egypt
from immemorial  time, and M. Souty, (Ibid.,  p. 241, 1834,)  makes
the same remark of the medicastres of India.   Manget  also relates
the case of  an English woman, who cured cataract  by piercing the
cornea.   In the collection of Haller, we find a thesis supported, by
Col.  de Vilars, under the presidency of Le Hoc, in which this oper-
ative process is  much extolled.
  It is in this  manner, says  the author, that birds recover  their vi- 
NEW ELEMENTS OF OPERATIVE SURGERY.
861
sion by plunging a thorn into the eye, and it is  thus, according to
Galen, that goats have pointed out to man the manner of operating
for cataract.   In the  18th century, Smith had  already revived the
process of the Arabs.  Dudell, the disciple of Woolhouse, consider-
ing cataract almost always membranous, proposes that we should
penetrate the cornea to reach the anterior capsule, and to remove
from it a circular  disc  by means  of  the  needle, in such manner
as to form  there a sort  of window to give passage to the rays of
light.  The famous Taylor and Richter frequently performed kera-
tonyxis in cases of milky cataract.  Gleize in France, and Conradi
in Germany, made  it known in the year  1786.   In  1785, Beer had
performed it twenty nine times.  Demours had performed it in 1803,
the epoch at  which Reil had endeavored in his lectures to call atten-
tion to it, and when he gave it the name which it bears.  But it has
required no less than the united efforts of Buckhorn  in 1806 and 1811;
Langenbeck, in  1811 and 1815 ; Dupuytren, Guille, and Walther in
1812; Wernecke, in  1823; and Textor and Pugin  in 1825, to as-
sign it a place among regular operations.
  a.  Operative Process.—The patient  and the assistants are placed
in the same manner as for scleroticonyxis;  the surgeon directs the
point of a curved needle, that of M. Bretonneau, for example, or that
of M. Langenbeck, which, though more  pointed, has a cutting edge of
less extent, at about a line from the sclerotica; supports the back of it
upon the finger which depresses the lower eyelid; causes it to pene-
trate into the anterior chamber at  the lower or external part of the
cornea ;  arrives  in the pupil; then turns  downward the concavity
of his instrument, which  up to this  moment he had held in an oppo-
site direction in order to  avoid the anterior surface of the iris ; freely
lays open the capsule;  detaches  the  crystalline ; hooks its  upper
border; depresses and reverses it;  endeavors even to push it below
the pupil into the  vitreous humor, or what  is better, comminutes it,
and breaks it up and depresses its principal fragments when he can-
not bring them into the anterior chamber; and afterwards turns the
back of his needle downwards again, and withdraws it by  making it
pass through the  same track in an opposite direction to that by which
it was introduced.
  b. Appreciation.—Keratonyxis should not be attempted until we
have  previously produced a sufficiently extensive dilatation of the
pupil, the borders of which nevertheless it is very  difficult in spite of
this precaution, to avoid  wounding severely, when we are endeavor-
ing to depress the crystalline.   It  is to obviate this  inconvenience,
and especially in order not to  puncture the  iris, that straight needles
among us have generally been proscribed, and that we penetrate at
some distance from the sclerotica, taking care at  the same time not
to approximate too  near  the centre of the  cornea.  The pyramidal
needle of  Beer,  the shoulder that M. Graefe has caused to  be added
to the stem of the ordinary needle to prevent its penetrating too deep,
the needle of Himly, and that of Schmidt, &c, do not in reality
present any advantage over those which  are used in France, and
require no further description in this place.   In animals this process
is preferable to all others, for reasons which it is unnecessary for me
to point out.   Though in the  human species it may in fact be em- 
862
GLOBE OF  THE EYE.
ploved wherever depression is practicable, it is not advisable to make
choice of it except for milky cataract, and in children and intracta-
ble subjects, and where the  eyes are very movable and irritable or
deeply depressed.  The same  hand will answer for  both eyes;  no
nerve or vessel incurs any  risk of being wounded.   The retina re-
mains intact; nor is  the iris in more danger than  by the  posterior
method.  The  tissues that  are traversed  have scarcely any sensi-
bility, nor does the membrane  of the aqueous humor, which MM.
Wardrop,  Langenbeck and Chelius appear to have so much dread
of wounding, possess any more than a very slight degree of vitality.
The operation then resolves itself definitively into a simple puncture,
and may be repeated a certain number of times without any  serious
inconvenience.  But to these advantages no less numerous objections
may be opposed.   The adhesions of the  capsule, the contraction
of the pupil, the narrowness and  flattened  form  of the cornea, the
projection  of the iris, and hard gypseous or stony cataracts,  do  not
appear to be adapted to it.  Properly understood, it is for the break-
ing  up and reversion of the lens only that we may sometimes have
recourse to keratonyxis.  Though it has  succeeded  in seven times
out of eight with M. Textor;  that in many hundreds  of patients, M.
Smalz, according  to M. Eccard, has never seen it produce suppura-
tion of the eye; that out of 345 cases of M. Walther, he failed only
in twenty-six ;  Dupuytren, in one out of six ; and  M. Langenbeck,
in four only out of 112, this process nevertheless has been abandoned
as a general method, by even its warmest partisans themselves.  M.
Wedmeyer, who has performed it fifty-three times, rejects keratonyxis
as well  as M. Langenbeck, and M. Schindler, (Bull, de Fer., t. X.,
p. 352-354,) who  prefers in this operation to pass through the centre
of the cornea, will not succeed  in giving it any great degree of popu-
larity.  Nor do I think that M. Pauli, (Arch. Gen. de Med., 1838, t.
III., p. 352,) who, penetrating at the cornea, then divides the vitreous
humor above the crystalline in  order afterwards to perforate through
this opening through the  entire body of the lens, will ever succeed
in causing his method to be adopted.  Nor can I comprehend  any
better the superiority of what M. Quadri (Gaz. Med., 1833,  p. 643)
calls  his mixed method.  How is it possible that a sort of forceps-
needle introduced through the cornea in order to extract the  capsule
of the crystalline, while the cataract is being depressed by means of
an ordinary needle passed through the sclerotica, could render the ope-
ration more  simple, more  sure and less  dangerous ?   I conclude
therefore  that keratonyxis cannot be substituted for  scleroticonyxis,
which alone enables us to push the  crystalline wthout extracting
it, outside of the  visual axis, and to fix it there securely, promptly
and permanently; and  that in  fact it only  deserves a place in books
of surgery under the character of an exceptional method.
  c. As to the  simple puncture of the cornea, as formerly practiced
by Lehoc, and  more recently by M. Wernecke with the view of pro-
moting  the solution or absorption of the cataract, it has not yet suffi-
cient  proofs in its  favor to authorize its  being formally recommended.
If nevertheless, as  cannot be doubted, the decomposition of the crys-
talline  separated  from its  membrane, is a phenomenon much more
chemical  than  vital, we cannot see why the evacuation of the aque- 
              NEW ELEMENTS OF OPERATIVE SURGERY.          863

ous humor, when once impregnated with the foreign substance, might
not favor the dispersion of the cataract, in permitting  the  liquids
with which it is  surrounded to be renewed.
  IV.  Operation for Cataract in Children.—In the early period of
life, we can scarcely  have recourse to the method  of extraction.
We should rarely succeed in accomplishing it without emptying the
eye.   As is demonstrated by the observations of Scarpa,  Ware,
Saunders, Gibson,  M. Lusardi, and M. Lawrence, who has  seen it
in four brothers, &c, congenital cataract and  accidental cataract in
young persons are almost constantly liquid and membranous.  There
is consequently but little to do with depression  or extraction.  The
object to be attained is to lacerate as completely as possible, the an-
terior  disc of the  capsule, and  to empty it of the matters  that it
contains.  In  such cases it is a matter of indifference whether we
operate by keratonyxis or  scleroticonyxis, at least when the pupil is
very large, a condition which ordinarily exists.   The most difficult
point  is to  restrain the little patient.  Ware  confines  himself  to
placing him upon a table, raising his head by means of pillows, keep-
ing him held  down by assistants, and  holding  the eye steadily by
means of the fingers, while another assistant raises the upper lid
with  the elevator of Pellier.   Gibson, who first gives an anodyne
potion to blunt the sensibility, causes the most  intractable  to be im-
prisoned in a sort of sack,  open at both ends, and which is confined
above the shoulders and below the feet by means of a running string.
Finally, M.  Lusardi finds it more commodious to seat  the child  upon
the angle of a prepared table, after having fastened his arms  around
his  trunk and  placed  his  legs between the thighs of the  operator.
Whether we  penetrate through the  cornea or the  sclerotica, it is
always important  to effect a complete loss of substance at  the  ante-
rior disc  of the capsule, and not to confine ourselves to its  simple
rupture, unless we wish to  incur the risk of seeing a secondary cata-
ract supervene soon after.  If the crystalline should still retain some
degree of resistance, and if it should appear that the capsule itself
ought to be broken up into fragments, it would become necessary, as
in an adult, instead of leaving them in their place, to force them into
the vitreous humor or push them forward into the anterior  chamber.
If at  the expiration of fifteen or twenty days, any fragments should
remain at the place of the crystalline, Ware  recommends that we
should repeat the operation, without waiting any longer, and states
that he has performed  it four or five  times successfully in  this  man-
ner on the same child.  Such a course of procedure ought not  to be
imitated, unless  we have satisfied ourselves that  the fragments of the
cataract have absolutely ceased to diminish in volume.  This perhaps
would be an occasion for making trial of the process of Wernecke,
and of evacuating the aqueous humor by a puncture in the cornea.
  V.  Subsequent Treatment.—When everything is finished after the
operation for cataract by depression, the patients are recommended
to keep the  eyelids gently closed.  The practice of  placing before
the patient some object to ascertain the result of  the operation should
be abandoned by all practitioners.  The light arriving in full  force
and suddenly into the bottom of the  eye, irritates the retina  too se-
verely, and such  a test in every respect can  only  be intended to 
864
GLOBE OF THE EYE.
 gratify an idle curiosity.  After the employment of the needle espe-
 cially, it must completely fail in its object, since the disturbance we have
 just produced in the chambers of the eye may render the sight very
 confused at first, though it is to be completely reestablished afterwards.
 Nobody at the present day would venture to follow the recommen-
 dation of Purmann, by applying over the puncture of the sclerotica,
 a small piece of gold-leaf, with  the view of preventing the escape
 of the aqueous humor  or the vitreous body.
   Brandy  and the white of an egg, employed by the ancients, and a
 thousand  other  topical applications lauded without any foundation,
 are also proscribed.  We confine ourselves to wiping out the eyelids
 with a sponge or a fine compress, then  placing in front of them the
 oval piece of linen perforated with holes, dry or imbued with cerate,
 and over these a soft compress of lint, and  a bandage of linen, which
 is arrested under the nose by the bridle formed by its notch, and which
 is fixed behind  to the  cap by means of some pins; finally, the  band
 of taffeta which is to cover the whole.   It is important that none of
 these portions of dressing should  be drawn so tight as to compress
 the parts contained in the orbit.  For myself I  confine myself in
 most cases to the employment of a simple bandeau, which bridles the
 nose, and which I  attach to the cap behind  by  means of pins.  The
 patient operated upon should make no effort nor  any movement.
 Being carried back to his bed he is to be laid upon his back, with the
 shoulders and head elevated by means of pillows.  The habit of sur-
 rounding him with thick and colored curtains, and  of allowing but
 little light  to penetrate into his chamber, has appeared to  me to be
 more hurtful than useful.   During the space of  three or four days we
 allow him only bouillon or light soups.  If the stools are not regular,
 emollient  clysters  or even laxatives are  to be administered.  We
 may give  him also, for example, a drink of a more  or less  relaxing
 character, such as whey, barley-water  sweetened, syrup of prunes,
 veal  broth, or decoction of tamarinds.  However little cephalalgia,
 heat of skin or febrile movements, may supervene, bleeding is not to
 be omitted. When nausea and vomiting should at the same time be
 present, laudanum  by injection, as Scarpa  recommends, is  indicated
 and produces very good effects.   In ordinary cases  the  usual drink
 to be employed is infusion of linden, violet or wild poppy, sweetened
 with some  syrup.  Loss of sleep and restlessness are to be relieved
 by an ounce of syrup of white poppy or diacodium made into a julep,
 which  is to be taken  by teaspoons full.   When no serious accident
 supervenes we do not uncover the eyes until the third or fourth day;
 while everything goes on well it is perfectly useless to examine them
 before  that time.   Should  any accident occur we should be apprised
of it by the state of the pulse, the cephalalgia, the pain in the orbit, the
running of the tears and the  saturation of the  dressing by a yellow
discharge.  To perform the dressing the patient must be first seated.
 The  different portions  being  removed,  a basin with warm water is
placed under his chin, and by means of a sponge he himself moistens
and separates his  eyelids, which  he immediately opens  after the
 operator has wiped them.  At this time the curtains are to be closed.
 Even though the pupil should appear to be regular, it  is scarcely
yet prudent to undertake to ascertain the extent  to which  the sight 
NEW ELEMENTS OF OPERATIVE  SURGERY.
865
is re-established.  The dressing is to be reapplied and renewed every
day, and we proceed in  the same manner  as  in cases of simple
ophthalmia, while the eyes retain their redness.  If everything goes
on well we allow at every dressing a  little more light to fall  upon
them, in such manner that at the expiration of twelve to fifteen days
they may be left uncovered and protected only by a simple shade of
dark taffeta.  Nor is there  any longer any necessity of the diet being
very rigid, and the patient may get up in the course of the second
week, resuming by  degrees his  customary regimen.  I have fre-
quenty  even made  them  or allowed  them  to  get  up at  the be-
beginning of the fourth day.  Under a contrary state of things, we
must look  to the kind of symptoms which are developed, in order
to employ in  good  season, antiphlogistics, general or local, purga-
tives, revulsives, and collyria, of this or that description, in the  same
way as we would do in a disease  of the same kind  produced by any
other cause, not forgetting at the  same time that iritis, retinitis, and
choroiditis  are  under these circumstances the accidents that we are
especially to endeavor to prevent or to combat.
  D.  Operation for Cataract by Extraction.—Cataract was still but
very imperfectly known, both in respect to  its seat and its nature,
when it was already proposed to  extract  it.   Antylus,  according to
Sprengel, opened the cornea by means  of a needle, and proceeded to
seize hold of the opaque pellicle through the pupil, in order to extract
it.  Lathyrus  operated in the same manner.  It  appears also that
Galen practised incision of the cornea in front of the membranes, in
order to extract the  cataract.  Ali Abbas and Avicenna speak of
extraction  as  a common method.   Abu '1 Kasem  states  that he
learned from an inhabitant of Irack,  that in that country the  prac-
tice was to introduce a short needle  into the anterior chamber in
order to void  the  cataract.  Avenzoar and Isa Ebn-Ali, who reject
it, state that in their time  it was in  general use in Persia.  G. de
Chauliac himself has not  forgotten it; and Galeatius, who extols it
greatly, gives himself out as its author.  Entirely forgotten, however,
or laid aside, by the authors of the middle  ages, the operation for cata-
ract by extraction does not appear to  have been revived in  practice
until about the end  of the seventeenth century and  the commence-
ment of the eighteenth.  In 1694,  Freytag laid open the cornea in
the manner of the Arabs, and  succeeded afterwards in extracting
from the eye  an opaque membrane,  which doubtless was no  other
than the anterior layer of the capsule of the crystalline.  Woolhouse
passed through the anterior chamber with a needle arranged in such
manner as  to be susceptible of being  transformed at pleasure into a
forceps, and which  enabled him afterwards to seize hold of the opaque
uody in order  to effect its extraction.   Petit, effecting, in the pre-
sence of Mery, the extraction of a cataract which had fallen into the
anterior chamber,  surprised  many of  the assistants  by showing to
them an opaque crystalline in place of the pellicle they had expected
to see.  St. Yves  also  decided upon extracting the crystalline lens,
but without success, which induced him,  but we do not see for what
reason,  to  maintain  more  strenuously than ever that cataract does
not have its seat in the body of the lens.  These different attempts had
then scarcely attracted any attention when Daviel, in 1748, submitted
  vol. n.                      109 
866
GLOBE OF  THE EYE.
 his method to the judgment of the Academy.  By means of a large
 instrument shaped like the tongue of a carp he opened into the lower
 part of the cornea;  the wound in which he afterwards enlarged by
 means of a second instrument narrower than the  first, or by small
 curved scissors.  A gold spatula to keep the lips of the wound open ;
 a needle  of the same metal, which was flat  and triangular,  for the
 purpose of opening the capsule, and a scoop to favor the issue of the
 crystalline or its connections, were also necessary to  this  surgeon.
 A crystalline wliich had fallen into the anterior chamber, had obliged
 him to put his process in  practice for  the first  time in 1745.   One
 hundred and twenty-two cures  out of  two hundred and six opera-
 tions, as announced by him, made a vivid impression  on the public
 mind; and although the Caque of Reims had  mentioned only seven-
 teen successful  results out  of  thirty-four operations,  every body,
 nevertheless, was anxious to repeat his  essays.  Pallucci, who pro-
 fessed, in  1752, to have performed extraction  before Daviel,  opened
 the cornea from the small to the great angle of the  eye by means of
 a knife, the apex of  which being very much elongated, resembled  a
 kind of needle.   Poyet devised a narrow instrument, pierced near its
 point in order to pass through this eye a noose  or thread, which would
 be capable of supporting this organ while the  flap of the cornea was
 being  made from above  downwards.   La Faye proposed to substi-
 tute for all  these instruments of Daviel, a knife in form of a lancet,
 somewhat narrow, slightly convex on one of  its  sides,  and the back
 of which was blunt up to near its point.  To these  he added a cysto-
 tome,  a  sort of triangular  lance,  supported  by a padded spring,
 (ressort en boudin,)  and enclosed  in a  sheath which was dilated in
 its  middle in such  manner as  to  resemble the  body of a syringe.
 Beranger  soon after modified the  keratotome of La Faye,  gave it
 more breadth, rendered it flat on one side, convex  on the other, and
 much thicker, especially on its  back.   Sigerist gave still greater
 length  to the point of Palluci's knife, in order to open into the capsule
 by traversing through the anterior chamber.  But Jung has remarked,
 with great propriety, that a cataract needle is much better than any
 particular kind  of cystotome for this last stage of the operation.  It
 was during  this state of  things that Richter,  who  appeared in Ger-
 many,  Wenzel in France, and Ware in England, definitively estab-
 lished  the rules  for the method by extraction.  Two methods have
 been proposed  for extracting  cataract.   One, but little known in
 France, bears the name of scleroticotomy ;  the other, almost the only
 one in use, is called keratotomy.  The same  preparatory steps are
applicable to them.   The pieces  of dressing are similar to those
 which are required for depression.   Nevertheless the position of the
patient, assistants and operator, require  still more exact precautions
than in this last method.
  It is  for extraction especially that Richter  and Beer urge the ne-
 cessity of  a chair with a solid and vertical back, against which they
 assert it will  always be more easy to keep the head of the  patient
 immovable, than by supporting it against the  chest of an assistant.
 The horizontal position proposed by some, and extolled by Rowley
and Pamard, is nevertheless but rarely adopted ; doubtless, because
it is a little inconvenient for the surgeon.  I have often  made use of 
NEW ELEMENTS OF OPERATIVE SURGERY.
867
 it, and do so daily, and I confess I never have been able to compre-
 hend why it is not more frequently had recourse to.  In that case, it
 is necessary for the surgeon to place himself upon  the side of the
 eye affected.  Should  it not, however, be adopted, and that it should
 be thought  preferable  to place the patient on a chair, it is,  if not  in-
 dispensable, at least  more  convenient for the surgeon  to  stand  up
 than to be seated before him.   The speculum devised  by F. Aqua-
 pendente, still employed by Sharp, and modified  by Heister, the in-
 strument of Van Wy (Arrachard, Dissert., &c, p. 69, 106, Paris, 1805,)
 the  ring of Bell or Assalini, which M. Lusardi  has  placed upon a
 handle and  reproduced under a new form ; the erignes of Sommer,
 and all the other instruments invented to separate  apart, elevate or de-
 press the eyelids, which are useful when we have not a  sufficient
 number of expert  assistants, are advantageously replaced by the fin-
 gers.  Almost all of them incur the risk  of compressing or of emp-
 tying the eye.  The same remark may  be made of ophthalmostats,
 among which are to be mentioned the  forceps of Ten-haaf, the pique,
 the stem of  which  Casamata caused to be curved into an S, in order
 that it might be better  accommodated to the form of the nose, which
 Rumpelt  attached to a sewing  thimble, in order  to use the middle
 finger while the  forefinger of the same hand depresses the lower
 eyelid, and to which Demours wished to add another modification by
 mounting it upon a thimble open at its two ends.   The trefoil (trefle)
 of Pamard, such as the son-in-law of the inventor made  known in
 1825, is liable to nearly the same objections.  I find it less danger-
 ous, however, than to apply the two first fingers of the assistant and
 the operator in the great angle, as is recommended by Ware, to pre-
 vent the  eye from inclining inwards, and to compress it  up to the
 moment at which the knife  terminates the flap of the cornea.  The
 species  of elevator, the kystotome forceps, the double keratotome of
 M. Martin,  the instrument contrived by M. Bonnefin (These, No. 41,
 Paris, 1837), are doubtless  constructed with sufficient ingenuity, but
 may be too easily dispensed with to  make their utility a matter of
 importance  with  surgeons.   The  ophthalmostat of M.  Fardeau
 (Journ. Hebd., 1835, t.  IV., p. 117,) differs from that of M. Lusardi in
 this, that in  place of a  prominent arc, it carries on its ring a kind  of
 large concave and blunt nail (ongle).  That which 1 have proposed,
 (Estevenet,  Journ. Hebd.,  1836, t. II., p. 147,)  has  some  analogy
 with the ancient probe of Segwart; resembling in its handle the or-
 dinary keratotome, it is composed of a small plate of shell, slightly
 curved on its flat side,  and which, moreover, represents the scoop of
 Daviel.   Being perfectly blunt and  destitute of any kind of rough-
 ness, this  plate irritates the parts in no respect, whatever.   As soon
 as the point of the  knife has passed through the cornea at the side of
 the great angle I glide this instrument below and between it and the
 sclerotica, in such manner, that by holding  the  eye  immovable  in
 that  position, I render  it  impossible for  it to become displaced in-
wards, giving at the same time a point d'appui  to the  keratotome,
which allows me  every liberty desirable for completing the section
of the cornea.
  I.  Scleroticotomy.—B. Bell, after making some trials upon the dead
 body, averred that it was full as easy to-extract the cataract by the 
868
GLOBE OF  THE EYE.
 sclerotica as through the cornea.   This idea, the first  application of
 which upon  living man was made by Earle, and which was revived
 by D. Lebel and M. Giorgi, has been definitively adopted by M.
 Quadri, of Naples, who founds upon it his new method or that of scle-
 roticotomy.  An incision of about three lines in length is  first  made
 by any keratotome  whatever, upon the sclerotica at two lines from
 the cornea.  The crystalline and its envelope  are then seized hold
 of by means of a small pair of forceps, and  the whole  extracted
 through the outer angle of the eye.   In proceeding in this manner.
 M. Quadri affirms that he failed but in four instances out of twenty-
 five operations.   The first stage of the operation is less difficult, and
 exposes  perhaps to  fewer immediate accidents than the ordinary
 method, nor can  it be  very difficult to seize hold of the  cataract;
 but how can it be embraced with  sufficient firmness to enable us to
 bring it through the  opening of the sclerotica without  emptying the
 eye ?  How  can it be believed that so large an incision through the
 three principal coats  of the eye, will not, in a majority of instances, be
 accompanied by an internal hemorrhage, wounds of the ciliary nerves
 or vessels, and  followed by accidents a hundred times more serious
 than those which take place after the opening  through the transpa-
 rent cornea ?
   II.  Keratotomy.—Extraction, properly so called, is  composed  of
 three different stages:  the  incision  of the  cornea,  the  opening
 into the capsule, and the expulsion or extraction of the crystalline
 through the incision whether made upon the inferior or superior half
 of the eye.   The instruments employed  to effect this have varied
 considerably, and are far from being the  same with  all  operators.
 In France, they freely employ the knife of Wenzel, the inventor of
 which, Richter, (Bibl. Chir. du Nord, p. 212,) has so  severely cen-
 sured, and which differs  from  that of La Faye only in this, that nei-
 ther of its sides is more  convex than that of the other.   Some prac-
 titioners  however prefer the keratotome of Richter,  the  blade of
 which, which is  very pointed,  expands from the point towards the
 handle in such a manner that  it may divide one half of the segment
 (hmbe) of the cornea while traversing the anterior chamber.   That
 of A. Pamard resembles half a myrtle leaf, and  has, upon  its upper
 border, which is  straight and blunt, a small rib,  in order to increase
 its force.   Ware's knife, which is generally employed in England, is
 almost in every respect similar to that of Richter, and the instrument
 of Beer, so much praised in  Germany, differs from it only by the
 shortness of its point, and in having a little less degree of length  in its
 blade, which latter, moreover, is somewhat broader.   Beranger has
 proposed one which is convex on one side, flat  on  the  other, and
 somewhat broader that than of La Faye.  Lobeinstein gives it still
greater breadth,  and  slightly elongates its  point.   Under  this form,
its convex side,  turned backwards, protects the iris, while its  plain
 surface glides behind the cornea.   This knife, slightly modified by
 B. Bell, has since been  improved  by Jung, one  of the most skillful
cotemporaries of Beer.   According to  Sprengel, the keratotome of
Jung, which is convex on both sides, and cutting on both its edges, is
very short and somewhat broader  than is  necessary to divide with
one stroke half the circle of the cornea.  According'to  M.  Hare! on 
              NEW ELEMENTS  OF OPERATIVE  SURGERY.          869

the contrary, tne knife should be like  that of Lobstein, convex only
on its posterior side, and should  resemble a kind of guillotine.  Fi-
nally, that of Barth is distinguished from the preceding by the small
notch which is found near its back on one of its sides.   The impor-
tant point in the midst of so great a number, is  to choose an instru-
ment whose form and dimensions will enable us to divide completely
the half of the cornea, in traversing  the anterior chamber, without
giving egress to the aqueous humor while  the knife remains in the
wound.  To effect this object, its blade, being of a triangular form, ten
lines in length, at least three lines in breadth near its heel, and slightly
convex on both its sides, ought to be  somewhat thicker at its back
than near its cutting edge, and should gradually increase in thickness
from the point to the handle.  In this  respect, Richter's  knife, some-
what shortened as Beer has recommended,  appears to me to deserve
the preference over all the  others.  I have had constructed a carp's
tongue, four lines broad at its heel, six lines long, terminated by a point
somewhat tapered, and which is more convenient for laying open the
cornea than the lance of Daviel.   An instrument which is longer, of
less breadth, and  with  a  point more projecting, has been proposed
by M.  Furnari for the same object.    It is however  perfectly under-
stood that we may, if necessary, make  use of a simple lancet, the
little sickle-shaped knife of Sharp, a very sharp-pointed  bistoury,
or, in  fact,  any  cutting instrument whatever.   The  point under
these circumstances is, which is the best, and not what is of absolute
necessity.
   The second stage has also attracted much attention from surgeons.
The needle  of Thuraud,  the lancet of Tenon, those of Hellmann and
Grandjean, Mursinna's probe, and the kystotome of La Faye himself,
with or without the modification of M. Rey or M. Bancal, are gene-
rally abandoned.   The serpette of Boyer would have also fallen into
disuse, if the scoop of Daviel, which Dusaussoy (Gaz. Salut. 1786,
No.  29,  p.  3,) considers that he has improved,  and which is still
sometimes  made  use of, was  not mounted upon the same handle.
Small  and straight forceps, having  a small hook at their extremity,
like those of Reisenger;  the erigne  forceps of Blaemer, or  the tooth
forceps of Beer; in fine, an ocular forceps, such as are  found  at
every cutler's ; a hook-needle; a small spatula  or  gold scoop, and
Anel's  syringe  in  case of necessity, and which are  useful, either for
detaching or afterwards removing any fragments  of  capsule, of
membrane or of crystalline ; ought also to be placed by the side of
the knife on the operating  table.   In a  woman on whom I operated
for a black cataract at the  Hospital of  La Pitie, the capsule was so
thick and so firm, that  it resembled in almost every respect the cor-
nea, causing me  a vast  deal of trouble to open into and to extract
it, for which cases the instruments could not be too sharp.   An ossi-
fied crystalline, as in the case cited  by M. Middlemore, (Transac-
tions of the Prov. Assoc, vol. VI.; Revue. Med. 1838, t. III., p. 269,)
would not be more difficult of expulsion than any other.  It is prob-
able, however, that if the cornea or vitreous humor were indurated,
as in the  patients of M. Wardrop and Kulm, the operation for cata-
ract would hardly be thought proper.
  a. Inferior  Keratotomy.—1. Ordinary Process.—First  Stage.— 
870
GLOBE  OF THE EYE.
The patient and the assistants being properly arranged, the surgeon
depresses the lower  lid with the forefinger, which he  at  the same
time presses  against the caruncula lachrymalis, in order to support
the globe of the eye on the inside; seizes the cataract knife with the
other hand ; directs its point at  a line or half a line in front of the
sclerotica, while taking with his little finger a point d'appui on the
temple ;  then plunges the instrument  immediately into  the  anterior
chamber perpendicularly to the  axis of the cornea, a little  above its
transverse diameter, and at the  side of the  outer angle of the eye;
immediately inclines backwards the handle of the knife, whose point
without this precaution would not fail to wound the iris; then pushes
it horizontally  with firmness, and without any shaking, to a point
diametrically opposite  of the cornea, which he again  pierces,  but
from the interior to  the exterior; makes it advance upon this  line
without pressing upon its cutting edge ; takes care never to withdraw
it towards the outside, and that one of its sides should be exactly pa-
rallel to the  anterior surface of the  iris, while the other looks to-
wards  the  front part of the  eye, until in the progress of its track it
has entirely divided the inferior  semicircle of the cornea, as near as
possible to the sclerotica, that is to say, at a line  or  half a  line from
the greater circumference of the iris.  It is at the moment when the
keratotome terminates this section, that the slightest pressure would
be particularly dangerous, and  which it is important therefore to
avoid, as far as it is  in  our power to do so.  At the same instant,
therefore, the assistant is to let go his hold upon the eyelid, which the
patient, to whom some few moments are accorded to recover himself
from his emotion, gently closes.
  Second stage.—After having  carefully wiped  out the vicinity of
the orbit, the  surgeon raises up the eyelid or causes it to be raised a
second time, taking particular care not to touch the globe of the eye;
presents with the  other hand  the back of the kystotome at the most
depending  point  of the wound ; penetrates  in this manner to above
the pupil, whose superior semicircle he passes around by preference
from one side to the other, and in such manner as freely to divide the
crystalline  envelope  with  the point of the instrument whose con-
cavity  is to be turned downwards.   When the two eyes are to be
operated upon  successively, the surgeon rests here for the first, in
order not to return to  it,  until after  having opened the cornea and
capsule of the second.
  Third stage.—If the cataract  does  not  of itself pass into the an-
terior chamber, its expulsion is  to be favored by  means  of gentle
pressure properly applied.  The operator pushes the  left forefinger
against the lower part of the eye.  With his right hand he places the
handle of the keratotome or the  back of Daviel's :coop, transversely,
upon the upper eyelid,  in  order  to execute  while  making pressure,
slight movements backwards and forwards, upon a level with the cili-
ary circle, in the direction of a line which would reach from this point
to the union of  the two anterior  thirds with the postero-inferor third
of the sclerotica, in passing from  above downwards between the crys-
talline and the vitreous humor.   Immediately the lens is seen to pass
through the pupil, and to present  itself by its  border, at the wound of
the cornea, which it escapes from, or from which we force it to escape 
               NEW  ELEMENTS OF  OPERATIVE SURGERY.          871

 by gradually directing  upon it the pressure from above.   We then
 remove it with the scoop, needle, or point of the knife, when the opera-
 tion is usually  found to  be terminated.
   Fourth stage.—If opaque fragments  of the capsule, of such large
 size as  to compromise the success of the operation, should  be  found
 to be left behind, they are to be seized hold of and extracted with
 the forceps.  Any other fragment should be removed in the same
 manner, should the  spatula or the scoop prove insufficient.  As to
 those which become arrested in  the anterior chamber, unless they
 should be of a certain volume, it would be much better to abandon
 them to the dissolving action of the  humors, than to irritate  by re-
 peated  trials with Daviel's scoop, the  posterior  surface of the cor-
 nea.  The same  remark may be applied to the diffluent layer which
 is sufficiently often detached from the crystalline, when  it escapes
 into the anterior chamber, and  remains adherent to the environs of
 the wound.  Whether the contact of the instrument with the mem-
 brane of the aqueous humor inflames  this lamella, as  Sommer has
 asserted, or whether it is detrimental in any other way, certain it is,
 that a manoeuvre of this kind is frequently followed by a complete and
 speedy  opacity of the cornea.  Warm water injected into the cham-
 bers of the  eye with Anel's  syringe, as Forlenze was in the habit
 of doing, would evidently be much preferable.   As to the dangers
 of air, which according to  M. Maunoir, (Carron du Villards, Oper.
 de la Catar., p. 156, 216,) gets into  the eye in place of the crystal-
 line, making  it necessary to  fill the anterior chamber with  distilled
 water to drive out this gas, I must differ in  opinion from the skilful
 surgeon of Geneva.
   2.  Remarks.—In  place of commencing  the  incision  exactly at
 the extremity,  or a little above  the transverse diameter of the eye,
 Wenzel recommends that the knife should be directed upon the mid-
 dle of the outer and upper fourth of the cornea, and that it  should
 be made to come out at the same point on its lower and inner fourth.
 His reason is, that by this mode the  root of the  nose  runs less  risk
 of being wounded, and that the wound  being  oblique, the eyelids
 forced in closing  to  conceal its  two extremities, cannot either of
 them become  entangled between its  edges.  This precept, which
 is generally  recognized in France, is far from having attracted as
 much attention in other countries.  In Germany, for example,  it is
 so little known, that  Weller, who advises it, appears desirous of ap-
 propriating the mode to himself.   We should be  wrong, perhaps, not
 to adopt it when the eye is large and projecting,  because under such
 circumstances,  the lower palpebral border in fact might have a con-
 tinual tendency to open the  lips of the wound;  but in other cases,
 the advantages which are attributed to it, certainly originate much
 more from theoretical ideas than from practical facts.  The puncture
 of the inner angle of the eye is a matter of too little consequence to
 be regarded, and  the natural pressure made by the  upper eyelid
 usually suffices to prevent the separation of the edges of the wound,
 whether it be  transverse or oblique.   Then again, the projection
 which usually exists in most persons in  the outer  orbitar process, and
that of the superior maxillary bone near  the ascending process, cannot
but have the  effect to impede the march of the instrument, and of in- 
872
GLOBE OF  THE EYE.
 curring the risk of making such tractions upon the eye, as to endan-
 ger the expulsion of the vitreous  humor.  Between the two  angles
 of the eye, nothing  similar  is encountered.   When judged  neces-
 sary,  it is generally under  such circumstances practicable even to in-
 cline  the handle of the keratotome towards the temple  beyond the
 transverse axis, without making severe tractions on the eye.  In in-
 cising at less  than half a line from the cornea, it would  be with dif-
 ficulty that we could avoid the iris ; at more  than  a line we should
 have  to apprehend that after the cure, the  opacity of the cicatrix
 would be brought too near the centre of the pupil.  A stage  which
 students  have most  difficulty in comprehending or executing pro-
 perly, is  that which consists in  falling perpendicularly on the eye.
 It is* however, a point of the highest degree of importance.  If we
 approach more to the horizontal line, the point of the  instrument,
 almost always becoming entangled between the laminae  of the cor-
 nea, works itself  obliquely through them,  and sometimes does not
 reach into the anterior chamber, but at a line and a half  from its en-
 trance, making in reality but a small aperture, though in appearance
 the wound is  very large.
  To attain the object desired, the surgeon must not lose sight of the
 position of the eye, and that  according as  this organ is more or less
 turned inwards, he must always present the instrument to it from before
 backwards, and from without inwards, but more or less inclined to-
 wards the temple  or towards the face.  We should also  at the same
 time recollect that the cornea being curved upon a cord shorter than
the  sclerotica, there  must* exist in front of the union of these two
 membranes a slight  circular  excavation,  which causes its perpen-
 dicular to be a little less inclined forwards  as compared with the di-
 ameters of the body of the individual, and the  perforation more easy.
 As soon as the knife has entered into the  anterior chamber, its cut-
ting edge must be kept downwards as accurately as possible, in order
to avoid the  ciliary circle  and iris behind, or having a cicatrix too
near  the centre,  should it be inclined forward.    At the  moment
when  its point is about to emerge  at the side of the caruncula lachry-
malis, it would, should it not  be directed a  little towards the anterior
plane, bear too  much upon the sclerotica, and  might  again wound
the cornea.  As soon as we have  commenced  inserting  it,  it  is im-
portant not to give  it any  retrograde  movement until it has com-
pletely traversed the eye.   The gradual increase of its thickness and
breadth, enables it to fill up the wound exactly, from whence it fol-
lows that the aqueous humor does  not flow  out till at the end.  How-
ever little it may be withdrawn, on the contrary, it leaves necessarily
a void from whence  this liquid immediately escapes.  The iris then
protrudes forward, and may be easily wounded.   The  rule is, that
we  should  detach the half of the circle of the. cornea.   A smaller
wound would render the expulsion of the crystalline difficult, espe-
cially should it be of a large size, and  would necessitate dangerous
pressure.  Should the wound be  greater, there could be but little
inconvenience in it.  Ware extended it to  two-thirds of the cornea;
but though in such cases gangrene of  the flap, dreaded by Maunoir,
 can scarcely be apprehended, it is nevertheless unnecessary to go so
 far. Should it be  necessary to enlarge the incision of the cornea, the 
              NEW ELEMENTS OF  OPERATIVE SURGERY.          873

 instrument in form of a double lithotome, devised by M. Carron du
 Villards, (Marini, Bull, de Therap., t. VI., p. 282,)  might be service-
 able, and would readily enable us to attain our object.   When the
 eye obstinately  continues at the vault of the orbit, the trefoil of Pa-
 mard may be required to render the process of extraction practica-
 ble ; if it is concealed at the great angle of the eye, we may some-
 times bring it out by means of the finger  directed upon  the carun-
 cula lachrymalis; and better still, with  the scoop (curette d'ecaille)
 which I am generally in the habit of using.  It could  be fixed with-
 out difficulty and  even without danger, between the middle and fore-
 finger of the assistant and the  operator, if we  could feel perfectly
 sure that  we  could  suspend aU  kind  of pressure the moment the
 knife had penetrated through and through the cornea, that is, a little be-
 fore the definitive formation of the flap.  At least  I do not see any
 risk in proceeding in this manner, until the point of the knife arrives
 in the great angle.  Then we are masters of the organ, and no ob-
 stacle prevents  our bringing it forward, provided, however, the blade
 of the instrument is not displaced.  In place of the sound or flexible
 probe, which were used  by Pellier and Siegerist, we might, when
 the pulp of the finger did not appear to  be capable of effecting our
 object, use  advantageously the nail  of the forefinger, or even of the
 little finger, to  aid the knife in terminating the flap of the  cornea.
 The extremity of  the finger is then directed upon the great angle,  in
 such manner that  its  pulp falls  perpendicularly upon the inner side
 of  the eye, at  the same  time that its back faces forwards and to-
 wards the median line.  As soon as the keratotome presents itself, its
 cutting edge is placed at a right angle on the free border of the nail,
 as  if to  support it;  after which, while  making it pass from the ex-
 ternal to the internal  angle  of  the eye, the nail  fixes the cornea by
 making  a slight effort, as if for the purpose of gliding  outwardly to-
 wards the  heel of the instrument,  until the  incision is completed.
 The shell scoop which I am now in the habit of employing, substi-
 tuted in place of  the  nail, renders this  stage of the operation  still
 more simple and easy.
  In  spite of all these precautions the  iris will sometimes present
 itself under the cutting edge of the knife.  Gentle frictions on the
 front part of the eye, through the upper lid, often oblige it to withdraw
 itself backwards, either because we in this manner favor its contrac-
 tions and its narrowing, or, as appears to me more probable, because
 the pressure that we must almost  necessarily make upon the cornea,
 restores  it to  its  natural position, by forcing the liquid which is in
 front of the keratotome from the anterior into the posterior chamber,
 or perhaps because we straighten its  folds by flattening the vitreous
 membrane. Certain  it is that we never succeed  better than when
 we apply the finger naked upon the eyelid, and moderately compress
 it.  After all, the  worst that can result from it  is a  second pupil;
 which accident has happened to Wenzel, M. Roux, and Forlenze;
 numerous examples of it  are to be found in  the works of authors.
 It has happened many times with myself, and I have  not found that
 the  re-establishment of the  sight has been thereby interfered with.
1 am therefore  of  opinion that  it  is less dangerous to incur the risk
of this accident, than to withdraw the knife to finish the incision with
  VOL.  ii.                       110 
874                    GLOBE OF THE EYE.

the scissors,  and that prudence, moreover, allows us  to  dispense
with it, if in  order to avoid  it we expose the eye  to fatiguing mani-
pulations.  The elasticity of the sclerotica, and perhaps also the action
of the  recti muscles, may quite frequently be found sufficient to ex-
pel the crystalline, which then immediately presents itself at  the
wound, as soon as the instrument is withdrawn, or a short time after.
It is indeed owing to this fact that many practitioners have suggested
the idea of opening the capsule at first, and not to return to the ex-
pulsion of the cataract until  after having  proceeded in the operation
to the  same  extent upon the other eye.  Bell, and after him Jung,
from fear of breaking up the crystalline, have proposed to scrape the
capsule rather than  incise it.   After having cut through the cornea,
M. Jungken (Jour, de Kleinert, Juin, 1836, p. 76,) considers that the
chances of success  would be  augmented  by removing  the  capsule
before  extracting the crystalline.  It is a practice which is decidedly
pernicious, and which nothing but the extreme skill of the German
oculist has rendered somewhat  popular.   Pellier,  Siegerist,  and
especially Wenzel, have considered  that it would  be better to open
this membrane  with the keratotome while  passing through  the
anterior chamber, than to return to it afterwards.  It was an easy
thing  for Wenzel,  who  reached its anterior layer by inclining
slightly backward the point of his knife, when it was passing in front
of the  pupil.   For operators who are less experienced, it would be
an exhibition  of force, and  an act of imprudence which might be
attended with danger.  The operation would be  uselessly complica-
ted by raising the flap of the cornea  with a  spatula,  while another
instrument  was  being directed towards  the  pupil.   The  cataract
knife is rarely employed  for  this incision, because  the iris might
thereby be  easily wounded.   Hey's needle, the little  myrtle-leaf of
Morenheim, and the  spear-shaped  instrument of Beer,  are special
instruments which are replaced by the ordinary curved needle, or the
serpette of Boyer, which, however, in  consequence of its convex and
rounded border, is much better adapted for going through the wound
than lacerating the crystalline envelope. I would say the same of the
instruments  of M.  Furnari,  which,  nevertheless, are  constructed
with considerable ingenuity.  This surgeon after having incised the
cornea with his lance-shaped knife, the point of which at the same
time  lays open the capsule, proceeds to break  up the crystalline in
its place, by means of a kind of small polypus forceps, which after-
wards allows of expelling or extracting it without difficulty through the
incision.   The crystalline escapes readily through a puncture in  the
centre, or a semilunar incision at the depending point  of the capsule,
as well as by the numerous incisions  vertical and transverse, which
Beer was in the habit of making upon it, because it lacerates what
makes  resistance to it; but the flaps of the  opening  afterwards
approximate,  or  fall back again into the visual axis, and may, should
they  become  opaque, produce a secondary cataract.  On the con-
trary, by placing the semilunar incision above, as I have recommend-
ed, the tearing open of the capsule is  made from above downwards,
in such manner  that  the flap which  results  from it must remain
below  the pupil.  Beer, perceiving that it was sometimes  exceed-
ingly difficult  to effect this  destruction of the capsule conveniently, 
NEW ELEMENTS OF OPERATIVE SURGERY.
875
decided  upon  removing  it entire, either by  means  of a hook in
cases of silicose cataracts, or by a small forceps, when  it is an
encysted cataract, or finally, in cases of capsulo-lenticular cataract,
by  means  of his needle-shaped lancet.   Richter,  maintaining  the
idea,  that, in  depression, the capsule and crystalline are always
reversed  together, (Bibl Chir.  du Nord, pp. 269,  271,) asserts
that in  the operation for extraction  also, it is advisable and  not
difficult to remove them  both at the  same time.   Though Beer
asserts that he has often followed this  precept  with success, he has
not found, and will not find in the future but  a very  small number
of partisans.   Who, in  fact, does not see  that  the remedy is worse
than the evil; that we should succeed much better by making free
incisions into the capsule than by detaching it in mass; that by
these repeated movements the crystalline will, in most cases, lacerate
it, and leave  it remaining, so much  the  more so as  the  posterior
capsular layer is not susceptible of being readily detached from the
vitreous  humor.   It  is not often, moreover, that this deep-seated
portion of the crystalline envelope becomes opaque.  This is fortu-
nate, for unless it was very limited, the evil probably would be without
a remedy.  Even in  such cases  I do  not know to what extent it
would be allowable to follow the advice of Morenheim and Beer, by
isolating the opaque point, and attempting its extraction witka hook.
I do not think that  the  laceration  of the posterior capsule *m many
directions, after having  extracted the crystalline, as is recommended
by  M. Landrau, (Arch.  Gen.  de Med., t. XIV., p. 113,) would be a
prudent course, or present the slightest advantage.
  It has been suggested when the cataract was milky to give, egress
to the altered liquid, or when it  was membranous to destroy the
capsule only, in order  to preserve,  according to M.  Jiingken,  the
crystalline in its place with its natural transparency; as if in liquid
cataract the  whole lenticular  apparatus was not at the same  time
diseased; as  if the crystalline could  maintain itself with its normal
conditions a moment after the capsule had been opened !  Diseased
or not, it should be removed in every case therefore, should there be
no obstacle to our doing so.  The putrid cataract of Schifferli  does
in reality exist; an instance of which  I saw at La Charite in 1837.
The lenticular capsule, which was of a greyish  color and very much
distended, extended beyond  the  plane  of the  pupil in front.   The
purulent matter which it contained, emitted in coming out an infected
odor 'which surprised all the assistants.  In producing a dilatation of
the pupil the preparations of belladonna, which were already in use
in such cases in the  time of Pliny  (Carron du Villards, t. II.) and
Raymar (Causard,  Theses de Paris, &c.,) give greater facility to
the egress of the vitreous humor, and may in this  manner become
more or less dangerous.   If they are omitted  the  pupil sometimes
remains so contracted as to interfere with the expulsion of the crys-.
talline.   In order to obviate these  two  inconveniences, Bischoff and
others have recommended that we should first open the cornea, then
the capsule,  and afterwards  turn the  back of the patient  to  the
light when we desire  to expel  the cataract.  By this means the  pu-
pil, which was strongly  contracted in the beginning of the operation,
becomes, they say,  dilated of itself, and without any danger towards 
876
GLOBE OF THE EYE.
the termination.  If it were necessary, we might also, say these same
practitioners, not make use  of  any medicated  applications until
after the eye had been opened into ; as if the pupil could then  re-
spond to the action of belladonna!
  Finally, before  proceeding  to any active means, we  must cause
the globe of the eye to be moved upwards, inwards, and outwards,
seeing that such movements frequently favor the egress of the opaque
body.  If from  some  cause or another the vitreous humor escapes,
we must immediately close the eyelids and  turn the head of the pa-
tient towards his back.  This  accident, which involves the complete
loss of the eye when the hyaloid membrane is entirely emptied, is in
the other cases much less dangerous than has been for  a long time
supposed.   It has in fact this thing remarkable about it, that the loss
of a certain quantity of the vitreous humor seems rather calculated
to augment than to diminish the prospect of a  favorable result  for
the operation.  The loss of a fourth part  or even a half of this liquid
ought not to cause us to despair of success.   There is no evidence that
it is again produced ;  but the aqueous humor being more abundantly
secreted, takes its place, and the functions of the eye scarcely suffer.
  3. Process of Guerin and  Dumont.—With the view  of reducing
the operation to its most simple condition, Guerin, and almost at the
same time, Dumont, captain of the coast  guard in Normandy, each
contrived an instrument, the  object of which was, by an ingenious
mechanism to hold the eyelids apart, steady the globe of the eye,
and complete the incision of the cornea by one  stroke.  The first
of these instruments, terminated by a sort of ring bent to a right angle
on its handle, concave behind, and  shaped  to  the front of the eye
to which it  was accurately adapted, includes a cutting blade in form
of a fleam,  which  being put  into operation by means  of a spring,
immediately divides the half of the circle of the cornea either from
below upwards  or from above downwards.  The  ring and the han-
dle of the second  are upon the same line.   Its blade has some anal-
ogy to  the pharyngotome, and is to be applied horizontally, differing
in this respect from the other, which falls on the eye in  the manner
of the cutting edge of a guillotine.  The instrument of Guerin, which
was suggested perhaps by the fleam of Van Wy, has been long since
abandoned  in France, and M.  Eckhold, after  having modified it, is
the only person to my knowledge who has been desirous of its adop-
tion in  Germany.  Though more convenient and less dangerous, that
of Dumont has not met with a better reception.
  4. Guerin of Lyons, (Mai des Yeux, p. 380, 1769,)  uniting the
lance of Pamard with the keratotome, was not more fortunate than
his namesake of Bordeaux.
  If the instruments of which the ancients were so lavish, if every
species of brute force has been so carefully rejected from practice in
the operations of  modern surgeons, with still greater reason ought
they to be proscribed on the eye, which is an organ of such  delicacy
and so easily destroyed.  The stroke which is  necessarily given to
them by letting loose a mechanical spring, the  danger of wounding
what it is important to  avoid,  of making  an opening either  too great
or too small, and of cutting sometimes  too  near and sometimes too
far from the sclerotica, are  the reasons which have especially intimi- 
NEW ELEMENTS OF OPERATIVE  SURGERY.
877
dated practitioners.  It would, however, be unjust to accord no praise
to such inventions, and to qualify them as absurd, as some have done,
without having it in our power to judge of them with a full  know-
ledge of circumstances.  A number of physicians can attest, like M.
Hedelhofer, that Petit of Lyons frequently and  successfully made
trial of the instrument of Dumont.   Modified by the nephew of its
inventor, it has been said  to have obtained sixty-two successful results
out of seventy-one operations, if we can receive literally all that has
been said of it.  What we may affirm is this, that notwithstanding
the improvements which have been made  upon it  by M. Guepin,
(Soc  Med. de Nantes,  1834, 2d trim.,  p.  46,) the  instrument of
Guerin has been completely proscribed from general  practice.
   b.  Superior Keratotomy.—When  the lower  semicircle of  the
cornea is opaque or altered in  any manner whatever, its section
is, in the first place, quite difficult in  certain cases.   Afterwards the
wound is found in unfavorable conditions  for cicatrization.  This
membrane, though sound, may be very small, so that it  becomes neces-
sary to detach more than half of it in order to obtain a sufficient open-
ing.   In such cases Wenzel advises that we should divide the superior
semicircle, and states that he  found it to answer perfectly well in the
case of the Duke of Belford.  Richter is of the same  opinion, and B.
Bell has formally advised it, even for ordinary cases.   According to
him there  is less danger of the escape of the vitreous body, the cicatrix
of the cornea is perfected more rapidly and is  less perceptible, and less
troublesome to the vision than by the ordinary process.   M. Wagner
states  that M. Alexandre has not hesitated to put the suggestion of
Wenzel to a trial, and M. Wilmot, as quoted by M.  Eccard, asserts
that MM. Lawrence, Green, and Tyrrel have  frequently employed
it.  Dupuytren, in France, also thought proper to  make  trial of it;
but nobody, before the time of M. Jaeger, had  gathered a sufficient
number of facts upon  living  man  to establish it  into a general
method.   With the upper incision, says M. Jaeger, we have nothing
to apprehend from the friction of the palpebral border or of the eye-
lashes, the tears run  more freely and irritate the wound less, which,
in its turn, does not so often suppurate, while the prolapsus of the iris
must be very rare.   A difficulty which first arrested his attention, was
the tendency of the eye to turn inwards, or to reverse itself under the
upper  lid.  In  this respect he believes that he has removed every
objection, by contriving a peculiar keratotome formed of two blades,
one of which  is a little less than the other, applied face to face in
such manner as to represent the knife of  Beer or Richter when  it is
closed. By pressing upon a lateral button the small blade is made
to glide upon the large  one as in opening a knife  with a sheath.
The patient and the assistants are to be arranged as in the ordinary
method.   The operator seizes the double keratotome in the manner
of a writing-pen, turns its cutting edge upwards, and passes through
the anterior chamber parallel to its transverse axis, while conforming
himself in other respects to  the  precepts laid down above.  This
being finished  he brings back the globe of the eye to its natural posi-
tion, even depresses it a little if necessary, and fixes it by means of
the largest blade of the knife, while the other blade put into operation
by the thumb of the  same hand, effects the division of the cornea in 
878
GLOBE OF  THE EYE.
 gliding from its point to its base.   M. Alexandre, (Wagner, Bull, de
 Feruss., t. X., p. 284,) who, after having passed through the cornea
 leaves a bridle of it which he afterwards divides with a small blunt-
 pointed knife, appears to have acquired such practice in the use of
 this instrument, that  he can  operate alone and  without assistants.
 Since M. Jaeger, in the space of six months, has forty times extracted
 cataract successfully by means of his double  keratotome, it would
 be incorrect to say that this instrument was positively objectionable.
 A priori, nevertheless, it  is difficult to understand  its advantages.
 If  it be true that we may firmly fix the eye with  its immovable
 blade, while its other blade is dividing the upper segment of the
 cornea, it  must, on the other  hand, pass through the tissues with
 greater difficulty.   Upper  keratotomy, moreover, may be very well
 performed with  the  ordinary knife.   M.  Graefe,  (Arch. Gen.  de
 Med., t. XXL, p. 271,) who has used this successfully in seventeen
 out of eighteen cases, among others upon the Duke of Cumberland,
 believes it preferable  to the double keratotome,  and I have employed
 no other instrument in the fifteen cases in which I have had recourse
 to  this  kind of keratotomy.   As to the  operation in itself,  of all
 the advantages  that  are ascribed to it, there are very few that are
 substantial.  It perhaps exposes less to a wound of the iris, to the
 escape  of the vitreous body, and to the  separation  of the  wound
 by the border of the eyelids; but the manipulation in all its stages is
 is unquestionably more difficult and less secure than in lower kera-
 totomy.   How  can  we afterwards proceed  to  laying open  the
 capsule, if the eye keeps itself raised up under the vault of the orbit?
 What means have we of depressing it, if the will of the patient does
 not effect it ?  How direct the pressure, if the crystalline delays in
 coming out ? And the attending circumstances  of cataract, can it be
 supposed that it will be always in our power to reach them?  It is,
 therefore, a method of exception and not of choice, applicable only to
 the cases pointed out  by Wenzel, even supposing then that it would
 not be preferable to recur to the employment of the needle.
  III. Dressing and subsequent treatment.—Dressing and the subse-
 quent treatment after extraction differ but very little from what has
 been  recommended after depression, only perhaps that it would not
 be  altogether useless, before  covering  his eyes,  to exhibit  to the
 patient  some objects  that are not shining, to see if he distinguishes
 them.  It is  not in order to gratify mere motives of curiosity that
 this precaution is recommended, but because we are obliged by such
 a test, when it is not satisfactory, to ascertain again if some opaque
 substance which it is  important to extract,  does  not remain in the
eye.  Repose, avoidance of all movements of the eye and the upper
portion  of the trunk,  now become of more  absolute necessity than
ever.   Though the  head should be only slightly elevated, I  see no
reason,  however, which should induce us to place it lower than the
feet, as was done by Forlenze.   The regimen ought to be more rigid,
and continued for a longer time,  a longer  interval also allowed to
elapse before the first dressing, and the eye not so soon exposed to
the light as after depression.
   The suppuration of the cornea, (la fonte de la cornee,) which we
 have  especially to dread, ought to be watched with extreme atten- 
NEW ELEMENTS OF OPERATIVE  SURGERY.
879
 tion.  We can prevent or arrest it only by means of very energetic
 treatment;  bleeding to the amount of from ,twelve to sixteen ounces
 morning  and evening,  leeches to the temples, purgatives internally,
 and cutaneous revulsives, simultaneously employed the first, second
 and third day, are not too severe in such cases.  It is important even
 that we should not hesitate, but recur to it immediately as soon as the
 linen which  covers the eye becomes soiled, and as it were saturated
 with pus, and that the patient complains at the same time of pains in
 the orbit, before the fourth or fifth day after the operation.
   E. Comparative examination of the  processes. — I. Depression,
 which was alone in use up to the middle of the last century, fell into
 such discredit, in France at least, after the publication of the labors of
 Daviel, that in spite of the efforts of Pott to cause its revival, it was
 scarcely any longer had recourse to by any one at the commencement
 of the present century.  The modifications which it has received from
 Scarpa rescued it  from this oblivion.  But the question, which of the
 two .methods is the best? which has so often  been  debated,  and
 always remained undecided, is still daily revived.   In admitting that
 it is not incapable of solution,  it must nevertheless  be conceded that
 the  circumstances which enter into its  nature  are difficult to be
 appreciated.   How can we  conclude,  for  example, because  one
 process possesses  a greater number of distinguished partisans than
 another?  because Scarpa, Hey,  Dubois, Dupuytren, Richerand,
 Beclard, Lusardi and Langenbeck, have procured  a greater propor-
 tion of cures by depression than by extraction;  while for Wenzel,
 Richter, Beer, Demours, Boyer, Roux, Forlenze  and Pamard, the
 case  is precisely the  reverse ?  As  soon as  an  operator  has made
 choice of a method which he is in the habit of employing, his predi-
 lection always more or less deceives him, and renders him, in most
 cases, unfit to judge of other methods. Nor are the results, announced
 by different  men equally well instructed, decisive arguments.  The
 successful issues procured by Dupuytren from depression, in no wise
 prove that this  operator would have been less  fortunate,  if in the
 beginning he had exerted himself to give popularity to extraction.
 In promulgating that by means of extraction Sharp had the same num-
 ber  of successes as reverses ; that Richter succeeded in 7 times out
 of 10, Pelletan and Dupuytren 20 out of 50, M. J. Cloquet 28 out of
 80, M. Roux 188  out of 306, and  A. Pamard 302 out of 359, we
 prove nothing more,  either for or against this method, than do we
 demonstrate the pre-eminence or inferiority of depression, by saying
 that in this  manner Beer, Weller and M. Roux have failed in more
 than  half their cases, while Dupuytren cites five cures  out  of six
 cases, M. J.  Cloquet 97 out of 166, M. Bowen 154 out of 160,  and
 M. Lusardi  4168 out  of 5034.  M. Robertson, (Presse Med., t. L,
 p. 430,) having examined 1307 cases of operation by extraction, taken
 from twelve different authors, has ascertained that 397 of them were
 failures, while out of 7529 examples of depression, there were but
 104  failures.  Out of 64 patients that he himself operated upon bv
extraction, he cured 32; 14 obtained some relief from the operation,
while 18 remained uncured.  In 115 cases of depression, on the con-
trary, he  procured 94 cures, with 10 cases of amelioration, against 
880
GLOBE OF  THE EYE.
11  failures.   M. Serre,  (Bull, de VAcad., t. I., p. 90,) who  adopts
depression, states that he has succeeded in 62 instances out of 70.
  In the table of Brunner (Anc Journ. de Med., t. 84, p. 80, and es-
pecially p.  86, 1790,) we find 252  extractions, and out of them 149
favorable, 24 mediocre, 61 unfavorable; out of  169 depressions, 134
favorable, 36 unfavorable; out of 100  extractions, 59 favorable, 17
mediocre, and 24 failures; out of 100 depressions, 79 favorable and
21 failures    M. Fabini, (Bull de Fer., t. XXVIL,  p. 71,) who in 107
patients, operated 100 times by extraction, states that  he obtained 71
cures.   In  an aggregate  of  179 cases of extraction by M.  Roux,
(Maunoir, These citee, p. 78, 79,) there were at one  epoch 97 cures
and s«) failures.  Suppose, in order to show how deceptive this kind
of proof is, that the twenty most skilful surgeons of Europe have ope-
rated only by extraction, while 20 others taken  at random, have
always had recourse to depression.   Because the practice of the first
shall * have  furnished a larger proportion of  cures than that of the
second,  does  it necessarily follow and  by that proof alone, that ex-
traction is preferable to depression?
  II. Let us see whether,  after having passed in review the princi-
pal  advantages and inconveniences of both methods, we  may not
arrive at something more  satisfactory.
  Extraction enables us to remove with certainty and without a re-
turn of the  disease, the  impediment to  vision.   Besides  being at-
tended with but little pain and rarely followed by an internal inflam-
mation,  it incurs the risk of wounding  neither the ciliary nerves or
vessels,  leaves intact the whole interior of the eye, the  retina, choroid,
ciliary circle, &c, but in performing it, we may wound  and deform the
pupil, and cause the escape of vitreous  humor;  if the wound which
it produces  does not cicatrize  by first intention, it  ulcerates, soon
brings about a prolapsus of the iris, and sometimes an atrophy of the
globe of the eye, or at least a very extensive opacity  of the cornea ;
the  subsequent symptoms also are tedious ; it rarely happens that the
ophthalmia which accompanies it, terminates  before  the fifteenth or
twentieth day ; finally, it cannot be employed in all  persons  nor at
all ages.  M. Roux, (Maunoir,  These  citee, p. 81,)  who  operated
upon 43 cases in the spring of 1833, had the misfortune to lose three
of them.  In 35 patients operated upon in 1836, by the same prac-
titioner, (France Med., t. I., p. 50,) the  escape of the vitreous humor
took place in five ; the iris was wounded several times ; and a violent
inflammation  of the eye occurred in eleven cases.  Thirteen patients
recovered their vision perfectly.  The result was incomplete in eight
others ;  in fourteen cases the operation did not succeed.  One of the
patients operated upon, died of erysipelas.  In 179 patients operated
upon by M. Roux at another epoch, (Maunoir, These citee, p. 79, 80,)
suppuration of the eye took place in 14 cases, opacity of the cornea
in 28, and a false cataract occurred  in 22.  It  would appear, how-
ever, according to M. Maunoir, (These citee,  p. 49,) that at La Cha-
rite, during the time of M. Roux, membranous cataract was ascer-
tained to have occurred but in 5 instance out of the above men-
tioned 179 cases.
  Depression confines itself to displacing  the opaque body, and
abandons it in the depth of the organ, leaves  there, consequently,  a 
               NEW ELEMENTS OF OPERATIVE SURGERY.           881

 permanent cause of irritation in the eye, incurs the  risk of the reas-
 cension of the  crystalline, and  is frequently followed by secondary
 membranous cataract, iritis, deep-seated pains and general nervous
 symptoms.  The needle penetrates through delicate tissues, neces-
 sarily wounds  the choroid, the retina and the vitreous  humor, and
 sometimes also the iris and ciliary body.  But on the other  hand, it
 does not give rise to the escape of the vitreous  humor, nor does it
 expose to spots, or  ulceration of the transparent cornea, or  prolap-
 sus or  excision of the  iris, nor to the immediate destruction of the
 eye.  On the  following day the puncture which it makes is closed,
 and the  conjunctiva, which in a majority of cases is but slightly in-
 flamed, ordinarily resumes its natural  appearance at the  expiration
 of from eight to twelve days.  Finally, we  may if necessary apply
 it  to all  cases, and repeat it one or several times upon the same or-
 gan, without incurring the risk of any great danger to the patient.
   III. After this enumeration it would appear at first view, that de-
 pression  ought to  have the  preference over  extraction.   A rigid
 examination, however, does not permit us to come to a conclusion so
 clear and positive.  It is true  that the puncture of the sclerotica, cho-
 roid, retina and  vitreous body, rarely produces more pain than the
 section of the cornea, when we proceed in the manner I have pointed
 out. The wounding of the nerves, and vessels  of the ciliary body,
 is easy to be avoided, and generally attended with no unpleasant cir-
 cumstances.  When the crystalline capsule is properly lacerated, we
 cannot see why secondary cataract should be  more common after
 depression than after extraction.  If the crystalline  is securely fixed
 in the vitreous humor,  it is difficult for it to reascend or for its pre-
 sence to  disturb the retina.  With skill also we may succeed in avoid-
«■ ing the iris, which the needle moreover never wounds as seriously as
 the keratotome.   But we should be wrong in maintaining that this
 method is more simple and more easy than the other.   It is not so
 easy as some persons  imagine to pass  the instrument between the
 uvea and the cataract;  not to get it entangled between  the  crystal-
 line  and  its envelope;  to  make  the  proper opening into the  cap-
 sule ; or  to hinder the opaque body from being  reversed, either up-
 wards  or downwards, should the  concavity of the  needle  press it
 ever so  little  more in  one direction  than  another,  or  be deviated
 from the  direction indicated, or that the lens shall have contracted
 adhesion with the surrounding parts ; finally, it is not until after pro-
 Ion o-ed trials that we are enabled to detach it and fix it at the bottom
 of the eye.  The greatest degree  of address, therefore, is indispen-
 sable to perform depression in  such manner that it may have every
 possible  chance of success.  If inexpert surgeons  generally prefer
 it, it is less owing to its apparent simplicity, than because it does not
 allow their mistakes to be so clearly noticed  as the method by ex-
 traction.   On the other hand,  the irritation which it produces aug-
 ments the  secretion of the humors, and soon creates in  the eye a
 feeling  of distension which does not take place in the other method.
 A  chronic or acute iritis,  and afterwards  a contraction and even a
 complete  obliteration of the  pupil, may frequently be produced by
 it.  The  lesion of the  vitreous humor, without being immediately
 dangerous, may not however  be altogether free from inconveniences.
   vol. n.                      Ill 
882
GLOBE OF  THE EYE.
 The crystalline, which in fact  disappears sometimes by absorption
 or dissolution, still more  frequently remains with all its usual form
 and size during  the space of years, and  even during the whole life,
 whatever the moderns may have  said  of it to the  contrary, on the
 authority of Pott, Scarpa, and Dablin, (Biblioth de Planque, t. III., p.
 341, in 4to.) who,  in  the year  1722, had ascertained its absorption,
 and concluded that this ahvays  took place after depression.  Beer has
 seen it reascend at the expiration of 26 years.   Out of twelve pa-
 tients whose eves I have  had it in my power to examine after death
 in the  different  hospitals, at  one  year, two  years, two  years  and a
 half, and four  years after the operation, it had scarcely diminished a
 fifth of its  size in  the only  subject in whom it was perceptibly al-
 tered.   In the others it  had ultimately, by means  of some lamellae
 of the  hyaloid tunic  which separated that  coat from it, contracted
 adhesions with points of the retina and  choroid, which  themselves
 exhibited  a sort of knot  or cicatrix of about three lines long.  M.
 Campaignac, who  has made special researches upon this  point of
 practice, also  asserts  that after depression the crystalline lens is far
 from disappearing as  speedily, and especially as constantly as had
 been supposed.   This therefore,  it must be allowed, is  a serious in-
 convenience, one which no argument can extenuate, and which will
 always render the operation for cataract  by depression less complete
 than by extraction.
  IV. Keratonyxis,  which  Dr.  Wedemeyer rejects after having
 made trial of it in  fifty-three instances, would succeed no better, and
 whatever M.  Schindler, who defends it,  may say of it,  it would be
 an objectionable mode of giving confidence to practitioners  by pene-
 trating after  the manner of this  author, through the centre of the
 cornea, instead of passing through the depending point of the anterior
chamber.   The  crystalline, after  it has escaped or  been abandoned
in front of the iris, whether in mass or in fragments, is far from being
dissolved  there as speedily as  some  authors assert. Observations
 collected by M. Plichon at the Salpetriere, prove that it then often forms
 there a foreign body,  and that if  we do not hasten  to remove it the
■eye is exposed to serious dangers.  Another defect  still  more grave
 is the following: the  pupil  may remain movable and perfectly uni-
form, the whole organ  have an appearance of the most perfect
 integrity,  but the vision nevertheless be  totally  destroyed.  I  have
 seen four  persons at  the  central bureau, who were blind  from this
 cause, and who had been  operated upon at Paris.  A man sixty-two
 years of age,  whom I had operated upon in 1829, at the hospital of
St.  Antoine, came to  consult me  in 1831.  At first view one would
say that  his sight  was perfectly  free.  The  pupil is of a  beautiful
 black, round, regular,  movable, nor abnormally contracted or dilated,
 yet nevertheless the blindness is complete.  What has imposed  upon
 the partisans of  depression is this, that the patients quite frequently
 appear to recover their sight after the expiration of a certain  time,
 and preserve it, in fact, during the space of one or  two  months, but
 afterwards find  that  it gradually becomes  enfeebled, and that the
 vision is totally destroyed in less  than a year.  If the operation, re-
 peated seven times in one case, six times in another, and in a  third
 as often as thirteen times on each eye, enabled Hey to  cure his pa- 
NEW ELEMENTS OF OPERATIVE SURGERY.
883
tients, it is nevertheless true  that these repeated attempts prove un-
successful in a majority of cases.  The truth is, however, that their
consequences are generally not very serious.  After depression, parti-
cles more or less opaque almost always remain or are formed in fron*
of the vitreous body.  Experience proves that after extraction this
accident is infinitely more rare.   As to this last method it is evident,
that the section of the cornea is much more delicate than the perfora-
tion of the sclerotica ;  that in spite of every precaution the vitreous
body may escape, and the iris be extensively divided  by the knife, or
separated or torn by the crystalline; but after all, if  the operation is
well performed and the  patient in a favorable condition, three  acci-
dents, the escape of the vitreous  body, the suppuration of the eye,
and the consecutive opacity of the cornea, can alone render it dan
gerous;  while  all other things being equal, it procures without ques-
tion a result either immediate or definitive more satisfactory than the
method by depression.   It is requisite to state, however, that the
escape of  the crystalline again  exposes to  two other  accidents.
Though largely dilated by the action of belladonna, the pupil almost
constantly contracts so much as to oppose a certain degree of resist-
ance to the opaque body, which then has a tendency to detach the
iris from below, in such manner as to make its escape there if the
pressure upon the eye has not been made with an extreme degree of
caution.  This pressure in its turn, if made quickly upon the cornea
in consequence of some unexpected movement of the patient at the
moment when the border of the cataract presents itself at the wound,
may thrust back the lens  above the vitreous body;  in such manner
that we may remain in doubt whether it is still in the  eye, or if it has
actually escaped, as has happened to me in one instance.
  V. The prolapsus of the iris, which often occurs after the  opera-
tion, and more frequently in old men, in consequence  of the cornea in
them being tardy in cicatrizing, is treated by mechanical means or
belladonna, so long as there is no adhesion; in the contrary case, by
nitrate of silver;  and is not  more  difficult  of cure here than under
any other circumstances.  When our object is to  leave no obstruct-
ing particle in the eye, there is no objection to throwing up through
the wound  one or two injections of tepid water with a  small Anel's
syringe.  Perhaps even it would  be really advantageous  to imitate
Forlenze and to adopt this method generally.  Finally, if the dangers
of extraction are more serious and more  apparent, those of  depres-
sion are more numerous and more real.   Operators alike skillful will
more easily avoid the first than  the  second, and if the  employment
of the needle less frequently fails of procuring some  relief to the pa-
tient, the method of Daviel furnishes by compensation  a  greater
amount of radical cures.   Find a way to avoid the suppuration of the
cornea, and extraction will obtain a large  amount of  cures; prevent
iritis after depression, and the patients, though free from suffering or
danger, will nevertheless run the  risk of obtaining but  imperfect re-
sults from the operation.  Out of 300 operations for  cataract whose
cases I have  minuted, I count 200 cures.   In the hospitals where I
have adopted sometimes extraction  above or below, sometimes de-
pression by different methods, I am still uncertain  to which  method
I ought to attribute the greatest amount of advantages or inconveni- 
884
GLOBE OF  THE EYE.
 ences.  In private practice, extraction evidently succeeds better.  I
 conclude therefore that under circumstances where the two methods
 might either of them be indifferently made trial  of, extraction is pre-
 ferable ; but that in other cases, it is sometimes one and sometimes
 the other which should  be adopted.   Depression, for example, ap-
 pears to be preferable in children and intractable subjects;  or when
 the eyes are small and sunk deep in their sockets, when the cornea has
 spots  upon it and is small and  flattened, when the eyelids or conjunc-
 tiva have been for  a long  time diseased, when we have reason to
 fear an acute inflammation of the connecting tissues of the eye, when
 the cataract is perfectly liquid, when the pupil  is contracted or the
 iris adherent to the cornea, and when the eye has great prominence
 and is very irritable.  Extraction, on the contrary, presents more
 advantages in old men and even in adults, if the anterior chamber is
 large, the crystalline very hard, the cataract membranous  or  adhe-
 rent, and the eye perfectly sound, possessing  little sensibility, and
 admitting the keratotome to penetrate through it without difficulty.
   [Ossified Crystalline Lens.—The  crystalline lens having become
 opaque from a  blow  in a man aged 44, (see Mr. France in Guy's
 Hospital Reports, Oct., 1845,) was afterwards extracted  and found
 to consist chiefly of carbonate and phosphate of lime.  T.]

                           [cataract.
   Dr. Dubois, of Neuchatel, in Switzerland, (Gaz. Med. de Paris,
 Nov. 8, 1845, t. XIIL, p. 721,)  removed in July, 1841, by depression,
 a cataract which was situated  in the right eye of a woman  aged 49,
 accompanied with a slight albugo in the cornea, both  of which had
 existed for  the space of 40  years.  She was induced to undergo the
 operation from  a cataract  having commenced  to form also on the
 left eye, in  1841, which when ripe the succeeding year was  also re-
 moved. This left eye being, from its long use, fully developed, could
 now see better than the other,  where a contrary state of things ex-
 isted, with the addition of the  partial opacity of the cornea, which
 still presented some obstruction to vision.   Doctor Tavignot remarks
 (lb., loc. cit, p. 720) that disuse of the eye for a long period undoubt-
 edly arrests its development, and that on this account persons a long
 time confined in dark places (as in dungeons) lose the  sensibility of
 the retina, and thus become liable to amblyopy,  or even to amauro-
 sis.  But the condition of the  eye, where a cataract  complete has
 existed in both organs for a great number of years, is not precisely,
 or at least is only partially analogous to that which takes place from
 the total exclusion of light  from sound eyes.  In old cataracts, the
retma still retains its sensibility to a certain extent, and receives  a
certain portion of the rays  of  light transmitted through the opaque
lens.   Hence the important deduction that such  cataracts, however
ancient, as  recent facts have proved,  are not beyond the  hope of
surgical relief.  Dr. Tanchou alludes  to  the remarkable  case  of a
man aged 67, in whom M. Serre, of Montpellier, operated with en-
tire success in 1844, for a cataract which had existed in the left eve
for sixty  years.  (Gaz. Med. de  Paris, t, XIIL, 1845, October 25
No. 43, pp. 677, 678.)   The occasion  which led to the operation
was a traumatic cataract, which suddenly formed in the right eye, 
NEW ELEMENTS OF OPERATIVE  SURGERY.
885
 accompanied with protrusion of the iris through the cornea.  On ex-
 amining  the  left eye, he found there a  lenticular  cataract, with a
 slight albugo in the cornea.   Deeming this the most secure, he haz-
 arded the operation in this eye, when the sight was restored perfect-
 ly.   Dr. Tavignot furnishes a number of examples of the cure of old
 cataracts, single or double,  congenital or otherwise, and which had
 existed  for various periods from  12 to 20, 26,  30, and even 45
 years.   Dr. Alexander Watson, of Edinburgh, (Ed. Med. and Surg.
 Journ., Jan. 1, 1846, p. 57, &c.,) considers that the process of break-
 ing up soft cataracts, in order to promote their  solution  and absorp-
 tion, as now practised and in vogue, is so eminently successful, that
 it promises to be substituted altogether for  depression or extraction
 in this form of the disease.   For hard cataracts, and where depres-
 sion or displacement is decided  upon, he recommends a  process
 somewhat new, and the intention  of which is to avoid any injury  to
 the hyaloid  membrane  and iris, and to prevent the reascending of
 the lens.  As  the important  point  is to  disengage the lens from its
 capsule  before depressing it, this is to be effected by lodging it in a
 breach to be first made with the needle in  the vitreous humor, after
 which the posterior part of  the capsule opposite this breach is to be
 carefully opened by an incision, and the lens also pushed through it
 into the  humor by means  of the  same needle.   Dr. Watson pene-
 trates the coats of the eye at a line and a half  posterior to the mar-
 gin of the cornea,  with  the small cataract bistoury.   This brings
 him readily upon the part of the vitreous humor  designated.  After
 making a suitable breach there, the needle  incises the posterior por-
 tion of the capsule transversely from the nasal side outwards.   The
 point of the needle is then applied flatwise on the anterior part of the
 capsule, between it and the iris, so  as  to  make  pressure upon the
 lens upwards  and backwards, in order that the lower margin of the
 lens may pass backwards through  the opening  in the posterior  por-
 tion of the capsule; after which, by shifting the point of the needle
 forwards upon the lens, the latter is pushed backwards and down-
 wards into the breach of the vitreous humor, from whence, he says,
 it never rises. If the capsule remains entire, it is an advantage, as the
 humors in the different chambers of the eye are thus prevented from
 incorporating, which lessens the risk of subsequent inflammation, and
 if it should afterwards become opaque, it can easily be  removed by
 a subsequent operation.  Address  is required  for  this operation,  as
 the capsule is usually transparent.   This  process  answers  also for
 reclination.   If the lens should unexpectedly be found to be soft, it
 can be  broken  to  pieces, and these fragments,  or some of them,
 pushed into the breach of the vitreous humor, where they will dis-
 solve.   The breaking up of an opaque  lens, that it  may dissolve  in
 the aqueous humor, and performed in such  manner as not to wound
 the hyaloid, is a process well suited  to young subjects, whether the
 cataract be spontaneous or from an injury.   For keeping the eyelids
 open, Dr. Watson finds a plain, broad, flat, smooth ivory hook, the
 end of which  is  curved short, so as to be parallel with the shaft, bet-
 ter than metallic instruments.  T.]
   F. Artificial Cataracts.—For a long time it  has been thought ne-
• cessary to produce  cataracts artificially, and to  exercise ourselves 
886
GLOBE OF  THE EYE.
 beforehand upon animals or dead bodies, and to give morever to the
 eye all that mobility which renders  it so difficult  to  steady it at the
 moment of the operation.  Troja in Italy, and M. Bretonneau in France,
 have made trial of some experiments in  order to renuer the crystal-
 line opaque, by means of diluted acids.  M. Leroy, (D'Etiolles,) has
 supposed that this  could be effected better by means of electric dis-
 charges, but nobody before the  time of M. Neuner of Darmstadt,
 (Maunoir, These citee, p. 43,) had made this point a subject  of par-
 ticular attention.  The liquid which he made use of with most suc-
 cess, was a solution of six grains of corrosive sublimate in one  gros
 of pure  alcohol.   A  small glass  syringe,  garnished  with platina
 and terminated by a very fine syphon, and which is traversed by an
 extremely sharp probe, in  such  manner as to  be enabled to  pass
 beyond its two extremities, is first filled with this solution.   It is  then
 passed through an opening previously made at the outer angle of the
 eye, from above downwards, from without  inwards, and from behind
 forwards, until it  reaches the posterior surface of the crystalline,
 into which the point of the  probe, which serves as a conductor to
 the syphon of the syringe, is plunged,  after having perforated its
 capsule.   The small probe being then no longer necessary, is with-
 drawn, and the thumb,  resting upon the extremity of the piston, gently
 forces the liquid into the substance of the  lenticular body, which soon
 changes its color.   The same  process is  performed, if necessary, on
 the inner angle of the eye, when the operation is terminated.  Among
 the contrivances devised for representing upon the eyes of the dead
 subject, the principal difficulties which are  encountered upon living
 man, the opthalmo-phantome of M.  Sachs, is certainly  the most in-
 genious ;  composed of a socle mask, and eye-supporter (porte-ceil),
 the description of which I cannot give  in this  place, it appears to
 me, however, to be too complicated ever to be  received into gene-
 ral use.  I have no necessity in  saying,  that one of the middle re-
 fractors of the eye being now removed  or  displaced, almost every
 individual who has been operated upon for cataract, ought to wear
 spectacles with convex glasses, like long-sighted  persons.  Upon this
 subject, moreover, Maitrejan had established upon the dead body,
 what  M. Roux and others have since announced—to wit,  that after
 the extraction of the crystalline, the vitreous body becomes  more
 convex in front, as if for the purpose  of filling  up the void, which
 after the operation has  been left in the eye,  and to render spectacles
 less necessary.   In children, and  in persons  blind from birth, in all
 those in fine who for the first time are obliged to subject their sight
 to  a course of discipline, it  is well to add to the precautions which
 are generally used, a very simple means successfully employed by
 Dupuytren, and which consists infixing the hands behind the back,in
order that being deprived of the use of these members, they may'be
compelled to make greater efforts  with their eyes to direct them upon
external objects.

                    §  IV.—Artificial Pupil

  Two very distinct conditions of things  may require  the formation
of  an  artificial pupil; the  opacity of the cornea, and the contrac-
tions or obliteration of  the natural pupil.  In the  first case, whether • 
              NEW ELEMENTS OF OPERATIVE  SURGERY.           887

the impediment to vision be the result  of a simple ophthalmia, an ul-
cer, or a wound, or any other lesion of the cornea, is a matter of little
importance.  Provided  the interior of the eye is  not  affected,  and
that a  transparent point remains outside, the operation- for artificial
pupil  may be undertaken.   In the  second case, whether there be
myosis or phtisis, synezizis or atresia; whether the pupil  is completely
closed or merely contracted ; whether the alteration be congenital
or accidental, the effect of an internal  ophthalmia, of an iritis, or of
the operation for cataract, by depression, or extraction ; whether the
iris preserves its form or not, adheres, or is not adherent to the  cor-
nea or the capsule of the crystalline; or whether there may or may
not be sinechia,  whether  anterior or posterior,  the  operation is
equally practicable, (though  it offers infinitely less chances  of  suc-
cess,) so long as  the retina has not lost the faculty of perceiving the
rays of light, and that the anterior chamber retains its  transparency.
If this last condition  is wanting, it will be in vain that we make  a
new pupil, and  that  the light arrives at the  bottom of  the  eye.
Acute or  chronic  inflammations of the internal  tunics, the progress
of which has not  been definitively arrested,  also constitute  counter-
indications, which, though less absolute,  are nevertheless sufficient
with a few exceptions to restrain a prudent surgeon.  Almost all
authors prohibit, moreover, the making of an artificial pupil, so long as
there is but one eye only diseased, and that the patient sees sufficiently
well to  get  along without  a guide.   The operation,  in fact, being
sometimes followed by accidents, which may in themselves  produce
serious injury to the vision, it would not appear to be prudent to ex-
pose the patient  to lose the little that  remains to him, when, more-
over, in the attempt to ameliorate his condition, the chances of  suc-
cess are sufficiently precarious.
   A.  Operative  methods.—All the processes recommended for form-
ing a new pupil  may be resolved into three methods.   In  one, iridi-
otomy or coretomy, we incise the iris only; in the second, iridectomy
or corectomy, we  excise  a flap from  this membrane; while in the
third, iridodialysis or coredialysis,  we confine ourselves to detaching
its circumference at one of its points.
   1. Coretomy or method by incision.—Before the time of Cheselden,
no one spoke of iridiotomy; since then it has attracted the attention
of Mauchart, Sharp, Spraegel, Meiners  and Rathleaw, who have  pro-
posed it in cases of persistence of the pupillary  membrane ; and of
Odhelius, Guerin, Janin, Wenzel, and MM.  Maunoir, Adams, &c,
who have subjected it to various modifications.   The patient, opera-
tor, and assistants, are  to  be placed in the same manner as in the
operation for cataract.
   a. Process of Cheselden.—By means of a  small knife of the shape
of a scalpel, with one cutting edge only, Cheselden penetrated in the
same manner as is done for depression through the sclerotica as far
the uvea.  Having arrived there, he caused  the  point of his instru-
ment to  pass  into the  anterior chamber.  Afterwards directing  it
from without inwards, and from before backwards, according to some,
or on the contrary, according to others, from the internal to the ex-
ternal angle,  and from behind forwards, he made at the centre of the
iris a  transverse  incision of from two to three lines in  length.  A 
888
GLOBE OF  THE EYE.
pupi. of an elliptical form, similar to that of certain quadrupeds, was
the result of this delicate operation, which was attended with entire
success, and vividlv attracted the attention of  the  learned world.
  b. Process of Sharp.—Sharp in performing  coretomy, professes
nothing else  than  to have  imitated Cheselden.   A  small scalpel,
slightly convex on  its back, a figure of which he gives, is first directed
horizontally, its cutting edge turned backwards, into the  posterior
chamber, between  the circle and root of the ciliary processes.  No-
thing then remains but to incline its point forward, and to  push it a
little in order  to  penetrate  into the anterior  chamber.   We  have
now to incise the iris transversely, either upon a line with or below,
or what is better, above the natural pupil.   The opening  made by
this operation, which continued  for some time, was not long in con-
tracting, and ultimately closed up completely.  Sharp thus appears to
accord very little confidence to  the method of  Cheselden.
  c. Mauchart has no other claim to be mentioned  in this  place,
except because he appears to have  been the first to  have  ad-
vanced the idea of perforating through the cornea in order to form
the pupil.   He moreover cautions us against giving too great an ex-
tent to the artificial opening, and remarks that this kind of pupil is
not capable either  of spontaneous dilatation or contraction like the
natural one.   Henkel also recommends that we should  go through
the anterior chamber.   Heuermann, who is  of the same opinion,
recommends for the incision of the iris and cornea, that we  should
use the ordinary lancet in place of the needles  or knife of Cheselden.
  d. Process of Odhelius.—Odhelius, in  a patient with an opaque
cornea, after having incised the cornea in the same way as  for ex-
traction in cataract, divided the iris from its  centre to  the circum-
ference, on a line with the pupil, which in  other respects was very
much contracted.   By this means he obtained  a  triangular opening
continuous in its base with  the remains  of the  primitive pupil, and
which enabled the vision to be completely reestablished.
  e. Process of Janin.—Janin, having frequently made trial of the
method of Cheselden without success,  supposed  that we would suc-
ceed better by giving a vertical direction to the wound.   The trans-
verse incision, he remarks, closes speedily and almost of necessity,
because the radiating fibres of the membrane are separated  only ;
while they are actually divided by means of the perpendicular inci-
sion, made  a little within the  natural pupil.   It  was  an  accident
which led him to make this  modification.   It happened  to  him as it
would to any person, that he divided the iris in performing the ope-
ration for cataract by extraction, and that he thus  made, against his
will, an artificial pupil on the side of the  natural  one.   Perceiving
that this opening, which he did  not intend to make, did not close up,
while those which he had effected designedly always became oblite-
rated, he proposed  to take advantage of this, and directed his atten-
tion afterwards  to systematizing  the  process  which  chance had
pointed out to him.   Kortum proposes that in  place of  the scissors,
we should incise the iris vertically with the keratotome.   But, not-
withstanding the experience of Weissemborn, and the observations
of Pellier, which are calculated to corroborate  its advantages, the
process of Janin was soon abandoned.   It was soon evident that the 
NEW ELEMENTS OF OPERATIVE SURGERY.
889
pupil made in  this manner, does not endure any longer than, and
closes and disappears fully as much as it does by the transverse
method.
  /. Process of Guerin.—With the view  of uniting their  advanta-
ges, Guerin proposed to combine the  processes of Cheselden and
Janin, and  to employ them  together, that is to say, to make a cru-
cial  incision in  place of a simple vertical or transverse slit.  But
while on the  one hand  the  operation is thus rendered much more
difficult, on the  other, it is not uncommon  to see the four  flaps  ap-
proximate so much at their apex as to prevent the light from arriving
at the bottom of the eye ; so that this recommendation has been rare-
ly adopted in practice.
  g. When the  vision is impeded by a leucoma, Pellier confines him-
self to enlarging the  natural  pupil, in place of making one  complete
in itself.   For that purpose he incises the  cornea in the same way
as for extracting the  crystalline ; introduces a small canulated sound
into the posterior chamber of the eye ;  uses this as  a guide to  the
point of a small pair  of  scissors, and first divides the iris outwardly,
then inwardly and upwards,  from the pupil to the ciliary ligament.
  h. Process of Maunoir.—The process  by M. Maunoir, though
the result of researches made  by this  author, nevertheless appears
to be only an  improvement of that of Pellier.  This surgeon, by
means of a keratotome or lancet, makes an opening of  two or three
lines in extent at the  outer and  lower part of the cornea ; introdu-
cing  through this a  small pair of scissors bent at an  angle on the
border near their heel, and one  of the blades of which terminates in
a button, he opens them in the anterior chamber; then plunges one
branch through the iris  into  the posterior  chamber, in such manner
that the other which bears the button remains behind the cornea; inci-
ses the membrane thus included inwards, then outwards and  upwards,
and forms at its expense a triangular flap whose adherent base faces
the circumference of the eye.   The needle-shaped scissors, devised
by M. Montain, with the view  of avoiding the  previous section of
the cornea, though ingenious, do not however present  an  improve-
ment of sufficient importance ever to obtain the preference claimed
for them by their inventor.   By this  double  incision  the circular
fibres that M. Maunoir supposes to exist in  the iris are divided twice,
while the radiating  fibres remain intact;  from whence it happens
that these  latter by  their contraction constantly tend  to dilate  the
new pupil, in place of favoring its contraction, as  in the method of
Cheselden.
  i.  The ideas of the surgeon of Geneva,  which he has frequently,
and  again  in 1837 (Bibl.  Universelle de Geneve, Avril, 1838) prac-
tised  upon  with success, have  received the sanction  of the cele-
brated Scarpa,  who, in order  to sustain  them, was   eager to re-
nounce his own method.   They have also met with  partisans in
Germany.   But in England and France  they  have not generally
been  made trial .of.   Moreover, it  is evident that if we were  de-
sirous  of- performing coretomy upon this principle,  of which  M.
Carron  avows  himself  the  champion, it could be advantageously
modified by making use, as I have often done, of the ordinary kera-
totome, or the movable cutting needle, which I contrived  for form-
  vol. n.                      H2 
890
GLOBE OF THE EYE.
ing the triangular flap of the  iris, thus doing designedly what  we
often  do in spite  of ourselves when we perform the operation for
cataract by extraction; this is the process which Daviel, Horn and
Wenzel  appear to have recommended for adoption, and  which
Odhelius has also sanctioned.
  j. Process of M. Adams.—-M. W. Adams has gone back  to  the
process of Cheselden, with this difference, that in place of a straight
knife  like that of Sharp, he employs  a small scalpel convex upon
its  cutting  edge,  breaks  up the crystalline when  he considers it
opaque, and endeavors, what  is sufficiently singular, before quitting
the eve, to entangle some  fragments of it in the transverse incis-
ion of the iris to  prevent its closing up.  M. Roux frequently made
use of this  process while I served  him as  assistant, and in every
case  the new pupil  ultimately disappeared.  Nor does it  appear,
moreover, to have received much respect  in  the  country of  its  au-
thor, for it is rare  that it  has  been had recourse to there by other
surgeons. Nor have I myself been more fortunate with it in the two
trials  that I  have made of it.
  k. Coretomy, still further modified  by Jurin,  MM. Langenbeck,
Weller, Faure, and by Wardrop, who by means of a needle  passed
into the  posterior chamber, perforated the iris a first time from be-
hind forwards in  order  to enter into the anterior chamber;  then a
second time from before backwards, and nearer to the inner angle
of the eye in order to  return into the posterior chamber ; and who
afterwards  united together by means of one of the cutting edges,
rather than  by the point of his instrument, the two small wounds, by
detaching one of the extremities of the flaps  which they circum-
scribed, and all this with entire  success, in a lady 46 years of age,
blind  from her birth, has  found in these latter years numerous anta-
gonists among the oculists of  Germany.
  I Process of the Author.—I make use of a knife somewhat longer
and of less  breadth than that  of  Wenzel, cutting on its  two edges
to the extent of  four lines from its point, and afterwards blunt or
rounded upon the  back  as far  as the handle, an instrument in  fact of
which the  serpenl-tongued  lancet  may convey  a tolerable idea.
Held  as a writing  pen, it is plunged through the cornea on its tempo-
ral side, and a little obliquely  from before backwards.  When it has
arrived  in the anterior  chamber, its point is guided with precaution
into the posterior chamber, dividing the iris as it proceeds, and then
brought back after making a track of two or three lines, into the ante-
rior chamber through the  same membrane. In continuing to advance
it forward, up to  the point  of piercing the  cornea a second  time, il
becomes easy to divide the  species of bridge which covers its  an-
terior surface, and not to detach completely one of the extremities
of this flap of the iris, until after having transformed the other into
a pedicle as  narrow as may be  desired.  We thus procure a divi-
sion which amounts to a loss of substance.  The fragment of mem-
brane which  has  been  cut out cannot be long in rolling up upon it-
self, and must ultimately become  dissolved  in the aqueous humor.
It is even possible in most cases to excise it entire, when  the mani-
pulation which I have just pointed  out has been properly executed.
In fact if the instrument  acts  in  an equal  manner on the two  ad- 
NEW ELEMENTS OF OPERATIVE SURGERY.
891
herent points of the bandelette to be  divided, up to the moment
when the section of one is completed, all that will be required to
detach the other and to transform coretomy into corectomy, will be
to advance the keratotome  a little farther, and to incline its cutting
edge  correspondingly  towards the cornea.  My keratonyx attains
this object still better.
  II.  Coredialysis  or Method by Decollement.—To Scarpa we are
indebted for having systematized decollement into a method ; many
authors, however, had mentioned it before him.  Sharp for example,
in speaking of coretomy, makes the  remark that the iris very fre-
quently detaches itself when  pressed  upon by  the  instrument in
place of being divided. In a patient  operated upon for cataract
by Wenzel,  the  crystalline  escaped in  this  manner through an ac-
cidental opening.  The natural pupil afterwards almost entirely dis-
appeared, but the patient continued to see by the abnormal opening.
If we may believe Assalini, Buzzi de Milan,  who performed coredi-
alysis in 1788, plunged a spear-shaped needle through the posterior
chamber into the body of  the  iris, at a line distant from the oblite-
rated pupil,  and  by well directed tractions detached this membrane
from  the  ciliary circle.  A. Schmidt, who on his part published a
good memoir  on this subject in 1803, states that he  had  recourse
to this  operation in 1802,  and had  conceived the first idea of it
in 1792.
  a. Process of Scarpa.—Scarpa, when his  needle has reached into
the interior  of the eye, as  in the operation  for cataract by depres-
sion, turns its concavity forwards ; directs  it behind  the upper and
inner portion of  the uvea; pushes its point  through the iris into the
anterior chamber; and uses it  afterwards as a hook in oscillating it
from above  downwards, from behind forwards, and from within out-
wards, in order to detach the great circumference of this membrane
to the extent of  three or four lines, in  such manner in fact as to pro-
cure an opening a slight degree larger than the natural pupil. •
  b. Process of  T.  Couleon.—Toche-Couleon, one of  the  first, Fla-
jani, Himly, Beer especially, and Buchorn, proposed that the needle,
whether straight or curved, should  be directed in some way or an-
other through the cornea, and not through the  sclerotica.  Accord-
ing to them, it becomes full as easy in this manner to  place the new
pupil  upon the out as upon  the  inside ; moreover, we see better what
we are doing, and the puncture of the eye must be less dangerous.
  c. Process of Assalini.—Assalini,  after having made an incision
at the outer angle of the cornea, introduces into the anterior chamber
a pair of fine curved forceps, soon after opens them, seizes the iris at
a short distance from its ciliary border, and detaches it as in the pro-
cess of Scarpa.   These forceps are  considered useless by Bonzel,
who substitutes for  them a very small hook, which  is conducted in
the same manner.  Dzondi makes use of a description of forceps, the
inner side of one of whose branches is to be grooved in order to receive
the other when the  instrument is closed.   He pretends that with this
forceps we run no risk of lacerating the iris,  and that by it it is more
easy to effect decollement than with any other instrument.  The strong-
est and best  founded objection to be made against coredialysis is, that
the detached border of the iris gradually reassumes  its natural posi- 
892
GLOBE OF  THE EYE.
 tion, and that, at the expiration of a certain  time, the new pupil al-
 most alwavs closes.                                     .
   d. Process of M. Langenbeck.—To obviate this inconvenience, M.
 Langenbeck, after having seized hold of the  iris by means of a small
 hook protected in a sheath, draws it forwards and insinuates it into the
 wound of the cornea, which should be very small, and then attaches
 it there as if for the purpose of producing a  myocephalon.   The ad-
 hesions which this species of hernia soon contract prevent the pupil
 which has been formed from narrowing, and give to the operation all
 the certainty desirable.
   e. Reisenger, who advances the same idea, censures the sheath-
 hook of Langenbeck, and  makes use of a  simple eye-forceps,  the
 point of which is curved like an erigne on one of its sides.   This for-
 ceps is introduced flatwise, and shut to the farthest limits  of the an-
 terior  chamber.   Its concavity is then  turned backwards.   It is
 opened the space  of one or two lines, to be closed again after having
 plunged it through the  iris, which membrane is thus found pinched
 or hooked up, and is then detached and drawn to the outside in order
 to produce an artificial prolapsus through the cornea.  The coreon-
 cion, so much extolled by M. Graefe, is used in  the same manner as
 the sheath-hook of M. Langenbeck, and differs from  it scarcely ex-
 cept in the little keratotome which it has on one of its extremities.
  /. Process of M. Lusardi.—M. Lusardi has  proposed  to reduce
 core"dialysis to its  greatest degree of simplicity, by devising a hook-
 shaped  needle which alone would answer for  the whole  operation.
 When  closed, this  instrument has the  form  of a Scarpa  needle, or
 rather of a very small serpette.  The  two stems which compose it
 are arranged in such  manner that, by drawing a  little  upon the
 shortest or that which  corresponds to its convexity, there immedi-
 ately results from it a notch which transforms it into  an actual for-
 ceps.   In  is introduced through the cornea  in  the same way as in
 keratonyxis, in order to pass it through the anterior chamber, if that is
 free, or in the  opposite case through the posterior  chamber, after
 having cut through the iris  up to the ciliary circle.  Having arrived
 there, the  surgeon presses its back  against the  great border of the
 ocular  diaphragm, which he endeavors to  detach by means of an
 oscillatory movement, then opens his needle, and afterwards loosens its
 spring,  by which  means  the  membrane is  thus  found embraced.
 Nothing remains but to bring it to the opening of the cornea, with the
 precautions required for giving to  the  new  pupil  the necessary di-
 mensions.
  g. With this instrument, already described in Italy by Donegana and
 Baratta about twenty years since, M.  Lusardi  thinks  we run no risk
of wounding the capsule of the crystalline, which is not demonstrated,
and that we may be enabled to establish an artificial  pupil upon any
 point whatever of  the ciliary circumference, which is more correct;
 but the ordinary needle presents nearly the same advantages.   I do
not speak here of the process of Assalini, which, in order to  remove
the new pupil as far as possible from the crystalline, proposes that in
 coredialysis we should destroy a portion of the ciliary circle and pro-
 cesses, at  the same time that  we detach the great circle of the iris. 
NEW ELEMENTS OF OPERATIVE SURGERY.
893
 This method clashes so much with the object which the practitioner
 has in view, that no surgeon has ever yet had recourse to it.
   h.  The process of Donegana is not obnoxious to the same objec-
 tion.   Perceiving that the pupil, after coredialysis by the method of
 Scarpa,  almost always finished by closing up,  this oculist has pro-
 posed, in order to prevent such an inconvenience,  that we should
 unite the method by incision  to the  method by decollement.  He
 therefore, after having detached the iris from the sclerotica, divides
 it to the  extent of one  to two lines, in a direction parallel to its radi-
 ating fibres, and from  its greater to its smaller circumference.  For
 that purpose we  may penetrate through the  posterior or anterior
 chamber, and make use of the ordinary needle,  or of an instrument
 with  a blade which is somewhat more slender,  almost straight, and
 very keen.  Unfortunately it is not so easy as might  be imagined to
 incise the  iris  after having detached  it in the  interior of the eye.
 Unless we make use of the keratonyx, it  folds itself up under the
 knife, and tears or separates itself from  the surrounding parts, much
 sooner  than it is divided.   Nevertheless it  is  an  improvement
 which may have some advantages, and  which it would be advisable
 to make  trial of when  we perform coredialysis according to the me-
 thod of Scarpa.
   III. Corectomy, or  the method by Excision.—a. Wenzel appears
 to be the inventor of corectomy.  Nevertheless it cannot be denied
 that before him it was  put in practice by Guerin, who,  as Sprengel
 remarks, sometimes excised the point of the flaps of his crucial inci-
 sion.   Sabatier, who adopts the process of Wenzel, gives the most
 satisfactory account of it.  We proceed in the same manner at first
 as for the extraction of a cataract.  The keratotome, while passing
 through the eye, ought to cut out,  at  the expense of the iris, a flap
 similar to that of the cornea.   A pair of small scissors are then intro-
 duced into the  anterior chamber,  and serve to excise this flap near
 its base,  while the point of it moreover,  if necessary, is seized  with a
 pair of eye forceps.  By this means we obtain an opening with loss
 of substance, which cannot be closed up, and which presents every
 possible chance  for success.
   b. Demours,  however, adopted  a  mode  somewhat different  in a
 case of leucomatous cornea.  He made an incision into the anterior
 chamber, which comprised at the same time both the cornea and the
 iris ;  then with  two cuts of the scissors, he circumscribed and re-
 moved a flap of this  membrane of the size of a sorrel seed.  The
 difference between these two modes is in reality  very trifling.  The
 first has some advantages, in the fact that it  enables us to confine our-
 selves to coretomy, if we should prefer this after having  commenced,
 but the second evidently exposes us to less  risk of emptying the eye.
 It is  from one  of these processes, moreover, that are derived the
 principal methods  extolled by the oculists of our  time.
   c Process of T.  Couleon and  of  M. Gibson.—M.  Gibson,  like
 Wenzel,  first opens the cornea to as great an extent as for extract-
ing a cataract, but without touching  the iris.   He then causes this
membrane  to  protrude through the  wound by  means  of  a slight
pressure  made upon the globe of the eye; then by means of scissors,
properly  hollowed and curved  on their flat side, he excises a disc 
894
GLOBE OF  THE EYE.
 from it of suitable size.   Forlenze has no fear of incising the cornea
 to the extent of two-thirds of its circumference, in order to seize the
 iris with  the forceps  or hook, and to remove a flap from  it in the
 manner of Demours.   In  a thesis supported in  1803, M.  Mirault
 gives the credit of a similar process to Couleon.
   d.  Beer asserts that  all  that is required is to make an opening of
 two lines in the anterior chamber to make the iris  protrude of itself
 into this small wound, when the part which tends  to escape outside
 may be immediately excised.   Otherwise he seizes this  membrane
 with  an erigne, and effects its exsection as in the preceding  cases.
   e. Process of M. Walther.—M. Walther, with  a view no doubt
 of reconciling the principles of Gibson with those of Beer, incises the
 cornea to the extent of about three lines; draws the  iris to the outside
 by means of a hook, and by means of a small pair of scissors excises
 a "flap from it of the proper dimensions.  By means of a wound of
 nearly the same  dimensions, M. Lallemand  has found  that he could
 seize the membrane with a small pair of hook forceps, draw it to-
 wards him, excise from  it a flap of considerable  size, and form in this
 manner an elliptical pupil  like that of cats, vertical in its position,
 and two lines in breadth and six in length.  The success in one case,
 says  the  author,  was so complete, that  the patient was enabled to
 follow the army of Spain in the capacity of a nurse.
  f. The needle  forceps of Wagner,  and of Dzondi;  the raphian-
 kistron of Emden; the iriankistron of Schlagintweit; the plomise
 of Menser, and the process of Himly, do not differ sufficiently frpm
 some of the instruments and  processes described  above to make it
 necessary for me  to detain the reader with an account of them.
  g. I will make the same remark of the method of Autenrieth, which
 consists in destroying a  portion of the sclerotica and  of the ciliary
 circle and processes, and removing a disc, in a word, of the globe of
 the eye outside the cornea, with the simple precaution to close up the
 opening which has resulted  with a flap of the conjunctiva, which
 should have previously  been separated from it.  The best  that can
 be done in reference to such a suggestion, is to say nothing of it, and
 I am astonished  that Beer,  Himly, Muller, Guthrie,  Ammon  and
 Ulman, (Nimmo,  Arch.  Gen. de Med., 2d ser., t. III., p. 237,) should
 have gone to the trouble of making a trial of it.
  h.  Process of Physick.—Physick, after having incised the cornea
 and iris, in conformity to the precepts of Wenzel, introduces into the
 anterior chamber  a forceps terminated by plates, in some respects
similar to those of our  chimney tongs.  The inner surface of these
plates presents upon its circumference  a cutting  edge, which forms a
scissors of peculiar description, and by means of which it  becomes
easy to seize hold of and remove the flap of  the iris which has  pre-
viously been cut out by the keratotome.
  B. Relative  value  of  the different Methods.—I.  These numerous
processes show at least the constantly reiterated efforts  of practition-
ers, to improve one of the most delicate operations of ocular surgery.
 Unfortunately there are  often to be encountered here obstacles  and
difficulties, which the greatest address and most consummate skill are
incapable of surmounting.   When rigidly  examined there  can be
no doubt  that corectomy is preferable to the  other two methods. 
                NEW ELEMENTS OF  OPERATIVE SURGERY.        895

Nevertheless  since, in order to perform it, it is necessary that the
instrument should traverse the anterior chamber, it is next to impos-
sible to have recourse to it, when the iris adheres to  the cornea,  or
when this last membrane  is opaque throughout a great portion of  its
extent.   Coretomy presents nearly  the same inconveniences without
having the same advantages, since,  as experience has  demonstrated,
the opening which it makes rarely endures beyond a few weeks.   It
is to coredialysis, therefore, that we should then give the preference.
The same would be the case in instances  of adherent membranous
cataract, in those of any description of opacity whatever, situated  in
front or behind the iris, and which could not be destroyed, inasmuch
as we are here obliged to bring the pupil to the circumference of the
ocular diaphragm.
  II.  Coretomy  and  coredialysis  alone enable us to operate  by
scleroticonyxis.   Nevertheless, as they may also be performed by ke-
ratonyxis, we ought not, as a general rule, to prefer the first, except
in strongly marked cases  of anterior synechia, (sinechie,) inasmuch
as we almost  unavoidably wound  the crystalline.  Should we  be
disposed to restrict ourselves to  coretomy, but  not to employ the
process which I have proposed, that  of  M. Maunoir,  or better still
that of Wenzel, would  appear to  me  to  merit the preference.  To
perform corectomy, we may adopt,  so to  speak, indifferently, the pro-
cess of Demours, Forlenze, Gibson,  Beer, or M. Walther, though the
best of all, in my opinion, would be that  of Physick, such as I have
modified it, or the  iridectum of M. Onsenort, if it were possible  to
procure a sufficiently small punch,  and one that was  perfectly con-
structed ;  which, up to the present time, I have not been enabled  to
obtain.
  III.- When we decide in favor of coredialysis, the simple  hook  of
Bonzel  is quite  as  good  as  the more complicated instruments  of
Langenbeck, Beer, Reisinger, &c.; but I doubt  if it be as  easy  as
these authors seem to imagine, to attach in the opening of the cornea,
the portion of the iris which has been brought  there with more  or
less difficuty.  Should  the accident for which we desire to establish
an artificial pupil have taken place as the consequence of an opera-
tion for cataract, there would  be much less inconvenience here than
in the other cases, in directing the instrument through the posterior
chamber.   In such cases, also, the  bottom of the eye is too much
altered  to leave room to  hope for much  success.   Nor can we per-
ceive  that it would be necessary to open into the anterior chamber  as
largely as has been recommended by Wenzel, Forlenze, and  Gibson.
It would be otherwise should the crystalline or its capsule have pre-
served their natural relations.
  However little we may suspect opacity in these parts, they should
be extracted or depressed.  Perhaps, also, their extraction or  their
displacement should be laid  down as a  law, whether opacity has
commenced or not.  We  should thus avoid the unpleasant conse-
quences of the  occurrence of a consecutive cataract, destroying
the prospect of  success for the first  operation,  as happened to me
in the case of a man aged thirty years.   In this respect, the open-
ing of the cornea cannot be too large, since we not only establish an
artificial pupil, but perform at the same time an operation for cataract 
896                   GLOBE  OF THE EYE.
   IV. When there are spots in front of the eye, and that we cannot
 operate by keratonyxis, the case necessarily becomes embarrassing.
 If the incision is made on a sound part of the cornea, the cicatrix
 which must result from it, and  the  inflammation  which  may super-
 vene, very frequently destroy the transparency of the small  portion
 which the primitive "disease had respected.   Upon the leucomatous
 portion on the contrary, it is to  be apprehended that the wound may
 be transformed into an ulcer, and suppurate and  cause the destruc-
 tion of the eye.  Nevertheless many practitioners, MM. Faure and
 Lusardi among others, have asserted that the section of a  cornea
 thus affected, is not as formidable as is generally  thought, and go so
 far as to say that it  agglutinates more rapidly than that of  a tunic
 which is not  diseased.  This also may readily be conceived.   Such
 tissues being  less  sensitive, less excitable  and more approximate in
 their character to vegetative life, must be more moderate in their in-
 flammation, than if  they were  in their  normal state.  If then, the
 cornea is  opaque to a great extent,  we must cautiously respect the
 part that  remains, and penetrate through its altered portion.  In the
 opposite  case, when its transparency is not affected but by  a  spot
 which is accurately circumscribed, and of little extent, it is prefera-
 ble to incise in the  natural tissues.
  V. Moreover, in order to be  prepared to meet  all the  necessities
 and exigencies of the disease, it is well to  familiarize ourselves with
 the greater part of the processes which I  have deemed it advisable
 to point out, since  there are  cases  in which each of them may be-
 come particularly  applicable.   I would however remark, that  the
 method by excision is in fact the only one which presents real chan-
 ces of success.   All the methods by incision, whether simple or com-
 plex, are decidedly bad, and ought not any more than decollement to
 be adopted, unless  as an exceptionable resource.   I  have performed
 the operation for artificial pupil  according to the precepts of Scarpa,
 Wenzel, and M. Maunoir, and I have noticed that the opening in the
 iris, after having remained sufficiently large  during  a certain space
 of time, has almost constantly  become  ultimately reduced to a tri-
 fling affair.  I performed it in a young girl by the process of Odhe-
 lius, and although the slit at first appeared very large, it finally  be-
 came contracted to a considerable degree.
  VI. These facts, and the wounds of the same membrane, during the
operation for cataract, have  moreover satisfied me that the different
processes suggested by the alleged muscular nature of the diaphragm
of the eye repose on  a false  basis.   In place of retracting itself "to-
wards its root, the flap which I  made in the iris in  1829, at St. An-
toine, in a man  sixty years  of age, gradually approximated on  the
contrary, by its free border, to the point from which  I had separated it
 I he same  thing occurred to me  in 1831 at La Pitie ; and I have late-
ly had a  similar instance  following  the extraction of a cataract.
Here is another example which appears to me entirely conclusive.
A peasant 45  years of age,  was operated upon by  me at La Pitie, in
the  month of June, 1831.   On  one  side the iris  slipped  under  the
edge of the knife, and I removed  a flap from it which left a notch, one
line deep and two in breadth, and a little nearer the ciliary circle than
the pupil upon the border of which it was made.  But in place of be- 
NEW ELEMENTS OF OPERATIVE SURGERY
897
ing transformed into a large oval opening, and becoming deformed,
the circle of the pupil absolutely lost nothing of its  regularity.
  It continued  to dilate and contract as before, to such degree that
its two extremities appeared to be drawn towards each other, as if
to establish its continuity, rather than having a tendency to retract
outwards, or to be withdrawn  towards  the  great circumference of
the membrane, and to become  confounded with the bottom  of the
notch.  M. Graefe (Arch. Gen. de Med., t. XXL, p. 271,) states that
he has five times performed the operation  for  artificial pupil with
success, and M. Eckstrumer (Bull de Fer., t.VIIL, p. 203) appears to
have been not less fortunate in three of his patients ; I have succeed-
ed with it but twice.  M. Laugier, (Bull de Therap., t. VIIL, p. 380,)
by introducing a needle through  the cornea, has succeeded  in de-
stroying  the  adhesions which kept  the pupil contracted.  I was
no less fortunate in 1835, in a patient of M.  Requin.   This method,
which was so much extolled at first  by M. Silvy, (Mem. de VAcad.
de Med.,  t. IV., p.  445,) for cases of obstruction and contraction of
the  pupil from the debris of a cataract, would be better  adapted for
the  obstructions caused by  inflammations of any kind, as  pointed out
by  M. Simeon, (Revue Med.,  1828, t.  III., p.  126,) and wherever
opaque flaps or adhesions should mask  the pupil, or keep it immov-
able.  I will  add, that in such cases  scleroticonyxis, by  enabling us
to depress false cataracts with greater facility, would be preferable
to keratonyxis.
  C. Consequences of the operation.—After the operation the patient
is to be submitted  to the same regimen, and treated with the same
precautions as if he had been operated  upon for cataract.  Never-
theless, the accidents that  follow are rarely  as severe.   Should we
confine ourselves  to keratonyxis,  or even  to  scleroticonyxis, they
are often reduced to inflammatory symptoms of the most unimpor-
tant character.  If the eye has not completely, or for a great length
of time, lost the function of perceiving the light, very frequently the
patient, under  such  circumstances, may dispense with  keeping his
bed, and  wear only a black silk bandeau during the space of a few
days.  The lady operated  upon by Wardrop was enabled to re-enter
her  carriage immediately  after,  and without any inconvenience.
An intractable patient, whom I could not restrict to any systematic
course, got up on the evening of the  same day of the operation, and
on the following day was indisposed  to  make  any retrenchment in
his diet or occupations, yet not the slightest inflammation supervened.
Out of seven other individuals whom I have  operated upon, none of
them experienced any  inflammatory symptoms.  When, however,
we perform  keratotomy  and  largely  open into the cornea,  like
Wenzel,  &c, and when we have deemed it necessary to extract or
displace  the  crystalline or its  connections,  and when  the natural
pupil has been completely closed for a long time, it would be impru-
dent not to proceed in the same manner precisely as after the opera-
tion for  cataract.   In all  these cases, as that of M.  Lallemand,
(Arch. Gen. de  Med., t. IV., p. 69,) for example, demonstrates, the
most intense  ophthalmia  may be readily developed.   Out  of  an
aggregate of 18 operations for artificial pupil, I have obtained only
three successful results, but none of the patients were attacked with
  vol. n.                      113 
898
GLOBE OF  THE EYE.
 any severe accidents.   Moreover, we ought not to be. apprehensive
 of giving too great an extent at first to the opening into the iris, for
 besides that the new pupil for  a long time retains a great tendency
 to contract, we have now the proof that the  absence of the iris does
 not  abolish vision.  M. Hentzchel (Lancette, t. V., p. 440,)  relates
 the  history  of three  sisters, in  whose eyes  this membrane was
 wanting, but who could, nevertheless, see very well.  The same was
 the  case  in  the child six years  of age mentioned by M Stoeber,
 (Journ. de VInstil, 5th  year, p. 394,)  and with the persons whom I
 have elsewhere mentioned, (Diet, de Med., Art. iris, 2e edit.)   I
 have already seen in  eight or  ten  instances, one, or even three
 accidental pupils in the neighborhood of the natural one, without its
 being productive  of  the  double  vision mentioned by Righellini,
 (Portal, Hist, de la Nat., &c, t. V., p. 480.)  If we have to operate
 to remedy the  consequences of an internal ophthalmia, wre must be
 prepared  to meet with a sort of true or false cataract behind the iris,
 and adopt measures to remedy  this difficulty or destroy its effects.

             §  V.—Puncture and Incision of the eye.

   Formerly  puncture  of the  eye was  made  use of in onyx, or
 -effusion of pus  between the lamellae  of the cornea, in hypopyon or
 abscess in the  anterior  chamber, in empiesis, or abscess in the pos-
 terior chamber, in hydr-ophthalmia, and buphthalmia, and in all cases,
 in fine, where the  eye was the seat  of too great an accumulation,
 either of its natural humors or of any abnormal fluid whatever.
   A. Onyx.—When the small purulent collections, which are met with
 sometimes in the substance of  the cornea, have obstinately resisted
 antiphlogistic, emollient and discutient remedies, &c, nothing appears
 more rational than to open them.  The operation, moreover, is so
 simple that it  is scarcely necessary  to describe it.  The surgeon
 depresses  the lower lid;  causes  the  other to  be raised up  by an
 assistant; seizes with the right hand  for the left eye, and with the
 left hand for  the right  eye, a common lancet, divides the layers of
 the cornea, which  separate the  onyx from  the exterior, and repeats
 this puncture as many times as  there are distinct abscesses in front
 of the eye.   A  cataract needle  would be full as good  as  a  lancet,
 and  it is readily understood that we might if necessary make use,
 with  the same  advantage, of any sharp-edged pointed instrument
 whatever.  Unless the  transparency of the cornea should be  irre-
 deemably lost, the instrument ought to be directed as  far from the
centre of the  organ as the  disease will  possibly permit.  In the cases
 under consideration, surgeons  of the present day do  not approve
either of puncture  or  incision.   It aggravates, they say, or  repro-
duces the  inflammation, leaves among its consequences ineffaceable
 cicatrices, and may hasten, or even produce the suppuration  of the
 eye.  Moreover, the matter  which forms  the  onyx,  beim*  almost
 always adherent to the lamella? of the cornea, is  rarelv sufficiently
 fluid to enable a simple incision  to allow of its escape.  " Finally this
 pus, which never constitutes any other than quite thin layers, sponta-
 neously disappears as soon as the ophthalmia which produced it has
 subsided or is subdued.   While adopting a portion of these reason- 
              NEW  ELEMENTS  OF OPERATIVE SURGERY.          899

mgs, which already have  been contested by Woolhouse, Mauchart,
&c, I nevertheless  consider the operation useful, when, as an excep-
tion, the pus constitutes a legitimate abscess.  The facts that science
possesses, and the  last memoir of M. Gierl  in particular, appear  to
me to demonstrate that puncture of the eye under such circumstances,
presents unquestionable advantages, and that  the  moderns  have
exaggerated its dangers.
  B.Hydrophthalmia.—Hydrophthalmia, whether accompanied or not
by liquefaction of the vitreous body, whether there be or be not blood
or pus effused into the humors, possesses in puncture of the eye a last
resource, which at the present day, perhaps, has not been had recourse
to sufficiently  often.  It would be doubtless imprudent to commence
the treatment with this;  but  when  the  proper  general or  top-
ical medications  have proved unsuccessful,  and  that the difficulties
which continue are manifestly owing to an unnatural distension of the
globe of the eye, I see nothing more rational than the paracentesis of
this organ.  By putting a period to the compression of the retina, the
iris, and of the ciliary circle, processes, vessels, and nerves, it  mod-
erates the most violent pains, and appears to me capable of prevent-
ing the most serious disturbances, and to constitute a means, if not
curative, at least palliative, and one of the  most valuable  auxiliary
remedies.
  I. Paracentesis of the eye, which has been practised in Japan and
China  for  centuries, and performed by Tuberville and Woolhouse,
can scarcely be said to have been formally proposed for hydrophthal-
mia before the time of Valentini, (Coll. Acad., partie etrang., t. VII.,
p. 434,) Nuck, (Journ. de Simmons, t. L, p. 282,) and Mauchart.   In
the beginning  it was performed by a small trochar, which Woolhouse
recommends should be  plunged through the sclerotica, while Nuck
directed it upon the centre of the cornea itself.  At present, punc-
ture, properly so called, has been generally abandoned.   Incision  in
almost  every  case  is  advantageously substituted for it, except that
some recommend opening into  the  anterior chamber, while others,
as M. Basedou for  example, advise the posterior chamber. Bidloo
made use of a bird-beaked lancet, directed  upon the lower part of
the cornea.  Meckren used a large triangular needle expressly made
for this  purpose.   At the  present day we  more especially employ
the cataract keratotome.   Saint-Yves made a transverse incision  in
the transparent  cornea.  Louis proscribes  too  large   an  opening,
while Heister recommends that we should incise the sclerotica.  Fi-
nally, there are those who  recommend a puncture  first,  and who af-
terwards enlarge the  small wound by means of scissors or any other
cutting instrument.  But in truth, we have in reality only to choose
between the process of Bidloo or rather of Galen, and that of Maitrejan
and Heister.  None of the others in  fact attain the object better, and
most of them  are infinitely more complicated or much more danger-
ous.  The species of  cataract needle devised for this purpose by M.
Adelmann, who has shown it  to me, and which has a groove upon
one of its  sides, would however possess the advantage of allowing
of the escape  of the  liquid, while at the same time it reduces the
operation to a simple  puncture.  The incision of the sclerotica, whe-
ther outwardly or below, and parallel to the fibies  of this tunic, con- 
900
GLOBE OF  THE EYE.
9titutes  in reality a puncture  of little  importance, and  should have
the preference if the  aqueous humor could  always escape through
it   Unfortunately this is not the case.   To derive  any advantage
from it in simple hydrophthalmia, it would evidently become necessary
to divide through  the sclerotica  transversely at  less than  two lines
from the ciliary circle, and under this point of view the section of the
cornea is certainly a less serious  operation.   It is only then in cases
of liquefaction of the  vitreous body, and which are distinguished
from ordinary hydropsy by the  projection which the ins forms in
front, that the operation by  the method  of Heister could  possess
some advantage.  Moreover it is of little  importance in such cases,
whether we  follow one process or  another, inasmuch as the  eye is
usually lost beyond redemption.
  II. 'Operative process.—After having arranged the patient and as-
sistants, in the same manner as for extraction of a cataract; and af-
ter having properly separated the eyelids apart,  and fixed the eye,
the surgeon makes with  the point of a lancet, a bistoury, Adelmann's
needle, or a keratotome, held like a writing pen, an incision of from
two to three  lines in length, and at the lower or outer part  of  the
cornea,  as far as  possible in  fact  from the pupil, and in such manner
as not to wound  the iris.  It is unnecessary then  to make any pres-
sure on  the globe of the eye.  The aqueous humor immediately runs
out; and an evident relief is  generally the immediate consequence.
So long as any hope remains of preserving the organ intact, it would
be dangerous to do anything to prevent the wound from cicatrizing.
We should dress in the  same manner as after  the operation for cat-
aract, and should a new accumulation of the  liquid seem to render it
necessary, repeat this puncture at the expiration of a certain number
of days, after the  manner  of M.  Basedow, who gives  four suc-
cessful examples of it,  and as I myself have frequently done. No one
moreover, at the present day, would recommend that we should imi-
tate Nuck and certain surgeons  of  the last  century,  by placing a
piece of sheet lead between  the  eyelids, in order to be enabled to
compress the eye from  before backwards, so as to make it gradually re-
enter into the orbit. A practice like this, which moreover is unworthy
of discussion, could not have been adopted but by those who have
confounded exophthalmia, buphthalmia, and proptosis, with legitimate
hydrophthalmia.   Should any point on the tunics  of the eye be obvi-
ously more altered, prominent  or attenuated  than others, there is  no
doubt that this  point  should be  preferred for the paracentesis, and
that we should make it  a  place of  necessity.   When buphthalmia and
the projection of the eye depend  upon hydropsy or  a dilatation  of
the sclerotica, it is then hydrophthalmia also  that we have to con-
tend with, and the puncture is  indicated, as in  the preceding  cases
On the contrary, it could have no object, and must aggravate  the
condition of the patient,  when the disease is  owing to the develop-
ment of some tumor, or to the existence of some organic lesion in  the
orbit.
  C. Hypopyon.—Galen appears  to have been the first who proposed
paracentesis  for hypopyon. Nevertheless he did not have recourse to
it until after having unsuccessfully made trial of  succussion (succus-
•ion), so much lauded  by Justus,  and which  Heister  and Mauchart 
NEW ELEMENTS OF OPERATIVE SURGERY.          901
have since thought not unworthy of reviving.  According  to this
author, we open into the lower part of the cornea, a little in front  of
its union with the sclerotica, and the pus soon escapes to the outside.
Aetius recommends that we should perform it with the needle at some
point upon the membranes which is not inflamed.
  Guy de Chauliac,  Benedetti, Pare,  and Dionis  have adopted the
precepts  of Galen with  success, and despite the efforts  of Nuck,
Woolhouse and a great  number  of others, who like  the  Arabs re-
commended that we  should confine ourselves to one puncture to ena-
ble us to suck out the effused matter, and who even went so far as to
advise leaving the canula of the trochar in place, and afterwards
making use of it for  throwing injections into the interior of the eye;
modern practitioners also restrict themselves to a pure and simple
incision, when they decide upon treating  hypopyon by paracentesis.
It would be in fact  the  best process  to follow under such circum-
stances were the slightest operation then  necessary, and if M. Gierl
is to be believed, (Journ. de  Simmons, t. L, p. 278;) but  the small
quantity of pus which forms the  hypopyon very readily disappears
of itself when the ophthalmia ceases ; the way to augment its secretion
and produce opacity of the cornea, is to open into the anterior cham-
ber with  any instrument  whatever.   Chronic  purulent deposits, the
only ones perhaps which paracentesis would not aggravate, are consti-
tuted  of a matter too adherent either to the iris or the cornea, to
enable us  to evacuate them by means  of an incision of a few lines in
extent; we must place our reliance in fact  upon general treatment,
resolvent collyria, and an effort to put a term to such an affection, so
long as it  does not exceed the limits that belong to a true hypopyon,
and so long as we have  any hope  of  preserving the visual function
For all these reasonsjl am of opinion, with Boyer and Dupuytren,
that puncture of the eye,  either with a trochar or lancet, is but rarely
applicable to abscesses in the anterior chamber,  unless like Lehoc
we should employ it with the view of renewing the aqueous  humor.
and at the same time for  evacuating the purulent matter.
  D. Empyesis.—In abscess of the posterior chamber, that is to say,
in empyesis or empyema of the eye, it would appear at  first view
that all the world would  concur in the necessity of having recourse
to paracentesis.   It  would however be an  error  to suppose  so.
Though many persons have recommended it;  and in fact almost  all
the oculists of the last century frequently made use of it, it can  nev-
ertheless be then but a feeble resource.   By it we evacuate but in a
very imperfect manner the morbid collection.  As it soon shuts  up,
the accidents which  belong to it are remedied  but temporarily.   As
soon as the eye is implicated it is irrecoverably lost,  and there  is no
use in incising it any more.  We ought to excise a sufficiently large
portion of it to evacuate it completely and  bring about atrophy.  The
seton employed in China and Japan, and which had already been eulo-
gized by  Woolhouse as  a substitute  for puncture, and revived  by
Ford   (Southern Med. and  Surg. Journ.,  June,  1838 ; Gaz. Med.,
1838* p. 617,)  is a barbarous remedy, and unworthy of any criticism.
  E.' Practice of the  author.—I  have however  found that in  all
these  cases repeated punctures on  some  region  of the  sclerotica
which remained intact, by means  of the point  of a lancet, possessed 
902
GLOBE OF  THE EYE
a great deal of efficacy.  So long as the eye is distended and pain-
ful, whether there be hypopyon, empyesis, hydrophthalmia, or ophthal-
mitis, I have found nothing better than this practice.   I  choose the
point of the sclerotica which is most visible and projecting,  and plunge
in the lancet there perpendicularly and parallel to the fibres of this coat.
The relief is prompt and the operation may be repeated the day after.

                  § VI.—Excision of the Eye.

  Staphyloma of the cornea, empyema, hypopyon, and hydrophthal-
mia, are almost the only diseases which  sometimes require excision
of the anterior part of the eye, or for which we may properly have
recourse to this  operation.  Its object is to  evacuate the organ, to
bring about its  atrophy, and  to transform it  into a simple stump,
which  may be  adapted to the support of an artificial eye.   It is
therefore a dernier resource, which  is not allowable except where
all others have failed, and  only in cases where it has satisfactorily
been demonstrated that the sight cannot be  preserved or re-estab-
lished.   In hypopyon, empyesis, and hydrophthalmia, for example, it
is not to be resorted to  until after incision or puncture, unless the in-
sufficiency of these last methods should have been previously ascer-
tained.  M. Dugas,  (Ibid.,) in a case of hemophthalmia, did not de-
cide upon it until after having lost every hope of preserving the  eye.
The most ancient authors had  already made use of it  in prolapsus
(procidence) of the cornea.  Galen mentions it as a common method.
Aetius  recommends that we should associate it with the ligature ;  and
that before removing the staphyloma, we should  pass two threads
through its base crosswise.  The ligature that Paul of Egina and others
proposed to apply either circular, crucial, or transverse, the taxis and
compression proposed by Manget, and the crucial incision of Wool-
house, are now no longer in use, and all surgeons at the present day
adopt the advice of  Pare or of Louis when  they  wish to obtain a
radical cure of staphyloma of the cornea, that is to say, they perform
pure and simple  excision.
  A. Operative process.—Whether it be for one disease or another,
we must, as soon as  we decide upon  not removing the entire organ,
confine ourselves to the excision of  its  apex.   Cancerous affections
alone  would  constitute an exception  to this rule,  did  they  ever
allow  of a simple excision.  In penetrating  beyond the  iris, up to
the middle of the posterior chamber, we should incur the risk of  see-
ing the muscles retract the  rest  of the sclerotica and the optic
nerve to the bottom of the orbit, and of having no stump to the  eye
after the cure.   On the other hand, if we should confine ourselves to
a small opening,  the humors contained in the chambers would  only
partially flow out, and the wound might cicatrize too soon, and leave
only in its place  a depression which would be as great a deformity as
the staphyloma itself.  We should avoid these two extremes by remov-
ing almost the entire cornea and without going any farther.   Then we
are sure that the vitreous humor will finally escape or be dissolved, that a
new accumulation of humor will not take place to such extent as to pro-
duce a painful distension in the posterior chamber, and that after cica-
trization, the muscles will be enabled to impart to the remains of the or 
             NEW ELEMENTS OF  OPERATIVE SURGERY.          903

gan the greater part of the movements which it executed in its natu-
ral state, and transmit them to the artificial eye.  Nothing  is easier
than an operation of this  kind.  The crucial incision with excision
of the four flaps, as Richter recommends, is altogether useless. The
patient being properly arranged and  secured, we  divide the lower
half of the cornea with Daviel's instrument, the point of a lancet, or
any bistoury or keratotome, in the same way as for extraction of the
crystalline.  The flap is immediately seized with a good pair of for-
ceps, and detached in the  remainder of its circumference, by means
of a very sharp pair  of scissors or of a bistoury directed from below
upwards.  An erigne plunged into the middle of the segment to be
removed would  render its excision still  more prompt and certain in
intractable subjects or in those in whom it might be  difficult to steady
the eye.   This process, more simple than that of Terras, who passes a
thread through the tumor in order to exsect it more readily afterwards,
would enable us in fact to remove as rapidly as possible, and with a
single stroke of the instrument, the totality of the cornea or staphyloma,
by directing upon its base a good bistoury, which should be made to act
either from above downwards or below upwards.   The guillotine of
Guerin, extolled by  Demours, would not be more convenient, and
has no claim to a preference.
  I.  Consequences.—There is  generally developed after  this exci-
sion a sufficiently active inflammation in all the parts contained in
the orbit, together with fever  and cephalalgia, and sometimes even
symptoms much more serious.  In general, however, at the end of
from eight to fifteen  days, the swelling which it has occasioned  be-
gins to diminish; the suppuration, at  first abundant, soon  dries up,
and towards the end of the month, or a little sooner or a little later,
wre are enabled to  adjust the artificial eye.   As it is not an operation
without danger, we ought to make this known to those who demand
it  for simple deformities, and ought  not to  perform  it under such
circumstances, except at their solicitation, as in cases, for example,
of ancient staphyloma, unaccompanied with pain.  When,  on  the
contrary, the disease which it is designed to remedy is dangerous in
in itself, as empyema, hydrophthalmia, &c, we must not  hesitate.
Before such affections  as  these, every apprehension should be ban-
ished.   Punctures of the  sclerotica, I should think, would diminish
the inflammatory reaction and ought to be had recourse to.

                 §  VII.—Extirpation  of the eye.

   Though extirpation of the eye was not clearly described until near
the close of the sixteenth century, there is however every reason to
believe  the ancients  had had recourse to  it quite frequently.  There
were two principal classes of conditions in which it  was made  use of:
1st, for  proptosis, or  the fall of the eye; 2d, for deep-seated diseases
and degenerations of this organ.
   A. Proptosis—Exorbitism—Fall of the eye.—J. Lange, who wrote
in 1555, boasts of  having  caused the re-entrance into the orbit of an
eye which certain surgeons had proposed to  extirpate.  Donat, at a
little later period, in  1588,  endeavored to demonstrate the inutility of
this operation, and maintained  that compression, aided  by the judi- 
904
GLOBE OF THE EYE.
 cious employment of internal remedies, always triumphed over those
 diseases which seem to require it;  which proves at least that for a
 length of time it has been known to practitioners.  Bartisch, there-
 fore, who onlv published his work in the year 1583, has no claim to
 the merit of the invention, and has  only drawn attention to a serious
 operation, and one which had already been performed, but the execu-
 tion of which he rendered more easy.
   Some authors, as Covillard, Lamswerde, and  Spigel, also profess
 to have cured without  an operation, patients in whom the eye vio-
 lentlv  protruded from the orbit and hung upon the cheek.  A. Seig-
 neur" stated to Guillemeau, ((Euvres Chir., p. 743, edit. 1612,) that
 his surgeon seizing an eye which had fallen to the ground, success-
 fully replaced it in the  orbit.  An  eye  which had issued from the
 orbit  in consequence  of inflammation, was replaced  by Loyseau,
 (Obs. de Med. et de Chir., p. 46 ; Corps de Med.)   The eye of Cap-
 tain Naldi,  according to Rhodius, (Bonet,  t. III., p. 50,) which had
 been driven from the orbit by a blow given by a Turk, miraculously
 returned to its place by means of a large cupping glass upon the occi-
 put.  In a  young infant, the eye which had  inflamed and become as
 large as an egg, and escaped from the orbit, returned there by means
 of topical applications administered by F. Plater,  (Bonet, t. III., part
 2nde, p. 50.)  Verduc (Pathol Chir., t. IL, p. 44-47, in 12,) does not
 admit  the  fact of Covillard, but Lemaire,  (Eaux de  Plomb., &c,
 p. 59,) saw the  same thing in  a hemiplegic at  Plombieres.   Sal-
 muth,  (Cent. 2, hist. 42, dtat d'Ettmuller, Prat. Med., t. IL, p. 401.
 French trans.) speaks  of an epileptic, in whom the eye during a par-
 oxysm protruded  to the  size of the fist, and returned after this had
 ceased. Verduc, (Pathol, de Chir., t. IL, p. 244, in 12, 1719,)  more-
 over, admits to have seen a  young  painter, whose eye descended to
 the middle of the cheek, and which in less than the  space  of  an
 hour, descended from, and returned to the orbit more than six times.
 In a patient of C. White's,  (Cases in  Surgery, 1770;  Gaz. Salut.
 1771, No. 27, p. 3,) the eye, luxated upwards by the contraction  of
 its levator muscles, was relieved by the taxis :  a  wound made by a
 fragment of pipe-stem which had entered at the bottom of the orbit,
was the cause of the difficulty.   In  a case of protrusion of both eyes,
says Rossi,  (Elem. de Med. Oper., t. I., p. 203,) which took place
after violent vomitings, I found after the remedies which I had em-
ployed to give greater strength to the muscles of the eye in restrain-
ing the globes, that the  use of electricity and  camphorated vapor
produced a marvellous effect. M. Champion has known  an old lady
who was affected with strabismus in the left eye, and in  whom this
infirmity succeeded after the reduction of the eye, which had  been
driven  from the orbit  out upon the cheek in consequence of a blow
received upon the temple.  I frequently meet, says the same prac-
titioner, with a retired officer, who  declares that he had  a protrusion
of the right eye which it had been proposed at the time to excise, but
which was  perfectly reduced and is now in possession of all its func-
tions.    The accident  was  said to have been  produced  by  a ball
which had traversed the  left orbit, and  which had come out at the
inner angle of the right  one. Maitrejan has long since shown the
 impossibility of such a  result taken literally ; but Louis has  very 
NEW ELEMENTS OF OPERATIVE  SURGERY.
905
justly  remarked, that in divesting the assertions of observers of
every thing hyperbolical that they possess, we find in them the proof
that the optic nerve and the muscles which surround it may undergo
a considerable  degree of elongation without necessitating the extir-
pation  of the eye.   We have, moreover, numerous examples of this
elongation  effected in a gradual manner, in  cases of exostoses, and
tumors of every description in the  orbit, nasal fossae, maxillary sinus,
&c. If the eye  really hung down on the outside, in consequence
of a traumatic lesion, we  should  then, instead of attempting to re-
place or preserve it, complete  its separation and remove  it imme-
diately.  In such cases there is no process to be given.  A single cut
of the  scissors or bistoury sometimes suffices, and the  conduct of the
surgeon must necessarily  be  regulated  according to the accidents
which exact so severe  a remedy.  When on the  contrary the eye
has only been expelled gradually from the orbit, whether  entirely or
partially, or whether it be or be not in itself disorganized, we should
do wrong to atteptms it extirpation.
  It is not  to  the eye itself that  the  resources  of surgery  are to
be addressed.   Let the operator destroy, or cause the disappearance
of  the principal disease if he  can, and the  displaced  organs will
soon resume their normal situation.  St. Yves cured a severe  ex-
ophthalmia, by effecting the resolution of scirrhosities which had been
formed in  the  bottom of the orbit.  Brossaut, who is mentioned by
Louis,  has  seen the vision  re-established, and  the  eye re-enter into
its cavity, when the exostosis of the ethmoid  which had caused its
expulsion had been destroyed ; Guerin of Bordeaux, and Dupuytren,
have brought about the same result by removing  the various tumors
and cysts,  of which the tissues  which  surround  the  eye are very
frequently the  seat.   Extirpation  of the eye therefore is not called
for in buphthalmia nor exophthalmia, whatever may be  their cause,
nor in hydrophthalmia, empyesis, or staphyloma.
  B. Cancers of the  Eye and the  Orbit.—Cancerous  affections only
allow of our undertaking extirpation of an eye which has not been'
displaced.   Even when their  existence has  been well  established,
the question still remains whether the operation should be attempted.
Those  who go for the affirmative, with Desault, &c, argue princi-
pally that cancer  of  the eye is  much  more  frequently observed in
children than in adults, and that in the younger period of life its re-
production is much less to be apprehended than after puberty.  Others
appeal to the researches of M. Wardrop, which show that the dis-
ease is almost always constituted of fungus hematodes, a melange of
encephaloid, erectile,  colloid or melanotic tissue, or one of those sub-
stances only.   But since there is  no variety of cancer which repul-
lulates  either in  the  same  place or elsewhere, with more obstinacy
than this, they maintain that it would be inflicting  unnecessary suf-
fering upon the patient, and that  we ought to limit  ourselves to simple
palliatives.  What analogy and reasoning had foreshown to them, ex-
perience has but too often demonstrated.  Whatever, in fact, some au-
thors may have said on this subject, the labors of the ancients, like those
of the  moderns, sufficiently prove  that the ablation of cancer of the
eve is not less liable to a return of the disease than that of any other
part."  I would not, however, therefore  conclude that we  ought to
  vol.  n.                      114 
906
GLOBE OF  THE EYE.
 remain inactive.  Far from that, I think we ought to exert ourselves
 to operate  before the viscera have had time  to become invaded by
 the morbific germs, and as soon as the nature  of the disease appears
 no longer doubtful, and so often as it shall appear to be practicable
 to remove it entire.   All this, however, belongs to the general ques-
 tion, whether it is advisable or not to operate for cancer.
   1. Operative process.—a. Process of Bartisch.—The extirpation
 of the eye, much more frightful than difficult, more formidable by its
 consequences than its immediate dangers or the difficulty of its exe-
 cution, may be performed  by  quite a number of different modes.
 We find no details on this point in authors before the time of Bartisch,
 who, in order to excise the diseased parts, found no other instrument
 necessary than a species of spoon with cutting edges, like that used
 by shoemakers.  Though no person at the present day would ven-
 ture to recommend so crude an instrument, it is incorrect to say that
 it exposes to the risk of fracturing the  bones, and that it renders the
 operation much more difficult than with any other knife.  Its dimen-
 sions, it is true, do not allow of our carrying it as far as the extreme
 depth of the orbit, but I do not find that it is often  required to  go to
 this distance.  To be just, therefore,  we  should limit ourselves to
 its rejection  as useless,  or possessing but little advantage.  The ex-
 cavated  scissors of Delpech, (Diet, des Sc. Med., t. VII.,  p.  528,)
 and the concave scalpel of Mothe, (Journ. Gen. de Med., t. XLVIIL,
 pp. 121—136,)  are scarcely better.
   b. F. de Hilden, who  had occasion to extirpate an  eye in 1596,
 proposed at first to embrace the projecting part by means of a string
 purse.   After having censured the instruments of Bartisch,  (Cent. 6,
 obs. 1,—Bonet,  Corps de Med., p. 389,)  he speaks of the simple stran-
 gulation extolled by C. H. Chapuis.  Detaching the tumor  from  the
 eyelids by the  cuts of the  bistoury, he employed for the section of
 the muscles and optic nerve a sort of scalpel with two cutting edges,
 curved  flatwise, and  truncated  at  its  point.   In  this  process  we
 already recognize the principles of a more enlightened surgery, and
 the practitioner mentioned by Bartholin (Louis, Diet, de  Chir., t.  IL,
 p. 124,) is justly censurable for not having profited by it about fifty
 years subsequently, and for not having recoiled at the idea of tear-
 ing out the  eye by means  of a pair  of  hooks.   The instrument
 of Hilden,  though more ingenious, has nevertheless met with  the
 same fate as that of Bartisch. If Job-a-Meckren succeeded with  the
spoon of the oculist of  Dresden,  and  Muys and Leclerc with  the
knife of Hilden, Lavauguyon maintained "that  a good lancet fixed
on its handle would always suffice, and might be substituted for them.
St. Yves, for every step of the operation, found nothing else  required
than a thread to secure the cancerous mass, and a cutting instrument,
which he does not designate.   Nor do the observations of Bidloo make
any mention of a particular knife, except it be  a long bistoury bent
to an angle, near its handle,  and which is also praised by V. D. Maas.
  c It was Heister who showed, by sufficiently good reasoning, that
an erigne or forceps, and the ordinary bistoury, which Hoin of Dijon
had already  found to answer in 1737, are sufficient for this operation
  rf. Ihincrs were in this state when Louis undertook to  systematize
 the ideas of surgeons on the extirpation of the eye.   When the tumor 
NEW ELEMENTS OF OPERATIVE SURGERY.          907
no longer holds on except by the root of the recti muscles and of the
optic nerve, we must, says this surgeon, make use of a pair of  scis-
sors curved flatwise ; pass them  to the bottom of the orbit,  then
divide  the musculo-nervous pedicle, and at the same time act  with
them as with a spoon to bring the whole forward.
  e. Desault,  who, in the first years of his practice, had  adopted
the process of Louis, ultimately abandoned the scissors as useless,
and confined  himself to the simple bistoury, which in fact is better
than the curved bistoury of B. Bell.  Sabatier, Boyer, Dupuytren, and
all the operators of the present day, conform themselves to the recom-
mendations of Louis or of Desault almost indifferently.  With the
curved scissors we  run no risk of penetrating  into the cranium or
into the zygomatic fossa.   Their concavity accomodates itself better
to the form of the tumor, whose pedicle also they would seem to em-
brace with more security.  But with a bistoury it is not necessary to
change the instrument, from the commencement to  the end.  The
section of the soft parts is more neat, and all that  is required  is to
incline it in one direction while the eye is drawn in another, in order
to reach with facility the  root of this last.  We should have to be
very unfortunate or  very inexpert to perforate with its point into the
optic foramen or maxillary and sphenoidal fissures.  It is therefore
here also, as we have so  often already said, an affair of choice or
circumstances, much more than of necessity.
   First  stage.—The patient may, if necessary,  be kept seated upon
a chair, but it is better to operate upon  him in bed, taking care to
raise up his head considerably.  The surgeon being placed upon the
side of the affected eye, acts differently according as the surrounding
parts  are or are not invaded by the cancer.  In the first case he
adopts the precept  of Guerin, and makes two semilunar incisions,
which enable him to circumscribe the base of the orbit and to detach
the eyelids from it in order to remove them with the rest of the dis-
ease.  In the second case he is to  do all in his power to preserve the
connections of the eye.   If they have  contracted adhesions without
having undergone an actual disorganization, he  dissects each eyelid
on its  inner surface  and reverses it outwardly.  When the globe of
the eye is found to be free behind, all that is necessary is to prolong
with one cut of the  bistoury the outer palpebral angle to the extent
of about an  inch towards the temple, as Acrel,  and not Desault,
appears to have been  the first to have formally recommended.  In
 all cases an assistant secures the head of the patient, and keeps him-
 self prepared to follow  and to  favor all  the movements of the
 operator.   This  last secures  the  projecting part of the tumor with
 his hand  if he can, after the manner of Desault.  Otherwise he
 makes use of a simple erigne or double hook, an erigne forceps like
 that of Museux, or  the string purse of F. de Hilden, or better still,
    <^t  Yves recommends, (or a strong simple ligature or ribbon cross-
 wise) after the manner of Chabrol, (Gaz. Salut., 1782, No.  49, p. 4,)
 oassed by means of a needle through the degenerated mass.
    Second stage.—The operator takes the bistoury in his right  hand,
 holds  it as a writing pen, and directs its point to the great angle of the
 eye • plunges it in while grazing the ethmoid bone as far as to the neigh-
 borhood of the optic foramen, makes it pass round flatwise the entire 
908                   GLOBE OF THE EYE.
 lower semicircumference of the orbit;  divides the attachment of the
 small oblique muscle, the oculo-palpebral groove of the conjunctiva,
 and some adipo-cellular filaments; then brings it back into the inner
 or nasal extremity of the wound;  directs its cutting edge upwards
 and then outwards ;  divides the great oblique muscle, and endeavors
 to remove at the same time the lachrymal gland, when, by passing
 around  the orbitar vault, he arrives near the temple and finds him-
 self at  the point  of uniting the two  wounds by  their  outer  ex-
 tremity.
   Third stage.—The eye now holds no longer than by means of  a
 pedicle  formed by the  four recti muscles and the optic nerve.  If,
 in order to divide this pedicle, we prefer the scissors, the operator
 glides them upon  the  inner rather than the outer  side, with their
 concavity turned towards the tumor to as great depth as possible,
 and with a single cut completes the separation of the cancer.   If any
 bridles  still retain it, they are to be rapidly divided  in  the same
 manner, while with  the other hand we make the proper tractions.
 If, in pla:e of the scissors, the  surgeon  has recourse  to the bistoury,
 he  directs this also, by  preference, upon  the  inner side.  In this
 direction the orbitar  wall being almost  straight, it is easy,  by inclin-
 ing the  point of the instrument outward, to cross and divide the mus-
 culo-nervous pedicle.  I am ready, however, to avow that with the
 bistoury, as well as with the scissors, it would not be attended with
 much more difficulty to attain the same object by following the tem-
 poral wall of the orbit.   It was, in fact, here that  Desault usually
 entered it by choice, remarking  that this route was the shortest and
 most convenient.
  An object more worthy of attention, is  that we are more certain
 by  this  mode  to avoid  falling  upon the maxillary  and sphenoidal
 fissures.   Whether  the  lachrymal gland  be cancerous or not, we
 must when we  have missed it, seize it  immediately after with an
 erigne or forceps and extract it.  The secretion  of  tears  being no
 longer of any use must  necessarily be injurious.  It must be by inad-
 vertence that  some have  thought  proper to sustain the contrary
 opinion.   This gland when left in the orbit after the  removal of the
 eye, kept  up a  copious  discharge  of tears  with accidents, which
 obliged  M. Nelle (Encyclogr. des Sciences Med., 1838, p. 250) to ex-
 tirpate it six months subsequently.  We may moreover, by directing
 the  forefinger into the orbit, accurately ascertain the condition of the
 parts that remain ; and if there are any of them  which are not
 sound, we  should endeavor to reach them before we have finished
 the  operation, and remove  or destroy them, either by means of the
 bistoury, the scissors, or even the rasp.
  II.  Dressing.—No artery of any size  can have been wounded.
 All  those which  are  divided come from the ophthalmic ;  and their
 ligature is unnecessary, even though the blood should flow in abun-
 dance.  Small balls of lint sprinkled or not with colophane  and more
 or less  pressed upon, would be sufficient to arrest it.   In ordinary
 cases we fill up with lint the void  which  has been  left, but  mode-
rately and as if for the  purpose of supporting the posterior  surface
 of the eyelids.   The sponge, which has  been proposed by some prac-
 titioners in lieu of this substance, would have  the disadvantage of 
NEW ELEMENTS OF OPERATIVE  SURGERY.
909
irritating the tissues by becoming swollen  in the middle of a solid
cavity.   The small  bag filled with  emollient cataplasms also, as
recommended by M. Travers, and which is placed over all the other
dressing in order to prevent the slightest degree  of compression,
does not appear to me to present any real  advantages.  At the ex-
piration of four or five days the suppuration is established.   The lint
is  removed without any effort.   Nor is there any objection  if we
wish  to make the removal of the first dressing still more  simple, in
covering the bottom of the wound with a fine linen besmeared with
cerate and perforated with holes, and which serves as a sac to the
compresses, and when the eyelids have been removed may be  easily
reversed upon the  contour of the orbit.   A soft plumasseau, and
which is sufficiently large to  support in front the more deep-seated
portions of  the  dressing, together  with a long compress  placed
obliquely, and  the  monocle bandage, complete the dressing, which
the least skillful surgeon moreover  will know how to modify in a
proper manner, should circumstances make it necessary.   After its
first removal, which  is from the third to the sixth day, the dressing
has no longer any thing particular in it.  The wound being washed
with  tepid water and  gently wiped out,  should be supplied each
time  with  a small  quantity of dry lint.  The  eyelids being gently
raised up and protected by small bandelettes besmeared with cerate,
are finally covered with a soft plumasseau and a compress; the  whole
is  supported  by the monocle and a few turns of bandage.  The cure
is  usually effected between the third  and tenth week.
   III. Remarks.—Though the  preservation of  the  eyelids would
render the deformity less repulsive, it would nevertheless  be prefer-
able to sacrifice them rather than not to destroy the remotest vesti-
ges of the disease.   The incision at the external angle renders the
remainder of the operation more easy, and does not involve any
particular accident.   One point  of suture or a simple  adhesive strap
would moreover effect its reunion without any  exertion  or incon-
venience.  If we should  commence by the  superior incision, the
blood which oozes  out would necessarily create  a slight degree of
embarrassment for that  below.  The  eyelids  having their fixed
point upon the  inside, we manipulate with more security from the
nose  towards the temple  than from  the outer to  the internal angle.
When the globe of the eye alone is affected, as it  is attached in front
only by the fold of  the conjunctiva and  the oblique muscles, it  is not
necesary to  carry  the instrument over an inch  in depth.   On the
contrary, when adhesions are  established between the soft parts and
the bones, we must go as deep as the bottom of the orbit.  In such
cases the spoon-knife of Bartisch, the scalpel of Hilden, and the bis-
toury of Bidloo, would incur the risk of fractures, which it is always
advisable  to  avoid.   It is  under such circumstances  also that any
sharp-pointed instrument  whatever,  if directed without precaution,
might fracture the frontal bone and penetrate into the brain, should
we  in  order to reach with  more certainty the  levator muscle or
lachrymal  gland, elevate its point too much; or it might arrive into
the maxillary sinus and divide the suborbitar nerve or vessels,  if we
should incline it  too  much  in the opposite direction; or  penetrate
into the nasal fossae inwardly, or into the zygomatic or pterygo-max- 
910
GLOBE OF  THE EYE.
 illary fossa posteriorly, and wound the second branch of the  fifth
 pair of nerves (nerf trijumeau) or the internal maxillary artery; or
 in fact penetrate into the cranium through the sphenoidal fissure, and
 wound the middle lobe of the cerebrum.  If the bistoury, however.
 should not graze the bones, we should incur the risk of not  removing
 all the cancer, and of being obliged to operate again afterwards.  The
 lachrymal gland in particular being almost entirely concealed behind
 the external orbitar process, cannot be extracted with the eye except
 wTith a good deal of  difficulty.
   The rasp recommended by Bichat, or the chemical caustics, would
 be less dangerous  than the actual cautery, at least on the side of the
 orbitar vault, should  it become indispensable to go  beyond  the  soft
 parts.  In fact, the proximity of the brain would, under such circum-
 stances,  render the  application  of the iron extremely  dangerous.
 Should the fungus have commenced at the exterior of the eye, there
 would be reason to apprehend that there were branches of it in  the
 direction of the temple, sinus maxillary, the nose, &c.   M. Simonin
 (Decade Chir., p. 21, 1838,) having extirpated the eye, was obliged
 to resort to tamponing ; and his patient died.  The roof of the orbit
 was perforated, and  blood was found under the dura mater.  Being
 desirous of arresting  the blood and of destroying some  remains of
 cerebroid tissue in the temporal fossa  and maxillary sinus, I applied
 there an  olive-shaped cautery, avoiding with  care the vault of  the
 orbit.  The patient died on the third day, and we found an extrava-
 sation of blood in the corresponding lobe of the brain.   Was it  the
 operation which was the cause of this apoplexy, or was  it not only
 a mere coincidence ?  Though we may be in the habit of employing
 the same  hand for the first and second  incision, it nevertheless  ap-
 pears to be more convenient for the right eye, for example, to exe-
 cute that of below with the right hand, and that of above  with  the
 left one, unless we wish to make one of  them from the temple to  the
 nose.   We divide the levator muscle, because  otherwise  it would
 constantly tend to draw the upper eyelid  inwards after the cure,
 and might in this manner still further increase the deformity.  I have
 forgotten to say that  Dupuytren  began with the upper  incision,  and
 that  he terminates by detaching the organ   from the summit to the
 base of the orbit.

                   § VIIL—Artificial Eyes.

  Nothing, doubtless, would  be more desirable than to be enabled to
make use of an  enamel eye, when  the disease has permitted us to
preserve  the  integrity of its movable coverings; but we must not
flatter ourselves  too  much on this point.  The orbit,  like all other
natural cavities, when once emptied and void shrinks upon itself   Its
walls approximate  gradually from the bottom to the  exterior.'   Its
circumference diminishes and becomes  depressed  in  such manner
that at the expiration of a certain time, it is  found to be almost com-
pletely effaced by this contraction, and also by the development of a
fibro-cartilaginous substance.  The eyelids being obliged to conform
themselves to  this retraction, contract adhesions on their posterior
surface, are deformed, and become in most cases incapable of adapt- 
NEW ELEMENTS OF OPERATIVE  SURGERY.
911
jng themselves to the artificial organ that we wish to place behind
them.  If the patient, therefore, is desirous of concealing his mutila-
tion, we must be prepared whether the eyelids have been  destroyed
or not, to  be under the necessity of employing only spectacles that
nave been artistically arranged, or with a colored plate, which is to be
nxed in front of the obliterated cavity.   The ancients, as it appears,
devoted more attention to these matters than ourselves.  We find that
they had two species of artificial eyes, one to be inserted as at the
present day behind the eyelids ; the others, which were still used in
the time of Pare, who is said to have been the first who spoke of them,
and which were a  sort of convex plates upon which the anterior part
ot the eye and its  coverings were painted in wax colors, were to be
kept in place by means of a spring.  Formerly the first were made of
gold or silver: at  the present day the enamel is properly preferred.
In these  eyes everything is to be  represented, the cornea, the  iris,
pupil, the sclerotica and its vessels.   To  apply them, one of them
was held by the extremities of its longest diameter with the forefinger
and  the thumb, in order to pass its upper border under the frontal
eyelid, while the eyelid was gently raised up  with the other hand.
This being done, it enters so to speak of itself, as soon as the other eye-
lid is depressed.   In order to remove it when going to bed at night,
the patient glides under it the  head of a pin, and depresses the lower
eyelid while drawing the lid forward.  Being deposited in a glass of
water during the night, this eye should  be carefully cleansed every
morning before being replaced.  It is unnecessary to remark that its
dimensions ought to be in relation with the orbit of different individ-
uals, and that it is  important that another eye should be substituted as
soon as the  first begins to change.  When the  enamel  eye has  been
properly constructed, and that the two posterior thirds of the natural
eye remain to form a stump, the resemblance sometimes is so striking
as to produce a complete  illusion.  In the contrary case,  as it is not
susceptible  of movement, it remains fixed  in the centre of ihe orbit,
and unfortunately cannot be  concealed  in those who are  obliged to
wear it.
   [M.  Morant, of Mettrey  (Arch. Gen. de Med., June, 1844, 4e ser.,
t. V.) having found cases of epidemic  ophthalmia accompanied in
the beginning with coryza, was thereby induced to try repeated cau-
terizations to the mucous membrane of the nasal fossce, which proved
in many  instances  an effectual remedy.
   Encysted spheroidal liquid tumors in the anterior chamber of the
eye, with the capsule and  contained liquid more or less transparent,
and' the  whole adherent to the iris,  have been noticed in a few in-
stances, (see a case by J. Dalrymple, London Lancet, August, 1844,
and Ty well on Diseases of the Eye—also Archiv. Gen., Paris, Mars,
1845,) and are cured either  by puncture or  by dissecting out the cyst.
   Abrasion of the  cornea for cure of Opacity.—M. Malgaigne exhib-
'ted to the  Koyal  Academy  of Sciences  of Paris, April 28, 1845,
(see Arch. Gen., June, 1845, p. 236.)  a young girl in whom  an opa-
city of the  cornea was completely removed, and transparency re-
stored, by an  abrasion of one half the  thickness of this coat two
years before.   T.]
END OF VOL. II. 
I--------/—'—■■■ 
 
 ...... -.^'w/^itj

. vv.,.; -:-:r:v;^

... .:r,*f^	
■". ..' ' .".'*'..;:;:	-;\r.tf
	.&§£
'■-'.,'.. . vv'^;	
■''.'. ' 1 Ti**	if£i:ifr
'. '"■■•/■ ^"VjiSC'	xs.*.
	
	
..... ■ • . . • •-«	i: .,.."1.
' '..' : '£..".*,	f-.a?
■ ■.»• ■  .- .... •..,.. ..",',
--Si "^..".,'.^.  ;"Ct"
' • 4»  - . I ■'•*.• *,«. V.I.
, •..v;;;^.'^r.
NLM041394840